Disorders of the Inert Structures: Ligamentous Instability

Disorders of the inert structures: ligamentous instability

CHAPTER CONTENTS Degree of instability Ligamentous instability e270 The degree of instability is demonstrated during stress tests Types of instability ...... e270 and can be graded on the following scale (Fig. 1): Functional examination ...... e271 • mild/1+ = 5 mm or less separation of joint surfaces Treatment ...... e276 • moderate/2+ = between 5 and 10 mm separation • severe/3+ = greater than 10 mm separation. This scale is not very precise but is effective for clinical and Ligamentous instability therapeutic purposes. It should be remembered, however, that under anaesthesia the results of the stress tests are often exag- If the knee becomes unstable after a ligamentous injury, per- gerated so that patients with 2+ instability often show 3+ manent problems may result, especially if the patient is an instability in the test. athlete with high functional demand. If the history indicates that there is possibly instability, an examination to detect the exact location and degree of this is Classification of instability performed. It is important to make this supplementary exami- Instability may be classified as straight or rotatory. nation only when symptoms and signs found in the routine clinical assessment indicate ligamentous instability to be the cause of disability. Indeed, it is important to realize that not Straight instability every lengthened ligament leads to problems.1 If the athlete’s This is defined as an increased range of angular movement in muscles are strong enough to provide dynamic stability, a the frontal plane, i.e. valgus/abduction or varus/adduction slightly unstable knee will not cause trouble. Conversely, it is movement (Fig. 2), or an increased range of gliding movement quite possible that an athlete with slight laxity of one or more in the sagittal plane, i.e. the simultaneous forward or backward ligaments has a chronic painful lesion as well. If the diagnosis gliding movement of the tibial condyles in relation to the of the latter is missed because the routine functional examina- femoral condyles (Fig. 3). tion is not performed, it may well be that the patient is sent for surgery, which will solve the slight instability but does not Rotatory instability cure the main problem. This implies increased rotation movement of the tibia on the femur. The posterior cruciate ligament, located in the centre Types of instability of the joint, is the fundamental stabilizer and is the axis of the joint, both in flexion–extension and in rotation. Consequently, Knee instability is the result of loss of static and dynamic this ligament is always intact in rotatory instabilities; from the function. Stability depends on the tautness of the ligaments, moment the ligament is completely torn, there is no longer a congruency of joint surfaces, effectiveness of the menisci and centre of rotation and any kind of straight instability can 3,4 the well-balanced action of all musculotendinous units acting result. across the knee joint. Of these structures, muscles and tendons There are three types of rotatory instability: play a central role in joint stabilization. They are said to be the • Anteromedial rotatory instability: there is an abnormal ‘first defenders’ in distortion and loading situations.2 forward gliding movement of the medial tibial plateau

Fig 1 • Degrees of straight instability in the frontal plane: A, mild; B, severe; C, moderate.

3+ 2+ 1+

(a) (b) (c)

with respect to the medial femoral condyle, while the lateral tibial plateau retains a relatively normal relationship with the lateral femoral condyle (Fig. 4b). • Anterolateral rotatory instability: there is an abnormal forward gliding movement of the lateral tibial plateau with respect to the lateral femoral condyle, while the medial tibial plateau retains a relatively normal relationship with the medial femoral condyle (Fig. 4c). • Posterolateral rotatory instability: there is an abnormal backward gliding movement of the lateral tibial plateau with respect to the lateral femoral condyle. Again, as in anterolateral rotatory instability, the medial tibial plateau remains in normal contact with the corresponding femoral condyle (Fig. 4d). Various combinations of these rotatory instabilities can occur. The most commonly encountered are combined anterolateral and anteromedial, and combined anterolateral and 3+ 2+ 1+ posterolateral. Fig 2 • Degrees of straight instability in the sagittal plane. Posteromedial rotatory instability does not exist because an intact posterior cruciate ligament prevents any backward gliding movement of the medial tibial condyle in relation to the medial femoral condyle.

Functional examination

If the history or routine clinical examination indicates the possibility of instability, a supplementary examination is performed to detect the exact localization and degree of ligamentous insufficiency.

Acute stage In the acute stage, only the first few hours after the accident are suitable for clinical detection of ligamentous laxity. After this, effusion and muscle spasm resulting from the capsulitis will prevent a detailed examination. This is particularly the case in lesions of the medial collateral ligament because of Fig 3 • Straight instability: increased range of gliding movement in its close relationship with the capsule. So assessment should the sagittal plane. be made as soon as possible, preferably at the scene of the

(a) (b) )c( )d(

Fig 4 • Rotatory instability: (a) starting position; (b) anteromedial; (c) anterolateral; (d) posterolateral.

accident. If intra-articular bleeding is present, which especially accompanies tears of the anterior and posterior cruciate ligaments as well as of the medial collateral ligament, the first few minutes are often the only time available tomake a proper clinical assessment of ligamentous laxity. When time has elapsed, examination under general anaesthesia, eventually followed by arthroscopy, is the only course of action. However, if the lesion seems to be less serious, supplementary examination can wait until a proper clinical evaluation can be made.

