International Journal of Scientific and Research Publications, Volume 7, Issue 11, November 2017 386

ISSN 2250-3153

Impact of Proprioceptive Exercises Post ACL –

Reconstructive Surgery
Dr.S.S.Subramanian

M.P.T (Orthopaedics), M.S (Education), M. Phil (Education), Ph.D (Physiotherapy)., The Principal, Sree Balaji College Of physiotherapy, Chennai –
100., Affiliated To (Bharath) University, BIHER, Chennai – 73.

Abstract- An increasing prevalence of injury to the knee joint  ACL – R life time cost for a patient was $38, 121 and
leading to ACL reconstruction surgery (ACL–R) a common $7.6 million annually in US who were projected to
procedure getting done. Irrespective of the ages, rehabilitation develop radiographic osteoarthritis life time, would
post ACL-R needs more focus for early functional return of the need total knee replacement (TKR) (Scott etal 2000)
subjects. Aims and objective of this original research report was  Wright etal 2012 have in a systematic review post ACL
to analyse proprioceptive exercises among ACL-R, impact of –R reported with increasing health care cost, increased
exercises on obesity, and their combined effects on womac score psychological distress and re injury
in 1 year follow up. Materials and Methods: 5 subjects with
mean age of 34 years of both sex who had ACL-R with mean Keywords:
BMI of 42 kg/m2 were treated with proprioceptive exercises and ACL – R: Anterior Cruciate Ligament Reconstructive
weight reduction exercises in a one year follow-up from 2015- Surgery, ACL, Womac Score, TKR, CKC – Closed Kinematic
2016, with weekly twice frequency at Chennai. Results: pre and Exercise Proprioception, BPTB, EMG, QOL
post womac score p<.01 and BMI p<.05 were analysed
statistically and recorded. Conclusion: Than regular exercises Role and Need for Surgery in ACL Injury :
among post ACL-R, subject , focus on obesity, angular  ACL –R may aid patients in regaining proper joint
correction exercises , core strengthening, graft specific exercises kinematics, minimising poor joint kinematics are abnormal
along with continued follow-up are key focus of this monograph stresses that could occur with ACL – D (Losina etal 2009)
presentation.  ACL – R surgery is aimed at restoring joint stability,
minimizing further damage to the menisci and articular
Index Terms- ACL – R – Anterior Cruciate Ligament cartilage (Gold Blatt etal 2005) and (Lynch etal 2013)
Reconstruction, BMI, Womac Score  Have identified criterions such as absence of giving way,
absence of joint effusion symmetry of quadriceps strength,
patient reported outcomes, return to sports, as successful
I. INTRODUCTION outcome of the post ACL –R surgery.
 A Cochrane review by smith etal 2014 analysed ACL
A nterior Cruciate Ligament (ACL) is a anterior stabilizer of
knee, restricting anterior tibial translation and rotational
forces at the tibio femoral joint
injured subjects with ACLR and conservatively managed
with exercises, recorded no difference with regard to knee
function, health status and return to pre injury level.
Injury:
ACL deficiency results in pain increased instability and Aims & Objective of this monograph was to analyse
altered function (Heringston etal 2006). ACL injury is the most Proprioceptive exercises on obesity and womac among post
common injuries of knee joint and accounts for 50% of total ACL- R subjects
injuries occur in knee joint (Allan etal 2013)

Prevalence: II. MATERIALS & METHODOLOGY

In New Zealand 80% of all knee LG injured (ACL –R) 5 subjects with mean age of 3 who underwent ACL-R
Anterior Cruciate Ligament Reconstruction (Gianotti 2009) more following RTA were included in this research in a one year
than 2,50,000 ACL injuries occur yearly in US (Chapman etal follow up study. Their mean BMI was 42 Kg/m2 all the subjects
2001) and more than 50% of them under goes ACL - R(AAOS were regularly treated with weekly twice frequency at Chennai
2007) where this study was conducted during the period of Feb 2016 to
march 2017 with good adherence for exercises, all the subjects
Economy with ACL – R have continued their daily routine activities.
 With an average cost of an ACL – R surgery is $10, 32 All the subjects were treated by the author from the first
US dollars in 2011 (Lubowitz & Appleby 2011). Total .Post operative day of surgery, but PTB grafts were used on 3
costs including diagnosis, surgical reconstruction and subjects and hamstring Grafts on 2 subjects.
post operative rehabilitation of ACL injuries accounts to Key emphasis on closed kinematic, proprioceptive
13 billions in united states annually (Brophy etal 2009) exercises using air inflated, physioball, other weight bearing

