I am posting again from the American Journal of Sports Medicine about weight bearing and motion after ACL reconsturction. There is really no senario in which either should be avoided. When an athlete hears otherwise, he/she is usually getting bad information. Here is the excerpt again:
Below is the a partial reprint form the most recent Current concepts article from the American Journal of Sports Medicine. This is a review article that summerizes the current thinking in the field and is based on reasearch rather than doctor babble. I have included the subjects of early motion versus delayed motion, and the effects of weigh bearing.
Immediate Versus Delayed Motion
Our review identified 5 RCTs comparing immediate to
delayed knee motion during the initial stages of rehabilitation,
and there appears to be reasonable consensus that
immediate motion is beneficial for the healing ACL graft
and soft tissue structures that span the knee.47,50,86,92,95
Haggmark and Eriksson were among the first to perform
a prospective RCT of rehabilitation after ACL reconstruction
with a patellar tendon graft.35,47 Patients were
treated with a dorsal plaster splint during the first week
after surgery and were then randomly assigned to continue
rehabilitation during the following 4 weeks while wearing
either a hinged cast that allowed knee motion or an ordinary
cylinder cast that prevented knee motion. All of the
patients were followed up during a 1-year interval; those
treated with standard cast immobilization had significant
atrophy of the slow-twitch muscle fibers of the vastus lateralis,
whereas those treated with the hinged cast and
early motion demonstrated no changes in the cross-sectional
area of the slow- or fast-twitch fibers. Haggmark
and Eriksson47(p55) noted that “there appeared to be no difference
in the end result of the surgical procedure” and
that treatment with the hinged cast “facilitated an early
return to sports.”
A prospective RCT that compared immediate to delayed
range of motion after ACL reconstruction was carried out
by Noyes et al.86 Subjects in the immediate motion program
began continuous passive motion of the knee on the
second postoperative day, whereas those in the delayed
motion group had their knees placed in a brace at 10of
flexion and began continuous passive motion on the seventh
postoperative day. Subjects in both rehabilitation programs
reported similar rates of joint effusion, hemarthrosis,
soft tissue swelling, flexion and extension limits of the
knee, use of pain medications, and time of stay in the hospital.
Continuous passive knee motion immediately after
ACL reconstruction did not lead to an increase in anterior
knee laxity during healing.
Rosen et al95 carried out a prospective RCT of rehabilitation
after arthroscopically assisted ACL reconstruction
with a central third BPTB autograft performed by the
same surgeon. After surgery, subjects were randomized via
a lottery system to 1 of 3 programs: early active motion,
continuous passive motion, or a combination of both. This
work extended the research of Noyes et al86 by showing
that continuous passive motion during the first month
after ACL reconstruction, compared with early active
motion, produced similar range of joint motion and KT-
1000 arthrometer measurements of A-P knee laxity.
Richmond et al92 reported the results of a prospective
RCT that compared the effects of continuous passive knee
motion for 4 to 14 days after arthroscopically assisted ACL
reconstruction with a BPTB autograft. They found similar
values for knee range of motion and lower limb girth
between treatment groups.
More recently, Henriksson et al50 described a prospective
RCT of rehabilitation after ACL reconstruction with a
BPTB graft performed by 1 of 4 surgeons using the same
technique. After surgery, subjects were randomly assigned
to rehabilitation protocols consisting of cast immobilization
or early range of motion training with a brace.
Subjects in both groups underwent similar supervised
rehabilitation, and during the first 5 weeks, all rehabilitation
exercises, with the exception of range of motion exercises,
were the same for both treatments. Follow-up measurements
made after 2 years included 88% and 92% of
subjects in the brace and plaster cast treatment groups,
respectively. The researchers found that rehabilitation
with the use of a brace and early range of motion training
after ACL reconstruction produced equivalent knee laxity,
knee motion, subjective knee function, and activity level in
comparison to rehabilitation with plaster cast immobilization
for 5 weeks. There were, however, differences in terms
of strength. At 2-year follow-up, subjects in the brace
group had a larger strength deficit of the knee flexors
(5.9% loss compared to the contralateral, normal side) in
comparison to subjects in the plaster cast group (0.9%
loss). As well, there was a strong trend for subjects in the
brace group to have a strength deficit of the knee extensors
(11.1% decrease compared to the contralateral side) in
comparison to patients in the plaster cast group (3.8%
decrease).
Of the 5 RCTs reviewed above, only Rosen et al95 adequately
described their method of randomization, and only
Haggmark and Eriksson47 and Henriksson et al50 had minimal
loss of patients at follow-up; no author stated
whether the investigators were blinded at follow-up.
After ACL reconstruction, it is clear that extended immobilization
of the knee, or limited motion without muscle
activity, is detrimental (inferior structural and material
properties) to the structures that surround the knee (ligaments,
cartilage, bone, and musculature).4,10,62-65,70,84,112
There is little doubt that early joint motion after ACL
reconstruction is beneficial; it leads to a reduction in pain,
lessens adverse changes in articular cartilage, and helps
prevent the formation of scar and capsular contractions
that have the potential to limit joint motion.24,65
Immediate Versus Delayed Weightbearing
Two prospective RCTs have compared immediate versus
delayed weightbearing rehabilitation programs after
ACL reconstruction, and both have reported that immediate
weightbearing programs produce similar clinical,
patient, and functional outcomes to delayed weightbearing
programs.60,106
Jorgensen et al60 performed a prospective RCT to evaluate
the effect of weightbearing on the results of ACL reconstruction
with the iliotibial band graft. After surgery, subjects
were randomized to undergo rehabilitation with
either immediate weightbearing or nonweightbearing for
5 weeks followed by a gradual return to full weightbearing
during the first 9 weeks of healing. Evaluation 2 years
after surgery revealed no differences between the groups
with regard to A-P knee laxity and patient activity level
(evaluated with the Tegner and International Knee
Documentation Committee [IKDC] scores).
In a subsequent prospective RCT of ACL reconstruction
with a central third BPTB autograft, Tyler et al106 compared
rehabilitation with immediate weightbearing to
delayed weightbearing for 2 weeks. Only 2 subjects in each
treatment group were lost to follow-up. At a mean followup
of 7.3 months, there were no differences between the
treatments with regard to knee range of motion, vastus
medialis oblique function, and A-P knee laxity (clinical
examination and KT-1000 arthrometer measurement).
However, patients treated with immediate weightbearing
had a decreased incidence of anterior knee pain.
Authors of these RCTs did not describe their method of
randomization, and they did not mention if the subjects or
investigators responsible for the follow-up measurements
were blinded to the treatments that were studied.
The findings from these investigations indicate that
immediate weightbearing after ACL reconstruction does
not produce excessive loads that permanently deform the
graft or its fixation and suggest that immediate weightbearing
may be beneficial because it lowers the incidence
of anterior knee pain. After ACL injury and reconstruction,
the effect of weightbearing on the healing response of
injured articular cartilage or meniscus repair is currently
unknown.
