Clinical Case Commentary: Unlocking Flexibility: Approaches to DVT and Knee Stiffness in ACL Recovery

The management of Anterior Cruciate Ligament (ACL) injuries can be complicated by Venous Thromboembolism (VTE) and knee stiffness which can present several challenges. This commentary examines the Physical Therapy (PT) treatment of a 27-year-old female patient with a full ACL rupture who developed VTE. This case emphasizes the importance of timely intervention and comprehensive care strategies particularly in the rehabilitation setting.

Patient is a 27-year-old female who presented to PT for pre-rehabilitation after full rupture of her L Anterior Cruciate Ligament (ACL) during a ski accident. She is a recreational athlete who works as an event planner. Patient is healthy with no notable medical conditions or comorbidities. The only medication she takes are oral contraceptives. Although the initial presentation seemed simple, the events after her ACL injury made this case much more complex. The patient was unable to access PT or imaging for 5 weeks after her initial injury. During these 5 weeks, she was non-weight bearing and apprehensive to move her injured limb. By the time she presented to PT, the patient had developed three VTEs in her L lower leg along with significant loss of knee ROM and stiffness. Patient was referred by the surgical team to be seen by PT for gait raining and restoration of ROM prior to surgical ACL reconstruction.

Venous Thromboembolism (VTE) & Risk factors

VTE is the formation of a blood clot in a deep vein that can lead to complications, including Deep Vein Thrombosis (DVT), a Pulmonary Embolism (PE), or Post Thrombotic Syndrome (PTS) [1]. VTE is a serious condition, with an incidence of 10% to 30% of people dying within 1 month of diagnosis, and half of those diagnosed with a DVT have long-term complications [1]. While there have been no evidence demonstrating the rates of developing VTE after an acute ACL tear, the incidence after Anterior Cruciate Ligament Reconstruction (ACLR) is 0.4% [2]. Risk factors can be inherited and/or acquired which can lead to a VTE. The most common reason for developing a VTE is immobility [3]. An acquired risk factor of iatrogenic origin such as contraceptive agents can also cause VTEs. Of note, this was the only medication this patient was taking. Using hormonal contraceptives contributes to a significant percentage of VTE occurring among women of childbearing age, and VTE is the most important determinant of the risk-benefit profile associated with hormonal contraceptives [4]. It is important to consider the heightened risk of patients who are female and taking oral contraceptives on the potential risk of developing DVTs.

VTE management with medications

The patient was diagnosed with her DVTs via doppler US the night before her PT evaluation. She was started on Xarelto (Rivaroxaban) the following day. Xarelto is classified as a newer class of anticoagulant drugs (NOAC) [5]. Another anticoagulant used to manage VTE is Warfarin which is commonly encountered by PTs in the acute care setting. In patients using Warfarin, INR levels are used by PTs to determine what intensity of exercise can be performed [1]. However, with Xarelto there is no blood test monitoring required due to the nature of the fixed dosage [5]. The clinical practice guideline developed by Hillegass et al. [1] was beneficial in order to determine what level of activity could be performed with this patient [1]. Prior to seeing this patient, it would be essential to verify when and if the patient was taking the Xarelto. Patients taking NOACs can be mobilized >3 hours after taking the medication [1]. This was an important consideration point particularly with scheduling her PT appointments making sure she was in the >3 hour window after administering her medication.

PT management of knee stiffness

During the initial evaluation, patient presented with significant stiffness through the knee. Her initial knee ROM was 20-50 degrees. She was ambulating with crutches but was non-weightbearing through the involved limb. Extensive patient education was done discussing the importance of restoring pre-operative ROM to prevent risk of developing arthrofibrosis postoperatively. Patient was informed about the benefits of pre-rehabilitation prior to ACL Reconstruction (ACLR). A systematic review done in 2020 demonstrated that pre-rehabilitation prior to ACL-reconstruction improved neuromuscular and self-reported knee function as well as return to sport [6,7].

Knee stiffness is a complication that can occur after trauma, arthroscopic surgery, infection, TKA, and fracture fixation [8]. The rates of knee stiffness reported after traumatic knee injuries are as high as 14.5% [8]. Her initial interventions provided were passive to allow the patient to feel in control of her rehab and gain confidence in utilizing her limb. The principle of Total End Range Time (TERT) was essential in managing and restoring this patients ROM. The TERT principle states that the increase in passive ROM in stiff joints is directly proportional to the time the joint is held at the end of range [9]. The protocol followed were like if the patient were using a static progressive splint. Patient was educated regarding the potential need to obtain this splint early in her care in case she wasn’t making any progressive in restoring ROM with other PT interventions. The Table 1 below outlines her stretching routine. Although this program would be time consuming, the patient was educated on the importance of complying with stretches in order to achieve lasting gains in knee motion by permanently elongating scar tissue through load deformation [8,9].

