I. Common postoperative symptoms
1.Posterior pain
Nowadays, the mainstream technique of ACL reconstruction is to use the autologous N cord tendon. This postoperative pain is usually caused by damage to the subcutaneous tissue and deep fascia caused by the tendon extractor during tendon removal, and is manifested as pain in the posterior aspect of the thigh or the posterior aspect of the knee. This pain usually lasts until about 1 week after surgery, but some patients do not have this pain at all. Sometimes there is a small amount of bleeding into the skin that can also cause irritation and thus pain. Patients can observe for themselves and if they see bruising under the skin in the back of the thigh or behind the knee joint, mild pressure pain without significant swelling, this is normal. This pain, which is mild or only pressure pain, usually appears about 1 week after surgery and will last for 3-4 weeks.
2.Rising body temperature
A mild increase in body temperature after surgery, within 38℃, lasting but 4 days, is generally a normal condition for postoperative absorption of heat. If the body temperature exceeds 38℃ or the body temperature lasts for more than 4 days despite being around 37 or 5℃, be alert to postoperative infection or respiratory tract infection, and seek medical attention as soon as possible.
3. Joint swelling
The knee joint is usually swollen after ACL reconstruction, and the degree of swelling varies depending on the degree of cartilage and other injuries. In milder patients, the swelling will improve in 4-6 weeks after surgery, and the swelling can generally be reduced within 3 months after surgery. If the cartilage damage is more severe, there are patients with swollen knees 6-8 months after surgery. It is generally recommended that patients whose knee swelling has not subsided for more than 3 months should seek prompt medical attention. Knee swelling is usually caused by fluid accumulation. if the knee swelling is felt to be very pronounced and tense (sometimes accompanied by an increase in body temperature), you should see an outpatient clinic where the surgeon will decide whether to puncture and draw fluid and apply pressure bandages, etc. Mild swelling within 3 months can be strengthened with ice if rehabilitation of angles such as knee flexion is underway (see later for details). If the knee mobility has been restored, you can use topical joint wash and oral fotarine for anti-inflammation, and strengthen the knee muscle strength exercises (see later for details).
4. Internal ankle bruising
There will be a small amount of bleeding at the place where the ACL tendon is removed or at the mouth of the bone tract, and if the bleeding volume is more than 20-30ml, it cannot be absorbed in its vicinity. The bleeding that cannot be absorbed will stay along the gap between the subcutaneous and deep fascia and slowly ooze out, forming bruises and other signs of bruising under the skin, with mild pain when pressed. This phenomenon usually appears 7-10 days after surgery and lasts for 3-4 weeks. Sometimes the bruising may also be in front of the tibia or manifest as swelling in front of the tibia, etc. Local hot compresses and strengthening ankle pump exercises can be applied to promote its absorption.
5. Skin numbness
The special area for this numbness is the anterior lower lateral side of the tendon extraction incision or the medial calf, other areas of numbness require medical attention. The reason for this kind of skin numbness is saphenous nerve injury when taking the N cord tendon. Some clinical studies believe that using an oblique incision when taking the tendon can reduce the damage to the saphenous nerve, but it still cannot be effectively avoided. This numbness does not affect the patient’s life, but it can cause mild discomfort or panic. Most of the numbness is recovered in 3-6 months after surgery, and there can be a local insect bite or itchy feeling on the skin at the early stage of recovery, so there is no need to worry; some of them will continue until about 1 year after surgery.
6.Walking disadvantage
The so-called unfavorable walking is the phenomenon of “limp” when walking. This is usually seen in the postoperative period when the knee is limited in extension, and in the early postoperative period some patients tend to focus on knee flexion exercises, and extension is often poor by 3-5°, so that the patient’s knee will “drag the hind legs” when walking, causing the phenomenon of limp. In this case, it is important to see the surgeon in the outpatient clinic to strengthen the extension exercises in a timely manner, except for other causes of limited knee extension. There are two other conditions: one is atrophy of the muscles around the affected knee, and the solution is to strengthen the strength exercises. The second is a combination of cartilage repair and meniscal suture surgery, which delays weight-bearing walking compared to general reconstructive surgery, and the solution is to increase walking time and find a sense of balance in both lower extremities.
