28. appendix g: rehabilitation procedure … · appendix g: rehabilitation procedure ......

Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries – A Randomized study. Draft date 2001-08-31, version 10 Page:

Print date 2009-04-24

52

28. APPENDIX G: REHABILITATION PROCEDURE Rehabilitation procedure

The rehabilitation procedure follows the general principles described below. The protocol is moderately aggressive but avoids exercises with heavy loads on the graft initially. Each level ends with a set of goals to be achieved before the next level of rehabilitation is started. Time intervals are suggested and not superior to the goals. Pain, swelling and general discomfort slows down the rehabilitation process until each levels set of goals can be achieved without any problems. In addition to the protocol below there will be a bank of exercises coupled to each level of rehabilitation. This bank of exercises is formed by all participating physiotherapists and includes their traditional work with patients with deficient ACL. Anti- inflammatory drugs (NSAID) may be needed. A lack of extension in ROM shall be carefully analyzed and treated, if necessary with arthroscopy, early in the course.



53

0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Unloaded range of motion (ROM)

As tolerated As tolerated Normal Normal Normal

Goals Full extension

Flexion > 120 deg Full extension Flexion comparable to other side

Comparable to other side



Muscle function Quadriceps: unloaded full control Hamstrings: loaded exercises Exercises for other lower limb muscles and trunk are initiated

Quadriceps: loaded non-weightbearing in 40-120 deg and closed-chain (weightbearing) exercises in 0-80 Hamstrings: full ROM Exercises for other lower limb muscles and trunk

Quadriceps: closed-chain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk

Quadriceps: open-chain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk

Quadriceps: open-chain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk

Goals Full quadriceps

control in sitting and standing

Non-surgical: Less than 10% difference in quadriceps and hamstrings strength between legs

Surgical: Less than 10% difference in quadriceps and hamstrings strength between legs



54

0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Symptoms Pain: tolerated,

treated if necessary Swelling: tolerated, treated if necessary

Pain: tolerated, treated if necessary Swelling: tolerated, treated if necessary

No pain Occasional activity-related swelling tolerated



Goals No morning

swelling No pain Occasional activity-related swelling

No activity-related pain Occasional activity-related swelling



Walking As tolerated forward and backwards without pain* and limping (initially with crutches)

Full weight-bearing Daily walking without restrictions

Full weight-bearing Slow and fast walking on treadmill

Full weight-bearing Running on treadmill/even surface Non-surgical: Unrestricted running

Full weight-bearing Surgical: Unrestricted running

Goals Full weight-bearing

without pain or limping Crutches may be discharged when patient is able to walk backwards without limping

Full weight-bearing Walking without pain or limping

Full weight-bearing Walking without pain, swelling or limping

Full weight-bearing Non-surgical: Running without pain, swelling or limping

Full weight-bearing Surgical: Running without pain, swelling or limping



55

0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Balance/ Coordination

One-leg standing in functional positions

One-leg standing in functional positions on soft ground and Babs-board

One-leg standing in functional positions on more demanding surfaces and Babs- board

One-leg standing in functional positions on more demanding surfaces Two legged bounces Easy sport-specific movements Easy agility exercises

One-leg standing in functional positions on more demanding surfaces One legged bounces Provoked sport-specific movements Provoked agility exercises

Goals One-leg standing

without difficulties Comparable to other side


Non-surgical: One-legged hop and square-hop1 less than 10% difference between legs

Surgical: One-legged hop and square-hop1 less than 10% difference between legs



56

0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Activities Unloaded and

loaded biking on stationary bike backwards and forwards with clips

Biking on stationary bike without restrictions Wet-vest exercises and running in deep water Non-surgical: Outdoor biking without restrictions

Biking on stationary bike without restrictions Wet-vest exercises and running in deep water Slide-board training

Non-surgical: Introduction of sport-specific exercises Surgical: Outdoor biking without restrictions

