Original Rehabilitation Programme after Anatomical ACL Reconstruction Based on MRI Evaluated Graft Remodelling

OBJECTIVES: This study was carried out to design a rehabilitation program allowing for complete functional post-surgical recovery of the limb, that would not affect the remodelling process of the transplanted graft evaluated on MRI imaging. The main reason for changing the rehabilitation protocol was the 14 months of observation of the MRI images (a series of 9 MRIs performed over a two year period) among the patients after ACL reconstruction, in whom the adverse characteristics in remodelling of the graft were observed in line with the implementation of the traditional rehabilitation program. METHODS: A 23 years old patient, a professional hi-rank skateboarder, took part in this pilot study. He had a torsion injury of the left knee joint. The main concepts of the rehabilitation program were: functional training in CKC that would involve muscles of the entire kinetic chain of the operated limb; the co-contraction training under the axial load, active extension training, the avoidance of static flexor stretching for at least 24 weeks after the surgery, no passive movements while exercising, the use of posterior translation of the tibia while doing the exercises, and no knee joint extensor strengthening activities in OKC for at least six months after the surgery. In order to evaluate the remodelling of the graft, seven oblique axial MR images (DOA) were taken, on which the graft’s cross-sectional area was measured. The MRI's were performed in the second, sixth, and twelfth week; then in the fourth, sixth, and ninth month, and, finally a year after the surgery. The angle of the graft and PCL was also measured. Additionally, the quality of tendon signal was assessed. For the functional evaluation, isokinetic and isometric tests of the knee extensor and the flexor muscles, along with the tibial rotator functions were performed using Humac Norm device. Postural stability based on COP parameter was established, as well, using the stabilometric platform HUR. For the dynamic stabilography assessment Biodex Balance System device was used. In order to indicate the subjective functional evaluation by the patient, the Lyshom scale and IKDC questionnaires were used. RESULTS: The MRI 12 months after the surgery showed good tendon signal, and no significant changes characteristic for the anterior subluxation of the tibia were observed. In the functional evaluation, very good values of flexor and extensor muscle strength were recorded. These values were comparable to those achieved by the opposing limb. The strength of the left knee rotator muscles was comparable to that of the opposite limb. Additionally, very good stability index was recorded in both static and dynamic conditions. The results the two limbs were comparable. Patient’s subjective evaluation was also assessed to be on a very good level (the results of the IKDC questionnaires were 98,85 and 100/100 on the Lysholm’s scale). CONCLUSION: The original rehabilitation program in CMC seems to be a valuable protocol conditioning the return to sport activities without disrupting the the remodelling process of the graft. The case described is a part of a bigger project which includes the total of over 30 patients.