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ACL (Anterior Cruciate Ligaments) Reconstruction

What is an ACL (anterior cruciate ligament)?

The following diagram shows the main structures in a healthy (right) knee.

The ACL joins the back of the femur (thighbone) to the front of the tibia (shinbone). It helps to stabilise the knee. You can damage it by a twisting movement or a movement where your body continues to move forwards but your foot stays put e.g. dodging, pivoting or landing from a jump. The main goals of ACL surgery and rehabilitation are to restore knee stability and to allow your return to work and sport as soon as possible.

Surgery

Reconstruction of an ACL involves replacing the torn ligament usually with part of the hamstring (from behind the knee) or sometimes part of the patellar tendon (in front of the knee).

The surgeon drills tunnels through the bone. Your new ACL is brought through these tunnels, and then secured.

As healing occurs, the bone tunnels fill in to secure the tendon.

Rehabilitation

Rehabilitation starts immediately after your surgery. This is where all members of the Hospital Care Team (doctors, nurses and physiotherapists) help you to achieve your full potential following your ACL reconstruction. The rehabilitation is just as important as the surgery itself. You need commitment and effort to make the most of your rehabilitation.

To make sure your progress is quick and safe your physiotherapist(s) will follow a specially designed programme based on up to date information.

Why do I need physiotherapy after my operation?

• To minimise swelling

• To regain full range of movement

• To restore normal walking

• To strengthen muscles

• To allow safe return to sporting activities

Your physiotherapy care

Immediately after surgery

You will return from theatre with a padded crepe bandage from your calf to thigh.

You may have had a nerve block (an injection into a nerve to reduce pain after your surgery) or local anaesthetic put into your knee. These often cause numbness and a feeling that you are unable to move your leg. This is normal and usually improves within a few hours.

The medical and nursing staff will offer painkillers and we strongly advise you to take these regularly to minimise discomfort and swelling.

The padded bandage will change to a light wound covering and tubigrip.

Going home from hospital

Getting Up and About:

We will give you sticks or elbow crutches to help you walk and to get about, until you have better control of your leg muscle.

We will show you how to use them properly to walk and when on stairs.

It is really important that you take good care of your wound and pain control. It is also important to keep down any swelling.

Pain:

• Wound pain is normal, this will gradually lessen over the next few days. Use the painkillers supplied by the hospital regularly.

• If pain or swelling increase contact, your physiotherapist, GP, orthopaedic clinic or attend your local minor injuries clinic for advice.

Wound Care:

• Change the clear wound dressing. You may see dark blood stains – don’t worry this is normal.

• If your wound becomes hot, red and weeps fluid, contact physiotherapist, GP, orthopaedic clinic or attend your local minor injuries clinic for advice.

Swelling and Warm:

• Swelling is normal immediately after surgery. Use a cold pack if your knee is hot and swollen. You can make a cold pack by wrapping a bag of frozen peas in a damp tea towel. Remove the tubigrip and apply the cold pack to your knee for not more than 15 minutes at a time. You may reapply it once your knee has returned to its normal temperature.

• Wear the tubigrip during the day but remove it at night to allow your circulation to flow properly.

Stairs

Going up stairs:

1. Place unoperated leg up onto step

2. Place operated leg onto same step

3. Finally place sticks or crutch onto step

Going down stairs:

1. Place crutches or stick down onto step

2. Place operated leg onto same step

3. Finally place unoperated leg onto same step

Remember –

“up with the good, and down with the bad”

Always use your crutches or sticks to support the operated leg. Always use the hand rail, if there is one, as well as one stick or crutch.

When can I return to normal activities?

Every individual is different and you should follow the advice of your physiotherapist(s) and consultant. The following is a rough guideline:

  • Walking without crutches as advised by your physiotherapist
  • Work at a desk approximately 2 – 4 weeks, other jobs depends on activity
  • Driving approximately 4 – 6 weeks
  • Return to sport as advised by your physiotherapist
Exercise Programme

Your exercise programme should start from day one and has been carefully designed for safe and rapid progress.

Exercise:

• Rest your knee between sessions of exercise. When resting keep your leg up on a stool or settee.

• Walk only short distances for the first few days.

• Continue using your crutches as shown by the physiotherapist until we tell you otherwise.

• It is important that you can straighten your knee fully and you are walking without a limp before you stop using crutches.

• Finally, it is important to continue with the exercises as shown by your physiotherapist.

The early phase of your rehabilitation is included in this information sheet and your

physiotherapy sessions should start a few days following surgery.

