CRUCIATE LIGAMENT RECONSTRUCTION WITH THE QUADRICEPS TENDON

In the first phase of rehabilitation the emphasis is on protecting the knee joint while at the same time carrying out early functional mobilisation. The aim is to support the healing of the graft and to avoid complications such as swelling, restricted movement or loss of muscle.

Aims:

• Reducing swelling and pain
• Restoring full extension of the knee
• Working towards free flexion to 90 degrees
• Improving neuromuscular control

Measures:

• Partial weight-bearing with forearm crutches for about 2-3 weeks (20-30 kg)
• Knee orthosis in extension (where needed, for instance with accompanying injuries)
• Cooling and manual lymphatic drainage to reduce swelling
• Early functional physiotherapy: passive and assisted mobilisation exercises (CPM, levels 1-2)
• Isometric muscle training: activating the quadriceps, leg axis training

In the second phase of rehabilitation the emphasis is on a controlled build-up of load. The knee is gradually introduced to everyday movement, while targeted exercises encourage muscular stability and co-ordination.

Aims:

• Extending the range of movement (flexion to at least 120 degrees)
• Regaining reliable full weight-bearing in everyday life
• Strengthening the thigh and pelvic muscles
• Improving the stability of the joint and proprioception

Measures:

• Progression from partial to full weight-bearing (depending on the findings)
• Targeted muscle training in closed chains (for instance leg press, mini-squats, step-ups)
• Balance training and co-ordination exercises (for instance on unstable surfaces)
• Exercise-bike training without, and later with, light resistance
• Gait analysis and correction of faulty loading

A return to light work is often already possible in this phase – depending on how healing progresses and on the demands of the workplace.

In this phase the focus is on targeted building of muscle and on increasing how much load the operated knee can tolerate. The joint is now asked to do more, so that it is introduced step by step to sporting and dynamic movement.

Aims:

• Symmetrical build-up of strength in the leg muscles
• Stabilising the knee joint under dynamic load
• Improving co-ordination, balance and reaction
• Preparing for sport-specific patterns of movement

Measures:

• Strengthening with increasing resistance (for instance free weights, resistance bands)
• Training in open chains (free leg extension, lunges, forward lunges)
• Balance and jump training: for instance single-leg stance, hopping exercises, co-ordination drills
• Treadmill training, skipping and first changes of direction
• Targeted training of movement sequences, for instance climbing stairs or fast stop-and-go movements

Important: training continues under physiotherapy guidance, in order to avoid overloading and faulty movement. Capacity is increasing, but the graft is still in its biological remodelling phase.

The aim of the final phase of rehabilitation is to restore full physical capacity and to allow a safe return to sporting activity. The graft is now largely integrated biologically and sport-specific training can take place.

Aims:

• Restoring full functional capacity
• Stability, strength and co-ordination at a sporting level
• Mental and physical preparation for the demands of competition
• Avoiding overloading and re-rupture

Measures:

• Sport-specific training at high intensity (for instance sprinting, changes of direction, jump training)
• Return to team or contact-sport training under supervision
• Standardised return-to-sport tests (for instance hop tests, Y-balance, strength measurement)
• Individual adjustment of the load according to sport, playing position and level of performance
• Mental training to restore confidence and reliable reactions

Final clearance for competitive sport is given after 9-12 months at the earliest and rests not on time alone but on functional tests, objective strength ratios and the clinical assessment by doctor and therapist.