ACL reconstruction post op. rehab.
ACL reconstruction post op. rehab.
One of the most common complications following ACL reconstruction is loss of motion, especially loss of extension. Loss of knee extension has been shown to result in a limp, quadriceps muscle weakness, and anterior knee pain. Studies have demonstrated that the timing of ACL surgery has a significant influence on the development of postoperative knee stiffness.
ACL reconstruction 의 가장 흔한 합병증은 운동의 제한, 특히 무릎 폄의 제한이다. 이는 다리를 절게하고, Qudriceps의 약화와 전방슬관절에 통증을 유발한다. 연구들은 수술의 시기가 무릎의 경직에 상당한 영향을 미친다고 말한다.
The risk of developing a stiff knee after surgery can be significantly reduced if the surgery is delayed until the acute inflammatory phase has passed, the swelling has subsided, a normal or near normal range of motion (especially extension) has been obtained, and a normal gait pattern has been reestablished.
급성염증기가 지나기기 전에 수술을 한 경우 수술 후 무릎 경직의 위험을 크게 줄일 수 있었고 부종도 빨리 가라앉고 동작(특히 폄)도 정상 혹은 정상에 가깝게 만들어졌으며 정상적인 보행 패턴도 다시 설정되었다.
재활의 전체적인 흐름,
Phase의 이유
concentric ==> eccentric
점진적인 부하의 증가
부하와 빈도와 속도의 한계점에 대한 평가.
Phase 1 (0-2 wks.) - Acute managements & Early motion start
use clutches
knee splint(혹은 보조기)
Goal (골은 다음단계로 넘어가기 위한 기준점. 기간이 지난다고 해도 골이 성취되지 않으면 넘어가지 말것. 골이 성취되었다고 해서 기간이 지나기 전에 다음 단계로 진행되어서도 안된다.)
Control Pain and Swelling
Protect Healing Tissue
Begin to Restore Range of Motion (ROM) Especially Full Extension
make Good Quadriceps Activation
Cautions
WBAT(weight bearing as tolerance) with Crutches for Patellar Tendon Graft
PWB(partial weight bearing) with Crutches for Hamstring or Allograft
Bledsoe Brace locked in extension with ambulation and sleeping
Bledsoe Brace unlocked 0-90⁰ when non-weight bearing
Exercises
ROM exercises (w/o pain, 3~5sets in day)
Heel slide w/ assist. (hold 5~10 sec, 15~25 repititions x 3~5 set.)
Lie on your back with brace off and slowly slide your foot toward your hips, as far as possible.
use foot to make greater motion.
important thing is feel nomal feel at front of the knee
Seated knee flexion (hold 5~10 sec. 10~20 repititions x 3~5 set.)
seat on edge of chair or table with brace off and slowly knee flexion as possible w/o pain.
ROM wall slide (hold 5~10 sec. 15~25 repititions x 3~5 set.)
Lie on your back with your involved foot up on the wall, with your brace off. Slowly slide the foot down the wall as far as possible
건측 발이 아래.
Extension on a bolster (Q-setting) (hold 1~5 min, rest for 30~60 sec, 3~5 repititions x 3~5set)
수건같은 물체를 발목(혹은 오금부)에 두고 무릎릉 펴며 누른다.
손으로 눌러 힘을 가할 수 있다.
Knee extension stretch & Quadriceps m, strengthening
Prone hang (hold 1~5 min, rest for 30~60 sec, 3~5 repit x 3~5 set)
hamstring tendon을 사용한 경우 하면 안된다.
prone에서 다리를 밖으로 내어놓고 knee extension방향으로 힘을준다.
patellar mobilization (hold 2 sec, direction for 1 min x 3~5 set)
superior, inferior, medial, lateral 로 mobilization ⇒ hold end of the glide
prevent scar tissue
하면 안될것 : tip or tilt
Ankle Pumps without resistance (20 Repetitions x 2 set)
Strengthening exercises (w/o pain)
Quad Set (20 repetition x 2-3 set)
SLR of 10~20 (repetition x 2-3 set)
Hip Abd/Add/Extension (against gravity)(10~20 Repetition x 2~3 set)
Standing or Prone Hamstring Curls (unless Hamstring Graft) (10~20 repetitions x 2~3 set)
T-Band Ankle Pumps (20~25 repetitions x 2~3 sets)
+스트레칭
--> iliotibial band, calf m.
Phase 2 (2~6 wks) - Basic strengthening & Proprioception
use clutches ~ 4wks (환자에 따라 다르지만)
cast or splint 혹은 보조기 착용.
