Role of a Physiotherapist During an ACL Injury 1

Research Paper

ACL Injury Prevention

Austin Swedish

Career Life Education 11

Mr. Koshman

11-20-17
Role of a Physiotherapist During an ACL Injury 2

Research Paper

The physiotherapist has one of the most important roles in the rehabilitation process. A properly

guided rehabilitation program is required to minimize the effects of an injury such as swelling

and loss of motion as well as acquiring the necessary strength and stability of the joint. The best

way to treat an ACL injury is to prevent one from happening in the first place. The research will

educate me in the prevention and care of an ACL injury.

Rehabilitation of an ACL injury should be patient specific. Though the program will be the same

for everyone, but the progression of the program may be very different between patients. For

example if a patient has a lot of inflammation and swelling then that needs to be dealt with

first before exercises. As well as the program the physiotherapist may use modalities such as ice,

laser, IFC, ultrasound and massage to help with pain, swelling and inflammation. Patient

education is also very important, the physiotherapist will inform the patient about precautions,

contraindications and self-management.

Injuries happen, but a physiotherapist can minimize the occurrence of these injuries by doing a

full biomechanical assessment looking at body and foot alinement, muscle imbalances,

movement patterns and training techniques. For example foot alinement is very

important because if the foot isn't in proper alinement then the knees are also in a bad position

making them more prone to injury. The same goes for someone who has a muscle imbalance in

their hip, the hip may not be strong enough to hold the leg in proper position. Improper training

is also a big cause of injuries. For example, a basketball or volleyball player has to learn how to

properly jump and land. This program can train the muscles to develop a muscle memory that
Role of a Physiotherapist During an ACL Injury 3

will help their hamstrings contract at the right time when they land, helping with knee bend. It

will also train the abductor muscles to keep the legs wide apart when they land.

The knee is a hinge joint, made up of two separate joints. The tibiofemoral and

the patellofemoral joints. The joints are held together by ligaments with cartilage in-between

the bones acting as a shock absorber. The tibiofemoral joint is the joint that is affected with an

ACL injury. The ACL ligament attaches to the femur at one end and the tibia at the other. It

keeps the tibia from moving forward on the femur. The hamstring muscles and quadriceps

muscles act as dynamic stabilizers of the tibiofemoral joint.

Most ACL injuries occur in sports involving pivoting, hyper deceleration and jumping. The

typical ACL injury occurs with the knee externally rotated and in 10 to 30 degrees of flection

when the knee is forced inwards and then internally rotates. Another way is when the knee is

hyperextended, ether from being hit from the front or from rapid deceleration.

From doing this project I hope to gain enough knowledge to prevent any further injuries to

myself, but also have a good understanding into physiotherapy and whether its the right job

for me.

Physiotherapists are primary health care professionals with a significant role in health

promotion and treatment of injury and disease. They combine their in-depth knowledge of the

body and how it works with specialized hands-on clinical skills to assess, diagnose and treat

symptoms of illness, injury or disability. ( Canadian Physiotherapy Association, 2017). All

practicing physiotherapists must be registered in Canada. They must have an entry level

education and practice standards, and have successfully passed a standardized physiotherapy
Role of a Physiotherapist During an ACL Injury 4

competence examination. Eleven million Canadians over the age of 12 years old are affected by

musculoskeletal (MSK) conditions annually. Strong evidence exists to support physiotherapy in

their treatment. Physiotherapy contributes to improved physical function, allowing individuals to

return to healthy living, including return to work and recreational activities ( Canadian

Physiotherapy Association, 2012). Physiotherapists assess and treat patients in order to reduce

and eliminate pain and swelling, and address muscle weaknesses, imbalances, loss of stability

and limited functional abilities. One in ten Canadians with a musculoskeletal condition consults

with a physiotherapist ( Canadian Physiotherapy Association, 2012)

Physiotherapy roles include:

Education, consultation, health promotion and prevention services.

Personalized therapeutic exercise including testing and conditioning, neurotherapeutic

approaches to improve strength, range of motion, and function.

Soft tissue and manual therapy techniques; including massage, spinal and peripheral joint

mobilization and manipulation.

Physical, electrotherapeutic and mechanical agents; and acupuncture.

Cardiorespiratory techniques including airway clearance methods.

