Anterior Cruciate Ligament Reconstruction: A Clinical Profile

Author: Laurie Lunn, P.T.

Abstract: This article highlights the use of Integrative Manual Therapy on a patient status post ACL reconstruction. The technique that resulted in significant changes in range of motion and strength of the involved knee was Resistence Therapy to Immune Deficiency Motility. After therapy was completed, the patient presented with significant improvements in strength of the quadriceps muscle.

Key Words: Knee, Anterior Cruciate Ligament, Strength, Immune Deficiency Motility

Introduction: This profile outlines the initial phase of a client's anterior cruciate ligament (ACL) rehabilitation program, utilizing Integrative Manual Therapy (IMT) techniques. A discussion will follow, which provides the reader with an opportunity to see how the technique Immune Deficiency Motility (1) improved quadricep strength and thus helped to facilitate the client's recovery.

History: Client is an 18 year old male who sustained a right knee injury in a skiing accident in February of 2000. He re-injured his knee again on 4/17/2000 and was at that time diagnosed by his MD with an ACL tear. MRI on 4/18/200 confirmed the tear and the client began Physical Therapy for pre-op lower extremity strengthening. Surgery was performed on 7/10/2000. According to the surgeon's report, the medial meniscus was intact and the ACL was "completely torn off its femoral origin and it was scarred down into the PCL (posterior cruciate ligament)" (2). Surgery was a patellar tendon autograft via arthrosporic surgery with an anterior incision.

Evaluation: Initial Physical Therapy evaluation on 7/11/2000 revealed the following: Client ambulated with two axillary crutches, toe touch weight bearing with no brace (MD's orders). Active range of motion of the right knee was 20-60 degrees. Strength of the right lower extremity was as follows: hip flexion 2/5, hip extension 2+/5, hip abduction 2+/5, knee flexion 2-/5, knee extension 1/5 (client unable to perform a quad set, as assessed visually and through palpation), ankle dorsi flexion 4/5, ankle plantar flexion 4/5. The client reported using prescription pain medications every 4-6 hours.

Treatment: IMT techniques were utilized to address protective muscle spasm, lymph flow, circulation, fascial restrictions, Bone Bruises and neural tension in the right lower extremity.

The following techniques were used: Jones' Strain and Counterstrain (3), Lymph Node Advanced Strain and Counterstrain (1), Advanced Strain and Counterstrain (4), Myofascial Release (5), Bone Bruise (6), Disruption of Membrane (7), and Neural Tissue Tension (8). The following exercises were performed on a daily basis, as a home program, repeated at least 5 times a day: quadricep, adductor, hamstring and gluteal muscle isometrics; partial squats. 10 days post op, edema and pain had decreased significantly, (as evidenced by decreased pain medication) and range of motion increased to 8-95 degrees, however, quadricep strength remained 1/5. 15 days post op, the client was still unable to do neither a sustained quadricep set (quad set), nor a straight leg raise without assistance. His gait remained antalgic, with decreased weight bearing on the right lower extremity. The client was thus reassessed with Myofascial Mapping (9), which was positive along the right femoral nerve. The technique, Immune Deficiency Motility (1), was then performed to this nerve anteriorly along the thigh for a total of 15 minutes. On that particular day, the reassessment and Immune Deficiency Motility (IDM) technique were the only IMT tools performed on the client during that session.

Outcome: Two days after the above treatment, the client returned to the clinic and reported a significant improvement in his ability to perform a quad set approximately 3 hours following therapy. Reassessment at that time revealed significant improvements. The patient presented with increased strength of the right quadricep muscles as evidenced by: an ability to maintain a sustained quad set for 10 seconds, 10 repetitions (there was a superior glide of the patella noted during this exercise); an ability to perform 10 repetitions of a straight leg raise with 0 degree extension lag; an ability to ambulate at least 200 feet with no crutches, with equal weight bearing on both lower extremities. The patient presented with increased strength of the right lower extremity as follows: hip flexion 4+/5, hip extension 4/5, hip abduction 4/5, knee flexion 4/5, knee extension 4-/5, ankle dorsi flexion 4+/5, ankle plantar flexion 5/5. Active range of motion of the right knee increased to 5-120 degrees. The patient also experienced sensory improvements: no further complaints of paraesthesia at the anterior distal thigh; she continued to have altered sensation at the distal lateral thigh. The patient reported that she was no longer taking any pain medications. Subjective reports from the client included decreased pain, increased ease of walking, increased strength, and a continued decrease in edema.