Goal
protection of healing tissue
improve ROM Normalize
gait mechanics Begin to make return of L/E
strength especially quadriceps
Cautions
Wean crutches with Patellar Tendon graft 슬개골건은 2주부터 목발 안쓴다.
Hamstring and Allograft PWB for 4 wks post op. 슬괵근건과 동종이식은 4주간 사용.
Progress to WBAT at 4 wks post op and wean crutches as appropriate.체중부하주의
OK to begin closed chain exercises, but maintain weight bearing restrictions with gait Bledsoe brace 0-90⁰ with ambulation 과도한 굽힘에 주의
Must stress proper gait 비정상적인 보행패턴에 주의
Exercises
Range of motion exercise (w/o pain)
Phase 1 exercises ⇒ for achieve normal ROM
Stationary bike (minimal resistance) (5~10 min, no resistance)
재건 부위에 부하가 가지 않도록 주의.
Standing knee flextion (hold 20~30 sec, 3 repitition x 3 set)
의자를 뒤에 두고 서서 발이나 발가락을 의자 위로 무릎을 굽혀 올린다.
Slowly squat down ⇒ knee flexion
Prone knee flexion (hold 20~30 sec, 3 repitition x 3 set)
prone에서 contract abdominals to prevent hyperlordosis
발을 엉덩이로 당긴다.
Strengthening exercise
Continue Quad Sets (as needed for VMO activation)
Partial lunge
step back
Crunches
Bridge (both/single)
Continue 4 way SLR program (add ankle weight as needed)
Hamstring Curls (Patellar Tendon and Allograft Only)
Standing Terminal Knee Extension (Theraband-Y)
Mini Squat and/or Wall Slide Leg Press
Heel Raises
Single Leg Stance
CKC exercise 전에 무릎의 안정화를 확인.
Phase 3. (6~12 wks) - Dynamic Neuromotor Strength, Endurance and Coordination
~ 8wks ; splint or 보조기 (patients needs)
hamstring tendon 쓴 경우에도 hamstring exercise 해도 된다.
Goal
Avoid patellofemoral pain
Full ROM and flexibility
closed chain strength and proprioception
Cautions
Continue to stress proper gait
Must avoid patella femoral stress
No pivoting or lateral movements
No running
Exercises
ROM exercise (+ flexibility)
필요하다면, ROM exercises from phase 1
Lower Extremity stretching (Hamstring, Quadriceps, Calf, Glutes, Adductors, ITB, etc)
Belt Stretch (Calf/Hamstring) (Hold 30 seconds 3~5 repetitions)
Cardiopulmonary exercise (20~30 min x 2~3 set)
저항을 늘린 stationary bike
8wks~ : Elliptical.
6~8 wks : swimming
Strengthening (20~30 repitition x 2~3 set
4 way SLR, Hamstring curl w/ weight at ankle.
Gym Equipment (Leg Press, Ham Curl, Multi-Hip)
Squats to 90⁰ (possible with reach)
Begin Single Leg strengthening
Step Up Progressions (Forward Step Ups) ⇒ down은 patella tendon을 신장하므로 x
Static Forward/Backward Lunge
lateral/forward lunge walk
Step off
Proprioception
Single leg stance
Static balance on Bosu, airex, balance boad, etc
Phase 4. ( 12~16 wks) - Athletic Enhancement and Return to Activity
Goal
Continue to avoid patella femoral pain
Progress with single leg strengthening
Achieve normal ROM
strength to begin jogging and plyometric training
Cautions
Straight ahead running only
No pivoting or cutting
No sports
Exercises
ROM & stretch
Daily stretching (30sec, 2~3 repitition)
Cardiopulmonary exercise (20~40 min, 3~5 times a week)
Cycle, elliptical, swimming
running progression
Strengthening (15~20 repitition x 2~3 set, 3 times a week)
4 way SLR programs & Gym equipment progression
lateral / crossover step-up exercise
Dynamic / lateral lunge
Single leg strengthening ( single leg squat/split squat/single leg dead lift)
Proprioception (15~20 repitition x 2~3 set, 3 times a week)
Dynamic balance (Bosu, foam, etc)
Dynamic progression (2 times a week)
Plyometric
Jump
Phase 5. ( 16~24 wks) - Sports Performance and Injury Prevention
Goal
Full ROM, flexibility and strength
progressive/dynamic strengthening, proprioceptive, plyometric and agility training
strength to begin return to sport
Cautions
Limited and controlled lateral movements
Gradual return to sport pending surgeon’s clearance (6 months or greater)
Physical Therapist to develop specific return to sport progression
Exercises
Stretching
