Anterior cruciate ligament treatment 

Conservative (do not operate), preoperative, surgery and rehabilitation

Conservative (do not operate) recovery after a torn anterior cruciate ligament.

The first step of rehabilitation is to reduce fluid in the knee, improve strength, and optimize flexion and extension. But also: discussing treatment options and the pros and cons of a surgical and conservative course. 

The second step focuses on improving functional strength, coordination and stability. The intensity is built up according to the load capacity and the exercise therapy focuses more and more on your sport. Besides training the muscles around the knee, it is important to train the entire chain. Think of the trunk, hip and ankle. Also the condition should be built up in this phase.

At each stage, the progression should be evaluated. Especially in the final phase, when sports resumption is possible, it should be discussed whether resuming your sport is wise. It is an individual choice that you make in consultation with your physical therapist or orthopedist. If necessary, you can adjust the sport level downwards, or choose another sport. An anterior cruciate ligament reconstruction still remains an option. In the case of sports resumption, the intensity will have to be further built up and outdoor training should be part of this. 


Get the most out of your rehabilitation!

A non surgical rehabilitation will be as intensive and sports-specific as after anterior cruciate ligament reconstruction. After all, the goal is sports resumption. It means that you should train regularly and properly under the supervision of an experienced knee specialist. Wanting to get everything out of your rehabilitation also means that there is a risk of a recurrent injury during one of the training sessions. On the other hand, without risk, the knee is not sufficiently tested to determine a proper return to sport. 

voorste kruisband conservatief herstellen

In addition to physically, you also need to recover mentally. For a good return to sport, confidence in your knee is essential. Usually a program that is built up gradually and that is concluded with outdoor training is sufficient to get your confidence back. A psychologist may be an option if fear continues to play a significant role. If the symptoms and/or instability persist, an anterior cruciate ligament reconstruction can be considered. The advantage is that you have trained well. The muscles and knee are almost recovered which is an advantage after surgery. 

preoperative

If anterior cruciate ligament reconstruction is unavoidable, train your leg muscles before surgery and take the time to allow the knee to recover properly. The better the knee condition before surgery, the better the final result. The conditions for an optimal result are a good stretch, no swelling and a minimal difference in strength (<20%) between the left and right upper leg. Be guided in the process by an experienced knee specialist. A recurring injury unfortunately occurs and therefore the following applies: the first shot is the best shot!

Biodex test voor het meten van de progressie van de revalidatie

Preoperative training: better in, better out.

The orthopedist's conclusion is that an anterior cruciate ligament reconstruction is necessary to regain the stability of the knee. The doctor will refer you to a knee specialist to go over the preoperative course. This course is important to prepare you for surgery. There are a number of factors that should be in order preoperatively to positively influence the outcome of the rehabilitation: no to minimal swelling, good extension and flexion and a minimal difference in strength between the thighs. If necessary, strength can be assessed with a preoperative test on the biodex.

Positive effects

Another positive effect of a pre-operative course is that you become familiar with the exercises. Nothing is as annoying as walking with a limp with two crutches and having to learn all those new exercises in the meantime. In addition, you will usually meet other cruciate ligament patients. Fellow sufferers contact where you can ask questions. In this way you can learn that discipline and regular training is important. Most clients are nervous before the operation, but that is only an hour of lying still. A well-functioning knee is mainly determined by your rehabilitation and you really have to do that yourself. If you have the will and the perseverance, you can get the most out of your rehabilitation and recover optimally. 

Pre operatief voorbereiden voorste kruisband reconstructie doe squats

Not everyone needs surgery.

Research also shows that not everyone needs surgery. Gradually, you may find that you can also do well without surgery. If you have no intensive sports requirements, surgery can be postponed. You can discuss this with your physical therapist and / or doctor.

A preoperative course consists of an informative conversation in addition to muscle training. During a preoperative discussion, home exercises, living rules and physical therapy policy are discussed. Set goals for yourself and an end goal. It is wise to make agreements with your employer about reintegration.

It is important to be aware of the rules of life and expectations after surgery. Think about the planning regarding the time of surgery, study, home situation and work. Ask your physical therapist or doctor about your specific situation. 

Consider the following:

  • What are the precepts?
  • What exercises should you do? 
  • What symptoms should you look out for?
  •  How do you walk with crutches? 


But also practical matters such as:

  • How long can you not work? 
  • When can you ride your bike outside again? 
  • When can you drive again? 
  • What sports can you do again soon?

Arrange your crutches in advance for after surgery. Borrowing, renting or buying from a health care storeis possible.

The anterior cruciate ligament surgery | anterior cruciate ligament reconstruction:

There are several options where the tendon can be taken for the new cruciate ligament. 

