Physiotherapy - Anterior Cruciate Ligament (ACL) Reconstruction

Post-operative regime

The post-operative rehabilitation programme can be divided into 3 phases:

Phase 1: Early recovery (the first 2 weeks)

Phase 2: Initial strengthening (2 weeks – 6 weeks)

Phase 3: Functional recovery (6 weeks – 9 months)

Day of surgery (Day 0)

You will be admitted via the day surgery unit for preoperative checks and signing of the consent form.

The physiotherapists will provide you with crutches and advise on use and assess how safe you are on them. They will also provide exercises on a sheet for you to complete as soon as you have had your operation. You will not routinely be seen by a physiotherapist after your operation. After the operation you will then be in recovery for a few hours on the day surgery unit.

Local anaesthetic and pain medication will be given during the operation to make you feel as comfortable as able. However, some pain is to be expected, particularly around thigh where the graft has been taken from.

Once you are deemed safe for discharge you will have pain medication to take home. You must have an adult with you for 24 hours after the anaesthetic.

First post-operative day

The bulky bandage put on in the operating theatre can be removed. Leave the small adhesive dressings in place until you are reviewed in clinic in 2 weeks’ time.

When resting, the knee is kept as straight as possible. You should complete the exercises from the provided sheet, to
straighten and bend the knee actively (by yourself). It is quite safe to bend the knee and to put weight on the leg, taking as much weight as is comfortable. You may spend time sat out in a chair with the leg elevated – you can flex the knee into a normal sitting position for short periods of time of up to 15 mins (e.g. to enable you to sit and eat a meal or use the toilet).

Second and third post-operative days

You will gradually become more mobile. The movement in the knee will increase as pain permits with no restriction on bending. Again, most of the time is spent with the leg rested and elevated, in bed or sitting out in a chair.

Day 3 until 2 weeks post-op

Much of the time will be spent with the leg rested and elevated, gradually increasing the movement in the knee. You should have full extension and 90° of flexion by 2 weeks.

You will have an appointment with the physiotherapist, which is routinely at your closest hospital, within the first 2 weeks after the surgery. If you do not hear from them by 2 weeks post- surgery, please ring number provided on the exercise sheet to arrange an appointment with outpatient physiotherapy.
 
It is normal to experience some pain, bruising, swelling in the operated leg. The discomfort can be controlled by regular elevation, pain medication and using ice.

Phase 1 (the first 2 weeks)

Anterior cruciate ligament (ACL) reconstruction is a common surgical procedure to improve the stability of the knee. The early postoperative period is an important phase in the recovery process. Every patient is different, and progress can be variable but there are several important things which can contribute to success of the procedure.

• Rest - The knee must be allowed to recover from the operation. The surgery is performed by keyhole surgery, but a lot of work is done inside the knee joint including drilling the bones and trimming or fixing cartilage. It is normal to experience pain, stiffness and swelling for the first two weeks. Rest is essential but moving around your home with/without crutches is recommended every couple of hours. It is not recommended to go for long walks whilst the graft is healing.
• Elevation - Along with rest, elevation is very important in the early post-operative period (please see picture for true elevation, the operated leg should be supported in a position where the foot is higher than the heart, with the knee straight). Swelling and bruising of the operated leg is common. After returning home, regular application of ice (e.g. bag of frozen peas wrapped in a tea towel) may be useful to ease pain and swelling.

• Full extension - Regaining full extension (straightening) of the knee is vital to the success of the operation. Pillows should not be placed under the knee for comfort. A pillow can be placed under the ankle and heel when in lying, to allow the knee to fall back into full extension. Sitting in a chair with the knee bent in the normal sitting position should be avoided for long periods of time >15 mins. Ideally place the foot on a footstool.
• Movement - It is quite safe to move the knee immediately after surgery and you will be encouraged to do so. As stated previously, regaining full extension is of prime importance but it is also important to flex (bend) the knee. Most patients will be able to achieve 90° of flexion (a right angle) after a few days and the sooner movements return the better.
• Weight bearing - Following surgery it is quite safe to take your full weight on the operated leg, although you will probably find that initially full weight bearing is uncomfortable. Take as much weight on the leg as is comfortable and use crutches as needed. It is safe to weight bear unless your surgeon has instructed you otherwise. Some additional surgery performed at the time of your ACL may require a period of altered weight bearing. You will be informed of this by the nurses/therapists prior to leaving the hospital.

Phase 2 (2 weeks - 6 weeks)

If you have had stitches, then these will need to be removed by your GP practice nurse or at the walk-in centre after approximately 2 weeks, this should have been arranged by the nurses on the ward before your discharge. You will be seen by the outpatient physiotherapists and progress through the ACL rehabilitation programme.

Aims of physiotherapy treatment at this stage are to fully extend and flex the knee, strengthen the muscles around the knee joint, improve balance and to teach you how to walk correctly.

The physiotherapy team will adapt your home exercise programme as you recover. By this time, you should be taking full weight through the leg and should be weaning off the elbow crutches as advised by your physiotherapist. You will also be encouraged to gradually increase your walking distance after 2 weeks.

You may return to sedentary (non-physical) work after 2-3 weeks if comfortable. However, return to physical work should be delayed for at least 6 weeks following surgery starting with light duties, building up to full duties by 12 weeks. Your physiotherapist and surgeon will guide you on this.

It is important to be guided in your return to activity by the physiotherapist as the critical time for the new graft to
incorporate in the bone and become stable is the first 6 weeks (as graft fixes to the bone) and again at 8-12 weeks when the new graft weakens slightly as the new blood supply is established.  Returning to too much activity too soon can affect the success of the surgery.

Driving should be possible after 6 weeks, or even earlier if your car has automatic transmission and the left knee has been operated on. At the end of 6 weeks the knee should extend fully and flex to at least 120°.

Phase 3 (6 weeks - 9 months)

There is a gradual increase in the level of activity concentrating on “straight line” work avoiding those movements that put the knee at risk e.g. turning, twisting, jumping, sharp acceleration and deceleration, change of direction at speed and walking, jogging, or running on uneven or unpredictable surfaces.

Cycling and swimming are the best activities together with gym work and jogging or running on soft, even surfaces. Every patient is different and has a different pace of recovery and it is difficult to make firm rules regarding progress.

From 8-12 weeks, the physiotherapist will maintain the level of function and movement to allow the graft time to strengthen up. It is important at this time not to over-exert the knee, as this can risk graft failure. After 12 weeks you will be able to increase the rehabilitation again.

6 months following surgery there should be a full range of movement in the knee. At 9 months it may be safe to return to full activity and sport specific training – this will be guided by your physiotherapist.

Virtually every patient experiences some lack of confidence in returning to full activities and this is very natural. Every patient is different and the speed of your return to sport is variable and depends on several factors including the extent and severity of the injury to your knee. It may take as long as 2-3 years for confidence to fully return.

Fairfield General Hospital Useful contact numbers:

Outpatient’s Physiotherapy

North Manchester 0161 720 2423

Oldham 0161 627 8517

Bury 0161 778 3882

Rochdale 01706 517316

Salford 0161 206 4100 / 01612065328

Inpatient Physio Team 0161 778 2595

Ward 14 contact number 0161 778 2514