Chronic stage In the chronic stage thorough clinical examination suffices to estimate, in almost all instances, the degree of functional instability and to determine the type of treatment required.

Tests Passive abduction or valgus stress test in 30° of flexion The patient is placed supine on the couch, the head resting on a pillow to enable observation of the examiner without active raising of the head (which often causes tightening of the hamstrings). The thigh rests on the couch and the lower leg hangs over the side, with the knee in 30° of flexion. One hand is placed about the lateral aspect of the knee, the other grasps Fig 5 • Passive abduction or valgus stress test in 30° of flexion. the lower leg at the ankle (Fig. 5). Then abduction stress is applied gently and repeatedly, gradually increasing up to the point of pain. The degree of movement and the end-feel are Passive adduction or varus stress test in estimated. 30° of flexion The normal limb is assessed first, especially in acutely This test is performed in the same position as the previous one, injured patients, because this shows the patient that the but the hands are changed; so one hand is placed about the examination will not be rough and is unlikely to be painful. medial aspect of the knee while the other grasps the lower leg The examiner also gets a measure of the stability of the at the outer side of the ankle (Fig. 6). The degree of movement unaffected knee. and end-feel are estimated. Instability indicates a tear limited to one or more of the Adduction stress is applied to test the stability of the medial compartment ligaments, i.e. the medial collateral liga- lateral compartment ligaments: the lateral collateral ligament, ment, meniscotibial or meniscofemoral capsular ligaments and meniscotibial or meniscofemoral capsular ligaments and the the posterior oblique ligament. arcuate ligament. If the abduction stress test in full extension also shows Instability of the lateral compartment is less common but instability, the posterior cruciate ligament is probably also rup- causes significantly more disability than a comparable amount tured. It should be borne in mind that, in the fully extended of instability medially. position, an intact posterior cruciate ligament still holds the Lateral instability cannot be detected when the test is per- joint surfaces in firm apposition, even in complete tears of the formed with the knee in full extension because the intact tight medial compartment ligaments. posterior cruciate ligament precludes any movement in this

Anterior drawer test in external and internal rotation The patient is positioned as for the abduction–adduction stress tests. The hip is flexed to 45°, the knee to 80–90°. The foot is placed on the couch, well fixed by a portion of the examiner’s buttock resting on the dorsum of the forefoot. The examiner places both hands around the upper part of the tibia with the index fingers palpating the hamstring tendons to make sure they are relaxed. Both thumbs are placed at the anterior border of the joint so that they can estimate the range of movement. Then the proximal part of the lower leg is pulled forward repeatedly, first gently then with a somewhat stronger pull. The test is first performed with the lower leg and foot externally rotated beyond the neutral position and as far as is comfortably possible, then internally rotated (Fig. 8). The findings are compared with those of the basic examination, for example in 0° rotation, as well as with the other knee. With the tibia in external rotation Fig 6 • Passive adduction or varus stress test in 30° of flexion. Anteromedial rotatory instability is indicative of a tear of one or more of the medial compartment ligaments: the medial collateral ligament, meniscotibial or meniscofemoral capsular ligaments and the posterior oblique ligament. An associated anterior cruciate ligament tear increases the amount of subluxation of the medial tibial condyle. This ligament is the second line of defence; in an acute isolated tear of the anterior cruciate the anterior drawer test will be negative. With the tibia internally rotated In patients with a medial compartment laxity, the test becomes negative because of the increased tension of the posterior cruciate ligament. Simultaneous forward subluxation of the tibial condyles indicates that the posterior cruciate ligament is torn. In this case, the rotational element is eliminated and straight- forward instability exists. Isolated forward subluxation of the lateral tibial plateau, for example anterolateral rotatory instability, can only be demonstrated if the knee is held in the neutral position, because internal rotation of the tibia will tighten an intact posterior cruciate ligament and prevent any subluxation. This type of Fig 7 • Lachman test. instability is indicative of a tear of the middle third of the lateral capsular ligaments.