  • Hamstring
  • Patella tendon
  • Quadriceps tendon
  • Donor tendon

Which surgical technique is right for you will be discussed with the orthopedic surgeon.


De verschillende pezen die gebruikt kunnen worden voor het maken van de kruisband

Different graft choices

Schermafbeelding 2021 12 10 om 22.42.00

The new anterior cruciate ligament

De hamstring pezen lopen aan de binnenzijde van de knie en worden gebruikt om de nieuwe kruisband van te maken

The narrow strands are the hamstring tendons used to make the new cruciate ligament.

De kniepees of patellapees is uitgetekend om eruit te halen en de nieuwe kruisband van te kunnen maken.

Drawing out the knee or patella tendon. The doctor may take out the tendon to make the new knee ligament.

Rehabilitating after anterior cruciate ligament surgery:

Rehabilitation varies from person to person and depends in part on your goal and the status of your knee preoperatively. On average, recovery takes nine to twelve months.

After surgery you may usually go home the same day. In the hospital you will receive a protocol for the first exercises at home. The stitches will be removed after two weeks. In the first 10 days you can shower with water-repellent patches or a plastic bag. For proper healing, the wound edges should not get too wet or soaked.

De wonden en jodium 3 dagen na de voorste kruisband operatie

3 days after anterior cruciate ligament surgery.

De blauwe plekken die na de voorste kruisband reconstructie ontstaan

The bruising that occurs after surgery.

Start practicing

After surgery, start gently stretching and bending the knee. A flexion of 90 degrees is sufficient in the first few days. The focus is on a full extension. A full extension should be achieved as soon as possible after surgery. A pillow or towel in the knee socket is the biggest culprit, you can develop a stretch restriction with that. The knee is swollen and painful. The amount of swelling and pain varies from person to person. The location of the pain depends on the tendon that was used during surgery. 

Swelling in the knee disrupts muscle control and leads to decreased stability and coordinated movement. In the process, the size of the upper leg decreases. This process cannot be stopped, but it can be slowed down by starting exercises immediately after surgery. The exercises are aimed at improving the control of the upper leg muscles and the cooperation between the muscles. In the beginning, the knee does not like pressure (standing and walking) but it does like unloaded movement. For this reason it is important to do a lot of bending and stretching exercises. Once the knee can be flexed 100 degrees, cycling on an exercise bike is possible. Cycling is medicine for the knee. No pressure on the knee and yet a lot of movement in a relatively short time. Cycling is allowed, after consultation with your physiotherapist, two to three times a day for half an hour. 

opnieuw leren buigen van de knie na de kruisband operatie

Learning to bend and stretch the knee.

Een gestrekt been heffen is een goede knie oefening om de spieren van de knie te versterken.

Knee exercise to strengthen the muscles.

Direct na de voorste kruisband operatie moet je weer leren lopen met twee krukken.

Learning to walk with two crutches.

Learning to walk

Typically, you are allowed a 50 percent load on your knee and walk with two crutches. The load with walking and standing may be built up based on the knee's response. Increasing swelling, stiffness and/or pain are signs that you are doing too much. Properly adjusting the load is important to build muscle strength. Increasing or persistent swelling will cause muscle strength to decrease.

The use of crutches is phased out over the course of three to six weeks after surgery. In doing so, it is important to monitor the knee's response. Build off walking with crutches in consultation with your physical therapist. 

After six weeks, you may resume driving and cycling (consult with your physical therapist). Office work you can resume full time after about two or three weeks. Do take sufficient breaks to exercise. Physical occupations can be resumed after eight to twelve weeks. How long it takes for you depends on your recovery and type of work. 

In the past, rehabilitation was time based. All progression in rehabilitation was determined based on weeks or months after surgery. Nowadays, the progression is criteria based. In your rehab, you must be able to do certain actions or have enough strength to build up to the next step. 

Halterschijf oefeningen met lunches en rotatie om te herstellen na voorste kruisband reconstructie.

Lunges variant with rotation and disruption by dumbbell.

Gerichte oefeningen na een voorste kruisband reconstructie. Leren afremmen met waterzak en rotatie

Sports specific exercises to learn to slow down with waterbag

Sports-specific training

Training consists of strength training, functional exercises, and stability and coordination. However, the training does not stop at training the leg muscles. A strong knee starts with a trained torso and powerful abdominal and back muscles. Rehabilitation is built up to eventually move to outdoor or field training. The focus here is on sport-specific rehabilitation. This is a more important component when you have the desire to return to sports. A specialized sports physiotherapist can guide you through this. 

Every three or four months, progress should be evaluated with an intermediate test. Think questionnaires, biodex (strength test), strength and functional tests. You will conclude the rehabilitation with a number of performance and jump tests to evaluate a return to the sports field. 