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International Journal of Scientific and Research Publications, Volume 7, Issue 11, November 2017 387
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means such as wobble board were used. Also core strengthening

and resisted means of exercises to contra-lateral limb were used
A set of 5 specific proprioceptive exercises in various positions Role of Proprioceptive Exercises in Post ACL – R:
such as supine, sitting and standing were used, progression was  Proprioceptive deficits have been found beyond 1 year
done with increasing repetition and duration with isometric post ACL –R (Decker etal 2002) and proprioceptive
holds. exercises have been shown to enhance strength gains in
Also 5 core strengthening exercises using physioball were , the quadriceps and hamstring muscles post ACL –R
where progression was done with more repetitions. (Zalter Storm 2000)
1. No undue pain were recorded with session but the  Proprioceptive input and neuromuscular control are to
subjects reported knee laxity with exertional activities be attended post ACL injury (Wojtys & Huston 1994)
such s long standing, prolonged sitting with travelling and proprioceptive exercises produces compensatory
on both knee. muscle activation patterns in the neuro muscular system
2. Also few articular changes such as crepitus and pain on that assist with joint stability (Cooper etal 2005)
movements with mild joint effusion was recorded  High intensity electrical stimulation to improve
3. An interesting feature is with an quadriceps easting of quadriceps strength and gait parameters were reported
mean 2 cm but hypertrophy of gastrocnemius with 3 cm by many studies (Fitzgerald etal 2003)
were recorded  Evidence appears with contractile activity improved if
4. Getting rid of brace usage post operatively depends on this can be done during weight bearing, in an upright
confidence pain, level of activities and strength of position, once the patient can tolerance placing the limb
quadriceps post ACL-R was noted among participants in a dependant position with at minimum partial weight
bearing (Baratta etal 1988)
 With CKC position, decreased stress placed on the graft
III. RESULTS tissue as compressive forecast the tibiofemoral joint and
Table of results of all the subjects post ACL-R with womac score co contraction of muscles surrounding the knee help
and BMI using paired t test: control excessive motion at all joints in the closed chain
(Oh Kohi etal 1991)
MEAN SD SE T  If the patient
P has difficulty in performing supine knee
extension, they can perform in prone position with hip
extensor aiding achievement of full extension (Weber
WOMAC SCORE etal 2004)
 Hamstring activity is needed as they are synergistic to
PRE
8.95 3.99 8.52 ACL, strengthening
<.01 XX of the hamstring muscles may
provide a primary dynamic restraint to anterior tibial
POST
translation (Gross etal 1993)
 Closed kinematic chain squats on a stable surface
BMI PRE
between 4-6 weeks post ACL – R, where knee flexed at
2.19 .97 3.50 <.05
POST 250- 300 and maintain that position as it will produce a
co contraction of the hamstrings and quadriceps (Wilk
etal 1996)
 Fitzgard etal 2000 have examined proprioceptive
Note: X - Statistically Significant, XX - Highly Significant
training in ACL deficient patients and recorded
decreased frequency of giving way episodes following
their ACL injury.
IV. DISCUSSION
 Between 6 weeks to 3 months, where auto graft
Rehabilitation of ACL: reaching nits weakest point structurally (Bulter etal
 Strengthening of quadriceps and gastrocnemius are of 1989) as controlled loading will enhance ligament and
greater important instead of hamstrings post ACL – R tendon healing, while excessive stress loading to an
rehabilitation (Kvist and Gillquist 2001) ACL graft may cause graft elongation leading to
 Closed Kinematic Chain (CKC) exercises were widely excessive un wanted anterior posterior laxity (Beynnon
used in the knee rehabilitation as they stimulate eta 1994)
functional activities and similar daily activities (Heijne  Post ACL –R between 3 months period core trunk
etal 2004) and increase tibiofemoral joint compression training and stability to maintain. Center of mass,
and emphasize co contraction between hamstring and balance and postural control, hence exercises for the
quadriceps muscle, thus stabilizing the joint and trunk and hips are more desired (Myer etal 2008).
minimize strain on the healing ACL (Escamila etal Which can consists of sit-ups, bridging exercises, single
1998) leg bridges, straight leg dead lifts and planks (Hewett
 Also CKC exercises helps to correct neuro muscular etal 2005) core exercises were part of this subjects
imbalances for optimal biomechanics and reduction of therapy regime as supported by the above studies
knee injuries (Ford etal 2003)

