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ACL Rehabilitation: Acute Management after Surgery

Original Editor - Mariam Hashem

Top Contributors - Wanda van Niekerk, Mariam Hashem, Jess Bell, Kim Jackson, Tarina van der Stockt, Tony Lowe, Chelsea Mclene, Rachael Lowe, Leana Louw, Robin Tacchetti and Jorge Rodríguez Palomino  

Introduction

Anterior cruciate ligament (ACL) injuries are common—over 200,000 injuries occur annually in the United States,[1] [2] with healthcare costs exceeding 2 billion dollars per year.[3] Professional athletes are more prone to ACL injuries, with annual incidence rates of 0.21-3.67% compared to 0.03% in the general population.[4] These injuries result in long lay-off times for athletes of all levels.[5] Surgical reconstruction of the ACL helps restore the passive stability of the knee, but only 65% of athletes regain pre-injury performance levels.[6] Females are at a higher risk[7] [8] due to factors such as higher valgus stress, altered loading patterns and strength imbalances,[9] though injury mechanisms may differ by biological sex (males: more contact injuries; females: more non-contact injuries).[10]

Long-term consequences are significant regardless of selected management approaches. Post-traumatic osteoarthritis (OA) develops in 37.9% of surgical cases and 40.5% of non-surgical management cases within 20 years of injury.[11] Overall, there is a 7-fold increased risk of developing OA after an ACL injury.[12] Altered loading mechanics following injury are thought to contribute to this.[13] [14] Other consequences include instability, inability to return to sport and recurrence.

Modern surgical approaches prioritise and facilitate early mobilisation over prolonged immobilisation.[15] Successful outcomes also depend on implementing effective, high-quality rehabilitation programmes.[16][17][18]

Pre-Surgical Rehabilitation

ACL reconstruction or repair in athletes with good pre-injury knee function is associated with good post-surgical outcomes.[19] Therefore, muscle strengthening and improvement in movement before surgery is important for successful rehabilitation.[20] Start immediately after injury, assess the condition carefully using objective measures to track progress and changes.

The following are goals of ACL pre-surgical rehabilitation and are predictive of good post-operative outcomes[5]:

  • full knee extension range of motion (ROM)
  • absent or minimal effusion
  • absence of extension lag during straight leg raise (SLR)

Pre-surgical rehabilitation should be built on aggressive quadriceps strengthening to increase quadriceps index > 90% (quadriceps index = the ratio of injured-side quads strength to contralateral side quads strength).[15][21]

Pre-surgical rehabilitation of an ACL injury should be function-based and not time-based if possible. A programme that focuses on restoring muscle strength, achieving quadriceps hypertrophy and improving hop performance leads to better knee function after the surgery.[5][22][23]

[24]

Research has shown that prehabilitation following ACL injury improves patient-reported knee outcomes and physical examination findings, and facilitates quicker return to sport.[25] Patients who underwent pre-surgical rehabilitation showed better International Knee Documentation Committee (IKDC) scores and Knee Injury and Osteoarthritis Outcome (KOOS) scores compared to those who did not and showed a higher likelihood of returning to preinjury sport.[26]

Make sure your patient is mentally prepared for surgery. Spend quality time educating your patient on their injury, surgical procedure, home programme, rehabilitation process and outcomes.[27] Research suggests that pre-surgical rehabilitation may help patients prepare mentally for surgery.[28]

Considerations Before Designing a Post-Surgical Rehabilitation Programme

ACL injuries often occur alongside other injuries, such as meniscus injury, medial collateral injury, bone contusion and chondral injury.[29] Recurrence rates are high: approximately one in five professional male football players may experience a second ACL injury,[30] and female athletes with a previous ACL injury have a 4-7 times higher risk of re-injury.[31] Additionally, many players may not be able to return to their prior level of performance, experiencing reduced career longevity or competing at a lower level.[32][33][34] Return-to-sport clearance should therefore be based on performance criteria, not simply time-based criteria.

A multidisciplinary team is needed to help athletes recover and maintain their level of performance. As a physiotherapist, you should keep communication channels open with the following professionals and know when to refer your patient to them.

