Physiotherapy Rehabilitation for Post Ligament Injury - Varsha Jalandhara, DPT

Physiotherapy Rehabilitation
post Ligament injury
Varsha Jalandhara DPT
Acute Stage of
injury
The main aim of physiotherapy in the acute stage
is reduction of inflammation and pain. 1.
Cryotherapy – Ice packs for 15 min every hour.
2. Modalities like diapulse, ultrasound therapy,
interferential therapy and TENS can be used.
3. Compressive or pressure bandage with limb in
elevation.
4. Protection of knee from the position of stress.
5. Early initiation of isometrics for the quadriceps. They
should be done at least for 5 min every hour. Prevention of
quadriceps wasting and reflex inhibition is important. The
isometrics, progressed slowly to the maximum and sustained
for 10–15 s, assist in strengthening the quadriceps; whereas
speedy isometrics help in resolution of oedema and effusion.
6. When the leg is immobilized in a POP cast, vigorous
movements to the ankle and toes are important to prevent
venous thrombosis and to augment circulation. Static
contractions to hamstrings and quadriceps in the cast are
encouraged. Attempt may be made to perform assisted SLR,
abduction of the hip and strong hip extension against the
resistance of the mattress.
7. If cast is not advised, a small range of self-assisted
relaxed gentle knee swinging could be initiated.
Sub acute injury
When the symptoms of the acute stage are reduced,
mobilization is initiated and progressed gradually
along with strengthening exercises.
1. Initiate mobilization with the patient sitting at
the edge of the bed or table, injured limb fully
supported by the sound limb.
The patient is guided to perform relaxed self-
assisted small range of slow rhythmic knee flexion
and extension. CPM is an ideal mode of
mobilization at this stage.
2. The range of quadriceps and hamstrings should be
recorded.
3. Passive exercise to be progressed to assisted active
or active as early as possible.
Self-assisted relaxed passive stretching of knee flexion
is excellent for improving the ROM of flexion.
Patient in supine or sitting position slides the foot as
far back as possible.
Then the patient plants the foot on the plinth and
slowly moves forward over the planted foot; the
maximally achieved flexion is maintained. This can be
more effective if it succeeds the relaxed free heel-drag
session.
4. Isometrics can be made self-resistive by the patient
applying graded resistance with hand. A soft roll is placed
under the knee.
The patient carries out isometric quadriceps setting while
resistance is applied by hand, exerting pressure by the web
between the thumb and the index finger 5–7 cm proximal to the
superior border of the patella. With isometric contraction, the
patella moves upwards.
The patient resists this movement with hand and then sustains
the isometric hold by continuously resisting upward pressure
exerted by quadriceps with the hand for 10–15 s. This can be
made more effective by adding ankle dorsiflexion with toes
stretched in extension.
We have found this to be a very effective self-controlled
isolated quadriceps exercise. It is also well acceptable to the
patient.
5. SLR- Progressed to SLR + SLA ( Side lying hip
abduction).
6. Knee flexion: Knee flexion exercises should be
practiced in prone position as well as on a static
bicycle. Speed, resistance and seat height of the static
bicycle should be properly adjusted so as not to
overstrain the knee. Begin with half circle of the pedal.
The session should be for 15 min initially, increasing
gradually to an hour.
7. 5. Relaxed knee swinging should be made speedy with
increased arc of movement to attain free mobility.
8. Progressive resistive exercise (PRE): Gradual self-resistive
exercise with self-generated tension or graded resistance
exercise with De’lorme shoe or weight belts to be initiated.
9. Flexibility exercises: Flexibility exercises of static stretching
using a 30-s hold, relaxing and performing five repetitions to
hamstrings, iliotibial band and gastrosoleus are important.
10. Vigorous programme: When the pain is minimal, ROM and
swelling are near normal. The endurance strengthening
flexibility exercises are made progressive by suitable
techniques. Progress to guided prone-kneeling, assisted
squatting, stair climbing and descending and cross-leg
sitting.
A.
Graduated spot running and jogging
to be initiated as soon as the pain
permits.
B.
 Patients should be encouraged to
begin aerobics and go back to work
with well learnt precautionary
measures. Advice on regular sessions
of continuous halfway floor squatting
