Welcome to Part 2 of the ACL Rehabilitation Case Series!
In today’s post we are going to cover Emmett’s journey from week 1 post-operatively to his 2 week post-op follow up with the surgeon. In part 1 we recounted the month of extensive “pre-hab” Emmett did with Zenith to prepare him for his ACL reconstruction surgery. Read about how that went here.
Starting with a new ACL client there are several important questions that rehab providers should be asking their clients to help direct the plan for rehab back to their desired goals! Here is my list that I always ask even BEFORE the surgery happens:
1.What are your goals for your athletic career? What sport(s) are you trying to return to playing?
*asking these questions allows the provider to include sport specific drills during the rehab. Soccer players should be kicking soccer balls, Ultimate players should be throwing frisbees, etc.
2. How did you tear the ACL? Was it a non-contact tear or was there contact when it happened?
*if there is no contact with a tear I know I will always make sure to include a ton of change of direction (COD) drills and make sure the client feels really safe with these before returning to sport
3. What graft did they use to repair the ACL?
*this question is really important because different grafts can have different complications/limitations and knowing these up front will help the provider recognize potential barriers that can be addressed quicker
In Emmett’s case his goals were to return to high level Ultimate Frisbee so he can play at a college level as well as any other sport he plans to pursue! He tore his ACL attempting to change direction when a frisbee was thrown behind him at a summer practice, so we would classify this as a “non-contact ACL tear.” Emmett and his surgeon decided to go with a patellar tendon graft (the best option in my opinion!). I have used this information to help plan out Emmett’s rehab down the road!
I also have an “ACL Checklist” that I personally use to make sure we are on target with our rehabilitation goals! Obviously everyone is different, and different clients can have different complications during their rehab journey, but this checklist allows me to make sure I am prioritizing the correct things at each “phase” of rehab.
As you can see from the above image, the Return to Sport phase of the rehab process for me will be at a minimum 9 months - there is extensive research to support waiting until at least 9 months after an ACL reconstruction to return to sport with no restrictions. “For every month that return to sport was delayed, until 9 months after ACL reconstruction, the rate of knee re-injury was reduced by 51%.”
I make sure that ALL of my ACL reconstruction clients are fully aware of this information as we begin the rehab process so there are no surprises as we reach the later stages of rehabilitation. At the end of the day it is my responsibility to make sure my clients are safe, and regardless of how well the recovery process is going I will always delay returning to play until 9 months or later.
I saw Emmett for his first appointment 5 days after surgery. I know this seems pretty soon but there is a lot in rehab we can start to work on even as early as 5 days Post Op!
a
On a first session post operatively I am going to be checking for 4 key things:
Red Flags - how does the wound look? Are there any signs of infection or anything just not quite right with the knee? How is the pain management? Is the client having a normal post operative recovery or is there anything sort of “off” happening?
Knee Swelling - have I educated the client on all of the correct post operative pain and swelling management tools?
Knee Range of Motion - how can we start working on getting the knee fully straightening (most important) and fully bending within the first 2 weeks?
Quad Muscle Activation - How well does the client’s quad muscle want to contract? How full is the contraction? How long can they hold the contraction for?
The surgery itself went very smoothly with no complications, and he had been working diligently on his knee range of motion, swelling management and quad contraction even before our first appointment! We checked the wound for infection, did some soft tissue work to reduce swelling, and began to work on passive stretching of the knee into flexion and extension.
In order to help speed up the quad contraction we also began to use a Neuromuscular Electrical Stimulation (NMES) Device on his quad muscle during exercise. NMES devices work to send electrical impulses to nerves which help the muscle contract.
After surgery it is common for this “WiFi” connection from the brain to the muscles to be disrupted - devices like NMES can help restore the connection and get the muscles back on line. It is imperative to restore this connection as soon as we can after surgery! I like to use at home devices the clients can take home with them - in Emmett’s case we used a PowerDot NMES system.
Here was the “Homework” Plan Emmett left with on day 1:
Daily:
- towel under heel 3-5 min (2-3x/day)
- quad sets throughout the day (at least 100 per day!)
- quad sets with NMES (5-10 min, can do 2x/day if not sore or swollen)
- straight leg raise without brace 3-5 reps, focus on good quality
- heel slides (stop at stretch, don’t force it)
- hamstrings and ribs breathing
- continue to do swelling and pain management; elevate and compress the knee, take your pain meds on a regular basis
We also checked Emmett’s knee brace setting as well as the size of his crutches during gait to make sure they were fitted appropriately for him. As Emmett’s surgery did not require a meniscus repair, (yay!) he was able to begin
“Weight Bearing As Tolerated” (WBAT) pretty soon after the surgery so the crutches were only really used for a couple of weeks.
Emmett was diligent with these homework drills (and a few other progressions including adding more hamstring activation and weight shifting drills) over the next couple of weeks. He had his first post op appointment with his surgeon 2 weeks after the surgery and he was cleared to start walking with the brace unlocked and to begin Blood Flow Restriction Therapy (BFRT)!
By the 2 week mark Emmett had full knee range of motion in knee extension, was very close to full flexion, had no swelling and was practicing walking without crutches, as well as getting better quad activation. You can see from the list below that he was well on his way to having a great first month of rehab!
Join us next time as we begin post-op BFR, strength training and bring Emmett’s awareness back to his left leg using PRI concepts!