Another common phenomenon of unfavorable walking is the lack of flexibility in knee flexion and extension, which is especially evident after the knee mobility is fully restored around 2 months after surgery, which is related to the high expectations of the patient at this time. The normal lack of flexibility usually improves with activity, and the knee’s flexibility usually returns to normal by about 5 months after surgery.
II. Common problems and precautions during rehabilitation
1. Brace wear
Post-operative ACL brace is commonly known as “bending splint”. The splint should be worn 24 hours a day for the first month, removed at night for the second month, and worn when walking in the third month. Some patients with good knee muscle strength should have their splints ended early at the doctor’s discretion. The main purpose of the splint is to maintain the stability of the knee joint and to protect the reconstructed ligaments from excessive strain; of course, the trade-off between excessive protection and atrophy of the knee muscles must be discussed with the physician.
A common problem with braces is “dropping”. The solution comes from the patient: wrap a folded towel around the top of the inner ankle for one week, then wrap the bottom Velcro around the towel and tighten the Velcro from the bottom up.
2.Knee flexion exercise
Flexion of the knee can be painful and varies from person to person. Patients who follow a strict rehabilitation program will have no problems. Patients who have also had surgery to repair other stable structures of the knee, such as meniscal sutures and medial collateral ligaments, will have some difficulty flexing the knee, and the pain will be slightly more severe, so perseverance is required. It is important to note that the knee flexion exercises should not be performed too quickly from extension to the established knee flexion angle, and are generally performed for 10-20 minutes, with a 10-minute stay at the established angle, and ice can be started while staying. After straightening, you can knead the upper, inner and outer knee muscles with your hands to sense the stiffness and compare it with the opposite side.
The most important thing in knee flexion exercises is relaxation. Some patients relax very well and the knee flexion goes smoothly, the pain is mild when the knee is flexed, and the pain stops when the knee is finished. Some patients are more nervous, mainly because they are afraid of pain, and have difficulty bending their knees. Patients in the latter group who have not been able to relax for a long period of time and have a slow knee flexion process, mainly because the knee “hurts” every time it is flexed and the pain in the knee is greater than 5 minutes after flexion, need to seek help from the surgeon. Patients in the former category should not be rushed, as too rapid a flexion process, especially at about 6 weeks post-operatively, can cause laxity of the reconstructive ligaments. It is important to note that at 6 weeks after surgery, some patients feel good about themselves and are able to jog or run fast with or without a brace, which is dangerous.
3. Learn to ice
Ice is closely related to the knee flexion process. When bending the knee and after bending the knee are to ice.
Prepare an ice bag: a large plastic bag from the supermarket, filled with 600ml-800ml of water, placed in ice, the ratio of ice to water is about 1:1, the amount of the above ice and water mixture can be adjusted according to the size of the knee joint itself. Tighten the bag and try to exclude the air inside the pocket, so that the ice bag is easy to fit.
Ice areas: front, inside and outside of the knee joint. Painful areas during knee flexion exercises must be incorporated into the ice pack.
Note: A towel is used to separate the ice pack from the skin; for patients shortly after surgery, the wound is covered with a dressing, and the dressing must be partially removed when applying ice, keeping 2-3 layers of gauze (instead of the aforementioned “towel”), and a layer of plastic wrap can be placed between the gauze and the ice pack for waterproofing; each ice pack lasts about 20 minutes, and the first ice pack may last 25-30 minutes. To last 25-30 minutes, so you will feel the whole joint inside are “cool”; skin ice pain continues for 5 minutes to stop ice, to prevent frostbite; two ice interval 40-60 minutes, a knee flexion exercise after ice 6 times; according to the next day the degree of knee swelling to adjust the number of ice, gradually master to adapt to their own ice The number of times, the knee exercises during the knee flexion to mild swelling (can be in the review of the doctor to help determine) or not swollen is appropriate.
