sport and health

Principles of conservative treatment after anterior cruciate ligament injury

The lesion of the cruciate ligaments is typical of athletes (84%):

• 41% calcium

• 11% basketball

• 11% skiing

• 8% run

• 9% other sports

• 16% accidental events

In 90% of cases: male gender age 17 to 50 years

In 52% of cases: meniscal injury is associated.

After having diagnosed the ACL injury, the patient, the doctor, the therapist, the re-educator and the patient's family must choose the type of treatment: surgical or conservative.

The ideal patient for surgery is a young person, motivated and following high-level activities. This type of patient is willing to face the sacrifices necessary to successfully complete the rehabilitation program.

The conservative approach is indicated for elderly and sedentary people, who would find it too difficult to follow a rehabilitation program after surgery due to the lack of motivation and the lack of diligence to follow an intensive program.

CONSERVATIVE TREATMENT: Re-education program

The patient can immediately, after the injury, begin to perform quadriceps contractions and lower limb lifts with the extended leg on the thigh. Mobility exercises can be started within a pain-free range of motion. You can work on the ergometer cycle, with the saddle height adjusted to allow the knee to perform the maximum tolerated flexion.

As pain decreases, mobility improves considerably and flexural and isotonic extension exercises with an open kinetic chain can be performed; (it is advisable to limit the extension between 0 and 45 ° for the first 8-12 weeks to limit the stresses at the LCA level).

Strength training exercises must go to stimulate the gastrocnemius and posterior thigh muscles. The closed-chain exercises are valid and safe because they cause a minimal anterior translation of the tibia, improve neuromuscular control and increase dynamic stabilization through the simultaneous contraction of the posterior thigh muscles and the quadriceps.

The main goal of muscle strengthening is to have a 1: 1 strength ratio between the anterior and posterior thigh muscles.

The quadriceps can be rehabilitated, without overloading the knee, through various techniques: early multi-angle isometric contractions (110 ° -50 °); quadriceps / flexor contractions both outside and under load; active exercises, avoiding reaching over 45 ° of extension; extension against resistance, applying the load to the proximal region of the tibia.

The eccentric contraction is used for the strengthening of the ischiocrural muscles (biceps femoris, semitendinosus and semimembranosus). For this purpose, machines are used for isotonic strengthening at fixed load for the whole arc of the movement, isokinetic dynamometers, controlled functional acceleration / deceleration exercises.

The isokinetic method (work at a constant speed throughout the entire arc of the movement) optimizes the work of muscular reinforcement since it allows a maximum contraction for the whole arc of the movement. It also provides a quantitative assessment of muscle deficits.

These isokinetic exercises must be performed avoiding the last 20 ° -40 ° of extension to then gradually pass to a complete articular excursion with a greater number of repetitions, lower speeds and maximum loads.

At the end of functional re-education when the patient has reached adequate levels of eccentric strength and dynamic control of instability, pliometry is inserted to complete the whole.

The objective of re-education is the reprogramming of the perceptive experience of the movement. They can be used for this purpose, according to the rehabilitation phase,

open kinetic chain exercises, such as an exercise bike with passive entrainment of the injured limb; early walking, with partial load; recovery of gait patterns (can also be done in the pool) technical and agility exercises, running and jumping.

The use of a functional brace, both for partial and total ACL injury, provides advantages by increasing the sense of joint position through stimulation of proprioceptors. However, it can cause a decrease in the limb muscle mass and a further reduction in its functional performance. For this reason it is necessary to alternate the use of the brace during the exercises.

Physical therapies: Use of ice for 15-20 minutes at the end of each work even if there is no sign of swelling or edema.

Rehabilitation after lesion of the anterior cruciate ligament