Anterior cruciate ligament (ACL) reconstruction rehabilitation

NHS Borders clinical guidelines
NHS Borders

Evidence based and in agreement with BGH orthopaedic consultants

Consultant follow up at: 

  • Week 2
  • Week 6
  • 3 Months
  • 6 Months
  • 9 Months

Pre-operative phase:

Goals:

  1. Control inflammation
  2. Increase ROM
  3. Increase neuromuscular strength
  4. Preparation and education

Treatments:

Out-patient physiotherapy initially.
Education leaflet given at Pre–admission Clinic in the BGH.

Inpatient phase: hand out post-op education leaflet to patient

Goals: Treatments:
1. Control inflammation P.R.I.C.E. (ACPSM guidelines) and circulatory exercises Ankle PF/DF
2. Protect joint
  • Avoid Open Kinetic Chain Exercises / movement for initial 3 months
  • Ensure ability to achieve SLR (no lag)

If lag is evident while raising straight leg -teach patient to support operated limb with opposite leg.
3. Introduce initial exercises to promote ROM and neuromuscular
strength

To be completed 4 times per day

  • Passive Knee Extension stretch on towel
  • Static quadriceps
  • Straight Leg Raise
  • Supine Heel slides
  • Isometric hamstring contraction
4. Gait re-education Issue crutches and teach to mobilise FWB as pain allows
5. D/C Home same day or next day
post operatively.		 Stair assessment and advice to wean off crutches within 2 weeks of operation date.

Outpatient post operative ACL guidelines

Phase 1- Approximately 14 Days to 6 Weeks Post Op:

* Avoid excessive/ increased shear stresses – no twisting/ open kinetic chain
* Only progress if:

  • Able to SLR with no quadriceps lag
  • Normal gait pattern (no severe antalgia)
  • Minimal pain and swelling (some residual effusion is expected at this stage)

 

Goals: Treatments:
1. Increase ROM equal to contralateral limb
  • Patella mobility and scar massage as required
  • Continue with post operative exercises
2. Improve Neuromuscular Strength
  • Continue initial post op exercise
  • Introduce following exercises:
    • Double leg body weight squat to 45 degrees
    • Hamstring catches in standing and prone (0-90 degrees)
    • Weight bearing bilateral heel raises
    • Hip abduction strengthening
    • Single leg proprioception (static)
    • Hamstring stretch
    • Calf stretch
3. Gait re-education Wean off Crutches if not already done so

Phase 2 – Approximately 6 –12 weeks Post Op

* Return to work if light duties (no heavy lifting)
* Avoid excessive/ increased shear stresses – no twisting/ open kinetic chain
* Only progress if:

  • Able to SLR with no quadriceps lag
  • Normal gait pattern (no severe antalgia)
  • Full ROM
  • Minimal pain and swelling (some residual effusion is expected at this stage)

Note – Mr Middleton advises patients can commence driving at this stage if recovery remains uncomplicated.

Goals: Treatments:
1. Maintain ROM Static bike
2.  Increase Neuromuscular strength and control

CKC exercises:

  • Step ups on operated leg
  • Gluteal bridges
  • Resisted hamstring strengthening
  • Reactionary proprioceptive exercise (no twisting)
  • Heel-toe walking
  • Mini lunges (to 45 degrees)
  • Single leg squat (to 45 degrees)
3. Cardio-vascular activities
  • Cycling
  • Closed chain gym based equipment (hamstring curl, leg press, cross trainer, rowing machine)
  • Swimming -
    • straight leg front crawl
    • straight leg back crawl
  • No breast stroke until month 5 onwards

Phase 3 - approximately 3-6 months

* Only progress if:

  • Full ROM and functional strength
  • No pain mobilising at low speed or with exercises
  • Excellent proprioceptive control

* Return to manual work / tasks

Note – patient can now commence open kinetic chain exercises.

The aim of this stage is to prepare for a safe return to sporting activity.