4.Static squatting exercises
Squatting can not only practice muscle strength around the knee joint, the correct squatting posture for a long time on the lumbar spine, cervical spine, etc. are beneficial. The correct static squatting posture rehabilitation program in, here is to emphasize the following.
1, before the static squat generally have to experience a period of straight leg raising exercises, pay attention to increase the time and load of straight leg raising (in the calf on the weight), generally recommended straight leg raising will be affected knee muscle strength to more than 80% of normal before the static squat exercise.
2, static squat, the back can not lean on the wall, can not let the wall share the weight!
3, the knee flexion angle is not too large, in addition to a few patients with strong muscle strength, the general knee flexion should not exceed 60 °.
4, static squat, waist straight, head back, in addition to knee muscle tension, the rest of the body must be relaxed.
5.After practice, pain in the front and medial knee muscles is valid evidence of correct practice posture. Please note that increased pain within the knee joint after a static squat is an abnormal performance that can cause damage to the knee joint and aggravate patellofemoral joint cartilage lesions. Where this occurs, attention should be paid to changing the way: first, the affected knee muscle strength is not improved enough, to strengthen the straight leg lift exercise. Second, the squat is not avoiding the pain point.
6, the time of the static squat must be improved in sections, not stagnant, so that muscle strength will grow smoothly.
7, the practice of a variety of entertainment methods available to transfer fatigue, such as watching TV, movies, listening to music, listening to audiobooks and so on.
5.Intra-articular ringing
Knee mobility exercises smoothly late, began to walk normally. Some patients will find that there is a ringing sound in the knee joint, some ringing is small and can only be felt, while some patients have a larger ringing sound, which is a clear popping sound. There are many causes of rattling, meniscectomy, scarring of the fat pad area, and muscle atrophy are all common causes of popping after ACL reconstruction. These can be corrected by muscle strength exercises and adaptation training of joint activities. Most patients notice the popping sound about 1 month after surgery, and it tends to disappear about 6 months after surgery.
It is important to note that patellofemoral cartilage damage is a pathological clinical condition that causes knee popping. This can be found in the surgical record and is usually associated with pain and swelling in the anterior knee area, especially when walking up and down stairs. Patients with these clinical manifestations must communicate frequently with their physicians to obtain timely information on the treatment of chondromalacia patellae.
6. Muscle contracture
About 6 weeks after surgery, a few patients will hear a ringing sound at the back of the thigh when actively flexing the knee, and then find a “mass” or “depression” in the area. This is due to the lack of distal tendon counteracting the active contraction of the muscle after the tendon of the semitendinosus has been removed, the lack of strong adhesion of the semitendinosus itself to the surrounding muscles and other structures, or the relative strength of the muscle itself. The author himself found one case this year. A survey by our physicians showed a low incidence of such cases, with about 2-3 previously remembered cases, but we cannot exclude those who had problems and did not seek medical attention. A review of the literature revealed a report that semitendinosus contracture occurred in 2 of 23 patients, and that the remaining semitendinosus tendons were regenerable, with differences in postoperative flexor strength, but no significant differences in postoperative knee motion function. When such problems occur, it is recommended that the patient first see a physician for an outpatient examination to clarify the diagnosis in order to obtain a timely response.
Patients undergoing sports medicine surgery basically go through a rehabilitation process after surgery. My experience is that timely, thorough, and effective communication between the patient and the physician is most important. Patients who fail to provide timely information or physicians who receive incomplete information can have a detrimental effect on the recovery process. Doctors are not patients, so of course they cannot appreciate the process of recovery, so effective communication is a mutually reinforcing and improving process.