Role of Physiotherapy in ACL Rehabilitation: A case report
C.Sugendhiran1, A.Ramkumar2, S.Kamalanayagi3
1Senior Physiotherapist, Kauvery Hospital, Hosur
2Physiotherapist, Kauvery Hospital, Hosur
3Physiotherapist, Kauvery Hospital, Hosur
Background
ACL (Anterior Cruciate Ligament) tears typically occurs during pivoting movements. ACL can be injured or torn in a number of different ways, with an estimated incidence of 250,000 yearly injuries. Approximately 70% of acute ACL injury are sports-related injuries and affect women more than men. Most of the patients are received in OPD, investigated and managed as per protocols.
Anatomy of Knee Joint
The knee joint is one of the largest and most complex joints in the body. It is constructed by 4 bones and an extensive network of ligaments and muscles. It is a bi-condylar type of synovial joint, which mainly allows for flexion and extension (and a small degree of medial and lateral rotation).
The anterior cruciate ligament (ACL) is a band of dense connective tissue which courses from the femur to the tibia. It consists of type I (90%) and type III collagen. The length of ACL ranges from 27 to 38 mm and the width from 10 to 12 mm. The cross-section area measures approximately 44 mm sq1. It represents an hourglass or bowtie shape. The ACL is a key structure in the knee joint, as it resists anterior tibial translation and internal rotational loads as well as valgus angulation.
The anterior cruciate ligament runs diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur and provides rotational stability to the knee.
Case Presentation
A 29 years old male patient came to the hospital with the complaint of pain (+) and instability of left knee since 1month. Patient had the history of jump and fall, while playing cricket.
Occupation: IT staff (work from home)
Provisional Diagnosis
- Complete ACL tear with ganglion cyst at tibial stump left knee
- Grade 3 chondral defect medial ridge of patella left knee
Investigation
MRI
- Cartilage thinning and irregularity seen in medial fact of patella, suggestive of chondromalacia patella.
- Mild ACL edema with signs of mucoid degeneration.
- Marrow edema seen in lateral femoral and tibial condyle
- Small ganglion cyst seen posterior to ACL
- Mild ACL edema with effusion.
- Minimal MCL Strain
- Minimal subcutaneous /muscular plane edema noted surrounding the knee.
Surgical History
Name of surgery: Arthroscopic left knee/ACLR reconstruction (Ipsi ST3G2)/Ganglion cyst decompression/soft tissue notch plasty/Radio frequency ablation of under surface of patella done under spinal anesthesia on 28.12.2023.
- Site: (Lt) knee joint
- Date: 12.2023
- Anesthesia: Spinal Anesthesia
On observation
- Body build: Mesomorphic
- Posture: Supine lying
On palpation
- Tenderness: Present
- Spasm: present
- Swelling: present (Lt) knee joint
- Warmth: present
Pain Assessment
- Site: over left knee
- Type: aching pain
- Aggravating factor: during movement {knee flexion above 10-20- degree}
- Relieving factor: Resting position [extension of knee with brace] supine lying, analgesic
VAS pain scale
Range of motion (ROM) on 28/12/23
| Knee Joint | |||
|---|---|---|---|
| Active | Passive | ||
| Flexion | Right | 0-120 | 0-130 |
| LEFT | 5-30 | 0-40 | |
| Extension | Right | 125-0 | 130-0 |
| LEFT | 30-5 | 40-5 | |
Range of motion (ROM) on 22/06/24
| Knee Joint | |||
|---|---|---|---|
| Active | Passive | ||
| Flexion | Right | 0-130 | 0-130 |
| LEFT | 0-120 | 0-130 | |
| Extension | Right | 130-0 | 130-0 |
| LEFT | 120-0 | 130-0 | |
Discussion
A 29-year-old male patient, who works from home, regularly plays cricket on weekends in his hometown. During a game, he attempted to catch a ball and landed on his left leg, resulting in an injury to his left knee. Following the injury, he experienced difficulty standing and walking, along with pain and swelling in the left knee, as well as joint instability. He sought treatment at a nearby hospital where an X-ray was performed; it showed no abnormalities. He was prescribed painkillers and advised to rest for two weeks. However, after this period, he continued to experience pain and instability.
On December 26, 2023, the patient visited our hospital’s orthopedic department. The doctor recommended an MRI scan, which revealed an ACL tear. Consequently, the patient was advised to undergo ACL reconstruction surgery (ACLR). He was admitted for the procedure on December 28, 2023, and the surgery was successfully performed that same day. The following day, he was referred to physical therapy for ACL rehabilitation. We initiated Phase I exercises in his room.
The patient was discharged on December 30, 2023, with instructions for Phase I exercises and home care advice. He returned for his first review on January 23, 2024. During this visit, we assessed his right knee range of motion (ROM) at 0-60 degrees and noted quadriceps muscle wasting along with fixed flexion deformity (FFD) in the left knee. He was advised to continue Phase I exercises and incorporate FFD correction exercises. We monitored the patient every ten days; if he could not attend in person, we provided guidance online.
At the second review on February 25, 2024, there was improvement in his ROM to 0-100 degrees and correction of FFD. He was taught Phase II exercises and began walking without walker support. By the third review, he demonstrated further improvements in ROM and muscle power and resumed daily activities independently.
During the fourth review, he learned Phase IV exercises. After six months’ post-surgery, he gradually returned to playing cricket.
Eight months later, during a follow-up visit to our outpatient department (OPD), we assessed the patient’s knee range of motion as good, with coordination and stability also improved. We advised him to continue strengthening exercises. The patient expressed satisfaction with his full recovery and confirmed that he has been consistently following both doctor’s and physiotherapist’s advice.
Short Term Goals
- Patient education
- To relive pain
- To improve ROM of left knee
- To improve patella mobility
- To reduce swelling
- To improve strength of quadriceps muscle
Long Term Goals
- To get patient back to work
- To maintain ROM of left knee
- To increase strength & endurance of the lower limb muscle
- To improve co-ordination, balance & neuro-muscular control
- Gait training
- To improve cardiopulmonary condition
- To progress to functional training & improve ability to return to work
Physiotherapy management for the patient during our OPD ACL protocol of rehabilitation
Phase -1 [0-3 Weeks]
- Ice packs (cold compression)
- Ankle exercise (Plantar and Dorsiflexion)
- Patellar mobilization
- Knee rom exercise [extension =0 degree,
- Flexion 0- 30-40 degree]
- Seated knee flexion and extension with assisted
- Heel slides with towel
- Unilateral pelvic bridging
- Static quadriceps strengthening exercise
- Abduction and adduction exercise
- SLR with long knee brace
- Partial weight bearing walking {PWB} with walker support
Phase-2 [3-6 WEEKS]
- With walker support walking
- Continued same as phase 1
- Improve knee rom exercise (flexion=above 9 degree)
- Dynamic quadriceps exercise
- Standing Hamstring curls
- Bilateral pelvic bridging
- Squatting [half squat]
- Thera band exercise at lying [flex, ext, abd, add]
PHASE -3 [6-12 WEEKS]
Goal: Regain normal muscle strength
- Cardio Fitness – Jogging
- Continued as previous phase
- Open kinematic chain exercise -leg press exercise
- Hamstring curl exercise using weight cuff
- Lateral lunges
- Lateral step up and step down (using weight cuff)
- Single leg squat
- Sitting knee extension with theraband
PHASE -4 [3-5 month]
- Agility program
- Forward, backward running
- Figure of 8 run
- Jump on double box
- Lateral jump
Running program: warm up walk for 15 min, cool down, again walk for 10 min.