7 position. If an adduction stress test in full extension shows Prone rotation test lateral instability, rupture of both the lateral compartment liga- Sometimes doubt remains as to whether the range of rotation ments and the posterior cruciate ligament should be feared. has been increased. A decisive assessment can be made with the patient prone and the knees flexed to a right angle (Fig. Lachman test 9). The movement of external or internal rotation is performed The test is performed with the patient supine and the knee in bilaterally and the range of movement is assessed by the 20–30° of flexion. The distal femur is grasped from the lateral twisted position of the feet. side to obtain control just above the lateral femoral condyle. An increased range of lateral rotation results from a lack of The examiner uses the opposite hand to displace the proximal stability of inert structures at the medial compartment (medial tibia directly anteriorly (Fig. 7). collateral ligament, meniscotibial and meniscofemoral capsular In acute rupture of the anterior cruciate ligament this test ligaments and the posterior oblique ligament) and/or the is preferred to the anterior drawer test in the 90° flexed posi- arcuate complex (arcuate ligament, lateral collateral ligament). tion because muscle defence by the hamstrings may prevent An associated tear of the anterior cruciate ligament still the forward movement of the tibia and give rise to a false- increases the amount of rotation. negative result.5 Liljedahl et al6 found only 3 of 35 patients to An increased range of medial rotation is indicative of laxity have a positive anterior drawer test in 90° of flexion, whereas of the middle third of the lateral capsular ligaments, the ante- with anaesthesia 31 and on arthrography 29 were positive. rior and the posterior cruciate ligaments.

(a) (b)

Fig 8 • Anterior drawer test in external (a) and internal rotation (b).

Posterior drawer test A positive result is indicated if, on attaining about 30° of The patient is in supine position with the hip flexed to 45° and flexion, relocation occurs with a sudden movement, which is the knee to 90°. The foot is flat on the couch, in neutral posi- called a ‘jerk’. The forwards shift can be seen and felt by the tion. The heels of both hands are placed anteriorly against the examiner. At the same moment, the patient will recognize the proximal part of the tibia (Fig. 10). Both thumbs at the anterior feeling of instability. border of the joint can estimate the range of movement. The The test demonstrates an anterolateral rotatory instability proximal part of the tibia is then pushed backwards repeatedly, because of a tear in the middle third of the lateral capsular first gently then with a strong jerk. ligaments. Frequently, the anterior cruciate ligament and/or The posterior drawer test, which includes palpation of menisci are also ruptured and increase the instability.9 the tibia–femur step-off, was recently demonstrated to be the Anterolateral instability can also be demonstrated by carry- most sensitive and specific clinical test for posterior cruciate ing out the manœuvre in the reverse direction, starting from a ligament deficiency (accuracy 96% with a 90% sensitivity and position of a few degrees of flexion: the pivot-shift test. a 99% specificity).8 Bach et al10 found that the degree of pivot shift, probably because of the role of the iliotibial band, strongly correlates ‘Jerk’ test and pivot-shift test with the position of the hip and knee joint. They advised 30° The patient lies supine, the hip flexed to about 45°, the knee of hip abduction and 20° of tibial external rotation as the posi- to 90°. The examiner supports the patient’s leg, with one hand tion in which instability is most clearly demonstrated. at the foot, the other at the proximal end of tibia and fibula. The examiner stands at the foot of the couch in order to The hand at the foot rotates the tibia slightly internally while monitor hip position carefully. The ipsilateral hand cradles and the other hand exerts a mild valgus stress at the knee (Fig. 11). holds the foot in external rotation. The other hand, slightly Extreme internal rotation may dampen a shift significantly. supinated, holds the proximal and lateral leg. An axial load and Maintaining slight internal rotation and mild valgus stress, the valgus movement are applied simultaneously as the knee is examiner gradually extends the knee. slowly flexed passively from the extended position.

Fig 11 • The ‘jerk’ test.

Practitioner’s checklist

• An associated acute partial tear of the medial compartment ligamentous structures makes the test too painful to undertake • A false-positive test may occur in the presence of a torn meniscus Fig 9 • Prone rotation test. • In children, and in patients who have mild to moderate congenital genu recurvatum without symptoms, it is normal to find the ‘jerk’ and pivot-shift tests, and the anterior drawer test with the tibia in 0° rotation to be mildly positive on both sides

External rotation–recurvatum test The patient lies supine on the couch. Both legs are lifted simultaneously by grasping the big toes (Fig. 12). The amount of external rotation of the proximal end of the tibia and the degree of recurvatum are observed. In a positive test, unilateral excess of external rotation and recurvatum is obvious, which is seen as increased tibia vara. The test demonstrates posterolateral rotatory instability, which is located in the structures of the arcuate complex: the arcuate ligament, lateral collateral ligament and possibly the popliteus tendon. It is also advisable to observe the patient standing and actively extending the knees maximally or to observe a barefoot walk. Sometimes external rotation–hyperextension is absent, while these patients often walk with a slightly bent knee to avoid terminal extension. Fig 10 • Posterior drawer test. Clinical tests for knee instability are summarized in Table 1.