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Surgical Techniques and Exercises: requirements (Lee etal 2008). An improved womac
 Patellofemoral complications are common especially score of this subject treated with Proprioceptive as main
following with patella tendon grafts (Sachs etal 1989) tool have improved functional mean as shown in table
Tyler etal 2007 among 49 patients following Bone of results
Patella Tendon – Bone (BPTB) – R with immediate
weight bearing, have recorded decreased anterior knee Critical Analysis of the Topic:
and increased vastus mediatis activity with EMG 1. Knee exercises alone sufficient post ACL – Right?
(Electrotherapy) but no difference in range of motion Total leg strengthening exercises of the operated knee as well
and articular cartilage among weight bearing group trunk, contra lateral leg are important for better rehabilitation
 In BPTB- R as the extensor mechanism has undergone outcome from day one of Post ACL – R, are highly
significant insult in the harvesting process, so early recommended
motor control with an active quadriceps contraction 2. Does regular follow up favours functional outcome?
pulls tension through the patellar tendon, minimising the As reported 25% of patients post ACL – Right suffer a second
potential for entrapping scar tissue. Also it additionally tear in 10 years. Altered neuromuscular control of hip and knee
squeezes scar tissue of the anterior knee helping to during a dynamic landing task and postural stability deficits after
decrease swelling (Shelbourne 1990) ACL – R are predictors for second injury decreased muscular
 Hamstring Auto Graft when used, maximal isometric strength, joint position sense, postural stability are reported in 6
exercises in 4-6 weeks period can be useful. The ACL months – 2 years following post ACL – Right, hence regular
mechano receptor reflex arc to the hamstrings may therapy favours better functional outcomes is evident.
cause a loss of proprioception, as a latency of the 3. Other than Proprioceptive (Closed kinematic chain
hamstrings is almost twice that of the normal contra exercises) what specific exercises can be beneficial post
lateral uninjured knee (Lutz etal 1990) as at this time ACL – R
enough soft tissue healing of the hamstrings should Evidence suggests Cryotherapy post arthroscopic surgery
allow tolerance to perform gentle hamstring, decreases pain and disinhibition effect on the quadriceps muscle.
gastrocnemius and soleus flexibility exercises. Electrical stimulation to quadriceps core strengthening exercises
Procedures and Exercises: (Hewet etal 2005) in a 6 week plyometric have recorded an
 ACLR with a hamstring tendon graft has demonstrated increase in strength and function post ACL – R
better self reported function and decreased anterior knee 4. Any muscles to focus specifically post ACL – R?
pain when compared with a patellar tendon graft While quadriceps muscle strengthening is key post ACL – R,
(Wipfler etal 2011) Hamstring, Gastrocnemius also to be strengthened. Also Vastus
 Frobell etal 2013 have demonstrated with patella tendon medial’s of the operated knee to be given more attention
graft, have significant increase in patella femoral
arthritis, not tibio femoral, when compared to hamstring 5. Major factors influencing post ACL – R rehabilitation?
graft. Obesity, strength of quadriceps, type of grafts used, proper
rehabilitation injury to associated structures of knee such as
Complications Post ACL – R meniscus, medical LG, age of the subject, cost involved, type of
 Brittney etal 2014 have recorded that 44% of subjects exercises adopted all of which influences on the prognosis post
who underwent developed osteoarthritis knee ACL – R
 Oiestad etal 2009 n a 10 years follow up among ACL 6. Is Proprioceptive exercises alone enough?
tear subjects reported the risk of developing arthritis Through Proprioceptive exercises are key area to be focussed in
was 13% post ACL – R, other exercises to mobilise knee joint,
 As displayed in results table with reduction in BMI strengthening of various muscles in different angles in line with
which statistically proven P<.05, hence complications the protocol, core strengthening and resisted means of exercises
post ACL – R, were less among this study subjects to contra lateral leg have to be added along with Proprioceptive
 Barnius of osteoarthritis in a 14 year follow up post exercises for good functional Proprioceptive clinical result
ACL –R prevalence of osteoarthritis in a 14 year follow
up post ACL –R and increased knee laxity leading to 7. Range of motion of knee how much to expect and what
meniscal chandral lesions (Loger Stedt etal 2010) are the factors influencing?
 Palmieri etal 2008 have in a systematic review post Pre operative loss of knee extension (In comparison to Contra
ACL –R recorded 20% subjects with quadriceps lateral Knee) were likely to have limited knee extension after
strength deficit with 2 year follow up and Øiestad etal surgery but the good of knee flexion is 900 at week one and by
2009 link this to lower neural drive. 4th week 1200 post ACL – R (Maske etal 2012) but combined
with menisectomy or medical LG repair influences post ACL – R
Quality of Life: range of motion of knee.
 As QOL and psychological health of the injured
individual are often much lower than that of an 8. Is there chances of (Other) contra lateral knee getting
uninjured individual (Schweer etal 2006) also major affected post ACL – R?
knee injuries like ACL can directly affect the ability to With neuromuscular imbalances post ACL – R, contra level knee
participate in sports, daily activities and employment and ipsilateral lumbar spine, hip ankle, will undergo altered