  • Orthopaedic surgeon: communication between the surgeon and treating therapist is essential—surgeons need to trust their physiotherapy team and close collaboration improves patient care.[35]
  • Sports psychologist: psychological traits such as self-efficacy, resilience, kinesiophobia, and pain catastrophising may influence recovery. Psychological interventions may help some patients return to preinjury levels of activity.[36]
  • Sports nutritionist or dietitian: injury, immobilisation, surgery and reduced activity levels require individualised nutrition strategies. A structured, phase-based approach aligned with physiological changes throughout rehabilitation may reduce complications, support optimal healing and facilitate return to sport.[37]

Therapist-patient communication is essential for patient engagement and motivation. Rehabilitation is time-consuming. It can also be exhausting and mentally demanding for the patient. Without adequate motivation, patients are likely to disengage or drop out.[38] The therapist-patient relationship is an important facilitator of rehabilitation adherence.[39] Patient education, goal setting and regular outcome testing for feedback help maintain engagement.[40]

Acute Management and Goals

Rehabilitation aims to restore maximum performance while minimising the risk of re-injury. Milestones and outcome measures guide this process, helping structure the programme and track progress.[15] 

At this stage (0-6 weeks) after surgery, the aim is to protect the surgical repair/reconstruction and prepare the patient for restoring function. Acute management goals include[41]:

  1. Restoring joint homeostasis
  2. Scar management
  3. Restoring range of motion (ROM) in all directions
  4. Retraining quadriceps to work independently and achieve terminal extension
  5. Creating a long-term plan for 6-9 months of recovery
Protecting the Surgical Repair/Reconstruction

Protecting the graft in the early post-operative period involves managing range of motion, bracing and graduated weight-bearing.[41]

ROM Considerations: Begin range of motion exercises immediately post-operatively (Day 1).[5][42] Limit knee flexion ROM to 90° until the femoral and/or adductor nerve block wears off (typically 48-72 hours after surgery) to ensure accurate patient feedback and prevent excessive strain.[41] Once the patient can report accurate sensation, ROM can progress as tolerated - transitioning from passive to active-assisted and active ROM based on patient comfort and quadriceps control.[5] Achieving full knee extension is important.[5]

Note, while continuous passive motion (CPM) devices may provide short-term benefits for pain and swelling in the first 3 postoperative days, current evidence shows no additional benefit to using continuous passive motion compared to active motion exercises, and it is time-consuming and costly.[18]

Brace in an immobiliser until the femoral/adductor nerve block is off, then change to a hinged-knee brace for 3-7 days or until the patient can perform terminal knee extension.[41] The current evidence does not support the routine use of postoperative knee bracing following ACL reconstruction. While braces may provide a psychological sense of security to patients, it does not provide any other advantages such as improved surgical outcomes (including limb asymmetry, anterioposterior knee laxity and effusion).[43]

Partial weight bearing is recommended for two weeks after surgery to minimise swelling and allow the effusion to resolve. Achieving full weight-bearing within the first 6 weeks post-surgery is associated with high IKDC scores.[44]

Stationary biking without resistance can be introduced on day 10, or when the patient achieves >110° passive flexion.[45]

Complete weight-bearing strength training is delayed up until 6 weeks post-surgery.

Refer to this article for further information on the different phases of ACL rehabilitation.

Note: Protocols vary between surgeons and facilities. Always follow surgeon-specific guidelines while understanding the rationale behind restrictions.

Homeostasis

A joint with disrupted homeostasis presents as painful, swollen and stiff. Loading an inflamed post-surgical joint can trigger excessive inflammatory responses that prolong recovery. Frequent evaluation of activities and slowing down whenever a sign of overloading is present is required to restore homeostasis as soon as possible.[46]

Restored homeostasis is crucial to prevent the following consequences:

  • Limited ROM, particularly flexion. Extension could be limited due to other factors, such as a meniscus injury.
  • Inhibited neuromuscular firing pattern of the quadriceps.
  • Abnormal scar healing as a result of a prolonged inflammatory phase.
  • Unrestored homeostasis can lengthen the entire rehabilitation process.

