Sports Specific Rehabilitation: Postsurgical ACL Reconstruction

By Frank Gasparovic and Christopher Baldwin, BS

Editor's note: Dr. Frank Gasparovic has a master's in sports medicine. He is a certified athletic trainer, pain practitioner, strength and conditioning specialist, and an emergency medical technician. 
He treated rugby athletes at the 1996 Paralympic Games.

Christopher Baldwin is a personal trainer and rehabilitation director at a facility in New Jersey. He is completing a program that will make him eligible to take the national examination for athletic training.

History

The patient, a competitive athlete with a black belt in karate, was injured in an automobile accident, tearing his left anterior cruciate ligament (ACL), and causing cervical and lumbar disc bulges. A bone-patella tendon-bone graph was performed to repair the knee.

Four days post-operative, the athlete came into our facility to begin an intensive rehabilitation program. The complications of his other injuries were considered before beginning the rehabilitation program.

Rehabilitation Program

Week 1 

• bearing as tolerated in hinge brace, lock extension;
• aggressive passive knee extension to 0,o as tolerated, not to exceed 10 minutes;
• aggressive passive knee flexion to 90o in hinge brace when unlocked;
• quadricep isometric contraction, 10 times per hour (at home);
• straight leg raise in three directions, as tolerated with knee brace locked;
• posterior leg strengthening: heal raises with body weight and theraband;
• cryocuff and ice for pain and edema (after exercise and at home);
• deep myofascial release technique to the lower leg and thigh muscle groups.

Weeks 2-3 (Additions) 

• reinforce proper gait pattern; hinge brace removed while in therapy;
• stationary bike (5-15 minutes); muscle re-education;
• wall squats with support with both arms and knee over the ankle, 0-45o patella mobilization (Figure 1);
• electrical stimulation combined with ice for pain and swelling reduction.

Weeks 4-8 (Additions) 

• patient fitted with functional brace;
• use of Stairmaster and Versa Climber (5-15 minutes);
• leg press with knee directly over ankle 5-90o (Figure 2);
• stimulated ambulation with resistance to emphasize hamstring eccentri contraction;
• lateral step-ups as tolerated; knee extension isotonics; step-up and step-downs;
• proprioceptive activities, uni-leg stances and trampoline, single plain proprioceptive board, eyes open, eyes closed.

Weeks 9-12 (Additions) 

• progress to multi-plain proprioception exercises, no shoes (Figure 3);
• sports specific exercises including theraband stimulating karate kicks in all plains (Figure 4);
• sports specific exercises to include kicking paddles with specific karate kicks (Figure 5).

Weeks 12-14 (Additions) 

• functional evaluation; vertical and multiple jumps, both legs; hops, one leg at a time;
• 20 feet (plyometrics); agility test (i.e., figure eight, circles, forward, backward, zig-zag);
• sport specific exercises with weight resistance utilizing the karate components of kicking;
• initiate jogging on level surfaces.

Week 14 (Additions) 

• single plain plyometrics wearing function brace;
• step ups, jump rope, shuffle steps, open chain kinetic exercises utilizing Cybex extension and flexion. Closed chain exercise utilizing leg press and hip machine.

Week 16 (Additions) 

• passive stretching machine (Figure 6);
• reverse hamstring exercise (Figure 7);
• home program includes kinetic exercise, medication, range-of- motion exercises, isometrics, strengthening, ice, flexibility, cardiovascular exercises.

Discharge Criteria 

• The athlete will be required to continue his home program for approximately 12 months.

Sports Specific Training

In addition to the traditional rehabilitation program, we developed sport specific exercises designed specifically for a karate athlete. We began with basic kicking exercises to increase the range-of-motion in the lower extremities. This was restricted to nonexplosive movements, and the absence of pivoting on the injured leg. The athlete performed 20 repetitions on each leg, starting with front kicks, side kick, and axe kicks.

After one full week of air kicks, resistive bands were used to increase resistance. The same repetitions and kicks were performed. When the athlete performed the air kicks, 20 repetitions a piece, and the same kicks with the resistive band, we progressed to kicking paddles specifically used for karate training. At this point the athlete was performing air kicks, band kicks and paddle kicks without pain, 20 repetitions of each of the three kicks.

With these exercises successfully completed, we increased the proprioceptive exercises of the knee and ankle. The first exercise was a mini-trampoline that was used to practice karate stances. A balance board was also utilized. A third and final step was performing side squats with a resistive band (Figure 8). When the squats were performed with ease we increased the resistance of the band and had the athlete do the movements quicker.

Strength-Conditioning

Along with the sport specific exercises and rehabilitation, a conditioning program was implemented. This included giant sets between equipment, such as the Versa Climber, upper body ergometer, and stationary bike. We also included a light jogging program, which involved short bursts of speed in the forward, backward, and side to side motion.

Conclusion/Prognosis

The athlete underwent an intensive ACL rehabilitative program. His prognosis for a full return to competitive karate is excellent. Complicating factors of the cervical and lumbar disc pathology may limit him in those areas. The challenge of performing this rehabilitative program was developing sports specific exercises to meet the needs for a competitive karate athlete.