Goals: Treatments:
1. Increase Neuromuscular strength and control
  • Seated knee extensions
  • Lunges (forward & side)
  • Squat to 90 degrees
  • Arabesque (Single leg Romanian Dead-lift (RDL))
  • Continue to progress proprioception
2. Introduce plyometric programme (4 months onward)
  • Controlled double leg jump
  • Controlled single leg hopping
3. Cardio-vascular activities
  • Straight line running (3 months onwards)
  • Curved/ figure of 8 running (5 months onwards)

Phase 4 - approximately 6-9 months post op

6 months onwards: Patient can commence a graduated return to non-contact sport (e.g. racquet sports and sport specific drills).

You may wish to discuss transition of care to sport/club physio at this stage if appropriate.

9 Months onwards: Return to contact sport/ full competition.

Goals: Treatments:
High level plyometrics
  • Box Jumps (Depth)
  • ingle leg bounding
  • Hurdles
Proprioception/ co-ordination program
  • Multi directional running progressing to explosive power
Sport specific training
  • Live simulation sport specific drills
  • Low velocity progressing to high velocity contact  drills

Normal Milestones:


3 Months:

  • Return to manual work
  • Return to Golf
  • Commence open kinetic chain exercises
  • Straight leg swimming (no breast stroke)
  • Straight line running (low intensity)

4 Months:

  • Progress running: Straight line – increase speed and distance.
  • Light plyometric exercises e.g. Controlled jumping

5 Months:

  • Breast Stroke
  • Curved line running and large figure of eights
  • Horse Riding

6 Months:

  • Plyometric no restrictions
  • Racquet sports
  • Functional tests e.g. hop tests, quadrant Y balance test

9 Months:

  • Contact Sports
  • Skiing

 

Editorial Information

Last reviewed: 31/12/2020

Next review date: 31/01/2023

Author(s): Middleton P.

Version: Ortho002/03

Author email(s): paul.middleton@borders.scot.nhs.uk, jillian.gordon@borders.scot.nhs.uk.

Reviewer name(s): Gordon J Middleton P.

Related guidelines
References

1. 2006 Guidance for the use of Electro physical agents - Chartered Society of Physiotherapy

2. PRICE Guidelines - Association of Chartered Physiotherapist in Sports Medicine 1998 (there is an
updated version available from the ACPSM).

3. Shelbourne KD, Klotz C (2006) What I have learned about the ACL: utilising a progressive
rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction.
Journal of Orthopaedic Science. 11(3):318-25

4. Shaw T, Williams MT and Chipchase LS (2005) Do early quadriceps exercises affect the outcome of
ACL reconstruction? A randomised controlled trial. Australian Journal of Physiotherapy. 51, 9-17

5. Tyler TF, McHugh MP, Gleim GW and Nicholas SJ. (1998) The Effect of Immediate Weight bearing
After Anterior Cruciate Ligament Reconstruction. Clinical Orthopaedics and Related Research, 357,
141-148

6. Kyist J (2006) Tibial translation used early in rehabilitation after anterior cruciate ligament
reconstruction. Exercises to achieve weight bearing. Knee . 13(6):460-463,

7. Tsaklis P and Abatzides G (2002) ACL rehabilitation program using a combined isokinetic and isotonic strengthening protocol. Isokinetics and Exercise Science, 10, 211-219

8. Beutler AI, Cooper LW, Kirkendale DT and Garret WE (2002) Electromyographic Analysis of Single-Leg Closed chain Exercises: Implications for Rehabilitation After Anterior Cruciate Ligament
Reconstruction. Journal of Athletic Training, 37 (1) 13-18

9. Ross MD, Denegar CR and Winzenreid JA (2001) Implementation of open and closed kinetic chain
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10. Beynnon BD, Johnson RJ, Flemming BC, Stankewich CJ, Renstorm PA and Nichols CE (1997) The strain behaviour of the anterior cruciate ligament during squatting and active flexion extension.
Comparison of open and closed kinetic chain exercise. American Journal of Sports Medicine, 25: 823-
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11. Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament
reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surgery
& Sports Traumatology Arthroscopy , 8(6) 337-42

12. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA (2010) Progressive 5-Week Exercise Therapy
Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament
Injury. Journal Orthopaedics Sports Physical Therapy, 40(11) 705-722