Respect the physiological healing process and stress the healing tissue progressively within its tolerances to avoid a disruption in joint homeostasis.[45] Various modalities can be incorporated in the rehabilitation programme to resolve joint effusion and restore joint homeostasis, such as lymphoedema massage, pneumatic compressive devices, elevation, and active muscle pump exercises (quadriceps and calf contractions).[45] Swelling within 0.5 cm of the opposite knee is a key milestone; once achieved, mobility and balance exercises can be progressed gradually.[45]

Monitoring Pain and Swelling

Pain assessment: Use an 11-point numeric scale (0 = no pain; 10 = worst imaginable pain) for functional tasks, such as sit-to-stand, walking a set number of steps or climbing stairs to monitor pain and guide loading adjustments.[5]

Monitoring swelling: Monitor swelling regularly with knee circumference measurements and the Stroke test.[5] Patients can measure their knee circumference themselves; increases of more than 1 cm at the patella are clinically significant and indicate excessive joint loading.[47]

[48]

If pain and swelling increase, adjust the rehabilitation programme immediately. Often, the issue is not the structured therapy, but the patient's activity outside sessions. Educate patients on load management and consider activity tracking with step count or activity logs.[5]

Red Flags - When to Seek Medical Consultation

Frequent medical consultations (at least every 10 to 15 days) help monitor the patient's progress and address post-surgical complications quickly. Some post-surgical complications are[5]:

  • reduced passive knee extension at week 3 post-surgery
  • persistent moderate swelling and inflammatory signs
  • swelling, redness and soreness of the surgical leg
  • severe knee swelling, fever and other systemic symptoms
  • delayed wound healing and superficial wound infection

Scar Management and ROM

"The anterior interval of the knee is the space between the patellar tendon and infrapatellar fat pad anteriorly and the anterior border of the tibia and the anterior intermeniscal ligament posteriorly."[49] The suprapatellar pouch lies between the femur and the quadriceps tendon. These spaces allow the knee joint to move freely throughout the entire ROM. During the proliferation phase (up to 6 weeks post-surgery), rigid scar tissue can form in these spaces. Scarring in these areas can restrict knee ROM and cause a loss of knee extension.[49] It can also increase contact pressures in the knee joint, which contributes to anterior knee pain and the development of OA.[50]

Scarring also decreases the moment arm of the extensor mechanism, reducing the extension force produced by the quadriceps. This may explain why some athletes fail to regain full quadriceps performance even after 9 months of rehabilitation. The goal is therefore to guide organised scar proliferation without compromising ROM and mobility.

Early ROM Strategies

Early range of motion (ROM) exercises should begin from day one after surgery. These exercises create pressure gradients within the knee, helping to clear blood and inflammatory cells from the joint. ROM achieved in the first four weeks strongly correlates with outcomes at 12 weeks, making early gains critically important.[51]

Passive range of motion exercises (PROM) include: therapist-assisted flexion at the end of the bed to achieve full knee flexion; wall slides where the patient lies supine and uses the opposite leg to assist into maximum comfortable ROM (the elevated position also helps to flush the effusion); and flexion using a Swiss ball. For Swiss ball flexion, the patient lies with their unaffected leg straight on the table and their surgical leg on the Swiss ball. The therapist flexes the knee until the patient reports discomfort or pain, or tissue tension is felt. Small oscillations at end range help increase ROM over time.

The stationary bike is a useful low-load tool in acute phase management, as repeated flexion and extension facilitates mobility and smooth scar proliferation.

Loss of Extension

Loss of extension is one of the most common complications following ACL surgery. Full extension is required for efficient quadriceps contraction and optimal joint loading. Even a small degree of knee flexion contracture restricts the quadriceps' ability to regain full strength, which affects functional outcomes. Without full extension, point loading occurs, which increases joint contact pressures, accelerating the development of OA and increasing the risk of anterior knee pain.[52]

Methods of restoring extension:

  • Manual therapy/mobilisation (posterior femoral glides, screw home mobilisations)
  • PROM using external devices
  • Soft tissue massage
  • Self-mobilisation
  • Patellofemoral mobilisation
[53]
[54]
[55]
[56]
[57]
[58]

Restoring Quadriceps Strength

Quadriceps activation failure, often bilateral, is common following ACL reconstruction. The loss of joint homeostasis causes changes in neural control. Additionally, the loss of ACL mechanoreceptors disrupts the ligamentous-muscular reflex between the ligament and quadriceps, reducing the ability to recruit high-threshold motor units. This phenomenon, called arthrogenic muscle inhibition (AMI), occurs when a muscle cannot contract despite no underlying pathology to the muscle or nerve—instead, it results from injury to the joint it surrounds.[5] [59] AMI poses a clinical obstacle to rehabilitation.

