ACL Rehabilitation

The anterior cruciate ligament (ACL) is one of the important ligaments that stabilise your knee joint. If you have torn (ruptured) this ligament, the knee can collapse or ‘give way’ when making twisting or turning movements. An ACL rupture happens as a result of a twisting injury to the knee. The common causes are football and skiing injuries. You can injure other parts of your knee at the same time, such as tearing a cartilage or damaging the joint surface. ACL reconstruction is normally performed under general anaesthetic. The operation usually takes between an hour and an hour and a half. The surgeon will make one or more cuts on the front and sides of your knee. Some surgeons may perform the operation by arthroscopy (‘keyhole’ surgery) using a camera to see inside the knee. The surgeon will replace the ACL with a piece of suitable tissue (a graft) from elsewhere in the body. The top and bottom ends of the replacement ligament are fixed with special screws or anchors into ‘tunnels’ drilled in the bone.

Initial rehabilitation phase 0-2 weeks

Goals:
  • Achieving full range of knee extension to 120° knee flexion
  • Minimal joint effusion/swelling (particularly am)
  • Full quadriceps activation
  • Full weight bearing with mobility aid/s at 2 weeks
Restrictions:
  • If sedentary employment, may be able to return to work from 2-4 weeks post-operatively, as long as provisions are made to elevate leg, and no complications
  • No open kinetic chain quads work
Treatment:
  • Pain Relief: Ensure adequate analgesia
  • Advice / Education: Comprehensive education and instruction on restrictions and on carrying out activities of daily living to manage pain and swelling
  • Posture advice / education
  • Swelling management
  • Gait re-education & Mobility: to ensure safely and independently mobile with walking aid/s and to progress weight bearing status to FWB at 2/52 post op if knee control, pain and swelling allows
  • Stretches of tight structures as appropriate
  • Exercises: Example exercises
    • Knee range of movement exercises to ensure achieving full range of extension and progressing range of movement into flexion
    • Stationary cycling can be introduced at 2/52 post op as long as resistance is minimal and there is sufficient ROM to complete a revolution without pain
    • Strengthening of muscles stabilizing the knee i.e. closed kinetic chain quadriceps exercises in prone, open kinetic chain hamstring exercises
    • Thoracic rotation exercise- sitting and standing rotation
  • Manual therapy:
    • Soft tissue techniques as appropriate.
    • Joint mobilisations as appropriate ie patella mobilisations
Milestones to progress to next phase
  • Achieving full range of knee extension to 120° flexion
  • Minimal joint effusion (particularly am)
  • Full quadriceps
  • Full weight bearing with mobility aid/s

2- 6 weeks

Goals:
  • Achieving full active range of knee movement
  • Minimal activity related joint effusion
  • Wean from mobility aids as comfort, swelling and knee control allows, to achieve no gait abnormalities
  • Symmetry on ascending and descending stairs
Restrictions:
  • If sedentary employment, may be able to return to work from 2-4 weeks post-operatively, as long as provisions are made to elevate leg, and no complications
  • If manual employment may be able to return to work after 6 weeks with pacing provided no complications
  • Driving: May be able to return to driving a manual car if mobilising with no aids, has full range of movement of the knee joint and would be able to perform an emergency stop. May be able to return to driving an automatic car sooner, if the braking pedal is used by the unaffected leg. In both situations must be educated and understand pacing up of driving and general activities to manage pain and swelling
  • No OKC quads work
Treatment:
  • Pain Relief: Ensure adequate analgesia
  • Advice / Education: Comprehensive education and instruction on restrictions and on carrying out activities of daily living to manage pain and swelling
  • Gait re-education- splitleg squat with rotation direction split leg squat
  • Mobility: Ensure safely and independently mobile with walking aid/s progressing to safe and independently mobile without mobility aid/s
  • Exercises: Example exercises
    • Stationary cycling can be introduced as long as resistance is minimal and there is sufficient ROM to complete a revolution without pain. Progress resistance and duration as appropriate
    • Swimming can be commenced once there is satisfactory wound healing, but not breast stroke leg kick
    • Strengthening of muscles stabilizing the knee progressing resistance with theraband/weights and/or COG shift as appropriate leg press both double leg and single leg.
    • Core stability and gluteal control work – single leg bridges clams
    • Balance/Proprioceptive exercises progressing to an unstable BOS and COG shift as appropriate- single leg squat single leg squat with rotation, step up and down.
  • Stretches of tight structures as appropriate
  • Biofeedback may be used if altered sequencing of muscles Compex and muscle stimulation when squat and lunges
  • Manual therapy:
    • Soft tissue techniques as appropriate
    • Joint mobilisations as appropriate
Milestones to progress to next phase:
  • Achieving full range of knee movement
  • Minimal activity related joint effusion
  • Unilateral CKC squat with knee valgus control
  • Step up with knee valgus control
  • Single leg stance eyes open R=L