After an average of six weeks, you can resume most activities of daily living. On average, the knee has recovered after six to nine months and sport can be built up under the guidance of the physiotherapist. After nine to twelve months you can resume your sport completely. However, the rehabilitation does not stop. It is important to maintain the strength and specific exercises. 

Tips: 

  • Heb je een zittend beroep, probeer dan regelmatig van positie te wisselen en de knie te bewegen. Doe je oefeningen om de knie niet te laten verstijven.
  • While sleeping, place a pillow between the knees.
  • The knee may bend after surgery, but keep in mind the wounds need to recover first. The stretching is most important!
  • It may take several months until squatting and being on your knees is possible again.
  • Een zwelling kan zes tot acht weken en soms wel langer aanwezig blijven. Koelen met ijs is prettig en effectief tegen pijn. 


Notice: 

The course and development of rehabilitation are personal. Every person is different, has their own biology, sports background and experiences. The different surgical techniques or collateral damage can influence the recovery. The mental situation (fear, uncertainty, doubt etc) can also influence the course and speed up or slow down the recovery. Therefore, it is important to rehabilitate with an experienced knee specialist. 

The outcome after anterior cruciate ligament surgery:

Most clients recover reasonably to well from anterior cruciate ligament reconstruction. The outcome will depend in part on the severity and extensiveness of the injury. In addition, the conditions must be right to train and mental toughness and discipline are aspects that can affect the final outcome. It is also worth noting that the majority of cruciate ligament clients are amateur athletes with school, jobs and/or children. These people have a full time life next to their rehabilitation and can't be working on their rehabilitation non-stop like a professional. Therefore, don't stare at the nice stories in the media. It is your knee and your personal recovery. 

91 percent of clients expect to return to the same level of sport. In reality, only 65 percent return to the old level (amateur athletes). To the competition level, only 55 percent return. Among professional athletes, 78-98 percent return to the old level. The chance of a recurrence is about 25 percent for both the same knee and the other side. Children under the age of 18 have an even higher chance of a recurrence. Therefore, take your time in your recovery and slowly build up your workouts with sports.


Return to sport

91 percent of clients expect to return to the same level of sport. In reality, only 65 percent return to the old level (amateur athletes). To the competition level, only 55 percent return. Among professional athletes, 78-98 percent return to the old level. The chance of a recurrence is about 25 percent for both the same knee and the other side. Children under the age of 18 have an even higher chance of a recurrence. Therefore, take your time in your recovery and slowly build up your workouts with sports.

De littekens van verschillende pezen die zijn gebruikt voor het maken van de voorste kruisband

Een pechvogel die meerdere keren opnieuw is geopereerd.

Extra information

The outcome of your recovery (operative and conservative) will largely depend on your rehabilitation. The question of who you have surgery by is just as important as the question of who you will rehab with. Questions that can help you select a suitable place include:

  • How many cruciate ligaments do you rehabilitate per year?
  • Is there a suitable space to train?
  • Are there sufficient and appropriate training materials?
  • Wordt de progressie van de revalidatie beoordeeld met tussentijdse testen.
  • Does rehabilitation conclude with performance testing?
  • Is er buiten- of veldtraining?Hoe groot is het knieteam (bij ziekte, vakantie moet jij door kunnen)
  • Which clinics and orthopedic surgeons are collaborated with?


A good dose of motivation, discipline, proper timing of surgery and rehabilitation are essential and together largely determine the outcome of your recovery.

The risks of anterior cruciate ligament surgery:

Take your time in your recovery and listen carefully to your physical therapist. Adhere to the guideline of rehabilitation. 

Common complaints during your rehabilitation may include:

  • A stiff knee when bending and/or extending.
  • Persistent pain symptoms that do not respond well to physical therapy.
  • Pain around the kneecap (common, but treatable).
  • Overloaded knee due to excessive load in daily life.
  • Overly progressive build-up of training load.
  • Slip or fall with risk of recurrence. 

Knee surgery is a conscious decision and that includes rehabilitation. It is six to twelve weeks of disciplined following of the lifestyle rules and homework exercises to get the best effect of the surgery. After this period, the crucial phase is over and it is important to continue getting fit. 

In addition, you always have to deal with the risks of the surgery that the orthopedic surgeon will discuss with you.

Always contact your treating physician in the following cases:

  • Standing on the leg no longer possible, whereas before this went well.
  • Fever above 38.5 degrees Celsius.
  • The knee becomes abnormally thick and more painful.
  • The calf is thick, red, painful and warm (possible thrombosis leg).
  • If you don't trust it for other reasons
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