In article Torn anterior cruciate ligament (ACL) we described structures of the soft knee, the causes of the injury of the soft tissues of the knee are the most common clinical manifestation of this relatively serious injury.
In this article we want to explain and at the same time offer you modern physiotherapeutic approach focused on removal of the complications that occurred directly after the injury with a quality led physiotherapy, mechanical lymphatic drainage and application of shock wave.
PHYSIOTHERAPY IN ACUTE STAGE OF INJURY
Directly after the injury of the soft tissues in the knee, you will be likely mostly troubled by the following symptoms:
- Lowered or zero mobility
- Lowered muscle strength
- Spastic pain in the surrounding muscles
The goal of the physiotherapy is to remove all these unpleasant complications. It is important to note that the earlier you will start with physiotherapy, the earlier will these unpleasant factors of the injury fade away and the optimal function of the knee joint will be recovered.
DIAGNOSIS BY PHYSIOTHERAPIST
The client has to first go through kinesiological examination focused on the detailed examination of the knee joint, functional changes of the body posture and muscle along with chains with functional changes (changed tension in each muscles directly affects tension in the following muscles). Damaged ligaments or meniscus can be very well visible during ultrasound examination - this examination is non-invasive and it doesn’t hurt.
After the injury we find a significant swelling in the knee joint and high tension in the muscles that are affecting the function of the knee joint. This tension is a manifestation of one the protective functions of our body and it serves as a functional „casting” of the injured area, which restricts further damage. Protective hypertonus (increased tension) is found especially in the calf muscles but also in the back thigh muscles or in the tensor fasciae latae muscle on the outer side of the thigh.
On the other hand, the tension in the quadriceps muscle is directly after the injury lowered (hypotonus). The reason is mutual interconnectedness of the proprioceptors and nociceptors (nerve receptors) between the anterior cruciate ligament (ACL) and quadriceps muscle especially inner head of this muscle (m. vastus medialis). During rupture of the anterior cruciate ligament are getting these nerve pathways disrupted from the proprioceptors in the soft tissue of the knee and the quadriceps muscle is very quickly weakening.
In case the anterior cruciate ligament is disrupted, there is an immediate reflexive antalgic (releasing pain) protective activity of the hamstrings and calf muscles. They cause semiflexion (partial flexion in the knee joint), which stabilizes the knee in a posterior shift. Hamstrings therefore replace the primary function of the anterior cruciate ligament.
The cerebral cortex is through the proprioceptors calming down the activity of the quadriceps as the antagonist (nullifying the action of another muscle) of the anterior cruciate ligament, therefore we observe hypotrophy (decrease) of this muscle. This automatic repairing function of our body is very beneficial for the musculoskeletal system only in acute phase of the injury. Therefore part of the fast physiotherapy is also activation of the quadriceps muscles, especially its inner head, which is partaking in the stabilization of the knee.
After the injury are present also functional blockages directly in the area of the knee joint - blocked meniscus, or head of the shin bone, but also fairly distant blockages in the area of the foot or sacroiliac joint (SI joint). To all that is directly connected disrupted walking stereotype, which causes especially significant pain and increased concern that the knee would drop backwards.
METHODS OF TIMELY PHYSIOTHERAPY
In the area of the injured knee joint is shortly after the injury visible weakening of the quadriceps muscles, whose inner head is crucial for stability of the knee joint. Therefore is important to gently and functionally activate this muscle, but also weakened muscles in the area of the knee joint. In order to strengthen the muscles, you can use devices such as overball and thera-band, but also methods on the neurophysiological basis such as Kabat method and sensory motor stimulation which is crucial for correct function of the knee joint. For sensory motor stimulation we use especially very effective device Posturomed. Exercising on BOSU Balance Trainer is also idea along with other unstable surfaces.
In case the knee is swelling, part of physiotherapy should be also mechanical lymphatic drainage. Lymphatic drainage minimizes the swelling of the knee and that lowers the painfulness, increases the mobility of the injured knee and speeds up the regeneration of the soft tissues after the injury. Ideal is application of the lymphatic drainage already in the day of the injury (length of the application 60 - 120 minutes), because it quenches the further swelling and it lowers the bleeding into the soft tissues. It is very ideal to continue with daily lymphatic drainage in length of at least one week. From then on the frequency of applications can be lowered.
In order to affect the painful post-traumatic condition, it is possible to use techniques of the soft tissues and mobilizations of the joint blockages, which have a functional relation to the injured knee and alternative fixation of the functional problems in the more distant areas of the clients body.
Shock wave is very effective treatment for fast relief of painful spasms and trigger points in the disabled muscles of the knee joint. Its indisputable benefit is immediate relief from pain. Application of the radial shock wave or focused shock wave is affecting the condition already during the first application, afterwards it is optional to repeat the application approximately once every two or three days. (Note. - supplemented according to the experience: don’t let anyone tell you that its application directly after injury is unideal!).
In order for the physiotherapeutic intervention to be effective even after the therapy, we always recommend to apply the so called functional tape, which can help you to stabilize the knee and lower the painfulness and prevent formation of the swellings. Its effect significantly contributes to the effectivity of the therapy itself.
- Reconstruction of the ACL - Postoperative treatment
- Reconstruction of the ACL - consecutive treatment
More articles about the topic:
- Torn anterior cruciate ligament (ACL)
- Surgical methods by ruptured anterior cruciate ligament (ACL)
- Post-operative physiotherapy by recovery of the anterior cruciate ligament
Author: Mgr. Iva Bílková, FYZIOklinika fyzioterapie Ltd, Prague, Czech Republic