to be emphasized to keep fit and to
prevent recurrence of sprain
Chronic stage of
Injury
Even chronic ligament injuries respond favourably
to the regime of knee strengthening and
hamstrings stretching exercises.
However, the knee should be well protected with a
knee brace during strenuous activities.
Patients with chronic ligament instability may show
weakness of hip muscles and hamstrings. This has
to be tested and strengthening exercises to these
muscle groups are included in the therapy whenever
necessary.
Surgical repair
Tears of the menisci: Torn meniscus is better
excised. The operation of meniscectomy can be
performed by an arthrotomy of the knee or by
arthroscopic surgery.
Open meniscectomy: 
It is performed by doing an
arthrotomy of the knee joint. A compression
bandage is given to the knee joint, after operation.
The bandage is removed after 2 weeks and the
knee is mobilized. Weight bearing, however, is
started after 3–4 weeks, after building up tone in
the quadriceps muscle.
Post operative management
of meniscectomy
1st day – Ankle circumduction.
2nd day – (a) Simultaneous quadriceps and hamstrings isometrics are very
important and should be endured.
(b) Walking, gradual weight bearing with crutches.
5th day – (a) Assisted SLR could be begun if not too painful. (b) Hamstrings
stretching sessions should be started.
2nd week –
(a) Active and active assisted flexion–extension exercises.
(b) Resistive hamstrings exercise to inhibit quadriceps thereby allowing more flexion.
(c) Passive patellar mobilization. Progress to resisted techniques.
Cycling and Running by 1 month.
Post operative
manegement after
ligament repair
There is usually a prolonged period of immobilization (about 6
weeks), hence:
(a) Ankle movements, quadriceps and hamstrings isometrics should
be started in the cast.
(b) Non–weight-bearing crutch walking should be initiated
immediately.
(c) Assisted SLR may be begun after a week.
(d) Knee hinge cast (functional cast bracing) may be applied after
10 days to allow small range of knee flexion–extension.
(e) By 6 to 8 weeks, the cast is removed. Knee flexion–extension
exercises are made vigorous.
Since the process of ligament
reorganization is very slow, these
patients should be put on vigorous
activities only after a year.
They may require 4–6 months to
regain full extension. Utmost care is
needed while teaching floor
squatting and cross-leg sitting.
Arthroscopy and Arthroscopic surgery
Arthroscope is a tubular endoscope through which the inside
of a joint can be visualized.
It is most commonly performed on the knee joint. However,
other joints like shoulder, elbow, wrist and ankle can also be
visualized with an arthroscope.
Indications for arthroscopy
1. Recurrence of symptoms
2. Locked knee joint
3. In the diagnosis of internal derangements of the knee joint
and loose bodies, etc.
Arthroscopy is very useful in the diagnosis and
assessment of various knee disorders and internal
derangements like tears of menisci and cruciate
ligaments.
Apart from diagnosis, the arthroscope is used for
therapeutic purposes also.
Nowadays, the various structures in a joint can be
operated upon without performing a formal
arthrotomy by inserting athroscopic fine instruments
through a second puncture in the joint.
This arthroscopic surgery helps in removal of torn or
degenerated menisci and loose bodies from the knee
joint and even helps in the reconstruction of torn
cruciate ligaments.
Arthroscopic surgery (diagnostic as well as
therapeutic) is performed through one or
two small puncture wounds in the skin.
Postoperatively, generally, a compression
bandage is given for about a week.
The period of hospitalization is only a
day or two. Therefore, the greatest
advantage of arthroscopy is rapid
rehabilitation.
Mobilization and non–weight-bearing can
be started within a week, and full weight
bearing in the second week.
Physiotherapy management after
arthroscopic surgery.
The physiotherapeutic management depends upon the type of lesion and the
arthroscopic procedure procedure which could be diagnostic or therapeutic.
In a diagnostic arthroscopy, the programme of physiotherapy is short and
simple. It is basically directed to maintain and improve the knee function.
The basic principles of physical therapy are as follows:
 1. Reduction of effusion
 2. Quadriceps isometric contractions
3. Maintenance of full ROM
4. Relaxed knee swinging
5. Proper weight bearing and walking
Physiotherapy for arthroscopic surgery: As for any other surgical
procedures, the management falls into the following two distinct
phases.
 
