Getting Ready for ACL Reconstruction
Prehab for ACL reconstruction surgery
Pre-surgical Physical Therapy For ACL Reconstruction Surgery
The thought of an ACL injury can strike fear in the heart of any athlete, however, a thoughtful and proactive response to ACL injury can lead to better outcomes. For athletes preparing for ACL reconstruction, the question of how to get ready for surgery might be on your mind. You may be happy to hear that an active prehab program of physical therapy can prepare your knee and your mind for surgery and might even improve your surgical outcomes. In fact, there is some evidence that participation in an ACL reconstruction prehabilitation program ensures better self-reported knee function up to 2 years after surgery (van Melick N. et al, 2016). In this article, we will talk about what components of rehab may be included in an ACL reconstruction preoperative program.
WHAT PREOPERATIVE FACTORS SHOULD YOU TARGET?
Much research has been done to try and determine what preoperative factors are associated with better long-term outcomes for those undergoing ACL reconstruction. Some factors like age and sex cannot be modified. Other factors, however, such as knee range of motion, quadriceps strength, and level of activity before surgery are associated with positive indicators at one to two years post-surgery and beyond. Researchers continue to work to identify the optimal ACL reconstruction prehabilitation program. Let’s explore some of the goals of preoperative rehabilitation for ACL reconstruction further.
Decrease swelling and restore range of motion: The primary goal of early preoperative management for ACL injury is decreasing swelling (joint effusion) and restoring full passive and active knee range of motion. Regaining knee extension and flexion range of motion is an important goal. Significant swelling often develops immediately after an ACL injury and this can inhibit muscle contractions and motion in the knee. Trouble regaining knee range of motion is one of the more common complications of ACL reconstruction surgery and failing to achieve full range of motion in the preoperative phase is a risk factor for this complication (Quelard et al., 2010, van Melick N. et al., 2016).
Since swelling in and around the joint capsule impairs knee range of motion and can inhibit muscle activation, reducing swelling should be one of the first goals of an ACL surgery prep program. Here are a few methods for managing swelling:
Apply ice to the area for 15 minutes, 3-4 times a day
Elevate the leg above the level of the heart throughout the day
Apply compression with a bandage or compression sleeve
Modify weight bearing as needed to limit an inflammatory response
Start a progressive exercise program: While you might feel like maximizing rest before ACL reconstruction, having a higher preoperative Tegner activity level predicts a better outcome at a minimal follow-up of 22 months after surgery (van Melick N. et al, 2016). Note, the Tegner activity scale is a one-item score that grades activity based on work and sports activities on a scale of 0 to 10.
Goals in this second phase of early post-injury rehab for an ACL tear include maximizing muscle strength, specifically quadriceps muscle strength, and neuromuscular control. Notably, a preoperative deficit in quadriceps strength of >20% was found to have significant negative consequences on self-reported outcomes 2 years after ACL reconstruction (van Melick N. et al, 2016). Having at least 80% return of quadriceps strength compared to the opposite side is important heading into ACL reconstruction but undergoing additional therapy to address impairments in neuromuscular control of the knee and all the joints of the leg may improve functional outcomes two years after surgery (Failla et al., 2016).
Once you’ve attained a “quiet knee” without joint effusion, with full range of motion, and the ability to hop on one leg, progressing toward heavy resistance training and even plyometric exercises has been found to be safe with a low incidence of adverse events and can have benefits that extend years beyond ACL reconstruction (Filbay, S. and Grindem, H., 2019). Those who participate in ACL reconstruction prehab may be able to achieve improvements in single leg hop three months after ACL surgery compared to those who did not, a skill that might assist with return to sport (Carter et. al, 2020).
It is important to consult with a physical therapist who can prescribe and progress a program that is specific to you. Trying to do this on your own may lead to failure to achieve and sustain a “quiet knee” but also may lead to underdosing of beneficial exercises. Let's take a look at examples of exercises that might be included in a 5-6 week preoperative protocol. Please note that these exercises are not necessarily ordered as a progression.
Quad sets: performed in sitting with the injured leg extended in front of you, try and lift your heel as you press the back of your knee into a towel. When possible, try to sustain a contraction of the quadriceps muscle for six seconds. This exercise is great to establish motor control and volitional contraction of the quadriceps muscle.
Straight leg raise: lying on your back, with the injured knee straight, raise the leg up off the table without letting the knee bend then slowly lower it back to the table.
Squats: Starting with body weight, use a mirror as feedback to maintain equal weight through both legs. Progressions of this exercise include adding weight and performing as a single-leg squat or single-leg sit-to-stand.
Knee extension: Initially you may perform this exercise seated in a chair and extending the injured knee to raise the lower leg against gravity. As you gain strength you may progress to adding ankle weights or using a resistance machine.
Single leg balance: Stand on one leg while trying to maintain a level pelvis. Aim to increase the time you can hold this position and vary the surface to a softer or more compliant surface for added challenge.
Perturbation training: these dynamic exercises help to improve the stability of the knee. Most likely starting as a double-leg activity and progressing to a single-leg activity, perturbation training involves withstanding challenges to balance and postural control in multiple planes of movement. They may be performed on a variety of unstable surfaces.
Ready the mind: An additional benefit, one not to be overlooked, is the mental preparation a program like this can offer. Knowing what to expect following surgery and having an opportunity to meet your physical therapist ahead of time can instill confidence and lessen worry.
We hate to see you injured but we're glad we can guide you through your recovery. The physical therapists at Evolve are ready to help even on day one after an injury because the road to recovery from an ACL tear begins right away.
Click here to find out more information about prehab physical therapy for ACL reconstruction surgery
Resources:
Carter, H. M., Littlewood, C., Webster, K. E., & Smith, B. E. (2020). The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review. BMC musculoskeletal disorders, 21(1), 647. https://doi.org/10.1186/s12891-020-03676-6
van Melick N, van Cingel REH, Brooijmans F, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. British Journal of Sports Medicine 2016;50:1506-1515.
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