Table 1 Summary of clinical tests for instability

Type of instability Structures probably ruptured Diagnostic test Straight valgus Capsuloligamentous structures of medial and posteromedial Abduction stress test in full extension compartment, and posterior cruciate ligament Straight varus Lateral compartment ligaments and posterior cruciate Adduction stress test in full extension ligament Straight anterior Middle third of medial and lateral compartment ligaments, Anterior drawer test and anterior cruciate ligament Lachman test Straight posterior Posterior cruciate ligament and arcuate complex Posterior drawer test Rotatory anteromedial Medial and posteromedial compartment ligaments, and Anterior drawer test from mid-position and in internal rotation anterior cruciate ligament Abduction in 30° flexion Lachman test Rotatory anterolateral Middle third of lateral compartment ligaments, and anterior Anterior drawer test from mid-position cruciate ligament Adduction in 30° flexion ‘Jerk’ test Pivot-shift test Rotatory posterolateral Arcuate complex External rotation–recurvatum test Posterior drawer test from mid-position and in external rotation Adduction in 30° flexion

The results of conservative treatment of isolated grade III sprains of the lateral ligament compartment are generally poor and not acceptable.13 Surgery Surgical treatment of knee ligament injuries, particularly of the anterior cruciate ligament, is still controversial because the complex functional role of these ligaments makes them difficult to reconstruct effectively.14 Given that reconstruction is performed using high-strength bone–ligament–bone autogenous graft, placed isometrically and securely fixed internally, failure rates after 2 years’ follow-up have decreased to about 30%.15

Conservative treatment in acute instability Medial collateral ligament Fig 12 • External rotation–recurvatum test. Isolated acute grade III lesions of the medial collateral ligament seldom result in lasting instability. Successful conservative treatment of these lesions has been reported, with only a Treatment very small number of patients requiring subsequent reconstruction.16–20 However, this applies only to isolated inju- The best chance of success in treating a knee affected by liga- ries in which, for example, valgus stability in full extension is mentous instability is within days of the original injury.11 Man- normal. The key to success in non-surgical management of agement can be non-surgical or by surgical repair. Which is complete tears of the medial collateral ligament is to exclude chosen depends on the structure(s) at fault, the degree of those with concurrent damage to the anterior cruciate ligament rupture and the extent of the lesion. or menisci.18,20,21,22 Therapy must also include a structural rehabilitation pro- Conservative treatment gramme with early protected motion, followed by progressive In general, conservative treatment is indicated in all grade I strengthening. A small residual amount of medial laxity does and II sprains and in isolated grade III sprains of the medial not appear to have any influence on the ability to return to collateral ligament. Acute complete tears of the anterior cruci- competitive athletics.22 ate ligament, with an absent (0) or mild graded (1+) pivot-shift When surgical and non-surgical treatment is compared test, show excellent or good results in half of the cases.12 in isolated acute grade III lesions of the medial collateral

