pre-ACL reconstruction

Scorpio Clinics

A few notes to report on the use of the ATM for rehab pre-ACL reconstruction. Apologies for being long-winded!

Background:

The patient is a professional golfer who ruptured his left ACL in a sailing accident. He spent five days limping around with a fixed flexion deformity before he saw a surgeon who scanned him and operated on the same day to clean out the joint. He was seen at Scorpio Clinics two days post-arthroscopy. The immediate aim was to rehab the knee to regain full ROM and achieve minimal swelling before his reconstruction. This would normally be expected to take six weeks but in view of his career and status we were aiming at two weeks. Everyone felt under pressure.

Day 1: marked effusion. Flexion 110 degrees, extension -10 degrees. Very poor static quads contraction - pain ++ in medial compartment of the knee.  
Rx. soft tissue work hams and calf, passive mobilisation P/F and tibfem joints. To do SQ, co-contraction quads / hams, straight let adduction / abduction / extension, ice, stay off feet as much as poss.

Day 2: very painful. O/E effusion and ROM unchanged. 
Rx. passive mobs, soft tissue work, passive hams and calf stretches. Added stretches to exercise program. Better quads contraction post-Rx but extension remained blocked.

Day 3: Remains very painful in med. compartment. O/E extension slightly improved. Slight reduction of swelling.
Rx. worked ++ on SQ contraction and passive hyperextension. Kinesiotape for swelling. Added P/F against theraband,

Day 4: Pain unchanged - pt fed up!
O/E can just hyperextend knee, effusion decreasing - now about 50% down
Rx. Physiolog. flexion. Then ATM introduced. All exs done facing the cushion with the belts crossed over the SI joints and a thoracic belt looped round the lower thoracic spine slightly tractioning it. Worked on active hip extension staying light ++ on toes, resistd hip extension with theraband around back of knee and looped around central post. Also terminal knee extension with very strong theraband around back of knee.
This made a significant difference to his SQ contraction and increased his hyperextension ++

Day 5: remains painful but pt much more optimistic. Not flared up by ATM.......
O/E Effusion unchanged, fair SQ contraction but still has end range pain on extension.
Rx. ATM +++. Added theraband around back of left knee, patient holding thigh parallel with the right and actively flexing / extending left knee - had to work very hard not to let thigh drift forwards. Also did terminal extension standing on left leg only and maintaining hips level. Passive mobilisation afterwards.

Day 6: Still painful but almost full ROM, effusion 25% now
Rx. Continued with ATM. Added hip extension against theraband with toes on small ball located on step behind pt. Pt to roll ball side to side, forwards/ backwards and round and round. Difficult but very rewarding for the pt. Also did passive RF stretches.

Day 7: Pain continues, minimal swelling. Treatment as above. Surgeon comes to see pt at work on ATM.

Day 8: Full ROM, no swelling. Rx as above

Day 9: surgery planned for tomorrow. No ATM - just passive mobs - surgeon requests a "quiet knee"

Day 10: ACL reconstruction. Physio commenced five hours post-op. Patient had no swelling, FULL ROM immediately, perfect quads contraction. Must be the morphine!

Day 11: (today) Same as yesterday - but no morphine.

This has been the easiest "pre-hab" I have ever overseen. And it is the first time I have had a patient with full ROM on day 1 and 2 post-ACL reconstruction. It is also the first time I have used the ATM so extensively for an acute knee injury.
I will post a follow-up as the rehab progresses. We are aiming at gentle golf as soon as possible following the initial 6/52 post-op.

Sophie Dhenin 
Scorpio Clinics Ltd 
Virginia Water, UK