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rehabilitation protocol after anterior cruciate ligament (ACL) of the knee.

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This protocol is based on a consensus, which was proposed by the High Authority for Health (HAS).
What are the simple principles and issues of rehabilitation?
The goal is to take a sport in the best conditions maintaining plasty, knee and patient. Rehabilitation is a compromise between the knee and scarring of the transplant and physical recovery of the patient.
During the post operative rehabilitation, steps succeed. There are 3 elements whose evolution conditions the resumption of sporting activity:
- The new implanted ligament (also called "graft" and "transplant" or "tuck" or "neo ligament")
- The operated knee
- The physical preparation of the surgical patient
The new ligament is fixed between the femur and tibia in place of the broken. Over time, it gradually to the bone anchor. This binding "natural" with the bone will replace the attachment used during surgery (clip, screws, ...). From the 3rdmonths post surgery, the plastic surgery she will undergo all the same mechanical knee. This is called plastic remodeling of neo ligament.
Early in this period, we must remain cautious and avoid a too early return to sport, even if the knee is moving very well. The final step, after the 4th postoperative month, corresponds to the increase of the resistance of the transplant. This stage will last 2 to 3 years.
Rehabilitation lasts 8 months. 5 successive phases:
- Skin Healing
- Autonomy ambulation
- Consolidation
- Réathlétisation
- Resumption of sport
Phase 1 = HEALING: the day of surgery in the 21st postoperative day
3 weeks are required to obtain skin healing; the knee should be as dry and as painless as possible. Must obtain an active locking in extension and flexion of 60 °. Prevention of thromboembolic diseases is essential.
- Lower limb extension protected by a simple splint or variable amplitude with locking stop according to the procedure performed
- Ambulation possible bearing contact under two crutches
- Muscle work four sides in extension supine
- Manual and gentle mobilization arthromotor (0/70 °)
- Massage and muscle toning
- Icing and physiotherapy
- Electro-stimulation to prevent muscle atrophy
- Removal of surgical stitches or staples on or before the 3rd week
- Continuation anticoagulant and analgesic
possible incidents
- Swelling, hematoma, venous problems, delayed wound healing, painful knee
- Active work against open chain quadriceps strength and hamstring
- Recurvatum prohibited
Phase 2 = AUTONOMY: mobility and muscle toning: from 21 th to 45 th day
This is the recovery phase of progressive support and recovery of range of motion. The patient will gradually weaned from the brace and crutches. The knee should be dry, painless, non-inflammatory, and mobile, with 120 ° flexion and full extension.
At the end of the second month mobility must be total and painless and there must be a good reflex muscle control in the activities of daily living. If mobility is not progressing steadily, the surgeon's advice should be sought.
- Gait training
- Recovery of mobility by manual and instrumental techniques
- Moderate and progressive muscular activities in co-contraction
- Isometric knee lock
- Building muscle electro-stimulation
- Balance activities and bi-static proprioception podal then uni-podal
- Pressure therapy according to the needs
- Deep water therapy; Scottish baths if trophic disorders
- Massages and peri-scar
- End of period, bike without resistance if satisfactory amplitudes, treadmill
possible incidents
- Hot and swollen knee your sports doctor may suggest a puncture
- Painful knee: analgesic and anti-inflammatory
- Stiff knee: an obstructed for 3 consecutive weeks should lead to faster consult your surgeon
- Not working the quadriceps against open chain resistance
Phase 3 = CONSOLIDATION: the 45 th day in the 4th month
Recovery of the patient's confidence in his knee. Muscular work the quadriceps and hamstring co-contraction can be accentuated and intensified reasonable taking into account the phenomena of "ligamentisation". Proprioceptive activities become priority and gestures rehabilitation and endurance activities (walking, cycling, step, swimming in front and back crawl).
At period end, proprioception becomes dynamic bi and uni-podal with facilitating material.
- Work in co-contraction in different angulation of the knee: press type
- Work the hamstrings by developing the power and speed of contraction
- Quadriceps work in closed kinetic chain and isometric extension
- Development of neuromuscular control and proprioception (unstable platform, swing, trampoline ...)
- Cardiovascular exercise training (cycling, steps ...) start jogging on the flat and soft ground at end of period
possible incidents
- Sensitivity patellar
- Inflammatory knee
- Tendinopathy ( if KJ)
- Dynamic activities in full power.
Phase 4 = REATHLETISATION: 4 th to 6 th month
From the 4th and 5th month, the tendon recovers its strength, the most important activities can be undertaken, both in power and endurance. Jogging is added to the disaster recovery program, the base remains, swimming, biking, muscular rehabilitation and work endurance, power and dynamic proprioceptive activities.
- Athlétisation different muscle groups: press, weight bench ...
- Isokinetic work
- Dynamic work with jumps and direction changes smoothly
- Continuation with acceleration jogging, swimming like crawl with fins, bike ...
- Progressive physical rehabilitation activities
possible incidents
- Gene of the patella during flexion of the knee
- Inflammatory knee
- Patellar tendinopathy
- Physical and sports activities, and contact with pivot
Phase 5 = RESUMPTION OF SPORT: beyond the 6th month
Beyond the 6th postoperative month, the goal is to guide rehabilitation to sport specific practice. There is work to gradually bring the knee in a situation close to the sporting gesture. The duration of this step depends on the type of sport. For sports like football, rugby, judo, handball, dance, etc ... called sports hub, the resumption of training is between the 7th and 8th month. The resumption of the competition is between 9 and 12 months. In the 7th month, we can advise you to make a comparative isokinetic muscle balance knees to define muscle functional capacity to guide the sports preparation.
- Comparative isokinetic test
- Intense muscle building
- Re-learn sport-specific gestures
- Adapted and progressive resumption of training sport practiced
- Specific sporting balance sheets.
possible incidents
- Muscle-tendon pathology sport.
- Anticipation of the resumption of the competition.
The ligament is a procedure performed in order to restore a knee suitable for sports. The objective will be fulfilled provided you follow the post operative rehabilitation. It is important to consider the possible different ligament neo the healing stages to preserve it.
The proposed protocol is the result of expert consensus and recommended by the National Health Authority (HAS). It is therefore indicative. It must be adapted to each type of knee, patient and performed surgery.

Doctor Yoann BOHU, Doctor Serge HERMAN, Doctor Nicolas LEFEVRE. - 3 janvier 2015.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.


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