Recovery rehabilitation phase 6 weeks – 12 weeks

Goals:
  • Bilaterally equal propriocepton tests on single leg stance
  • Bilaterally equal strength of hamstrings, hip adductors, hip abductors and gastrocnemius
Restrictions:
  • No jogging until proprioception on an uneven surface, knee valgus control when leaping and unilateral CKC squat with knee valgus control is achieved. This can be expected to be at approximately 12 weeks post op
  • If manual employment may be able to return to work after 6 weeks with pacing provided no complications
  • No OKC quadriceps work until 12 weeks post op
Treatment:
  • Pain Relief: Ensure adequate analgesia
  • Advice / Education: Comprehensive education and instruction on restrictions and on carrying out activities of daily living to manage pain and swelling
  • Posture advice / education
  • Swelling management
  • Mobility: Ensure safely and independently mobile without walking aid.
  • Exercises Example exercises
    • Rowing machine can be introducedprogressing resistance and duration as appropriate
    • Stepper can be introduced progressing resistance and duration as appropriate
    • Road cycling  can be introduced progressing duration as appropriate
  • Balance / Proprioceptionprogress unilateral exercises with unstable BOS and COG shift
    • Strengthening of muscles stabilising the knee progressing resistance with theraband/weights and/or COG shift as appropriate
    • Strengthening exercises of other muscle groups as appropriate
    • Core stability and gluteal control work
    • Stretches of tight structures as appropriate to ensure normal flexibility of quadriceps, hamstrings and calf muscles
  • Review lower limb biomechanics and kinetic chain, addressing issues as appropriate- basic sport specific
  • Biofeedback may be used if altered sequencing of muscles
  • Manual therapy:
    • Soft tissue techniques as appropriate
    • Joint mobilisations as appropriate
Milestones to progress to next phase:
  • Bilaterally equal propriocepton tests on single leg stance
  • Bilaterally equal strength of hamstrings, hip adductors, hip abductors and gastrocnemius
 