Surgical: Introduction of sport-specific exercises

Goals Unloaded biking

forward with clips Non-surgical:

Back to pre-injury activity level

Surgical: Back to pre-injury activity level

Action if goal is not reached

If ROM, Symptoms, Weightbearing goals are not reached: Doctors Visit

*As tolerated = acceptable pain according to Pain Monitoring System Visual Analog Scale 5 (0-10) (Thomeé 199?) 1Östenberg et al 1998

Phase 1

2-7 days after injury/operation (home practice)

Mobility:

Lay on your stomack, bend your knee and lift it against the ceiling

Vastus medialis:

Sit with your X-leg slightly bent with a ball under it.Put the foot against the wall and press the knee towards the ground. Keep the tension in the thigh.

Sit on a chair and stand up controlled with even loadon both feet.

Approximately 2-4 weeks after injury/operation

Mobility:

Start using bicycle, 8-12min.

Lay on your back with your hips and knees in 90` angle with your feet against the wall. Slide your X-leg up and down.

Vastus medialis:

Stand with your back against the wall and a softballbehind your X-knee. Squeeze the ball against the wall.

"Norwegian push-ups"Have a ball between your knees, bend and stretch.

Stand on the floor, step up on a board

...in front

...sideways

Legpress, start at 90`degrees and stretch your knees.

Kneebend with a stick, the hips shall be rotated outwards.

Hamstrings:

Lay on your back with the X-knee on the pillow, keep your handsaround your other knee. Lift your pelvis.

Lay on your back with both legs on the pillow. Lift your pelvisand alternately move your legs sideways one at the time.

Triceps surae:

Stand with your X-knee slightly bent on the step.

Take one step up with your X-leg and stretch your knee.

Tensor fascia latae:

Lean towards the board with the X-knee. Lift your hip away fromthe board together with the other leg.

Balance:

Stand with your X-knee on a balanceboard.

Stand with your X-leg on the trampoline, bend your knee slightly.

Stand with your weight on your X-leg and glide with your other leg sideways and back again, have a small towell under your foot.

GOALS FOR PHASE 1: Full extention Flexion>120 degrees

Phase 2:

Approximately 5-8 weeks after op/injury

Quadriceps:

Legpress, full ROM

Stand up from the chair using only your X-leg.

"Stairsteptraining", bend your X-knee deeper.

Stand on your X-leg, keep balance with your hands, smallquick kneelifts.

Balance/Proprioception

Stand on your X-leg, pull with your other arm forwards and down.

Stand on your X-leg, have the pully around the other leg and pull in all four directions.

Stand with your X-leg on the balanceboard and throw a ball in the air.

Hamstring:

Lay on your back on a board with your X-leg on a Boobathball,hold around your well leg. Lift your pelvis.

Triceps surae:

Stand on your X-leg placed on a tilted board, and the other leg on the floor. Go up on your toes while your knee stretches and take the other leg forward and up.

Complementing treatment: Mobilising patella Stretching of tractus iliotibialis Stretching of quadriceps Stretching of hamstrings

GOALS FOR THE PHASE 2: Full control of quadriceps Easily stand on X-leg.

Phase 3


Lunge in different directions.

Rubberbandstraining

"Quick walk" on a thick math with a rubberband aroundyour waist.

GOALS FOR PHASE 3: Walk fast without limping, pain or swollness. Do onelegged kneebendings to at least 60 degrees kneeflection.

Phase 4:


Jogging

Lunge with medicinball to both sides.

Sidestep from stepboard with deep kneebends.

Leg extentions

Stand on your X-leg with your other leg on a pillow.With weights in your hands, do kneebends.

Have a ball between your legs and jump up and downon several stepboards with even legs.

GOALS FOR PHASE 4: <10% differense in onelegged jump. <10% differense in legpresstest. No differense in balance.

Tests: One-legged jump Balance "Stand up" Kneextentions/flexions

28. appendix g: rehabilitation procedure … · appendix g: rehabilitation procedure ......

Documents