What are the recommended pain management guidelines for a patient following Anterior Cruciate Ligament (ACL) reconstruction surgery?

Pain Management Guidelines Post-ACL Reconstruction

A multimodal analgesic approach combining regional anesthesia or local infiltration, NSAIDs, cryotherapy, and early mobilization provides optimal pain control while minimizing opioid consumption and facilitating early rehabilitation after ACL reconstruction. 1, 2

Immediate Postoperative Pain Control (0-24 Hours)

Regional Anesthesia Options

• Femoral nerve blocks (single-injection) provide superior analgesia compared to placebo for up to 24 hours postoperatively, though they cause temporary quadriceps motor deficit 3
• Adductor canal nerve blocks offer effective analgesia while preserving quadriceps function since the saphenous nerve is purely sensory 4
• Combined femoral-sciatic nerve blocks may provide the most effective analgesia based on meta-analysis rankings 4
• For longer-lasting pain control (72 hours), continuous anesthetic delivery via pump/catheter with ropivacaine or slow-release bupivacaine liposome is recommended 4
• However, continuous nerve blocks carry complication rates above 13% and should be used with caution 1, 2

Local Infiltration Analgesia (LIA)

• Peri-articular LIA at the hamstring tendon harvest site is effective and provides equivalent analgesia to regional nerve blocks 2, 3
• Intra-articular LIA does not provide superior analgesia and should be avoided 2
• Continuous-infusion catheters of local anesthetic should be avoided due to risk of chondrolysis 3

Systemic Medications

• Preoperative administration of acetaminophen 1000 mg and celecoxib 400 mg (1-2 hours before surgery) significantly reduces long-term patellofemoral complications 5
• NSAIDs are protective against delayed discharge and should be routinely used 2
• Preoperative gabapentin decreases postoperative opioid consumption 3
• Intravenous corticosteroids reduce pain and are recommended as part of the multimodal regimen 2

First Week Postoperative (Days 1-7)

Pharmacologic Management

• Continue acetaminophen 1000 mg every 6 hours and celecoxib 200 mg every 12 hours for 14 days postoperatively 5
• This regimen reduces anterior knee pain (15% vs 1%), complex regional pain syndrome (7% vs 1%), and flexion contractures (9% vs 2%) compared to placebo 5
• Oral ketorolac provides superior pain relief compared to hydrocodone-acetaminophen 3
• Ibuprofen reduces pain more effectively than acetaminophen alone 3
• Zolpidem given for the first week postoperatively decreases opioid consumption 3

Non-Pharmacologic Interventions

• Cryotherapy should be applied in the first postoperative week to reduce pain and swelling 1
• Compressive cryotherapy is more effective than cryotherapy alone 1, 6
• Cryotherapy is inexpensive, has high patient satisfaction, and rarely causes adverse events 1
• Elevate the limb above heart level when resting to reduce swelling 6

Early Mobilization

• Early weightbearing decreases pain compared to delayed weightbearing and should be initiated immediately 3
• Start isometric quadriceps exercises in the first week only if they provoke no pain 1

Weeks 2-12: Rehabilitation Phase

Exercise Progression Criteria

• Progress to concentric and eccentric exercises only when the knee does not react with effusion or increased pain 1, 6
• If effusion develops after exercise, immediately modify the program—this is the most critical error leading to prolonged symptoms 6
• Closed kinetic chain (CKC) exercises can be performed from week 2 postoperative 1
• Open kinetic chain (OKC) exercises can start from week 4 in restricted ROM of 90-45° 1

Ongoing Pain Management

• Continue cryotherapy after exercise sessions for symptom management 6
• Monitor for quadriceps strength deficits >20%, as this significantly impairs outcomes 6
• Blood flow restriction training can be considered as an adjunct to improve strength gains 6

Critical Pitfalls to Avoid

• Never progress exercises if knee effusion develops—this indicates excessive loading 1, 6
• Avoid functional knee braces for routine use, as they confer no clinical benefit after isolated primary ACL reconstruction 1
• Do not use intra-articular continuous-infusion catheters due to chondrolysis risk 3
• Avoid dense, long-duration nerve blocks in patients at risk for acute compartment syndrome 7
• Do not neglect quadriceps strengthening, as it is the primary determinant of long-term outcomes 6

Return to Activity Considerations

• Patients receiving the multimodal celecoxib regimen return to higher activity levels (84% vs 65%) and full sports activity more frequently 5
• Continue rehabilitation for 9-12 months depending on return-to-sport goals 6
• Use criterion-based progression rather than time alone, with minimum 12 weeks before considering running 6
• Evaluate psychological factors including fear of reinjury, as these influence rehabilitation outcomes 1, 6