ACL Rehabilitation: Physiotherapy Case Report

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
Flexion	LEFT	5-30	0-40
Extension	Right	125-0	130-0
Extension	LEFT	30-5	40-5

Range of motion (ROM) on 22/06/24

Knee Joint
		Active	Passive
Flexion	Right	0-130	0-130
Flexion	LEFT	0-120	0-130
Extension	Right	130-0	130-0
Extension	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.

Role of Physiotherapy in ACL Rehabilitation: A case report

Role of Physiotherapy in ACL Rehabilitation: A case report

C.Sugendhiran1, A.Ramkumar2, S.Kamalanayagi3

Nightingale Journals

C.Sugendhiran¹, A.Ramkumar², S.Kamalanayagi³