Preoperative training This has a conditioning
effect
 
on the patients and shortens the period of recovery. It
consists of:
1. Teaching the exact technique of isolated, sustained isometric
submaximal contractions of the quadriceps to avoid atrophy and
reflex inhibition.
 2. Relaxed speedy quadriceps settings to reduce effusion and oedema.
3. SLR to stabilize the knee.
4. Resistive exercise for hamstrings and gastrosoleus to increase the
posterior stability of the knee.
5. Relaxed coordinated knee swinging for the early return of knee
flexion ROM.
6. Single leg standing, balancing, weight transfers and gait training.
Post operative regime
Post operative regime
Phase I: Immediate postoperative period (3–5
days)
days). Phase II: Phase of early healing (5–15
days).
Phase III: Phase of late healing (15–21 days).
Phase IV: Phase of conditioning (3–5 weeks).
Phase V: Functional progression (6 weeks
onwards).
Phase 1
(immediate post operative
period)
To reduce pain: Electrotherapeutic modality +
Relaxation training
2. To reduce effusion – Speedy quadriceps settings or
electrical stimulation under pressure bandage with the
limb in elevation; resistive ankle, foot movements and
SLR
3. To prevent reflex inhibition – Sustained frequent
isolated quadriceps setting with hold for 6–10 s
4. Supported relaxed knee passive swinging in small
range with normal contralateral leg
Phase 2: Early healing (5–15 days)
Gradual but definite progression of earlier
measures in Phase I + Add:
1. Knee rachet, pedocycle or static exercise
regime
2. Weight transfers
 3. Supported or full weight-bearing ambulation
 4. Knee ROM should be 90 degrees at least .
Phase 3(15-21
days)
1. Vigorous progressive resistive quadriceps
exercise, supported and guided functional
positions
2. Floor squatting, cross leg-sitting and prone
heel sitting (kneeling)
3. Standing on the affected leg alone,
ambulation unsupported or with minimal support,
but no limp
4. Knee ROM should be around 120 degrees
Phase IV
1. High sitting speedy isotonic full ROM,
relaxed knee swinging
2. Progressive resistive quadriceps
exercises
3. Balance activities – proprioception
4. Gait training
5. Return to work
Phase V (Functional
progression)
1. Spot running – by holding wall bars
2. Straight jogging
3. Straight running
4. Jumping, hopping
5. Agility drills (e.g., figure-of-eight
running)
6. Gradual return to sports
–Johnny Appleseed
“Type a quote here.”
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In the acute stage of post-ligament injury, physiotherapy focuses on reducing inflammation and pain through techniques like cryotherapy and protective measures. As the injury progresses to the sub-acute stage, mobilization and strengthening exercises are gradually introduced to improve range of motion and muscle strength. Isometric exercises and passive stretching play a crucial role in promoting recovery and preventing complications. Throughout the rehabilitation process, a structured approach is followed to aid the patient in regaining function and mobility.


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  1. Physiotherapy Rehabilitation post Ligament injury Varsha Jalandhara DPT

  2. Acute Stage of injury The main aim of physiotherapy in the acute stage is reduction of inflammation and pain. 1. Cryotherapy Ice packs for 15 min every hour. 2. Modalities like diapulse, ultrasound therapy, interferential therapy and TENS can be used. 3. Compressive or pressure bandage with limb in elevation. 4. Protection of knee from the position of stress.

  3. 5. Early initiation of isometrics for the quadriceps. They should be done at least for 5 min every hour. Prevention of quadriceps wasting and reflex inhibition is important. The isometrics, progressed slowly to the maximum and sustained for 10 15 s, assist in strengthening the quadriceps; whereas speedy isometrics help in resolution of oedema and effusion. 6. When the leg is immobilized in a POP cast, vigorous movements to the ankle and toes are important to prevent venous thrombosis and to augment circulation. Static contractions to hamstrings and quadriceps in the cast are encouraged. Attempt may be made to perform assisted SLR, abduction of the hip and strong hip extension against the resistance of the mattress. 7. If cast is not advised, a small range of self-assisted relaxed gentle knee swinging could be initiated.

  4. Sub acute injury When the symptoms of the acute stage are reduced, mobilization is initiated and progressed gradually along with strengthening exercises. 1. Initiate mobilization with the patient sitting at the edge of the bed or table, injured limb fully supported by the sound limb. The patient is guided to perform relaxed self- assisted small range of slow rhythmic knee flexion and extension. CPM is an ideal mode of mobilization at this stage.