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biomechanical changes as inferred by Ford etal 2003. Also with VI. CONCLUSION
an abnormal alignment with varus or varus deformity along with As evidenced with various complications associated with
obesity can cause further degenerative changes of the post ACL-R, core should be taken while choosing exercises for
contralateral uninjured knee hip and lumbar spine. example keeping an eye on obesity holds a key for better
9. Quadriceps deficit mainly Vastus Medialis weakness recovery. Also continued follow up for knee laxity, quadriceps
perists? strength and regular check on contra-lateral knee and lumbar
Many studies evidenced quadriceps deficit mainly Vastus spine are highly recommended with altered biomechanics.
medial’s in post ACL – R subjects even 2 years post surgery The role of physiotherapist gets highlighted with increases
mainly in post BPTB graft is used prevalence of ACL injury and subsequent ACL-R, hence pattern
10. Changes in articular cartilage occurs? of prognosis should be patient centric and functional based one
Effects of early weight bearing post ACL – R, on articular are the major outcome of this original monograph presentation.
cartilage is known, but altered biomechanics with decreased
muscle strength, lack of range of motion, decreased joint position
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AUTHORS
ligament reconstruction. J Strength Cond Res. 2008; 22:987–1014. doi: First Author – Dr.S.S.Subramanian, M.P.T (Orthopaedics),
10.1519/JSC.0b013e31816a86cd.
M.S (Education), M. Phil (Education), Ph.D (Physiotherapy).,
[32] Hewett TE, Myer GD, Ford KR, Heidt RS, Jr, Colosimo AJ, McLean SG,
Bogert AH, Paterno MV, Succop P. Biomechanical measures of
The Principal, Sree Balaji College Of physiotherapy, Chennai –
neuromuscular control and valgus loading of the knee predict anterior 100., Affiliated To (Bharath) University, BIHER, Chennai – 73.,
cruciate ligament injury risk in female athletes: a prospective study. Am J [email protected],subramanian.podhigai1968
Sports Med. 2005;33:492–501. doi: 10.1177/0363546504269591. @gmail.com, Phone: 99400 47137.

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