Rehabilitation Guidelines: Post Anterior Cruciate Ligament (ACL) Reconstruction 0-2 weeks after surgery Appointments 1 - 2 times per week Rehabilitation Goals Patient education (re: weight - bearing status; progression of rehabilitation) Decrease pain and swelling Care for the knee and dressing Protection of healing graft fixation Early range of motion exercises Achieve and maintain full passive extension Maintain Quadricep muscle activation and leg control Adherence to home exercise program (HEP) and precautions Gait training Precautions Weight Bearing: Weight bear as tolerated (WBAT) with crutches Brace : Post-operative extension 0 degree for 2-4 weeks (wear during exercise) Knee ROM: Full extension Achieve 0-90 degree for week 1 Achieve 100 - 120 degrees of flexion by week 2 Hamstring graft: Avoid aggressive hamstring sets, heel slides, prone hangs and other hamstring activities that may aggravate the graft donor site. Slowly and progressively build in hamstring work. ACL graft care: Avoid aggressive/long hours (2-3) walking, repetitive loading during initial stage (even with brace) Contrai ndication Open Kinetic chain exercises (Inner range Quads) (after week 6) Suggested Therapeutic Exercise Mobility Exercise Heel slides (+/– slider board) Supine with legs up wall – heels slides with gravity assisted Bike pendulums: high seat (½ circles forward/backward) > lower seat (full circles) Sitting passive leg extension with roll under heel OR prone leg hangs off end of bed/plinth Seated calf stretches with towel Seated hamstring stretch Hip Straight Leg Raise (with brace): hip flexion/extension, abduction/adduction Standing hip flexion/extension, abduction/adduction Knee Static Quads with Electrical Muscular Stimulation Sit to stand (gradually decrease height of seat) Static lunge forward/side Mini wall squat (30°) Calf Ankle pump Standing calf raises with/without support Proprioception Single leg stance 30-60 seconds (with brace) Wobble boards with support through full range of motion (ROM): side-to-side, forward/backward Gait Weight shifting drills: side-to-side and forward/backward Progress from 2 crutches to 1 (maintaining normal walking pattern) Progression Criteria Minimal knee effusion 3-6 weeks after surgery Appointments 2 - 3 times per week Rehabilitation Goals Near or full ROM for knee flexion and extension Continue strengthening exercises with control: hip, hamstrings, quadriceps, calves Strengthening of non-injured leg Progress proprioception Normal Weight bearing gait Maintain cardiovascular fitness Precautions Weight Bearing: Wean off crutches, Full weight bearing Brace: Wean off brace by Week 3-4 (Depend on surgeon’s instruction, and when good knee control, pain control and safe gait mechanics is achieved) ROM Achieve near or full knee ROM after week 4 Hamstring graft: Avoid aggressive hamstring sets. Slowly and progressively build in hamstring work (after week 4) ACL graft care: Avoid overloading the fixation site (low amplitude low velocity movements) Contraindication Open Kinetic chain exercises (Inner range quads) (after week 6) Suggested Therapeutic Exercise Mobility Exercise Continue heel slides, wall slide as needed Stationary bike with low resistance Standing calf (gastrocnemius and soleus) and hamstring stretch Prone assisted knee flexion (belt, opposite leg) Patellar and/or tibial-femoral joint mobilizations to achieve terminal ROM (no ACL strain with passive movement) Hip Hip strengthening with pulleys or ankle weights - all directions (avoid trunk swaying) Isometric hamstrings/gluteals (supine with Swiss ball) > bridging Hip and core strengthening Knee Sit-to-stand +/- muscle stimulation Closed kinetic chain exercises (leg press / mini-squats>squats / static lunge>lunges) Wall squat (45°-60°) Forward and lateral step-ups 5-10cm (push body weight up through weight bearing heel slow and with control, avoid hip hiking or excessive ankle dorsiflexion) Calf Heel raises 2 > 1 foot Proprioception Continue with full ROM on wobble boards (decreased support) Double leg balance drills - balance board, BOSU, tandem balance (weight shift > eyes close > mini squat 30 ° ) Stationary single leg balance drills Mini trampoline Gait Gait drills - forward and backward march walk, soldier walk, side step, step overs, hurdle walk (avoid compensatory hip hike) Cardiovascular Fitness Bike with increasing time parameters Progression Criteria > 6 weeks AND: 1. Good quad set and open chain leg control 2. Full knee extension 3. Near normal gait without crutches 4. Minimal knee effusion 6-9 weeks after surgery Appointments 2 - 3 times per week Rehabilitation Goals Full and pain free knee range of motion Functional quadriceps strength Continue strengthening lower extremity muscle groups, specifically through full range hamstrings/quadriceps Advance proprioception exercises Increase cardiovascular fitness Preca utions Weight Bearing: Full Weight Bearing ROM: Active Full ROM & Passive Full ROM Hamstring graft: Slowly and progressively build in hamstring work (without pain at donor site) ACL graft care: Avoid overloading the fixation site (low amplitude low velocity movements) Suggested Therapeutic Exercise Mobility Exercise Mobilizations if needed to achieve end ranges Hip Continue hip