  5. 2. The range of quadriceps and hamstrings should be recorded. 3. Passive exercise to be progressed to assisted active or active as early as possible. Self-assisted relaxed passive stretching of knee flexion is excellent for improving the ROM of flexion. Patient in supine or sitting position slides the foot as far back as possible. Then the patient plants the foot on the plinth and slowly moves forward over the planted foot; the maximally achieved flexion is maintained. This can be more effective if it succeeds the relaxed free heel-drag session.

  6. 4. Isometrics can be made self-resistive by the patient applying graded resistance with hand. A soft roll is placed under the knee. The patient carries out isometric quadriceps setting while resistance is applied by hand, exerting pressure by the web between the thumb and the index finger 5 7 cm proximal to the superior border of the patella. With isometric contraction, the patella moves upwards. The patient resists this movement with hand and then sustains the isometric hold by continuously resisting upward pressure exerted by quadriceps with the hand for 10 15 s. This can be made more effective by adding ankle dorsiflexion with toes stretched in extension. We have found this to be a very effective self-controlled isolated quadriceps exercise. It is also well acceptable to the patient.

  7. 5. SLR- Progressed to SLR + SLA ( Side lying hip abduction). 6. Knee flexion: Knee flexion exercises should be practiced in prone position as well as on a static bicycle. Speed, resistance and seat height of the static bicycle should be properly adjusted so as not to overstrain the knee. Begin with half circle of the pedal. The session should be for 15 min initially, increasing gradually to an hour. 7. 5. Relaxed knee swinging should be made speedy with increased arc of movement to attain free mobility.

  8. 8. Progressive resistive exercise (PRE): Gradual self-resistive exercise with self-generated tension or graded resistance exercise with De lorme shoe or weight belts to be initiated. 9. Flexibility exercises: Flexibility exercises of static stretching using a 30-s hold, relaxing and performing five repetitions to hamstrings, iliotibial band and gastrosoleus are important. 10. Vigorous programme: When the pain is minimal, ROM and swelling are near normal. The endurance strengthening flexibility exercises are made progressive by suitable techniques. Progress to guided prone-kneeling, assisted squatting, stair climbing and descending and cross-leg sitting.

  9. A. Graduated spot running and jogging to be initiated as soon as the pain permits. B. Patients should be encouraged to begin aerobics and go back to work with well learnt precautionary measures. Advice on regular sessions of continuous halfway floor squatting to be emphasized to keep fit and to prevent recurrence of sprain

  10. Chronic stage of Injury Even chronic ligament injuries respond favourably to the regime of knee strengthening and hamstrings stretching exercises. However, the knee should be well protected with a knee brace during strenuous activities. Patients with chronic ligament instability may show weakness of hip muscles and hamstrings. This has to be tested and strengthening exercises to these muscle groups are included in the therapy whenever necessary.

  11. Surgical repair Tears of the menisci: Torn meniscus is better excised. The operation of meniscectomy can be performed by an arthrotomy of the knee or by arthroscopic surgery. Open meniscectomy: It is performed by doing an arthrotomy of the knee joint. A compression bandage is given to the knee joint, after operation. The bandage is removed after 2 weeks and the knee is mobilized. Weight bearing, however, is started after 3 4 weeks, after building up tone in the quadriceps muscle.

  12. Post operative management of meniscectomy 1st day Ankle circumduction. 2nd day (a) Simultaneous quadriceps and hamstrings isometrics are very important and should be endured. (b) Walking, gradual weight bearing with crutches. 5th day (a) Assisted SLR could be begun if not too painful. (b) Hamstrings stretching sessions should be started. 2nd week (a) Active and active assisted flexion extension exercises. (b) Resistive hamstrings exercise to inhibit quadriceps thereby allowing more flexion. (c) Passive patellar mobilization. Progress to resisted techniques. Cycling and Running by 1 month.

  13. Post operative manegement after ligament repair There is usually a prolonged period of immobilization (about 6 weeks), hence: (a) Ankle movements, quadriceps and hamstrings isometrics should be started in the cast. (b) Non weight-bearing crutch walking should be initiated immediately. (c) Assisted SLR may be begun after a week. (d) Knee hinge cast (functional cast bracing) may be applied after 10 days to allow small range of knee flexion extension. (e) By 6 to 8 weeks, the cast is removed. Knee flexion extension exercises are made vigorous.

  14. Since the process of ligament reorganization is very slow, these patients should be put on vigorous activities only after a year. They may require 4 6 months to regain full extension. Utmost care is needed while teaching floor squatting and cross-leg sitting.

