WTF?! No ROM machine and no PT for a month!

[GoNads]

Good point AG. I was looking at it as a straight-up ACL recon. If there was meniscus work he might have a valid reason to restrict weight bearing/PT.

Even if there is bone damage, or cartilage, they can still do muscle stim, laser and manipulation to prevent atrophy and keep decent range without weight bearing.

[altagirl]

Even if there is bone damage, or cartilage, they can still do muscle stim, laser and manipulation to prevent atrophy and keep decent range without weight bearing.

I absolutely agree. But I'm just trying to guess at his surgeon's logic. My PT's have complained about docs who won't prescribe PT for people in that situation because it's a "waste of money" until you can do more. I disagree and think it's very worthwhile do be doing whatever you can to prevent scar tissue and atrophy, but apparently there are varying opinions out there.

[penguin Lancer]

I'll put down everything I know.

He said I had Lateral Meniscus damage.
He said he removed some of my cartilage.
I had an ACL allograft reconstruction.
I had two screws placed in my knee
The doctor said I can bend my knee only 20 degrees. Why I would want to do this, I don't know. 20 seems like too small a number to do anything with,
He said no weight bearing at all.
I must keep it in a brace at all times.

[altagirl]

Call and ask if he repaired the lateral meniscus. He could have removed some cartilege and done a repair at the same time.

And even if you can move it 20 degrees, you can at least be working on extension? That can be harder to get back (and a bigger problem) than the flexion anyway. Did he tell you if you can do straight leg raises? At least doing those should help a bit with the atrophy.

[penguin Lancer]

He did do the Meniscus repair. I also already have full extension already. (The brace is a straight leg brace). I also asked about doing the SLD. He said that I shouldn't do them and that they wouldn't do much to stop atrophy. I really appreciate all the help.

[taoslcl]

The meniscus repair is probably the reason for the conservative approach although I think it is too conservative approach. We got a patient today 2 day post opp acl recon plus medial meniscal repair that was restricted to 0-90 deg with PT supervision only which everyone in the office thought was highly conservative. The ROM is to prevent scar tissue but also to pump nutrients in and out of the avascularized joint capsule for nutrition and healing needs so if he is giving you 20 deg you should be doing it often to keep the joint capsule healthy.

Be sure to ask lots of questions if you do see him soon but if he doesn't change his mind you won't be able to get a PT to do anything with you that is against the surgeons protocol. My advice to you would be to control inflammation with ice and elevation and ankle pumps, lots of isometric exs like quad sets, ham sets and glut sets and lots of heel slides from 0-20deg if he is allowing it.

Good Luck and be patient. If your young and healthy your biggest concern is wanting to do too much too soon and ruining something. You should do fine no matter what protocol you are on, just be deligent with whatever you can do.

[drmark]

We never let meniscal repair get in the way of getting people back to full function after ACL surgery. No one is ever issued crutches or a brace, and everyone moves their knee from normal hyperextension to as much flexion as they can get, usually about 140 by the fourth day.

The intraarticular enviornment after ACL surgery tends to the positive for meniscal healing and no special meniscal precautions need be taken. (Most of the time the lateral meniscus can be just left alone and not repaired and it will do fine.)

The only thing we don't encourage is weighted squats in the first few months.

[Huckwheat]

So, I had ACL Allograft, and Orr from S.Lake Tahoe did it (he does lots of big names: McConk, Ralves, etc).

First, the straight leg brace doesnt sounds right. I was in ROM day 1, and worked to keep it bending.

The no PT thing sounds reasonable, from what he told me. Orr was in no hurry for me to get in PT. Basically said, I "could" start, but he was more concerned with me being careful for the first month (to 3). Compared to friends with Patellar Tendon, Orr was megaconservative (like no bike for 3 months).

[Huckwheat]

Good Luck and be patient. If your young and healthy your biggest concern is wanting to do too much too soon and ruining something. You should do fine no matter what protocol you are on, just be deligent with whatever you can do.

Taos sounds like the expert, but I agree with the above. My Doc was WAY more concerned with doing too much, than with coming back 3-4 months down the line. I wouldnt stress over straight leg etc, it just means a bit more work when you do hit PT. #1 thing is to let the graft grow into the bones.....and not to stretch it (by doing to much too soon).

The time goes quick....

[drmark]

I am sorry but most of the current thinking in ACL rehabilation has emphasized weight bearing and early range of motion.

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 10of
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.

[amyzilla]

I know there are a lot of different theories out there, but I think it really is best to get that joint moving as soon as possible. I had a lot of trauma to my knee/ankle/leg (bus accident), and I didn't start PT until about a month later. When I started PT, it was a painful and frustrating experience because my knee ROM was so bad. It was a few months before I could bend my knee past 90 degrees and extend to less than 5. On the other hand, I started PT two or three days after having an ACL allograft recon (a year after the accident). From there I think it took me less than a week to get full extension and 90 degrees flexion.

[SnowTigress]

wow. interesting to just now find this thread.

I'm having patellar tendon ACL recontruction tomorrow morning and they have me not going in for PT for 2 weeks. They will have the cpm machine (but now you're saying this isn't useful?) and gameready (?) machine 1 day post-op....
I'm going to ask my surgeon tomorrow before the surgery about ROM exercises right away... I remember having a lot of pain trying for full flexion/extension due to waiting on ROM with my last ACL surgery 4 years ago....

What specific questions should I have for the surgeon?

[amyzilla]

Well, I think CPM is better than nothing. I've never used the Gameready thing, so I don't know anything about it. In addition to the CPM & Gameready, I would ask your surgeon if you can do any leg lifts, heel drags etc. until you start PT.

[SnowTigress]

Yeah, Amy...I'd tend to agree, but I'm not an orthopedic surgeon or a physcial therapist.

Did just speak to my physical therapist ...she says agressive flexion day one not smart because graft is too vulnerable ...weakens the graft's insertion into the bone. Extension is fine to work on day one (aka, putting a towel roll under your ankle).
Also she and the surgeon don't want to weight bear right away because they say your quadriceps shuts down following surgery due to post surgical inflammation. If you were to walk, you would be overloading the joint and the graft site.
Not sure with all the conflicting views...

These folks work with prof and college athletes...geared towards atheletes in general...so I dunno. But compared to the above opinions they sound way more cautious?

[flatlander420]

I had ACLR hamstring graft and didn't start PT untill 3 weeks after surgery. I have just passed 6 months and have been released to train and play soccer, which I have done with no problems, but no skiing! MY PT said to wait till next season. I injured it skiing so I guess thats the theory.

[drmark]

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 10of
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.