© Copyright 2013 Elsevier, Ltd. All rights reserved. e276 Disorders of the inert structures: ligamentous instability ligament, similar results are obtained. However, non-surgically patients developed a symptomatic knee but the majority did treated patients are rehabilitated in significantly less time.18 In not have a sufficiently significant functional disability to warrant combined injuries, it has been shown that the non-surgical reconstructive surgery. Furthermore, they found that knee management is successful only in 15%. function following a partial tear did not appear to deteriorate Rehabilitation in non-operated, acute complete tears22 with time (49 months after injury). In the first 2 weeks the knee is partially immobilized ina Rehabilitation programme in conservatively treated rehabilitative brace that prevents the joint from moving beyond grade II ruptures14 the painful range and protects against hyperextension, exces- In the first 2 weeks the knee is immobilized in 30° of flexion. sive lateral rotation and valgus strain. In order to maintain Isometric hamstrings and quadriceps exercises are instituted mobility while healing, Cyriax advocates moving the ligament within the first 3 days. Hamstring muscle function is essential, by deep transverse friction to and fro over the adjacent bone because the hamstrings act as dynamic agonists to the anterior in imitation of its normal behaviour.23 The first day, 1 minute’s cruciate ligament in preventing forward gliding of the tibial friction thus suffices, in that no unwanted adhesions have yet plateau during walking, running and twisting. formed. Friction is followed by passive flexion and extension After 2 weeks, limited motion in flexion between 30° and movements, within the limits of pain. This treatment is 60° degrees is allowed and can be increased to 30–70° after repeated daily. Within a week, tenderness is declining and fric- 4 weeks. Flexing the hip should be avoided until week 3 or 4, tion is performed for an increasing time, for up to 15 minutes, because quadriceps activity during this movement may stretch on alternate days during the second week (see p. 701). the injured ligament. From the moment the patient can undertake straight leg Partial weight bearing, using crutches, is permitted approxi- raising, weight bearing with crutches is started, provided the mately 2–4 weeks after the injury. Full weight bearing is patient can tolerate it. At this time, isometric exercises are allowed after 4–6 weeks. commenced (three times daily, 15 contractions) in order to Approximately 6–10 weeks after the injury the patient may avoid muscle wasting. start resisted exercises, such as swimming and stationary This period is followed by 4 weeks of controlled mobiliza- biking, while wearing a functional brace. Terminal extensions tion in a rehabilitative knee brace that allows a range of motion and bodyweight load should still be avoided. to be set within the limits of pain; hyperextension should still Jogging is allowed about 3–6 months after the injury. be prevented. This provides the opportunity to perform sta- Muscle exercises must be continued until there are no dif- tionary biking and to start isotonic exercises for the quadriceps ferences between the legs in hamstring and quadriceps strength. and hamstrings muscles. Thereafter, isokinetic exercises are Athletes are not allowed to return to competitive sports earlier added. than 6–12 months after the injury. After 6 weeks the orthosis is replaced by a functional knee Any swelling during the entire course of rehabilitation indi- brace. Isotonic and isokinetic muscle training are continued. cates that some overload has taken place and the programme Running exercises can be started from the moment the quad- should be modified accordingly. riceps has reached at least 60% of the strength of the unaf- Posterior cruciate ligament fected muscle. At this stage, hamstrings strength is equal to that of the opposite leg. Recent studies have shown that conservative management is If quadriceps strength has returned to 80% of normal, agility also acceptable in isolated complete ruptures of the posterior drills can be undertaken. At this stage training is, if necessary, cruciate ligament. Good results are obtainable even in athletes 28–32 intensified to reach the level required for competitive sports. who wish to return to competitive sport. 31 Strength, power and endurance should be compared with the In contrast, as found by Fowler and Messieh, surgical tech- unaffected leg. Contact drills are allowed, although still with niques of posterior cruciate ligament repair and reconstruc- a functional brace on the knee to protect it as much as possible tions are generally difficult and the long-term results are against valgus stress. unpredictable. The average time from injury to return to full activity and Rehabilitation programme competitive sports is about 9 weeks. This resembles the programme for the anterior cruciate liga- Anterior cruciate ligament ment. However, in posterior cruciate ligament instability, it seems to be essential that quadriceps atrophy is avoided. In acute complete rupture of the anterior cruciate ligament, surgical repair is the treatment of choice,24–26 although second- Lateral ligament compartment ary repair operations can still be undertaken. The long-term results of non-surgically treated grade II sprains Non-surgically treated complete ruptures of the anterior of the lateral ligament compartment of the knee are reported cruciate ligament commonly lead to recurring effusion into the as good and acceptable; however, in grade III sprains the results joint after slight trauma and, because of the integrated nature are mostly poor and unacceptable, resulting in an unstable knee of the whole stabilizing complex, intact restraining structures with severe symptoms and post-traumatic osteoarthritis.13 On may gradually be stretched as well so that a number of struc- examination in 30° of flexion, these grade III sprains showed tures are eventually involved and chronic instability results. a severe (3+) adduction instability. In full extension there is After some years an advanced arthrosis is often the rule. still some adduction instability, graded as mild (1+) or moder- Buckley et al,27 in their study of conservatively treated ate (2+). Kannus13 emphasizes that in grade III sprains the partial anterior cruciate ligament tears, found that most anterior cruciate ligament is often injured as well, and the

