Rehabilitation is a central issue after surgery to reconstruct the anterior cruciate ligament (ACL).

I have picked this discussion of a real-life situation from many hundreds on the KNEEguru Forum (bulletin board) because it raises a number of typical issues. Click the following link to read the initial conversation -

 

The discussion focuses on regaining range of movement after an ACL allograft. Although the discussion ends somewhat abruptly, the issues raised include -

  • When is the optimum time after ACL rupture to be subjected to reconstructive surgery?
  • At what stage should one start to be really worried about stiffness, and concerned that true arthrofibrosis might be developing?
  • What kind of range of motion (ROM) is acceptable at this stage in rehab?
  • What exactly is an MUA (manipulation under anaesthesia)?
  • What is the procedure of 'lysis of adhesions' and at what stage of stiffness might it be appropriate?

 

Let's look at these in a bit more detail -

When is the optimum time after ACL rupture to be subjected to reconstructive surgery?

See this discussion - "The case for early reconstruction of the ACL" of the different viewpoints of knee surgeons Prof Craig Bottoni and Dr K Donald Shelbourne and Dr Stephen A Wasilewski.

 

At what stage in ACL rehabilitation should one start to be really worried about stiffness, and concerned that true arthrofibrosis might be developing?

See this section of a course by knee surgeon Dr Frank R Noyes - "Early signs and symptoms of arthrofibrosis" in which he discusses normal expectations after surgery and what signs and symptoms offer a high index of suspicion that arthrofibrosis may be developing.

 

What kind of range of motion (ROM) is acceptable at this stage in rehab?

This postoperative rehabilitation protocol for anterior cruciate ligament reconstruction (patellar tendon graft - PTG) offered by knee surgeon Dr Robert F LaPrade gives an idea of the range of motion that is expected at each stage of rehab after ACL reconstruction.

 

What exactly is an MUA (manipulation under anaesthesia)?

Here is a video showing an MUA of a sedated patient performed by Dr Ty Talcott. Not every practitioner will perform an MUA in exactly the same way. By having the patient under anaesthetic or deep sedation, the clinician is able to gently but firmly take the knee through as much of a range of motion as possible in order to free any adhesions. A danger of course is that the inexperienced practitioner may be rough and cause damage to the tissues.

This video is really an MUA of much more than the knee, but you can get the idea.

 

What is the procedure of 'lysis of adhesions' and at what stage of stiffness might it be appropriate?

A lysis of adhesions is a surgical procedure to break down adhesions and scar tissue when the patient's problem has gone too far for an MUA and physiotherapy to resolve the stiffness. There are certain areas of the inside of knee where the soft tissues are in close apposition, and where scarring can be particularly troublesome. These areas include the tissues behind the tendon of the patella, the pouch-like space above and behind the patella, the 'gutters' on the lower side of the knee cavity and the area at the back of the knee cavity.

The word 'lysis' implies a 'dissolving' of the adhesions, and here in this video you can see Dr John Hardy using a wand-like instrument to do just this using radio-frequency.

 

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