What I wasn’t prepared for was the amount of pain that was involved in getting back flexibility in terms of bending and straightening my knee. It’s not easy—you have to make a commitment to therapy. I look at this as a down payment on being able to do things that I want to do for the rest of my life.
If I don’t do the therapy, if I don’t make the effort to get well, I’m not going to be able to play basketball with my kids, I’m not going to be able to play tennis with them. I don’t want to be limited – I guess that’s the whole issue.
Joan, thirty-six years old, ACL reconstruction
The typical patient for ACL reconstruction is someone who is very active and whose primary goal is to return to an active lifestyle.
If a patient is not committed to rehabilitation, the surgery will not be successful. The training for ACL recovery can take on average 6 months, at least three days a week for forty-five minutes a session. If possible, anyone contemplating an ACL reconstruction should consult with a physiatrist (a physician who specializes in physical medicine and rehabilitation) or a physical therapist prior to surgery so that he fully understands his role in his recovery. Some insurance companies will cover the cost of rehabilitation; however, given the increasing concerns over cost containment in this country, many patients are forced to do their therapy on their own.
The student or desk worker can return to work within a week following surgery. Patients can resume driving between four and six weeks. Use of pain medicine should be minimal after 3 weeks.
Rehabilitation for an ACL reconstruction should only be done at a center that is experienced in rehabilitating patients with ligament problems and should have special machinery geared for these patients. The staff at advanced centers should have expertise in training techniques to ensure a quick and safe return to maximum function. In addition, a center that works with ligament patients will know how far a patient can safely be pushed; more often than not, we have found that many rehab centers don’t expect enough from these patients, which can dramatically slow the patient’s recovery.
Rehabilitation for ligament reconstruction is typically broken down into four phases.
Getting out of bed the first day wasn’t that bad—the noninjured leg moved fine. The other one just sort of sat there like it was dead. I had to pick it up by the brace and put it on the floor.
Very often, ACL rehabilitation is a fight against time. After an ACL reconstruction, the knee can get very stiff, which can quickly lead to immobility. Movement can be painful and difficult. Patients are encouraged to use the CPM machine while in the hospital and also at home.
In the initial period after surgery (from week 1 to 3) the primary goal is to gain full range of motion (at least 0 to 120 degrees flexion) within 3 to 4 weeks and to relearn the normal gait cycles. Every 1 to 2 days, you should strive to increase 10 degrees of motion. Full weight bearing with crutches is encouraged immediately until you feel secure (usually by 3 weeks) at which point the crutches are no longer used. During this time, you are encouraged to do straight leg-raising exercises and active flexion and extension (bending and straightening).
You are encouraged to walk with the aid of crutches. Movement can be painful, and you may want to take an analgesic before physical therapy. This may be fine, but talk to your doctor and physical therapist before doing so. If you take painkillers before therapy, there is a risk that you may harm a structure if you push too hard. Remember, your ultimate goal is pain-free, drug-free living, and that can only be achieved through proper exercise.
Phase 2. The fourth week through about the ninth week is a critical period because the reconstructed ligament begins to weaken, which is part of the healing process. By the fifth or sixth week, you begin resistive exercises—trying to strengthen the stabilizing muscles around the knee. This can be accomplished by a technique called contract relax; for example, you attempt isometrically to contract or tense up a muscle for 5 to 6 seconds and then stretch the same muscle. Functional activities are also begun, such as stair climbing and single leg support. You usually discard the brace as soon as you are comfortable with walking without it. You may then wear a knee sleeve, which is usually a neoprene-type soft brace with a hole for the kneecap.
Phase 3. Depending on your progress, between 12 to 13 weeks and about 4 months, the emphasis shifts from strengthening to functional training. Exercises should be specifically geared to your activities; for example, if you want to return to playing tennis or basketball, you will be given exercises that can help you learn how to cut or pivot.
Phase 4. Between 4 and 5 months postsurgery, the final phase of recovery is geared to returning you to normal activity. Strength training continues; we periodically check the ligament for strength and endurance using special machines and functional tests. For example, KT 2000 testing is a pain-free test that measures forward and backward movement of the tibia relative to the femur.