© Copyright 2013 Elsevier, Ltd. All rights reserved. e277 The Knee damage to it may be missed by clinical methods at the initial after complete rupture of the anterior cruciate ligament, the examination. Such ligamentous laxity seems too severe to use of a high-strength bone–ligament–bone autogenous graft, be fully compensated for by muscle strength, i.e. dynamic placed isometrically and securely internally fixed, made it pos- stability. sible to commence joint motion, muscle re-education and, with the protection of a knee orthosis, even weight bearing up to 38–42 Conservative treatment in chronic instability 50% from the first week. A study of the results of accelerated programmes of reha- In chronic instability the action of the mechanical receptors in bilitation after anterior cruciate ligament reconstruction indi- the lengthened ligaments is normally decreased. This loss of cated not only the need for individualized, evaluation-based reflex activity influences the ‘protective reflex arc’ formed by rehabilitation, but also that caution should be used when intro- the ligaments and their companion muscles and leads to lack ducing high loads or repetitive exercises within the first few of active stability. months after surgery.43 In chronic grade III instability it is impossible to improve For this reason postoperative clinical evaluation of graft upon the loss of proprioception within the joint without surgi- failure, excessive pain and effusion must be strictly and regu- cal repair. Such repair is thereby limited to young and well- larly performed until termination of the rehabilitation. This motivated patients with no radiological evidence of degenerative includes joint arthrometer tests and stress diagnosis after the 33 disease. first week of rehabilitation and at every second week during Late examples of posterior cruciate and isolated lateral liga- the first 6 weeks, so as to have an accurate and objective evalu- 11 ment instability cannot be repaired with confidence. Thus ation of anterior displacement before progression to a more early detection and repair are most important. strenuous phase of rehabilitation.37 In all cases of chronic instability the patient should still be Any increase in joint displacement of 2 mm or more than encouraged to undertake an intensive programme of muscular the last result is an indication for adjustment of the rehabilita- training to improve the strength and endurance of all related tion programme. Weight bearing must be delayed, joint motion muscles – knee flexors, extensors, internal and external rota- must be limited to between 20 and 90°, and resisted exercises tors. Meanwhile the surgeon and therapist are able to judge for hamstrings and quadriceps must be limited at an angle of the patient’s motivation and to select patients appropriate for 70°. These measures decrease the tension on the graft. After surgical treatment. Exercises include isometric, isotonic and 1 week the arthrometer test is repeated. isokinetic contractions performed daily. Care should be taken Excessive synovial fluid may be another sign that therapy again not to overload the joint, because this can lead to capsu- has been too aggressive. It inhibits not only quadriceps litis, patellofemoral pain or increasing crepitus. Such symp- contraction44–46 but also may degrade cartilage matrix.47 toms should be seen as a sign that progress with exercises has Pain must also be controlled to block harmful effects been too quick. During more functional actions, such as jogging on circulation and muscular action. This can be achieved by on even or uneven ground, running in figures of eight and medication and physical agents such as cool packs (10°C) and jumping, it is advisable that the patient initially wears a knee transcutaneous electrical nerve stimulation (TENS). Signs of brace to control the instability. Which appliance is appropriate sympathetic reflex dystrophy contraindicate the use of low is determined by the type of instability that is to be controlled. temperature methods. The level of muscular condition determines the grade of sport Programmes that are performed too aggressively, with activity and the types of sport that are appropriate for each running and agility drills 5 to 6 weeks after surgery and return individual. to full activity and competition 16 weeks’ postoperatively, show 11–52% abnormal displacements at follow-up.48–50 In a Rehabilitation management after surgical repair less aggressive rehabilitation programme, with delay of high loads and strenuous activities for at least 4 months after Rehabilitation takes at least 6 months. It should be instituted surgery, abnormal displacements decreased to 15%, from carefully, because revascularization and structural conversion which only 5% showed failure (6 mm or more of increase).43 of any transplanted tissue is a very slow process. The final result is obtained about 1 year after the operation.34–36 The rehabilitation programme can be divided into four Early strength training phase phases:37 On the second day after surgery active assisted exercises are • Assisted ambulatory phase started. This prevents formation of adhesions which usually • Early strength training phase occurs within 2 weeks of immobilization. Excessive scar pro- • Intensive strength training phase duction is estimated in 10–20% of cases. Because structures of • Return to sports. the supra- and infrapatellar region and the posterior joint capsule are particularly prone to the development of contrac- tures, motion exercises must include passive mobilizations of Assisted ambulatory phase the patella in all directions. During the last decade a trend has developed to replace the Several studies recommend continuous passive motion via period of immobilization after surgical repair by early mobiliza- an externally applied force, especially if postoperative joint tion in order to decrease the risk of contracture building up motion causes difficulties.39,51,52 It has been shown not to and to prevent detrimental effects on cartilage. For example, increase effusion or haemarthrosis.42 However, if pain and