Skin and wound care.

Management of incontinence including pelvic floor re-education.

Functional activity and tolerance testing and training.

Work and occupational re-training and return to work planning.

Prescription, fabrication and application of assistive, adaptive, supportive and protective

devices and equipment.

Role of a Physiotherapist During an ACL Injury 5

Environmental change, focusing on removing barriers to function.

Physiotherapy management of an ACL injury focuses on regaining movement, strength,

proprioception and stability. The rehabilitation process is an ongoing process with specific

changes to the program based on their progression, healing times, tolerance to exercises and any

previous injuries.

The major goals of rehabilitation of the ACL injured knee:

Gain good functionality stability.

Repair muscle strength.

Reach the best possible functional level.

Decrease the risk of re-injury.

The ACL rehabilitation program is separated into 6 phases and should be closely monitored by a

physiotherapist or sports therapist according to your surgeons rehabilitation protocol.

Before Surgery

RICE and electrotherapy can be applied during several weeks ahead of the surgery in order to

reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. This will

help the patient to regain better motion and strength after the surgery. The patient must be

mentally prepared for the surgery.

Before proceeding with surgery, the acutely injured knee should be in a quiescent state with little

or no swelling, have a full range of motion, and the patient should have a normal or near normal
Role of a Physiotherapist During an ACL Injury 6

gait pattern.

It is important to prepare the knee for the surgery. These are the guidelines:

1. Immobilize the knee

Use a knee immobilizer and crutches until you regain good muscular control of the leg.

Extended use of the knee immobilizer should be limited to avoid quadriceps atrophy.

2. Control Pain and Swelling

Icing and anti-inflammatory medications are used to help control pain and swelling.

3. Restore normal range of motion

Quadriceps isometrics exercises, straight leg raises, and range of motion exercises should

be started immediately to achieve full range of motion as quickly as possible.

A. Full extension is obtained by doing the following exercises: Passive knee extension,

Heel Props, Prone hang exercise.

B. Bending (Flexion) is obtained by doing the following exercises: Passive knee bend,

Wall slides, Heel slides.

4. Develop muscle strength

Once 100 degrees of flexion has been achieved you may begin to work on muscular

strength. Examples of exercises are: Stationary Bicycle, Swimming, Low impact exercise

machines such as an elliptical cross-trainer, leg press machine, leg curl machine, and

treadmill can also be used.

5. Mentally prepare

Patient must know what to expect of the surgery and understand the rehabilitation phases

after surgery.
Role of a Physiotherapist During an ACL Injury 7

Pre-op therapy should encourage strengthening of the quadriceps and hamstrings. Range of

motion exercises should be included if there is no pain involved. See below for examples of

appropriate exercises.

After Surgery

Week 1

Regular icing and elevation are used to reduce swelling. The goal is full extension

and 70 degrees of flexion by the end of the first week. The use of a knee brace

and crutches are imperative.

Multidirectional mobilizations of the patella should be included for at least 8

weeks. Other mobilization exercises in the first 4 weeks are passive extension of

the knee (no hyperextension) and passive and active mobilization towards flexion.

Strengthening exercises for the calf muscle, hamstring and quadriceps (vastus

medialis) can be performed.

Week 3-4

The patient must try to genuinely increase the stance phase in an attempt to walk

with one crutch. With good hamstring/quadriceps control, the use of crutches can

be reduced earlier.

Week 5

The use of the knee brace is progressively reduced. Passive mobilizations should

normalize motility but flexion should not yet be thorough. 9 Tonification of

Role of a Physiotherapist During an ACL Injury 8

hamstrings and quadriceps (vastus medialis) can start in close chain exercises.

The exercises should be started on light intensity (50% of maximum force) and

progressively increased to 60-70%. The closed chain exercises should be built

from less responsible positions (bike, leg presses, step) to more congested starting

positions (ex.squad). The progress of the exercise depends on pain, swelling and

quadriceps control. Proprioception and coordination exercises can start if the

general strength is good. This includes balance exercises on boards and toll.

Week 10

Forward, backward and lateral dynamic movements can be included as well as

isokinetic exercises.

