Focusing on mobility in ACL rehab may boost outcomes

Protocols using early movement may protect against joint disease and arthrofibrosis.

Rehabilitation plays a significant role in long-term outcomes following ACL reconstruction, and the most important factor in rehab — mobility.

“My impression is at six weeks, if a patient has full mobility, they can build strength and the strength actually comes very fast,” said J. Richard Steadman, MD, founder of the Steadman-Hawkins Research Foundation in Vail, Colo. “On the other hand, if ... the mobility’s compromised, there’s a significant chance that you’re going to need surgery for adhesions in the joint,” he said during his presentation at Orthopedics Today NY 2005 — a comprehensive CME course.

A lack of mobility can lead to long-term postoperative stiffness. “I think that a lot of arthritis we see after ACL surgery is the result of increased compression on articular cartilage which, in turn, causes degeneration,” Steadman said.

He and his colleagues examined patients that suddenly developed arthritis after having a perfect outcome for ten years. “Our conclusion was that there was a loss of mobility between the patella tendon and tibia,” Steadman said. “If you lose that mobility in that area, [our study] pointed out that you get a subtle patella infera.” He noted that reconstructions using double-bundle techniques might avoid degenerative joint disease after 10 years postop.

Neglecting mobility can also create scarring between the patella tendon and the tibia. The condition may prove more common after bone-patella tendon-bone procedures “but, I’ve seen a number of cases with hamstring reconstructions that ended up with lack of mobility and arthrofibrosis,” Steadman said.

“So, [patellar mobility] seems to be a key point in avoiding arthrofibrosis.” Therefore, he advises manually moving the patella medially and laterally in all cases.

A successful rehab program focuses on helping the patient regain full mobility while matching the surgical technique and fixation type. “If you would do a meniscus repair and ACL reconstruction, and restrict your mobility during this first six weeks, chances are that it’s not going to be a perfect result,” Steadman said. “You’d get good results, but not perfect.” Therefore, he avoids performing an ACL reconstruction with a locked meniscus.

Physicians can prescribe aggressive rehab following ACL reconstruction, but he cautioned against issuing rapid programs after single-hamstring graft procedures. “If you use that single semi-T across the joint, then you probably wouldn’t want to use a program that’s very active,” Steadman said. His typical rehab protocol for patients with firm fixation includes the following sequential objectives:

motion;
mobility;
strength;
power; and
eccentric loading

Sequential progression

Steadman looks for full motion the first day following reconstruction, but most of his patients achieve 80% of flexion extension during one-week postop. Once they demonstrate motion and mobility, patients progress to strengthening activities. “I don’t think you should start strength until you've got motion and mobility,” he said. Exercises during this phase include stationary biking and treadmill walks, but not heavy resistance or weight training.

In a European study, Steadman and his colleagues noted that a 1.5 cm gap naturally occurred between the patella tendon and the tibia during full extension. Excessive strain limits this space and increases stiffness, he said. Finally, Steadman assesses eccentric load capability to determine improvement. “For me, that’s when I know people are right for going on to the next stage, which would be full recovery.”

Steadman’s rehabilitation protocol calls for a departure from traditional procedures. “At least a year ago, the protocol was that you kept the patients in bed after surgery ... until they got basically full flexion, full extension and good mobility ... ,” he said. “I think it’s two different approaches to the same problem and that is a stiffness in the joint that we’d like to avoid in the long term.”

For more information:
Steadman JR. Postoperative ACL rehabilitation. Presented at Orthopedics Today NY 2005 - A comprehensive CME course. Nov. 19-20, 2005. New York.