Pre and post-operative management of the anterior cruciate ligament (ACL) what are the best practices

Article written by Antoine FRECHAUD and Nathan Touati, publishing directors at NeuroXtrain

Introduction

Anterior cruciate ligament (ACL) rupture occurs most often in young, active individuals and can have long-term negative physical and psychological consequences. Diagnosis is based on a combination of the patient's history, clinical examination and, often, confirmed by magnetic resonance imaging.

The main objectives of the support are to:

• Restore knee function,
• Eliminate psychological obstacles to participation in an activity,
• Prevent further injuries and osteoarthritis and optimize long-term quality of life.

The three main ACL tear treatment options are:

• Rehabilitation as first-line treatment followed by ACL reconstruction (RLCA) in patients who develop functional instability or even in those who have regained good knee stability.
• RLCA and postoperative rehabilitation as first-line treatment
• Preoperative rehabilitation followed by RLCA and postoperative rehabilitation which is the most widespread and complete method offered to date.

What are the best practices to have?

The management of ACL rupture therefore generally consists of a first pre-operative phase and a second post-operative phase which are two phases with relatively similar objectives.

These phases consist of rehabilitation which must be carried out to improve post-surgical results. Rehabilitation should begin as soon as possible after diagnosis. Preoperative rehabilitation follows the principles of postoperative acute and intermediate phase rehabilitation, but deficits in passive and active knee extension range of motion and quadriceps and hamstring strength must be specifically targeted, as these factors are associated with poor post-surgical outcomes.

It is crucial during the pre- and post-operative phases to prepare the knee in the best possible way for the operation and for the start of post-operative rehabilitation. That is to say having a “dry” knee, therefore without edema, and functional with a good range of movement, and the main quadriceps and hamstring muscles with adequate strength.

To obtain good amplitude and strength of contraction, it will first be imperative to control this edema and make the knee as dry as possible. To control inflammation, we will have several good practices to follow:

• Elevation of the injured limb

Lift the affected limb as often as possible, so that it is higher than the heart.

• Protection

Stop activities causing pain during the first few days.

• Cold (cryotherapy) & compression of the area with edema

The application of cold will help control the inflammation without completely cutting it off like an anti-inflammatory medication would do. Inflammation plays a crucial role in allowing healing, we do not want to completely cut it off, but simply control it to avoid its abundance and therefore excessive edema which would hamper the operation or post-operative rehabilitation.

Applying cold locally during this first phase is therefore the solution of choice, and coupling this with compression seems to be the perfect solution. Cold and compression will play an important role in the recovery of tissue damage, including reducing cellular metabolism, delaying nerve conduction, inhibiting the expansion of edema and relieving pain.

For this there are cold kits Excell’ICE which revolutionize recovery by combining cryotherapy with adjustable static compression, controlled by an inflation pump. Its easy application involves recovery and/or healing sessions, particularly recommended after an injury or post-operatively. It is well established that static compression with ice intensifies skin cooling. ORTHONOV's innovation lies in its innovative concept where the compression chamber is integrated directly into the cold pack. This technological advancement simplifies compressive cryotherapy recovery sessions, lasting 20 to 30 minutes. These wearable devices are perfect for on the go, allowing athletes to instantly relieve musculoskeletal pain after their matches or competitions.

• Vascularization

Do cardiovascular activities to irrigate damaged tissues and increase their metabolism while respecting the condition of the injury.

• And the quantification of the workload

Quantify your mechanical stress by integrating weight bearing and movement, without causing pain.

Conclusion

Once these good practices have been implemented, all that will be required is to follow appropriate rehabilitation including exercises to gain amplitude, particularly in flexion and extension, as well as quadriceps muscle awakening exercises which, in some people, can find themselves inhibited. This inhibition can be linked, conversely, to overly contracted hamstrings and too much edema in the knee, hence the importance of implementing good pre- and post-operative practices.

As soon as the amplitudes and sensations of contractions are regained, all that remains is to follow a program of strengthening and resumption of support and activity over the months of rehabilitation. For more information on this pathology and its treatment, go to this article Rupture of the anterior cruciate ligament (ACL): explanation and treatment on the NeuroXtrain website.

All content in this article is presented for informational purposes. It does not in any way replace the advice or visit of a health professional.

Sources:

• Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47. doi: 10.1016/j.berh.2019.01.018. Epub 2019 Feb 21. PMID: 31431274; PMCID: PMC6723618.

• Evans J, Nielson Jl. Anterior Cruciate Ligament Knee Injury. [Updated 2022 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available