© Copyright 2013 Elsevier, Ltd. All rights reserved. e278 Disorders of the inert structures: ligamentous instability muscle spasm cause patients to resist these passive motions, the protective action of the hamstrings on the graft. These strong forces could damage the healing graft and contraindicate so-called close-kinetic exercises (standing with continued the measure. ground reaction force) also seem to reduce forces on the Isometric contractions and electrical stimulation of the quad- patellofemoral joint. riceps also start from the second day and are performed daily. From the moment the patient has achieved full weight Electrical stimulation not only stimulates quadriceps contrac- bearing, which is normally 6 weeks after surgery, it is advisable tion, but also increases pain threshold. From the moment con- to start progressive muscle training with an overload at each traction of the quadriceps muscle is normal again, isotonic exercise but only on condition that there is no pain, effusion contractions, which cause higher muscular forces, are neces- or difference of tibial anterior translation between the involved sary to maintain strength. Because the effects on the maturing and uninvolved limb and there is a full and painless range of graft are unknown, and a direct relationship exists between the motion. Patients with palpable patellofemoral crepitus are at inert and contractile structures, it is advisable to start with a risk of deterioration and are better to avoid strong resisted low load, which is applied close to the knee joint. Movements exercises. should also not pass 30° of extension because studies on strain The improvement of quadriceps and hamstrings must be in the normal and reconstructed anterior cruciate ligament evaluated weekly by isometric manual tests on strength and by during isotonic contraction have shown the final 30° of exten- the measurement of thigh circumference. sion to be seven times that of full flexion to 30°.53 Proprioceptive neuromuscular facilitation (PNF) training is A training programme for the hamstrings, gracilis, tensor another recommended exercise to increase motor activity. It fasciae latae and gluteal muscles is also instituted. improves strength and endurance of the whole limb, from After the first week, stretching exercises of the gastrocne- proximal to distal. With allowance for pain and weakness, mius, hamstrings and hip flexor muscles are included. resistance can be performed in an isometric or a concentric When the patient has achieved 50% weight bearing, nor- manner (either eccentric or isotonic). mally about 10 days after surgery, balance training can be After 2 months, training is broadened with more functional added. The patient tries for 5–10 minutes to stay with both elements such as walking, pool walking and stepping. The use feet on a balance board. This stimulates proprioceptive activity of a knee orthosis to control rotatory movements and the and arthrokinetic reflexes that increase the action of the knee flexion–extension range within 60° and 20°, respectively, must muscles, which in turn protects the graft. be continued. Attention should be paid to a normal, symmetrical Isokinetic contractions have their own value. Because mus- gait, which maintains normal articular cartilage and muscle cular defects have been shown to be more likely diagnosed re-education.54,55 Any abnormalities during gait must therefore at special velocities, it is of great advantage to investigate be identified and treated before weight bearing is increased. that aspect of muscular deficiency. With the use of a device, resistance can be adjusted accurately at the indicated veloc- ity.57 It is advisable to perform three sets of 10 repetitions Intensive strength training phase twice a day on every other day and the load should not To regain muscular condition resisted exercises may start the exceed 70% of maximum effort. However, because of the fourth week after surgery. These are performed submaximally process of incorporation of the graft, it seems better not to (about 60% of maximum effort), with a short lever arm and start such exercises before the sixth postoperative week and progressive repetition. Three sets of 10 repetitions are pre- also in the absence of pain and swelling. The effect of isoki- scribed. Increase of strength is to be expected if the limits of netic exercises on force and endurance has been shown to fatigue are reached after each session. be greater than that of isotonic exercises. The high loading Isotonic contractions of the hamstrings may be performed contraindicates these exercises when there is patellofemoral prone, with the patella lying free from the edge of the table. crepitus, unless this is limited to the range of motion outside As for the quadriceps, three sets of 10 repetitions are per- the crepitus. formed two times a day. Because there is no fear of stretching the graft, this exercise may be performed throughout the full range of motion. Isotonic contractions of the quadriceps Return to sports beyond 30° of extension should still be avoided. Because of its After 3 months, bicycling can be started, which is stimulating posterior drawing force, co-contraction of the hamstrings for the quadriceps and hamstrings with little effect on the during quadriceps action is an effective measure to decrease graft. At the beginning duration is 15–20 minutes. At that time strain on the anterior cruciate ligament. resisted exercises are still increased, although muscular effort In a study on this matter during standing, knee flexion of must not exceed 75% of maximum. 30° or more, together with trunk flexion of 30° or more, Running is allowed from the sixth postoperative month and, increased the protective posterior drawer force of the according to the patient’s goals, turning, twisting, cutting and hamstrings.56 jumping may gradually be added. Mini-squats and wall sits (patient leans backwards against a The use of a knee orthosis is still continued, especially in wall with the knees flexed, ranging between 30° of extension new training situations that impose high loads on the graft. and 90° or more of flexion) are also recommended exercises, ‘Joint reactions’, such as recurrence of pain and effusion, not only to increase strength but also endurance, without patellofemoral crepitus and any increase in anterior translation stretching the graft. Bending the trunk forward still increases of the tibia, should always modify the programme.