Manual therapy techniques, such as cryotherapy, transcutaneous electric nerve stimulation and neuromuscular electric stimulation (NMES), can help reduce quadriceps inhibition.[60][61][62][63][64]

Strategies to reduce AMI include facilitating isolated quadriceps contraction by teaching patients to fire the muscle independently, avoiding compensatory firing patterns from other muscles. One technique is to instruct the patient to glide the patella superiorly. Even if this simple cue only produces a flicker contraction, it still triggers an isolated quadriceps contraction. Progress from this point to achieve terminal knee extension. Loss of terminal knee extension often manifests as a flexed knee gait pattern. Terminal knee extension can be facilitated by asking the patient to "pop their heel off the table."

Additional techniques to address AMI can be considered based on clinical presentation and practitioner expertise. These include focal joint cooling, TENS combined with exercise, hamstring fatigue techniques, blood flow restriction (BFR) training, and cross-education training.[5] If you'd like to read more about these techniques, see: Optimising the early-stage rehabilitation process post-ACL reconstruction. [5]

Rehabilitation Planning

A multi-phasic ACL rehab plan has nine essential phases. Timeframes are individualised based on each athlete's needs:

  1. ROM restoration and protection
  2. Weight bearing tolerance
  3. Endurance
  4. Strength
  5. Power
  6. Running
  7. Speed and agility
  8. Return to training
  9. Return to play

Remember: Don’t rush rehabilitation. Let it take its time.

Progression to the Next Phase

Once joint homeostasis is protected, knee joint ROM restored and weight-bearing tolerance achieved, patients can move on to the next phase of rehabilitation. This phase focuses on the endurance component of periodised strength development. A patient is ready to move to the next stage of rehabilitation once they can demonstrate the following[45]:

  • Full active terminal knee extension (0°)
  • Flexion within 10° of the contralateral side
  • Resolved knee effusion (0.5 cm of contralateral knee)
  • Able to walk without assistive devices

If you'd like to learn more, you can read about the nine phases of the rehabilitation plan here.

References

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  27. ↑ Shelbourne KD, Klotz C. 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. 2006 May 1;11(3):318.
  28. ↑ Jenkins SM, Guzman A, Gardner BB, Bryant SA, Del Sol SR, McGahan P, Chen J. Rehabilitation After Anterior Cruciate Ligament Injury: Review of Current Literature and Recommendations. Current Reviews in Musculoskeletal Medicine. 2022 Apr 6:1-0.
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  44. ↑ Di Miceli R, Marambio CB, Zati A, Monesi R, Benedetti MG. Do Knee Bracing and Delayed Weight Bearing Affect Mid-Term Functional Outcome after Anterior Cruciate Ligament Reconstruction? Joints. 2017 Dec;5(04):202-6.
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  46. ↑ Van Grinsven S, Van Cingel RE, Holla CJ, Van Loon CJ. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2010 Aug 1;18(8):1128-44.
  47. ↑ Jakobsen TL, Christensen M, Christensen SS, Olsen M, Bandholm T. Reliability of knee joint range of motion and circumference measurements after total knee arthroplasty: does tester experience matter?. Physiotherapy Research International. 2010 Sep;15(3):126-34.
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  52. ↑ Marques FD, Barbosa PH, Alves PR, Zelada S, Nunes RP, de Souza MR, Pedro MD, Nunes JF, Alves Jr WM, de Campos GC. Anterior knee pain after anterior cruciate ligament reconstruction. Orthopaedic journal of sports medicine. 2020 Oct 27;8(10):2325967120961082
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  64. ↑ Stevens JE, Mizner RL, Snyder-Mackler L. Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series. Journal of Orthopaedic & Sports Physical Therapy. 2004 Jan;34(1):21-9.
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