Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol

PHASE 0: PREOPERATIVE

The ACL protocol ideally starts prior to surgery to educate and prime the knee for optimal outcomes.

To get the best outcomes from an ACL reconstruction surgery, we want to work towards regaining full movement, swelling reduction and strengthening exercises.

GOALS:

• Eliminate swelling

• Regain full range of motion

• Regain 90% strength in the quads and hamstring compared with the other side

WALKING AND BRACE USE:

Use a knee immobiliser until you get good knee control

Weight bear as tolerated

Not for prolonged use to prevent Quads atrophy

EXERCISES:

Regular elevation and ice for swelling

Range of motion exercises

Progressive strengthening and loading of Quads and Hams 

Low impact aerobic exercises

Avoid sharp changes in direction, pivoting etc

PHASE I: 0-2 WEEKS POSTOPERATIVE

The goals of the ACL reconstruction post surgical protocol is to protect the surgical graft while steadily progressing towards pre-injury level of activity. Strict adherence to rehabilitation criteria is essential to enable optimal healing. Please note this protocol is a guideline. Achieving the criteria of each phase is more important than the approximate timeline.

GOALS:

• Full straightening of the knee

• Knee flexion to 90 degrees

• Settle the swelling down to ‘mild’

• Activate quads control. 

• No Quads lag

WALKING AND BRACE USE:

• Weight bearing as tolerated

• Brace locked in extension with ambulation and sleeping

• Brace unlocked 0-90⁰ when non-weight bearing

EXERCISES:

Calf pumping every hour for circulation

Keep leg up, wear compression bandage and to ice knee for 15-20 minutes at least 4-5 times per day

Hamstrings stretch in long sit

Knee cap mobilisation

Long arc quads (90-45 degrees)

Quad and Glute sets in supine

Straight leg raise (SLR) x 3 in locked brace

Calf stretch

No stationary bike x 6 weeks

Ice pack with knee in full extension after exercise

PHASE II: ~2-4 WEEKS POSTOPERATIVE

GOALS:

•Increase knee flexion 

• Improve quadriceps control in SLR and walking

• Wean off knee brace for all activities

• Normalize gait pattern, decrease to least assistive walking aid

WALKING AND BRACE USE:

Brace x 8 weeks – Open to 0-45 degrees

Crutches – PWB in brace

EXERCISES:

Stair master/ellipitical/stationary bicycle • Progress quadriceps strengthening to weight-bearing exercises: wall squats/ slides, stepup exercise, in pain free range. • Prone knee hangs (if lacking full extension) • Patellar mobilization in flexion (if flexion is limited) • Gait training: heel-toe pattern, knee flexion during swing phase, terminal knee extension on heel strike • Progress to functional bracing as swelling permits and if indicated.

bridging

calf raises

hip abduction strengthening

core exercises

balance

gait re-education drills

non-impact aerobic condition such as cycling, swimming, and walking

PHASE III: ~4-6 WEEKS POSTOPERATIVE

GOALS:

• ROM 0-120 degrees

• No swelling

WALKING AND BRACE USE:

Brace x 8 weeks – Open to 0-90 degrees

Crutches – PWB in brace

EXERCISES:

Continue appropriate previous exercises

Scar massage for mobility

lunges

step-ups

squats

AAROM, AROM 0-120 degrees

Standing SLR x 3 with light resistance band bilaterally – May begin Hip ADD with resistance band if good LE control in full extension

Mini squats 0-45 degrees

Passive knee flexion to 90 degrees (push up with opposite leg) 

Leg press 0-45 degrees with resistance up to ¼ body weight

Hamstring curls 0-45 degrees – Carpet drags or rolling stool (closed chain) 

No stationary bike x 6 weeks

PHASE IV: ~6-8 WEEKS POSTOPERATIVE

GOAL:

Able to stand on 1 leg

• Grade 4-5 muscle strength

• Single leg squat with good technique and alignment

Full ROM

WALKING AND BRACE USE:

Brace – Open to full range

Crutches - Weight bearing as tolerated(WBAT),

D/C crutch when gait is normal

EXERCISES:

Continue appropriate previous exercises PROM,

AAROM, AROM to regain full motion

Standing SLR x 4 with light resistance band bilaterally

Wall squats 0-45 degrees Leg press 0-60 degrees with resistance up to ½ body weight

Hamstring curls through full range – Carpet drags or rolling stool

Forward, lateral and retro step downs in parallel bars – No knee flexion past 45 degrees (small step)

Proprioceptive training – Single leg standing in parallel bars –

Double leg BAPS for weight shift

Single leg heel raises

Treadmill – Forwards and backwards walking

Stationary bike – Progressive resistance and time

Elliptical trainer

PHASE V: ~8-12 WEEKS POSTOPERATIVE

GOAL:

Walk 3 km at a gentle pace

BRACE USE:

Stop brace when full quads control

EXERCISES:

Continue appropriate previous exercises with progressive resistance

Leg press 0-90 degrees with resistance as tolerated

Hamstring curls on weight machine

Knee extension weight machine

Forward, lateral and retro step downs (medium to large step)

Proprioceptive training – Single leg BAPS, ball toss and body blade – Grid exercises

Treadmill – Walking progression program

Stairmaster – Small steps

Pool therapy

PHASE VI: ~3-4 MONTHS POSTOPERATIVE

GOAL:

• Run 3 km at an easy pace

• Attain excellent hopping performance (technique, distances, & endurance)

• Progress successfully through an agility program and modified game play

• Regain full strength and balance

EXERCISES:

Continue appropriate previous exercises

Step down

BOSU mini-squats (0-30 degrees)

Physioball wall squats or wall squats (0-60 degrees)

Physioball one legged bridge with knee extended

Physioball two legged curl for hamstrings

Functional activities – Figure 8s, gentle loops, large zigzags

Treadmill – Running progression program

Pool therapy – Swimming laps

Quad stretches

PHASE VII: ~4-6 MONTHS POSTOPERATIVE

GOAL:

Return to all activities

EXERCISES:

Begin hamstring curl machine 

Lateral shuffle with band

Monster walk with band

Airex box drill with band for 4 way hip

Cone reach with knee straight

Cone reach with knee bent slightly

Forward lunge (limited range of motion)

Do not do lateral lunge

CRITERIA TO START RUNNING/AGILITY PROGRAM

No contact sports until 6 months post-op

No pain, crepitus, edema or giving way

Normal stability with valgus stress test

Muscle strength at least 5/5

ROM equal to uninvolved side or at least 0-125 

Normal gait pattern at least 20 minutes without symptoms

Leg Press test within 75-80% of contralateral leg

Hamstring and quadricep strength 70 % of the involved side isokinetically

Lateral step test within 75-80% of contralateral leg

Clearance from surgeon

References:

University Orthopaedics, Inc

Dr Glen McLung: Beacon Orthopaedics and Sports Medicine

Logan CA, O'Brien LT, LaPrade RF. POST OPERATIVE REHABILITATION OF GRADE III MEDIAL COLLATERAL LIGAMENT INJURIES: EVIDENCE BASED REHABILITATION AND RETURN TO PLAY. Int J Sports Phys Ther. 2016 Dec;11(7):1177-1190.