Intermediate – final rehabilitation phase 12 weeks – 1 year

Goals:
  • 1RM single leg press relative strength index (RSI) greater than or equal to 125%
  • Leg symmetry Index (LSI) 85% - 100% of knee extensors
  • Symmetry on hop tests
  • Graded return to sport if set as patient goal, when has satisfied functional performance testing requirements and when consultant has agreed for patient to return to sport
  • No contact sports for 6 months post op
  • Establish long term maintenance programme
Restrictions:
  • Return to sport when has satisfied functional performance testing requirements and when consultant has agreed for patient to return to sport
  • No contact sports for 6 months post op
Treatment:
  • Advice / Education
  • Posture advice / education
  • Mobility: progression of mobility and function
  • Exercises:
    • Jogging progressing to change of direction and rotation component as appropriate
    • Swimming breast stroke leg kick can be introduced from 4/12 post op
    • Plyometrics- ladders
    • Jump training – box jumping
    • Agility training –change of direction push double leg and single leg
    • Hop tests –single hop and double hop with directional change
    • Strengthening through range to include OKC quadriceps if appropriate, commence outer range first and progressing to inner range
    • Introduction of sports specific and occupation specific rehabilitation
    • Core stability and gluteal control work
    • Stretches of tight structures as appropriate
  • Review lower limb biomechanics and kinetic chain, addressing issues as appropriate
  • Balance / Proprioception work progressing to unstable BOS and COG shift Progress from static to dynamic exercises as appropriate
  • Manual Therapy:
    • Soft tissue techniques as appropriate
    • Joint mobilisations as appropriate
Milestones for discharge:
  • Good proprioceptive control dynamically
  • Return to normal functional level
  • Satisfied criteria for functional testing and return to sports if set as patient goal
Failure to meet milestones:
  • Continue with outpatient physiotherapy if still progressing and appropriate goals

Failure to progress

If a patient is failing to progress, then consider the following:
Possible problem Action
Swelling
  • Ensure elevating leg regularly.
  • Use ice as appropriate if normal skin sensation and no contraindications.
  • Decrease amount of time on feet.
  • Pacing.
  • Use walking aids.
  • Circulatory exercises.
  • Modify exercise programme as appropriate. Should continue isometric work at all times.
  • If decreases overnight, monitor closely.
  • If does not decrease over a few days, refer back to surgical team
Pain
  • Decrease activity.
  • Ensure adequate analgesia.
  • Elevate regularly.
  • Decrease weight bearing and use walking aids as appropriate.
  • Pacing.
  • Modify exercise programme as appropriate. Should continue isometric work at all times.
  • If persists, refer back to surgical team.
Breakdown of wound e.g. inflammation, bleeding, infection
  • Refer to surgical team.
Recurrent Instability
  • Refer back to surgical team.
  • Ensure exercise progressions are at suitable level for patient.
  • Address core stability.
Numbness / altered sensation
  • Review immediate post-operative status if possible.
  • Ensure swelling under control.
  • If new onset or increasing refer back to surgical team.
  • If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned.
Appendix Calculation of Limb Symmetry Index LSI (%) = injured limb score ÷ uninjured limb score × 100 Calculation of Relative Strength Index RSI (%) = weight pushed (kg) ÷ bodyweight (kg) × 100  

Summary of evidence

A comprehensive literature search was carried out to identify research relating to rehabilitation following Anterior Cruciate Ligament reconstruction of the knee. After reviewing the articles and information, and discussion with the consultants and therapists at the RNOH, the physiotherapy guidelines were produced on the best available evidence. Clark N (2001) Functional performance testing following knee ligament injury. Phyysical Therapy in Sport 2, 91-105. Herrington L et al (2009) A comparison of the Star Excursion Balance Test reach distances between ACL deficient patients and asymptomatic controls. The Knee 16 149-152. Mc Devitt et al (2005) Functional Bracing Was No Better Than Nonbracing After Anterior Cruciate Ligament Repair. The Journal of Bone & Joint Surgery Volume 87-A Number 8 Myer G et al (2008) Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. Journal of Strength and Conditioning Research 22(3) 987-1014 Risberg et al (2007) Neuromuscular Training Versus Strength Training During First 6 Months After Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial. Physical Therapy Volume 87 Number 6 Shelbourne D & Klotz C (2006) What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction. Journal of Orthopaedic Science 11: 318-325. Shelbourne D & Rask B (1998) Controversies With Anterior Cruciate Ligament Surgery and Rehabilitation. The American Journal of Knee Surgery Vol 11 No 2 Tyler T & McHugh M (2001). Neuromuscular Rehabilitation of a Female Olympic Ice Hockey Player Following Anterior Cruciate Ligament Reconstruction. Journal of Orthopaedic & Sports Physical Therapy 31 (10): 577-587.
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