To be successful in rehabilitation, exercises must also be 60 metre runs at full speed with 30 seconds’ rest after each similar to the specific demands of the individual sport or run; six 60 metre runs with small side jumps; 100 metre activity.58 Strenuous and difficult aspects are trained in isola- running with 10 left and right turns without losing speed. The tion until proficiency has again been obtained. From that whole question of successful rehabilitation is primarily one of moment, and on condition that pain, effusion and patellofemo- motivation. Older and athletically inactive patients tend to do ral crepitus are absent and forward translation of the tibia stays less well. normal, training in the group can restart. Tables 2 and 3 give a survey of the whole rehabilitation Return to competition is thereafter a matter of time and programme after anterior cruciate ligament (ACL) methodical building of strength. The level required for com- reconstruction.37 petitive sport can be judged from the following schedule: six

Table 2 Evaluation-based rehabilitation advanced weight bearing and minimal protection programme: range of motion after ACL reconstruction. Weeks 1–5a

Week 1 Weeks 2–3 Weeks 4–5 When Weight bearing with two crutches when: Weight bearing with one crutch when: Independent ambulation when: — postoperative pain is controlled — pain is controlled without narcotics — pain is controlled — haemarthrosis is controlled — effusion is controlled — effusion is controlled — patellar mobility is normal — ROM 10–100° — ROM 5–115° — voluntary quadriceps contraction — muscle control throughout ROM — muscle control throughout ROM — joint arthrometer results are within 2 mm Evaluation Pain Pain Pain Haemarthrosis Effusion Effusion Patellar mobility Patellar mobility Patellar mobility Joint arthrometer Joint arthrometer Joint arthrometer ROM ROM ROM Quadriceps contraction and muscle spasm Muscle control Muscle control Soft tissue contracture Active extension Complete extension Inflammatory response Inflammatory response Gait Treatment Pain management Pain management Pain management Control haemarthrosis Control effusion Control effusion Mobilize patella Mobilize patella Motion exercises Motion exercises Motion exercise 0–125° Flexibility Flexibility programme Flexibility Continue quadriceps exercises and mini- Muscle re-education Increase quadriceps exercises and add squats Knee orthosis mini-squats Knee orthosis CPM Muscle re-education Endurance and advanced muscle exercises — perform ankle pumps 5 minutes every Knee orthosis Balance training hour to maintain blood flow Balance training Increase joint arthrometer Increase in joint arthrometer result Address gait abnormalities Continue ankle pumps Goals ROM 20–70° ROM 0–125° ROM 0–135° Adequate quadriceps contraction control, Muscle control Maintain ROM inflammation and effusion Control inflammation and effusion to Muscle endurance 25–50% full weight bearing prevent scarring Control inflammation and effusion to prevent Joint arthrometer remains within scarring 2 mm of last test Joint arthrometer remains within 2 mm of last 50–75% full weight bearing test 100% full weight bearing with a normal gait Early recognition of complications (motion loss, RSD, laxity)

aRationale: Achieve full weight bearing and full range of motion without compromising graft fixation or graft maturation. CPM, continuous passive motion; ROM, range of motion; RSD, reflex sympathetic dystrophy.

Table 3 Evaluation-based rehabilitation advanced muscle training after ACL reconstruction. Weeks 6–52a

Weeks 6–12 Weeks 13–24 Weeks 25–52 Evaluation Hamstrings and quadriceps strength Hamstrings and quadriceps strength Hamstrings and quadriceps strength testing testing and endurance testing Swelling Swelling Swelling Joint arthrometer Joint arthrometer Joint arthrometer Patellar mobility and crepitus Patellar mobility and crepitus Patellar mobility and crepitus Function tests Treatment Discontinue EMS Increase speed and resistance for isotonic Increase isotonic exercise Increase isotonic exercise and closed chain kinetic exercises Advance isokinetic exercises Start isokinetic exercises Advance isokinetic exercises Continue aerobic conditioning Start proprioceptive neuromuscular Continue aerobic conditioning Advance running and start functional facilitation Advance proprioceptive training running programme Start aerobic conditioning Start plyometrics Continue proprioceptive training Proprioceptive training Knee orthosis Knee orthosis Therapeutic modalities Sport-specific training Knee orthosis Goals Increase strength endurance so Increase strength & endurance of lower Increase function there is no fatigue with ADL extremity for limited activity Maintain strength & endurance Return to previous activity level

aGeneral criteria: No effusion, painless range of motion, joint stability; performs activities of daily living without pain; range of knee motion 0–125°; full weight bearing. ADL, activities of daily living; EMS, electrical muscle stimulation.

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