I addressed this topic regarding the actuality of ligament reconstructions of the knee in the dissertation that I defended in June 2010, therefore I am sharing with you the accumulated information. Considering that the lateral ligaments are reconstructed less often, and the posterior cruciate ligament being a strong one does not break frequently, I focused on the recovery after the reconstruction of the anterior cruciate ligament. Ligament injuries can be isolated, or, more often, associated with other structures. The anterior cruciate ligament plays an important role in the biomechanics of the knee, and out of all the knee traumas, those of LIA are the most frequent.
Currently, it is considered that, in patients who have suffered injuries to the anterior cruciate ligament and who have not undergone reconstruction, the rate of meniscal injuries is 60-80%. If the meniscectomy is then performed, these patients will develop arthritic diseases. Therefore, it is very important to treat any existing injury at the level of the cruciate ligaments, because otherwise it becomes a long-term problem. Currently, special importance is given to prophylaxis, knowing that it is simpler and cheaper to prevent than to treat, the most effective method to prevent injuries at the level of the anterior cruciate ligament being the strengthening of the muscles of the lower limbs. Other measures that can reduce the incidence of injuries at this level are: avoiding high-heeled shoes, avoiding excess weight, avoiding walking on rough terrain, avoiding sports that require a lot of twisting and contact.
Currently, two methods of treatment are used:
- Orthopedic treatment is practiced in people over 50.
- Surgical treatment is used in athletes and active people, reducing the risk of arthrosis in the long term.
Currently, the arthroscopic method with autologous graft is used: from the patellar tendon (Kenneth Jones procedure) – the controversial method and from hamstings “paw” tendons. Bioabsorbable screws are also used with good results, which reduce operative time and shorten recovery. The recovery starts right before the surgery, doing mechanical work beforehand facilitates the “awakening of the quadriceps” immediately after the surgery. Knowledge of the transformation processes through which the tendon goes until it reaches the ligament-type structure must be well known by the physiotherapist in order to be able to develop the recovery protocol. The objectives pursued are: combating pain and inflammation, restoring stability and increasing mobility. Several factors can influence the occurrence of pain: the graft used, the surgical technique and the rehabilitation program. The patellar tendon graft is responsible for pain in most cases. The correct management of pain is given by finding the correct etiological diagnosis. Massage, laser and electrotherapy are used with good results with an analgesic effect, and to combat inflammation they resort to: cryotherapy, evacuation points, infiltrations, lymphatic drainage massage. Active movements are essential for the recovery of support, considering that the strength of the quadriceps is significantly affected even by a 48-hour immobilization of the knee. It has been shown that the electrical activity of the muscles does not increase if the load does not exceed 50% of the maximum force. The “musculature of the four faces” is the central element in order to increase the stability of the knee. The new studies show that training the quadriceps is more efficient at an angle of 600, and through closed kinematic chain exercises, and, unlike the quadriceps, the strength of the hamstrings is not much compromised, being able to be trained at any angle but having a tendency to retraction. The sural triceps has an important role in unipodal support, and the tensor fascia lata has a role in locking the knee. The current practices in obtaining mobility assume the reduction of the flexum and the gain of the flexion. In order to achieve these desired goals, the following are used: postures, massage, stretching, neuroproprioceptive facilitation techniques, passive mobilizations (preferably in water), passive-active, active-assisted movements, but active movement still being basic.
The recovery protocol is divided into 5 periods, so from day 2 the patient gets out of bed, and in week 3 the knee must not be painful and achieve a flexion of 600. At the end of the second period at 45 days, the knee will be unprotected and has a mobility of 1200 in flexion. in the third period proprioception and cardiovascular retraining are trained. in the 4th period, changes of direction are made, and in the 5th period, you can return to sports. Regardless of the type of ligamentoplasty, physical therapy pursues the same goal, but the immobilization is variable. Early movement with load is essential because it helps to fight back pain and tone the muscles. Isometrics are used until the inflammation subsides, then we move on to isotonics, but to obtain good results, the patient’s will is decisive. If the recovery is done correctly, the new ligament will behave like a strong one. I think that hamstring autograft will be the gold standard in ligament reconstructions in the future, because it significantly reduces pain. Also, the recovery protocol is indicative, but must be individualized for each individual case. in athletes, sitting during recovery contributes to cardiac maladaptation. therefore, physical therapists must complete the care of sports injuries through specific training with cardiorespiratory exercises.
Felician Strete