Daily L/E stretch
Cardiopulmonary exercise
increase intensity / duration
Strengthening
increase load / decrease volume
Fast feet exercise
Forward lunge walk with rotation
Power step
Core exercises ( Bridge, plank, lateral plank )
proprioception
increase difficulty of drills
Dynamic progression
Plyometric / jumping
jump rotation (Perform a squat jump, while in the air turn 90˚)
multi planar leap and land (한다리점프 양다리 착지)
Hopping (한다리 점프, 한다리 착지)
Power bounce
Speed / agililty program
Stop and go
Plyometric / Jumping progression
Simple Double Limb (12-16 Weeks Post Op) *Limit 60 foot contacts per workout
Double Leg Hops (forward and backward over line)
Box Jump (6-8 inches max)
*Focus on sticking each landing with good form in frontal and sagital planes. Stress a soft landing with good eccentric control.*
Complex Double Limb (16-20 Weeks Post Op) *Limit 90 foot contacts per workout
Double Leg Jump (for distance)
Double Leg Jump (for height)
Double Leg Jump (with 90⁰ or 180⁰ turn)
Double Leg Lateral Jump/Lateral Box Jump (side to side)
Depth Jump (6-8 inches max)
*Focus on sticking each landing with good form in frontal and sagital planes. Stress a soft landing with good eccentric control.*
Combination Jumps (begin at 18-20 weeks post op)
Repetitive Double Leg Jumps (distance, height, lateral, turns)
Jump for Distance into Jump for Height
Box Jump to Depth Jump
Depth Jump to Jump for Distance/Height
*String jumps together. Focus on quickly moving from jump to jump.*
Single Limb (20-24 Weeks Post Op) *Limit 100-120 foot contacts per workout
Heiden Hop Bounding
Single Leg Jumps (distance, height, lateral, 90⁰/180⁰ turn)
Single Leg Box Jumps (6-8 inches max)
Single Leg Depth Jumps (6-8 inches max)
*Focus on sticking each landing with good form in frontal and sagital planes. Stress a soft landing with good eccentric control.*
Combination Jumps (Single Leg)
Repetitive Single Leg Jumps (distance, height, lateral, 90⁰/180⁰ turn)
Jump for Distance into Jump for Height
Box Jump to Depth Jump
Depth Jump to Jump for Distance/Height
*String jumps together. Focus on quickly moving from jump to jump.*
Speed / Agility progression
*Work with P.T. to establish proper warm-up and cool down before and after each workout agility session.*
Forward/Backward Sprinting (16-20 Weeks)
Week 1: Sprint 50-100 yards at ½ speed 10 reps.
Week 2: Sprint 50-100 yards at ½ speed 5 reps. Sprint 50-100 yards at ¾ speed 10 reps
Week 3: Sprint 100 yards at ½ speed 2 reps. Sprint 100 yards at ¾ speed 5 reps. Sprint 50-100 yards at full speed 5 reps. Backpedal 50 yards at ½ speed 5 reps.
Week 4: Sprint 100 yards at ½ speed 1 rep. Sprint 100 yards at ¾ speed 2 reps. Sprint 50 yards at full speed 5 reps and 100 yards at full speed 5 reps. Backpedal 50 yards at ¾ speed 5 reps.
Basic Change of Direction (20-24 Weeks)
*Begin each workout with sprinting and backpedaling 50 yards (2 reps at ½ speed, 5 reps at full speed)
Week 5: T drill 3 reps at ½ speed, forward/backpedal shuttle 5/10/20 yard 3 reps at ½ speed
Week 6: T drill 3 reps full speed, forward/backpedal shuttle 5/10/20 yards 3 reps full speed, box drill with shuffling 3 reps at ½ speed
Week 7: Box drill with shuffling 3 reps at full speed, 10 yard shuttle run (quick direction change) 3 reps at full speed, Z drill 6 reps at ¾ speed
Week 8: Box drill with cuts 3 reps at full speed, 10 yard shuttle run (quick direction change) 3 reps at full speed, Z drill 6 reps at full speed
Advanced Drills (24 Weeks and Beyond)
*Begin each workout with sprinting and backpedaling 50 yards (2 reps at ½ speed, 5 reps at full speed)
Work with P.T. to develop sport specific drills. Perform drills from previous weeks with use of ball, stick, etc. Perform drills seen in typical sports practice with supervision.