Discussion: It is well documented that quadricep muscles quickly atrophy following ACL reconstructive surgery. (10) Paulos, et. al. note it is important to have a balance of quadricep and hamstring strength to maintain proper knee kinematics following ACL surgery (11). One early focus during rehabilitation is thus on the return of function of the quadricep muscles. During this early stage, quadricep strength is typically addressed through exercises such as quad sets and straight leg raise (12). The quadricep muscles are innervated by the femoral nerve, which runs along the anterior thigh and supplies both sensory portions to the anterior and medial thigh and knee, and motor portions to the quadricep muscles (13). It is noted that dysfunction of the femoral nerve will cause weakness of the quadriceps, as well as pain and parasthesia to the anterior and medial thigh (13). The client in the above case showed significant improvements in range of motion, decreased edema, and decreased pain prior to the completion of IDM (1). His quads, however, were not making the expected and necessary gains to allow for adequate functional outcomes. Once the IDM (1) technique was performed, the client showed signs of quadricep recovery within 3 hours following treatment. Among other improvements, the client showed significant increased strength at his next therapy session 2 days later, as evidenced by a sustained quad set, an ability to perform multiple straight leg raises, and the ability to ambulate unassisted at least 200 feet with equal weight bearing on both lower extremities. All three of these outcomes are documented evidence of increased quad strength (14) and therefore improved functional mobility. This client is now 7 weeks post op and continues to make progress towards recovery.

References

1. Assessment, Integrative Diagnostics, and Integrative Manual Therapy for the Lymphatic System, Level One: Congestion Therapy (An Introductory Level Lab Course), Sharon Weiselfish-Giammatteo, Ph.D., P.T., I.M.P.,C., Instructor; July 16-18, 1999.

2. Surgical Report: Albany Medical Center Hospital 43 New Scotland Avenue, Albany, NY 12208; Marc Fuchs, MD, surgeon; Wade McAlister, MD, assistant.

3. Integrative Manual Therapy: Immediate Normalization of the Lower Extremity with Strain/Counterstrain, Myofascial Release and Protocols (A Lab Course), Sharon Weiselfish-Giammatteo, Ph.D., P.T., Instructor; September 12-14, 1997.

4. Integrative Manual Therapy for Treatment of the Autonomic Nervous System and Related Disorders Utilizing Advanced Strain and Counterstrain Technique (An Introductory Lab Course), Sharon Weiselfish-Giammatteo, Ph.D., P.T., Instructor; November 20-22, 1998.

5. Myofascial Release, Kris Albrecht, M.S., P.T., Instructor; April 30-May2, 1998.

6. Type III Dysfunction of the Spine and Extremity Joints with Muscle Energy and Beyond (SM), Rosemary Hegarty, P.T., I.M.P.,C., Instructor; September 24-26, 1999.

7. Visceral Mobilization with Muscle Energy and "Beyond" Technique: Focus on the Gastrointestinal Tract ( A Lab Course), Tom Giammatteo, P.T., D.C., Instructor; Sharon Weiselfish-Giammatteo, Ph.D., P.T., Instructor; April 23-25, 1999.

8. Advanced Neural Tissue Tension, Kristin Godiksen, P.T., Instructor; May 14-16, 1999.

9. Myofascial Mapping, Kris Albrecht, M.S., P.T., Instructor; May 3, 1998.

10. Draper, Vanessa, Ph.D., Recovery of postoperative knee. PT and OT Today 1996; March 25: 8.

11. Paulos, MD, Noyes, MD, Grood, Ph.D., et al., Knee rehabilitation after Anterior Cruciate Ligament reconstruction and repair. The Journal of Sports Medicine. 1981; 9:140-9.

12. Mullin J., and Stone K., Anterior cruciate ligament reconstruction. The Stone Clinic Orthopaedic Surgery, Sports Medicine and Rehabilitation; http://www.stoneclinic.com/acl-protoc.htm.

13. Gray's Anatomy, 38^th Edition, Churchill Livingston, NY, 1995.

14. Sullivan P., Markos P., Minor M., An Integrated Approach to Therapeutic Exercise, Theory and Clinical Application, Reston Publishing Company, VA., 1982.