ACL Rehabilitation: Rehabilitation Planning

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Tony Lowe, Robin Tacchetti, Tarina van der Stockt, Simisola Ajeyalemi, Jess Bell, Chelsea Mclene, Olajumoke Ogunleye, Rachael Lowe, Leana Louw, Wanda van Niekerk and Abbey Wright  

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Considerations Before Setting up a Plan

After ACL reconstruction and the acute management after surgery, creating a log-term rehabilitation plan can be challenging for physiotherapists. It is important to set specific goals and milestones for your athlets and build time frames accordingly. These goals should be priotorized depending on athletic needs. The evidence is rich in ACL-rehabilitation protocols. There is no specific program that is superior to the others, however, there are mutual characteristics that should be considered in all rehabilitation progrmas.

In the acute management phase, there are some considerations to protect the surgical repair and allow scar heeling without compromising ROM.

Protection and Restrictions:

1-ROM: patient can move freely either actively or passively throughout the availbale ROM within pain tolerance.

2-Bracing: This is an area of great controversy in the literature and in clinical practice. While bracing may not be beneficial on the long run, some clinicians prefer placing the knee in a mobilizer then replace it with a c-hinge functional knee brace once femoral nerve block is off following the surgery. However, the main purpose here of bracing is to prevent re-injury in the acute stage. This is dependable on the on the environmental exposure for example, a patient in risk for slipping due to snow bracing is essential to prevent re-injury. A different environment may not require bracing.

3-Weight-Bearing: while full weight-bearing may be tolerated in the first few weeks, partial weight bearing is preferred to protect scar, allow healing and restore joint homeostasis as soon as possible.

4- Stationary bike: introduced on day 10 or once a 110° of knee ROM is achived. However, you may use a small range,rocking back and forth, as a way of facilitating ROM if the whole range is still restricted.

5-Resistance weight-bearing strength training: delayed until 6 weeks after surgery to avoid scar hypertrophy and stiffness.

Creating a Plan

As a physiotherapist, you have a role in guiding your patient through a long-term rehabilitation plan. Setting up milestones and goals depends on your patient's needs and aspired funciton. Predicting outcomes and time-frames, using your clinical exprinece nad clinical reasoning skills, for each goal is also part of your role.

The ACL rehabilitation plan has 9 Phases:

1-ROM: Aiming to maintian available range and facilitate regaining of full ROM. At this phase you should also manage effusion and inflammationa dn achieve knee terminal extension. Time frame: 0-6 weeks.

2-Increase WB tolerance gradually. Depending on the complxity of the injury:

• A single ACL injury requires 2 weeks of partial WB, then load weight fully. there is no need here to build tolerance over the two week period. would take up to 2 wks to full WB,no need to build tolerance.
• ACL injury combined meniscus and/or chondral injury would take takes 6 weeks to full WB. In this case, we need to increase the tolereance gradually.

3- Building muscular endurance: this also depends on the joint pathology and may take up to 8 weeks. So this goal is expected to be aciveed at the 10-18th week.

4- Developing strength: 19-26th week.

5-Muscular power: predted to be on 27-32th week.   

6- Building running tolerance: this is highly variable, depending on differnet athletic needs. Begin running progression for athletes who require great volume of running on 27th week till 32nd week.(4-6 wks)

7-Speed and agility trianing: start uni-directionsl training (forward, backward and lateral work) at week 32. Progressing to multi-directional drill training starts from week 33.

8- Return to training: expected around week 35

9-Return to play.: around week 38

Time frames vary among different sports.The previous are suggetions to build a road map for you and your patient.  

Weekly Plan

Each sport requires different levels of physiological characteristics. Understanding the needs of our athlets is essential to build up a weekly plan for your patient.

For a football player, for example, we need to develop strong lower body, cardiovascular fitness, core stability and upper body strength. All of these components should be considered according to their priority when setting up a weekly plan. The following is a suggestion for a weekly plan:

The week would include: 4 lower body strengthning sessions, 2 cardio sessions, 2 pool sessions, 2 core sessions, 2 upper body strengthning sessions.

Monday	Lower body strengthning + cardio
Tuseday	Lower body + upper body strengthning
Wednesday	Low load recovery (core stability + pool exercise)
Thursday	Same as Monday
Friday	Same as Tuseday
Saturday	Same as Wednesday.
Sunday	Off

Selecting Proper Exercises and Parameters

Planning specific exercises depends on what muscles you want to emphasis. For example, building a 30-40 minutes lower body workout that contains 6 exercises:

• Start with quadriceps dominant exercise such as Leg press
• Glute-dominant exercise:single leg bridge
• Hamstring: RDL (romanian deadlift)
• Quadriceps: Tuck squat
• Quadriceps: Single Leg Squat
• Hamstrings: Nordic Hamstring exercise.

Endurance is the ability to work for prolonged time and resist fatigue. To achive this, 15-20 reps of an exercise for 3 or more sets with less than 60 seconds rest between each set.

Strength is the ability to exert force/torque at a specific speed. It requires frequent increase of resistance, either by external weight or single leg posture. 8-12 reps for 1-3 sets with 2 minutes rest between sets.

Power is a combination of force and velocity. Training for high load activities requires 85-100% of 1 Rep Max, 1-3 sets with 3 minutes rest. Developing velocity requires lower resistance, about 30% 1 Rep Max for 6 reps, 1-3 sets with 3 minutes rest.

Increasing running tolerance should be gradual and slow for up to 4 weeks. You may begin with 4 minutes of walking to a minute of running repeated 4 times over 20 minutes, 2-3 times per week. Progress each week by increasing a minute of running and decrease a minute of walking, till the athlete is able to run for a progressive 20 minutes.

Speed and Agility are important for re-conditioning and return to sport. Build a specific drills program depending on your patient's sport-specific needs.