Anterior Cruciate Ligament (ACL) Rehabilitation

This article requires improvement to meet Physiopedia's quality standards. The reasons have been specified in the page's Discussion. Please help improve this page if you can. #qualityalert

Original Editor - Your name will be added here if you created the original content for this page.

Top Contributors - Laura Ritchie, Riccardo Ugrin, Admin, Lieselot Longe, Evan Thomas, George Prudden, Habibu Salisu Badamasi, Kim Jackson, Tony Lowe, Scott Buxton, Claire Knott, Tarina van der Stockt, Bisoffi, Ilkje De Vlieger, Falcone Tseng, Ines Corthals, Saeed Dokhnan, Saud Alghamdi, WikiSysop, Simisola Ajeyalemi, 127.0.0.1, Rucha Gadgil, Wanda van Niekerk, Jess Bell, Aminat Abolade and Naomi O'Reilly  

General Considerations

Before surgery

RICE and electrotherapy can be applied during several weeks ahead of the surgery in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. This will help the patient to regain better motion and strentgh after the surgery.

Therapy pre-ops can encourage strengthening of the quadriceps and hamstrings. Range of motion exercises should be included if there is no pain involved.

NMES combined with exercise is more effective in improving quadriceps strength than exercise alone.

After surgery

• Week 1

Regular icing and elevation are used to reduce swelling. The goal is full extension and 70 degrees of flexion by the end of the first week. The use of a knee brace and crutches are imperative.

Multidirectional mobilizations of the patella should be included for at least 8 weeks. Other mobilization exercises in the first 4 weeks are passive extension of the knee (no hyperextension) and passive and active mobilization towards flexion. Strenthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed.

• Week 3-4

The patient must trie to genuinely increase the stance phase in an attempt to walk with one crutch. With good hamstring/quadriceps control, the use of crutches can be reduced earlier.

• Week 5

The use of the knee brace is progessively reduced. Passive mobilizations should normalize motility but flexion should not yet be thorough. 9 Tonification of hamstrings and quadriceps (vastus medialis) can start in close chain exercises. The exercises should be started on light intensity (50% of maximum force) and progressively increased to 60-70%. The closed chain exercises should be built from less responsible positions (bike, leg presses, step) to more congested starting positions (ex.squad). The progress of the exercise depends on pain, swelling and quadriceps control. Proprioception and coordination exercises can start if the general strength is good. This includes balance exercises on boards and toll.

• Week 10

Forward, backward and lateral dynamic movements can be included as well as isokinetic exercises.

• Month 3

After 3 months, patient can move on to functional exercises as running and jumping. As proprioceptive and coordination exercises become heavier, quicker changes in direction are possible. To stimulate coordination and control through afferent and efferent information processing, exercises should be enhanced by variation in visible input, surface stability (trampoline), speed of exercise performance, complexity of the task, resistance, one or two-legged performance, etc.

• Month 4-5

Final goal is to maximize endurance and strength of the knee stabilizers, optimize neuromuscular control with plyometric exercises and to add the sport-specific exercises. Acceleration and deceleration, variations in running and turning and cutting manoeuvers improve arthrokinetic reflexes to prevent new trauma during competition.

Return to sport

Strength and power deficits after surgery may be a risk factor for future injuries and may set athletes up for failure when they try to return to their prior performance levels. Researchers suggest that the surgically repaired leg should perform at least 90% as well as the uninjured leg before you return to sport. Three hopping tests can be used as part of a comprehensive physical and functional examination to help ensure not just a speedy, but a safe return to sport after ACL reconstruction. These 3 tests are sensitive enough to measure side-to-side differences and can be used during more advanced recovery phases after surgery to help ensure that the athlete’s exercise program is successful in returning the injured leg at least to the level of the uninjured leg. 

When Should an Athlete Return to Sport After an ACL Surgery?

Rehab Protocols

Steadman Protocol

Fowler-Kennedy Protocol

Chester Knee Clinic

Sport Specific Considerations

Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing

Considerations for Female Athletes

Late stage rehab ideas with specifics for the female athlete

Adjuncts

NMES - Neurotech's Kneehab XP Quadriceps Therapy System has been shown to significantly improve rehab following ACL reconstruction.

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1h3SAs98aPqnd6UdzcSka13Q2QC0xPe6Uxyj13qIjh7-m7FgTo|charset=UTF-8|short|max=10: Error parsing XML for RSS