Exercises Programme – Initially your physiotherapist will assist you to move your knee.

Then they will teach you how to do exercise 1 – 5 safely (see Exercise Programme over page)

1. Static quadriceps

2. Knee bending.

3. Straight Leg Raise

4. Terminal extension

5. Prone Stretch

Continue with exercise No.1 to 5 as shown until your first Outpatient physiotherapy appointment.

Ongoing physiotherapy:

You will attend out-patient physiotherapy for at least 3 months.

Your rehabilitation usually takes at least 6 months depending on goals or sports.

Exercises Week 1-2

You will see the physiotherapist after your surgery. They will teach you the following exercises.

You may feel some discomfort with some of the exercises. If you have any concerns discuss these with your physiotherapist.

1. Static Quadriceps (thigh muscle). Position – lying down or Sitting.

Action – tighten the thigh muscle, pull your foot towards you and push your knee down into the bed or settee.

Hold for 5 seconds then relax

Repeat 10 times every 1-2 hours

2. Knee bending Position – lying down.

Action – Slowly slide your heel up towards your bottom. Stop at the point of pain and

hold for 5 seconds then straighten again.

Repeat 10 times every 1-2 hours.

3. Straight leg Raise You Must keep your knee straight and locked out. Position – lying down.

Action- Tighten the thigh muscle and keep your knee straight, slowly raise your leg off the bed. Do not lift the leg higher than 10 -15cm (4-6inches) from bed.

Hold for 5 seconds.

Repeat 10 times 3 times per day

4. Terminal Extension Position- lying down with your heel on a rolled towel. Or in a sitting position  with unsupported on a stool.

Action – tighten the thigh muscle, pull your foot towards you and press your knee down.

Hold for 5 seconds then relax

Repeat 10 times every 1-2 hours

Or

Rest in this positions for 10 minutes every 1-2 hours.

5. Prone Knee Stretch Position – Lying on your front with feet over the bed edge.

Action – Place a pillow or towel under your thigh for comfort. Allow the weight of your legs to stretch the back of your knee.

Hold position for 10 minutes.

Rest in this position for 10 minutes every 1-2 hours.

6. Calf Stretch Position – lying or sitting.

Action – Use a towel or belt around your foot, to pull your foot gently towards you to stretch your calf.

Perform 3 times, holding stretch for 20-30 seconds.

Repeat every 1-2 hours

Exercises Week 3 – 6

Only start the following exercises when your physiotherapist tells  you it is OK to do so.

7. Knee Flexion and Hip Extension

Knee Flexion Position – Lie face down.

Action – Tuck your good leg bend your operated leg to help bend your knee to 90

degrees.

Hip extension

If you can bend knee freely to 90 degrees, extend your hip by lifting your thigh off the bed.

Return to starting position.

Repeat each 10 times 3 times per day.

8. Hip Abduction Position – Lie on your side with your back against a wall.

Action – Keeping the heel in contact with the wall, slowly raiseyour leg.

Return to starting point. Repeat 10 times 3 times per day.

9.

Action- Move your weight from side to side over your feet.

Repeat 10 times 3 times per day.

10. Single leg balance Position – Standing on one leg.

Action – Practise standing on your operated leg. Try to increase the time to match your good leg.

Hold for 30 Seconds

Repeat 10 times 3times per day.

11. Calf stretch Position– Stand by a chair or wall for support.

Action – Step back with one leg and stretch the calf by pushing the front knee forward.

Make sure your feet are pointing forwards and your heels stay in contact with the floor.

Hold for 30 Seconds

12. Mini Squat Position – Stand by a chair for balance if needed.

Action – Bend your knees and hips as if going to sit on a chair.

Do not bend the knees more than 50 degrees (halfway down).

Return to starting position.

Repeat 10 times 3 times per daily.

13. Heel raise Position – Stand by a chair for balance if needed.

Action – Slowly raise your heel up from floor, move up onto your toes.

Repeat 10 times 3times per day.

To progress you can add a hand weight.

14. Cardiovascular exercise

Using a Static bike and cycle with low resistance.

Cycle for 10 -15 minutes – before (as a warm-up) and following your exercises.

Your physiotherapist will give you guidance on all exercises.

Contacting your care team

Please contact your Physiotherapist, G.P, orthopaedic department or attend your nearest Minor Injuries clinic if you have any issues regarding your knee.

Your Accident & Emergency (A&E) centre is for serious medical emergencies. Their staff prioritise patients on the severity of the condition.