Rehabilitation of ACL Injuries

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Cold knee wrapBelow is an example of a rehabilitation programme for an anterior cruciate ligament injury following surgery.

This 5 phase ACL rehab program begins immediately after injury and prior to surgery progressing to full sports training. It is an example only and may differ from patient to patient. We recommend seeking professional advice.

Phase 1: Prior to surgery

The aim of prehabilitation as it is sometimes known is to reduce swelling and restore full mobility and strength to the knee then build strength prior to surgery so recovery is enhanced afterwards. What can be achieved will obviously depend on time available before the operation.

Apply cold therapy to the knee, initially every 3 hours for a duration of 15 minutes to reduce swelling.  A knee support can also be worn to compress the knee helping to reduce swelling and increase stability. A professional therapist may use electrotherapy such as ultrasound and light massage to help remove swelling. Compression bandages may also be applied.

Exercises will depend on the ability of the patient. Some may be able to skip to stage 2 or 3 rehabilitation exercises before surgery, others may need more rest time.

Heel slide knee mobility exercisesMobility exercises to increase the range of motion at the knee can be performed if they are not painful. Strengthening exercises can also be commenced, providing they are pain free. Isometric exercises or static contractions which do not involve movement such as isometric quadriceps exercises are more suitable in the very early stages.

The athlete may be able to walk, swim or cycle in order to maintain fitness although taping or wearing a support may be necessary during these activities if the joint is unstable.

Phase 2: Immediately following surgery

Knee bracesDuration: 0 to 2 weeks post surgery. The aim immediately after surgery and for the following 2 weeks is to control swelling, straighten the leg fully, improve quadriceps strength and hamstring flexibility.

The initial protocol will be largely down to your surgeon. Some surgeons and therapists will advice the wearing a knee brace for protection although not all favor this approach. Rest and use of crutches is common. Ice and compression and electrotherapy can be continued as before to reduce post-operative swelling.

Mobility exercises along with hamstring stretching exercises can begin. Easy heel slide exercises can be done to begin to regain range of movement in the knee.

Static quad exercisesStrengthening exercises can begin with static or isometric quadriceps with the focus on contracting the vastus medialis oblique on the inside of the lower thigh. Static hamstring contractions and double leg calf raises along with hip abduction, hamstring curl and hip extension exercises with resistance band can be included. The patient should avoid walking, running, cycling, swimming or any other kinds of functional exercises during this phase.

Phase 3: Two weeks following surgery

Ultrasound for the knee jointDuration: from 2 to 10 weeks. Aims to eliminate swelling, regain 120 degrees of flexion or bend in the knee, full weight bearing and equal hamstring flexibility on both leg.

Apply ultrasound, cold therapy and compression to eliminate any residual swelling. By now the patient should be aiming to increase walking and ensure normal gait cycle.

Range of motion knee exercises should continue from phase 2. The patient should be aiming to be able to completely straighten the leg by now. Continue with isometric quadriceps exercises with particular attention again on setting the VMO or vastus medialis oblique.

Squat exerciseIntroduce half squats and shallow lunges, leg press with both legs, step ups and bridging exercises. Hip extension and abduction can continue with resistance bands. Calf raises should progress to single leg only. Single leg wobble board exercises should also be included. Maintain fitness with walking and cycling when possble.

Phase 4: Three to six months post surgery

JoggingDuration: 3 months. Aims to regain full range of motion, normal strength and power and return to jogging and restricted sports specific training.

By this stage there should be no need for cold therapy, compression or other treatment modalities. Progress to full lunges and squats, add weight for extra resistance. Increase resistance and number of repetitions for strengthening exercises. Leg press exercises should progress to single leg only aiming to have equal strength in both legs.

Lunge exerciseAerobic exercises should progress from straight line slow jogging, cycling and light swimming to straight line running. Over time gradually introduce agility type drills including running backwards, sideways and changing direction. Plyometric type jumping exercises and ball kicking can also be introduced when the knee feels comfortable enough to do so.

Phase 5: Returning to sport

Returning to normal sports training usually begins anywhere from 6 months to 12 months post surgery.

Sports specific trainingSports specific training should progress gradually and game players should first be introduced to restricted practice situations or drills before going back into a full competitive match situation. When a surgeon gives permission the athlete will be free to return to competition. This should also be done gradually for example playing 10 to 20 minutes of a football match rather than going straight into a full game.