Month 3

After 3 months, patient can move on to functional exercises as running and

jumping. As proprioceptive and coordination exercises become heavier, quicker

changes in direction are possible. To stimulate coordination and control through

afferent and efferent information processing, exercises should be enhanced by

variation in visible input, surface stability (trampoline), speed of exercise

performance, complexity of the task, resistance, one or two-legged performance,

etc.
Role of a Physiotherapist During an ACL Injury 9

Month 4-5

Final goal is to maximize endurance and strength of the knee stabilizers, optimize

neuromuscular control with plyometric exercises and to add the sport-specific

exercises. Acceleration and deceleration, variations in running and turning and

cutting manoeuvers improve arthrokinetic reflexes to prevent new trauma during

competition. (Bill Garcia, 2014)

ACL injuries are becoming quite common these days, however many of them can be prevented.

A physiotherapist can teach proper alinement to help protect the knees, help develop body

awareness, improve strength and balance to help support the knees, and instruct on correct

jumping, landing, stops and movement patterns. A successful prevention injury program would

focus on:

Improving flexibility.

Strength, particularly the core, hips and legs.

Balance.

Agility.

To jump and land safely.

Recent research has allowed therapists and clinicians to easily identify and target weak muscle

areas (e.g., weak hips, which leads to knock-kneed landing positions) and identify ways to

improve strength and thus help prevent injury. In addition, other risk factors such as reduced

hamstring strength and increased joint range of motion can be further assessed by a physical

therapist or athletic trainer to improve performanceor rehabilitation efforts after an injury has
Role of a Physiotherapist During an ACL Injury 10

occurred. Current studies also demonstrate that specific types of training, such as jump routines

and learning to pivot properly, help athletes prevent ACL injuries. These types of exercises and

training programs are more beneficial if athletes start when they are young. It may be optimal to

integrate prevention programs during early adolescence, prior to when young athletes develop

certain habits that increase the risk of an ACL injury. (Ervin Meqikukiqi, 2015)

The knee joint is one of the largest and most complex joints in the body. It is constructed of four

bones and an extensive network of ligaments and muscles. The knee is made up of two separate

joints. The tibiofemoral joint and the patellofemoral joint. The joints are held together by four

ligaments. Each ligament has a particular function in helping to maintain optimal knee stability.

The ACL is important for resisting anterior translation (moving forward) of the tibia on the

femur. The ACL runs from the anterolateral aspect of the medial intercondylar tibial spine to the

posteromedial aspect of the lateral femoral condyle. It is believed that there are two bundles of

fibres that form the ACL. Which bundle of the ACL is injured depends on the position of the

knee when it is strained. The ACL is also an accessory ligament in resisting rotary medially and

laterally as well as values and varus forces. The tibiofemoral joint is the joint that is affected with

an ACL injury.

A physiotherapist plays the strongest role in rehabilitating a patients ACL injury because

everyone heals at a different rate and experiences different signs and symptoms after an ACL

injury. The physiotherapist must be able to assess where the person is in the healing process and

what the signs and symptoms mean and then apply the correct treatment. This treatment may

include modalities to help with pain and swelling or could be teaching the right exercises to the

patient for increasing quadricep strength. The rehabilitation program is pretty straight forward,
Role of a Physiotherapist During an ACL Injury 11

but the progression of the program is very specific for each person. With the help of a

physiotherapist, a person could safely progress through the program with fewer incidents of

execrations and be back in action quicker and safer.

Role of a Physiotherapist During an ACL Injury 12

Bibliography

About Physiotherapy. Canadian Physiotherapy Association, 2017, physiotherapy.ca/about-

physiotherapy.

The Value of Physiotherapy. Canadian Physiotherapy Association, 2012,

physiotherapy.ca/value-physiotherapy

Garcia, Bill. Anterior Cruciate Ligament (ACL) Rehabilitation. Anterior Cruciate Ligament

(ACL) Rehabilitation - Physiopedia, 2014, www.physio-

pedia.com/Anterior_Cruciate_Ligament_(ACL)_Rehabilitation.

Meqikukiqi, Ervin. ACL Prevention | Sports Medicine 2015 | Conferenceseries Ltd. ACL

Prevention | University Of Medical Sciences, Pristina | Sports Medicine 2015 | Conferenceseries

Ltd, 2015, sports.conferenceseries.com/abstract/2015/acl-prevention.

Karadsheh, Mark. Knee Biomechanics. Orthobullets,

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