A consistent and medically determined follow-up treatment is crucial for the recovery of the knee joint after anterior cruciate ligament reconstruction. This is systematically structured and adapts to the progress of the healing process. From the first day postoperatively to the 360th day, recovery processes take place in the knee joint.
The following text describes the individual phases with their therapeutic content. The medical training therapy is part of the final healing phase. It aims at muscle growth on machines. However, before this can happen, the active inflammatory processes in the knee joint must be completed.
Aftercare
In the inflammatory phase (0-5 day postoperative), which is divided into the vascular phase and the cellular phase, the first healing processes occur. In the vascular phase (up to 48h postoperatively) a massive number of leukocytes and macrophages enter the tissue. These are part of the immune system.
The cells in the tissue begin to recover from the injury to the vascular system, which allows oxygen-rich blood to enter the tissue. This results in an increased PH value, which in turn triggers the necessary stimulus for further wound healing. The active macrophages ensure the division of fibroblasts into myofibroblasts.
These become necessary for the new formation of the cells. Likewise, the collagen synthesis for collagen type 3 begins, which is found exclusively in the inflammatory phase. Collagen 3 is primarily responsible for wound closure and forms the basis for further collagen synthesis.
In the cellular phase, further myofibroblasts are formed and collagen type 3 continues to close the wound. The tissue is still slightly resilient. Many sensitive nociceptors are found at the site of the injury.
These protect the tissue from overloading through their sensitivity to pain. Pain is an important warning signal of the body. For this reason, pain should be adapted during this phase and moved in a tension-free area.
Phase I, 1st to 2nd postoperative week, goals:
- Pain relief
- Edema reduction
- Maintaining or improving mobility in the femoropatellar joint
- Active movement 0-0-90° at the end of the second week
- After removal of drainage 0-0-90
- Manual lymphatic drainage (MLD) directly postoperative
- Cooling/ice directly postoperative
- Adequate pain therapy
- Mobilization on forearm crutches (UAG) with 20 kg partial load
- Thrombosis prophylaxis
- Instructions for self-mobilization of the patella
- Moving the knee joint in the pain-free area
- Working out the cocontraction in different flexion positions
- CPM in a painless range of motion, max. 0-0-90
- Physiotherapy under consideration of the partial load in a closed system
- If necessary, training techniques (e.g. Vojta or similar) to train proprioceptive skills
- Traction level I femorotibial
- Active splint
- Muscle stimulation device especially for the vastus medialis muscle
- MLD (manual lymphatic drainage)
- No stretching or strong activation of the ischiocrural muscles (after removal of the semitendinosus and/or gracilis tendon)
This phase (day 5-21 postoperatively) is characterized by the formation of new tissue. Here it is crucial to convey to the new fibers what they are needed for.
If these are only kept still in a gentle position, they adapt to this situation, stick together and intertwine. In order to avoid this, the knee joint must be regularly moved passively and actively in its physiological sense and stimuli must be applied in the direction of the tensile stress (controlled stretching). Muscles can already be strengthened isometrically to a suitable degree.
In this way, the fibers of the new tissue are optimally aligned for their later function. It is important not to put too much strain on the tissue yet, which in turn would disturb the healing process. At the beginning of this phase, movement should be carried out without much strain (in the pain-free area) and increased mobilization should take place.
In the later course of the proliferation phase, light strengthening exercises can now be added, whereby exercises with long levers and heavy loading should be avoided. The actual inflammation should be completed, the number of leukocytes, macrophages and lymphocytes should decrease. From the 14th day on, only myofibroblasts are left in the new tissue.Collagen synthesis and myofibroblast activity is crucial in this phase to further stabilize the wound.
It is also important to develop a proper gait pattern during the wound healing period. Phase II 3rd to 6th postoperative week Goals Measures
- Increase in load up to full load taking into account the swelling
- Restoration of coordinative abilities
- Stabilization of the physiological pelvis-leg axis
- Range of movement in the painless area, but maximum 0-0-120°.
- Intensification of proprioceptive training, e.g. Posturomed, SRT, mini trampoline, balance pad
- Cautious start of MTT in a closed system
- Bicycle ergometer/endurance equipment
- Stretching of all muscles except the ischiocrural group
- Training with proximal resistors
- Aqua training
Day 21-360. Postoperative.
The fibroblasts multiply and begin to synthesize the basic substance, thus improving the elasticity of the tissue. The newly formed collagen is more strongly stabilized and increasingly organized. The collagen fibers become thicker and more resilient.
Type 3 collagen fibers are slowly converted into type 1 collagen fibers. Myofibroblasts are no longer needed and disappear from the tissue. Up to the 120th day, collagen synthesis remains highly active and on about the 150th day, 85% of the collagen type 3 has been converted into collagen type 1.
The number of fibroblasts decreases steadily, cellular tissue of wound healing has been transformed into the resilient tissue of collagen type 1. Movements are finally allowed and the load can be increased. The therapy is only complete when the tissue can withstand the stresses of everyday life.
The devices can be included in the movement therapy. However, in cruciate ligament surgery it should be noted that the load should be increased slowly. Exercises in the closed system should first be worked out in order to be supplemented by the open system in the later course of wound healing.
The behaviour patterns learned up to that point are slowly replaced by normal movements to strengthen the newly formed tissue. Circulation-enhancing measures can still be applied as needed. The main focus in this phase of wound healing is to increase training.
All movement directions should be trained again. In addition to the training, the improvement of neural structures and the improvement of mobility, which are still part of physiotherapy/therapy, especially strength training is increased. A prerequisite for this is freedom from pain and the achievement of complete freedom.
Exercises can then be performed on equipment. Under the supervision of qualified personnel the affected muscles are trained with specific exercises. Through the individually guided training, the strength is rebuilt on special equipment and thus the joint is restored to its original stability and functionality. Phase III, 7th to 12th postoperative week, goals and measures:
- Achieving full mobility and strength
- Normalization of everyday activities
- Start of training in the open chain
- Sport specific training
- Complex coordination training
- Running training on level ground