  15. Arthroscopy and Arthroscopic surgery Arthroscope is a tubular endoscope through which the inside of a joint can be visualized. It is most commonly performed on the knee joint. However, other joints like shoulder, elbow, wrist and ankle can also be visualized with an arthroscope. Indications for arthroscopy 1. Recurrence of symptoms 2. Locked knee joint 3. In the diagnosis of internal derangements of the knee joint and loose bodies, etc.

  16. Arthroscopy is very useful in the diagnosis and assessment of various knee disorders and internal derangements like tears of menisci and cruciate ligaments. Apart from diagnosis, the arthroscope is used for therapeutic purposes also. Nowadays, the various structures in a joint can be operated upon without performing a formal arthrotomy by inserting athroscopic fine instruments through a second puncture in the joint. This arthroscopic surgery helps in removal of torn or degenerated menisci and loose bodies from the knee joint and even helps in the reconstruction of torn cruciate ligaments.

  17. Arthroscopic surgery (diagnostic as well as therapeutic) is performed through one or two small puncture wounds in the skin. Postoperatively, generally, a compression bandage is given for about a week. The period of hospitalization is only a day or two. Therefore, the greatest advantage of arthroscopy is rapid rehabilitation. Mobilization and non weight-bearing can be started within a week, and full weight bearing in the second week.

  18. Physiotherapy management after arthroscopic surgery. The physiotherapeutic management depends upon the type of lesion and the arthroscopic procedure procedure which could be diagnostic or therapeutic. In a diagnostic arthroscopy, the programme of physiotherapy is short and simple. It is basically directed to maintain and improve the knee function. The basic principles of physical therapy are as follows: 1. Reduction of effusion 2. Quadriceps isometric contractions 3. Maintenance of full ROM 4. Relaxed knee swinging 5. Proper weight bearing and walking

  19. Physiotherapy for arthroscopic surgery: As for any other surgical procedures, the management falls into the following two distinct phases. Preoperative training This has a conditioning effect on the patients and shortens the period of recovery. It consists of: 1. Teaching the exact technique of isolated, sustained isometric submaximal contractions of the quadriceps to avoid atrophy and reflex inhibition. 2. Relaxed speedy quadriceps settings to reduce effusion and oedema. 3. SLR to stabilize the knee. 4. Resistive exercise for hamstrings and gastrosoleus to increase the posterior stability of the knee. 5. Relaxed coordinated knee swinging for the early return of knee flexion ROM. 6. Single leg standing, balancing, weight transfers and gait training.

  20. Post operative regime Phase I: Immediate postoperative period (3 5 days) days). Phase II: Phase of early healing (5 15 days). Phase III: Phase of late healing (15 21 days). Phase IV: Phase of conditioning (3 5 weeks). Phase V: Functional progression (6 weeks onwards).

  21. Phase 1 (immediate post operative period) To reduce pain: Electrotherapeutic modality + Relaxation training 2. To reduce effusion Speedy quadriceps settings or electrical stimulation under pressure bandage with the limb in elevation; resistive ankle, foot movements and SLR 3. To prevent reflex inhibition Sustained frequent isolated quadriceps setting with hold for 6 10 s 4. Supported relaxed knee passive swinging in small range with normal contralateral leg

  22. Phase 2: Early healing (515 days) Gradual but definite progression of earlier measures in Phase I + Add: 1. Knee rachet, pedocycle or static exercise regime 2. Weight transfers 3. Supported or full weight-bearing ambulation 4. Knee ROM should be 90 degrees at least .

  23. Phase 3(15-21 days) 1. Vigorous progressive resistive quadriceps exercise, supported and guided functional positions 2. Floor squatting, cross leg-sitting and prone heel sitting (kneeling) 3. Standing on the affected leg alone, ambulation unsupported or with minimal support, but no limp 4. Knee ROM should be around 120 degrees

  24. Phase IV 1. High sitting speedy isotonic full ROM, relaxed knee swinging 2. Progressive resistive quadriceps exercises 3. Balance activities proprioception 4. Gait training 5. Return to work

  25. Phase V (Functional progression) 1. Spot running by holding wall bars 2. Straight jogging 3. Straight running 4. Jumping, hopping 5. Agility drills (e.g., figure-of-eight running) 6. Gradual return to sports

  26. Type a quote here. Johnny Appleseed

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