Progressive rehab while deciding on surgery (II)

As rehabilitation progresses after a cruciate ligament injury, the focus shifts to normalising ordinary movements.

First published in 2008, and reviewed August 2023 by Dr Sheila Strover (Clinical Editor)

This section is a continuation of Part 7a. I have split it into two parts so that you can benefit from larger images.

Stage 3

• Introduce balance and co-ordination work
• Progress strengthening exercises - single leg work, cycling, trampette, gym work

	Single leg balance and dips - practise standing and balancing on one leg, keeping your hips level and your knee straight - 30 seconds increasing to 1 minute. Progress to small single leg dips, again keep pelvis level, foot flat on the floor and bend the knee directly forwards over the middle of your foot. Only 10 reps but slow, controlled and repeat regularly.
	Terminal knee extension - place a piece of elastic resistance banding around a secure anchor which is approximately knee height. Put your leg inside so that the band is behind your knee. Step away so that you have to bend your knee to relax the tension on the band. Brace your knee back straight against the resistive band, hold for a few seconds and slowly relax. Begin by doing this with both feet on the floor (band around injured knee) then progress to single leg only.
	Balancing on a rubber cushion (or other soft surface), progress to dips as above.
	Gym-ball squats - stand with your calves against the ball (the ball must be against a wall). Fold your arms, slowly lower your behind onto the ball until your knees are bent to 90 degrees but do not sit - then straighten up but do not lift clear of the ball, repeat as many times as you can. You are roughly working in the middle third of a squat movement, this is tough on the thigh muscles.
	Gradually increase the height and number of step-ups.
	The trampette is great for proprioception training. Try single leg balancing, stepping from foot to foot and progress to gentle jogging - you may wish to have something to hold nearby, initially.

At this stage you could start to attend your local gym. The advantage of the gym is that it is a controlled environment and all exercises are 'straight line' in nature - there is no twisting or turning involved. Begin using the aerobic equipment - the static bicycle, the rower, the cross-trainer, the stepper - these are all closed chain activities and should not be a problem. Start by doing just a few minutes on a variety of different exercises rather than spending a long time on just a single piece of equipment, this way you will work more muscles in a greater variety of ways. You can also do some walking on the treadmill - gradually increase speed and distance but do not run yet.

If you want to lift fixed weights then you can do hamstring curls and leg press but avoid the quads bench (leg extensions in a sitting position) - these are open chain exercises. Begin lifting low weights and doing more repetitions, rather than trying to lift maximum weight, of course you can do any upper body training you wish.

	You can use a wobble or rocker board for balance training. If you have a rocker board you can also try heel raises and half squats while maintaining balance (have the board so that it rocks sideways).
	Begin walking on a treadmill. Brisk walking is good exercise - aim to build the speed up to 6km an hour, on the flat, for 1km (i.e. 10 minutes) before you consider increasing the incline. Steadily increase the time but no running
	Use a variety of other equipment in the gym such as this stepper, the rowing machine and the X-trainer. These will not only help to strengthen your knee but will improve your general fitness and confidence.

Stage 4

• Introduce change of direction activities
• Brisk walk / jogging programme

	Side-stepping - begin walking 5 steps to left & 5 steps to right, gradually increasing the speed. A bungi cord can be used around the waist to add resistance if available.
	Angled lunging - practice lunging directly forwards initially and then alter the direction of the forward leg moving from 10 o'clock through to 2 o'clock. You can use resistive cording around your waist if available.
	If you have access to suitable equipment you can do sideways movements on a slide board or on this 'fitter'.

Now is the time to try some running, you must start gently and build up gradually. Begin by increasing the speed of the treadmill up to a gentle jog, just for a couple of minutes, in the middle of a brisk walk (perhaps walk for 5minutes, jog for 2 and then back down to a walk again). Providing you do not have any adverse reaction you can steadily increase the jogging time and decrease the walk. Do not increase the speed beyond a gentle jog until you are completely comfortable.

The treadmill is the ideal place to begin a running programme because the surface is obviously flat, not too hard and the environment is controlled.

You can progress to running outside when you are confident but no cross country or accompanying football yet!!

Stage 5

This is the final stage before you return to full sports training.

Activities must be increased to include acceleration, deceleration and cutting movements. Jumping and hopping activities, including plyometric training, can be started. It is also important that you try to simulate some of the movements involved in your own particular sport - if you play soccer you can start dribbling and passing a ball, if you are a basketball player you can start dribbling the ball, initially in a straight line and then between cones - eventually add a jump shot at the end.

If you are attending a gym you may choose to join a training class at this stage - circuit training, step aerobics etc. will all help to improve strength, agility, endurance and general fitness. Be sure that the instructor knows that you are recovering from injury and you may not complete all activities.

	Carioca stepping/running - moving sideways, cross one leg alternately in front of and behind the other leg. Be sure to reverse the movement and go in the opposite direction. Gradually increase the speed of both movement and change of direction.		Figure 8 running - place two markers, perhaps 15-20 feet apart depending how much space you have, gently jog around them in a figure 8. Progress by accelerating and decelerating to vary the speed, change direction and eventually make turns sharper by bringing markers closer together. Get someone to help you by calling out varying instructions.
	Multi-directional jumping - mark out a grid pattern. Jump from square to square in forwards, backwards, sideways and diagonal directions. Get someone to call out random directions for you as you get more confident.		Multi-directional hopping - progress from jumping as above, to hopping, again in all directions.
		Jumping, rebounding and landing - plyometric training. It is important to combine these actions and, as you gain confidence, to progress to include occasional single leg take off and landings. In this picture the young man has jumped up two small steps, down onto the trampette and rebounded onto the mat. This has been taken from a video sequence - apologies for quality.

When you can successfully complete these activities without any symptoms and you feel confident that your leg is as strong as your other leg you can go back to your sports training. If you play a contact sport you will require a period of non-contact training before the contact element is added. How about trying skipping with a rope, this is easy to do at home and will also help your general fitness?

If at any time you have a period if relative inactivity such as a long vacation, then it is important for you to fully regain any loss of strength before you play competitive sport again.

Good luck, keep your leg strong and hopefully you will not have further problems.

If you have experienced episodes of instability or feelings of 'giving way' at any stage then you should go back a stage. If you find it impossible to progress because any increase in activity results in instability or giving way, you should seek further help. You may need to reconsider your expectations or consider surgery.

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