CLINICAL PRACTICE GUIDELINE BASED EVIDENCE FOR THE PHYSIOTHERAPY OF PATIENTS WITH ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION WITH HAMSTRING (T4)

Abstract

Anterior knee instability associated with rupture of ACL is a disabling clinical problem, especially in the athletic individual. The gracilis and semitendinosus tendon (T4) represent an alternative autograft donor material for reconstruction of the ACL.

The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with ACL reconstruction with T4.

The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

CPG include three phases determined from the evidence, physiopathology reasoning and the biological process of autograft (weeks after the surgery: 2^a–6^a, 6^a–10^a and 10^a–16^a). The recommendations included: In postoperative weeks (2^a–6^a) physiotherapy focused on early range of motion of the knee; manual therapy (passive range of motion (PROM) 0–120° and miofascial techniques), pulsed ultrasound of low intensity with a power of 0.3w/cm2 (1MHz) during 10min/day in tibial tunnel, early active hamstring beginning with static weight bearing co-contractions (closed-kinetic-chain) and adductors, partial weight bearing with crutches, exercises in the swimming pool and cryotherapy to pain control (30 mi/4 hours). In weeks 6 to 10, full weight bearing, manual therapy (PROM 0–140° and miofascial techniques), hamstring strengthening progress complexity and repetitions of co-contractions, electrotherapy hamstring and quadriceps co-contractions. Starting at week 10, progress to more dynamic activities/movements, proprioceptive work, open-kinetic-chain, stationary bike and Theraband squats. In week 12, progress jogging program and plyometric type activities. The patients performed sports-specific exercises by about 3½ months postoperative.