Table 1:Patient stretching routine.

Patient was seen twice a week in clinic where we could focus on manual techniques. A reason for knee stiffness can be attributed to fibrosis or shortening of the quadriceps muscles (e.g., rectus femoris and vastus intermedius), adhesion of the vastus lateralis to the femoral condyle, or intra-articular adhesions in the patellofemoral or tibiofemoral joint [8]. Due to this, PT interventions focused extensively on instrument assisted soft tissue mobilization through the distal quadriceps region where there were notable adhesions and restrictions through the muscle belly. This was in addition to passive stretching assisted in improving the patient’s ROM. Although there is limited evidence to support manual therapy techniques, one study investigated use of manual techniques in patients with hemophilic knee arthropathy which also presents clinical symptoms of knee stiffness and pain. The study assessed the effectiveness of manual therapy and passive muscle stretching exercises for reducing the frequency of hemarthrosis, pain, improving joint health and range of motion in patients with hemophilic knee arthropathy [10]. This demonstrated that manual therapy with passive muscle stretching exercises improved joint health, range of motion and perceived joint pain [10].

Connective tissues are most responsive to remodeling during the first 12 weeks instead of those with chronic contractures (>6 months) which can yield more optimal results with stretching [9]. This patient was seen 5 weeks after her initial injury and completed 6 weeks of pre-rehabilitation. By the end of 6 weeks of PT, patient was able to obtain terminal knee extension and flexion. Her L knee ROM at the end of her pre-rehabilitation phase was 0-120 degrees. Although the process and gains were slow, ROM was able to be restored without use of a splint.

Currently, the patient is several months post-op with full knee ROM (3-0-135 degrees). She is now able to independently perform all activities of daily living and has been able to return to her desired activities such as spinning. Effective management of ACL injuries with complications such as VTE and knee stiffness requires a multi-faceted approach. This case underscores the importance of comprehensive risk assessment, careful medication management, and thorough patient education in achieving successful rehabilitation outcomes [2]. It is crucial to identify the factors that may contribute to the development of VTE in younger individuals who are otherwise healthy and have no additional comorbidities [4]. Additionally, it is important to consider the heightened risk of patients who are female and taking oral contraceptives on the potential risk of developing DVTs. By applying lessons from this clinical case, clinicians can enhance their practices and improve patient outcomes.

1. Ellen Hillegass, Michael Puthoff, Frese EM, Mary Thigpen, Sobush DC, et al. (2016) Role of physical therapists in the management of individuals at risk for or diagnosed with venous thromboembolism: Evidence-based clinical practice guideline. Physical Therapy 96(2): 143-166.
2. Schmitz JK, Lindgren V, Janarv PM, Forssblad M, Stålman A (2019) Deep venous thrombosis and pulmonary embolism after anterior cruciate ligament reconstruction: Incidence, outcome, and risk factors. Bone Joint J 101-B(1): 34-40.
3. McLendon K, Goyal A, Attia M (2022) Deep venous thrombosis risk factors. In: StatPearls [Internet], Treasure Island (FL): StatPearls Publishing, USA.
4. Jang YS, Lee ES, Kim YK (2021) Venous thromboembolism associated with combined oral contraceptive use: a single-institution experience. Obstet Gynecol Sci 64(4): 337-344.
5. Singh R, Emmady PD (2022) Rivaroxaban. In: StatPearls [Internet], Treasure Island (FL): StatPearls Publishing, USA.
6. Queiros VS, Dantas M, Neto GR, Silva LF, Assis MG, et al. (2021) Application and side effects of blood flow restriction technique: A cross-sectional questionnaire survey of professionals. Medicine (Baltimore) 100(18): e25794.
7. Giesche F, Niederer D, Banzer W, Vogt L (2020) Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport-related and self-reported knee function: A systematic review. PLoS One 15(10): e0240192.
8. Vaish A, Vaishya R, Bhasin VB (2020) Etiopathology and management of stiff knees: A current concept review. Indian J Orthop 55(2): 276-284.
9. Bhave A, Sodhi N, Anis HK, Ehiorobo JO, Mont MA (2019) Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review. Ann Transl Med 7(Suppl 7): S256.
10. Cuesta-Barriuso R, Gómez-Conesa A, López-Pina JA (2021) The effectiveness of manual therapy in addition to passive stretching exercises in the treatment of patients with haemophilic knee arthropathy: A randomized, single-blind clinical trial. Haemophilia. 27(1): e110-e118.