strengthening Open Kinetic chain (after week 6): Hamstring curls Knee Step-ups forward/lateral (vertical trunk, watch for hip hiking or excessive ankle dorsiflexion) Static Lunge (¼ - ½ range) > dynamic lunge step (¼ - ½ range) with proper trunk and leg alignment Full wall squats to 90° Supine on floor legs on swiss ball: bridging plus knee flexion (heels to buttocks) Open Kinetic chain (after week 6): Quads curls Leg Press Proprioception Wobble boards with upper extremity activity Mini trampoline: single leg stance > weight shift > bouncing BOSU™ marching: progress with high knees > 1 leg balance > squats (60- 90°) Gait Treadmill walking (gradually increase speed) Cardiovascular Fitness Stationary bike with increasing time or resistance Swimming (flutter kick) Pool jogging Progression Criteria No active inflammation or reactive swelling post exercise Appointments 2 - 3 times per week Rehabilitation Goals Continue flexibility exercises Quadriceps strength progression Continue lower chain concentric/eccentric strengthening of quadriceps & hamstrings, both inner range (60– 95°) & full range Proprioceptive progression Sport specific cardiovascular fitness Precautions No reactive swelling or joint pain that lasts more than 12 hours Suggested Therapeutic Exercise Hip Continue hip strengthening with increased weights/tubing resistance 9-12 weeks after surgery Hamstring curls Knee Static Lunge (full range) > dynamic lunge > lunge walking all with proper trunk and leg alignment Plyobox back lunge Backward step up Leg Press (double leg > single leg) Quick walk forward/backward Quick side stepping Quick lunge forward with control Eccentric step down with control on 15 > 20cm step Calf Eccentric heel drops Proprioception Single leg stance drills on BOSU > add on upper body movements Cardiovascular Fitness Stationary Bike: increased resistance and time parameters Treadmill walk: increase incline > quick walk > running Progression Criteria Normal jogging gait Good single leg balance No active inflammation or reactive swelling post exercise 12-16 weeks after surgery Appointments Rehabilitation appointments as needed. Usually 1 time every 1 - 2 weeks Rehabilitation Goals Continue with flexibility exercises for the lower chain Continue strengthening of the lower chain Sport specific quadriceps & hamstrings strengthening Sport specific proprioception training Sport specific cardiovascular fitness Precautions No reactive swelling or joint pain that lasts more than 12 hours Suggested Therapeutic Exercise Continue with concentric and eccentric strengthening of hamstrings and quadriceps, working through full & inner range Hip strengthening - especially oriented at neuromuscular control in prevention of hip adduction at landing and stance Backward lunge > backward lunge walking Single leg drop (progressively increase height) Landing mechanics (double leg > single leg) (single plane > multi plane) Split squat jumps – progress to BOSU Agility training Ladder drills (forward and backward skipping, side shuffle, skater’s quick stepping, carioca, cross overs, backward jog, forward jog) Side step - overs (hurdle) > side hop - overs Carioca steps (foot crossing steps) Skipping Hopping 2 leg > 1 leg Strength and control drills (sport/work specific) Proprioception Continue progressing skill difficulty (sport/work specific) Single leg stance – tap down clock drill with mini cones BOSU: 1 leg balance with upper body or opposite leg skill Cardiovascular Fitness Bike – standing with interval training Jogging – straight on flat ground, no cuts/no downhill Treadmill – jog > interval running > running 16-20 weeks after surgery Appointments Rehabilitation appointments are once every 2 - 4 weeks Rehabilitation Goals Normal multiplanar high velocity exercises (without side to side differences or compensations) Normal double leg landing control (without side to side differences or compensations) Adherence to HEP Precautions No reactive swelling or joint pain that lasts more than 12 hours Suggested Therapeutic Exercise Landing mechanics - higher amplitude double leg > single leg landing drills (Uni-planar > multi-planar) Movement control exercise, low velocity + single plane activities > higher velocity + multi-plane activities Unanticipated movement control drills: cutting and pivoting Continue progressing strength and control drills (sport specific movements) Balance and proprioceptive drills (sport/work specific movements) Hip strengthening (develop neuromuscular control in prevention of hip adduction at landing and stance) Core strength and stabilization (to prevent trunk leaning forward during landing and single leg stance) Stretching Plyometrics and Agility Forward and lateral hopping (single leg) Vertical jumps (single leg) Box hop up /down Box jump down with sprint forward Box drop jump 2 legs (with proper form) > drop jump with vertical hop (maximum height) Single leg drop landing (increasing step height) Proprioception Forward hop and lateral hop (maintain balance for 5 sec on landing) Cutting drills with quick stop and maintain balance Cardiovascular Training Stationary bike: Increased distance, time and resistance parameters (sport specific) Treadmill: running > sprinting Jogging and running (on an uneven surface and sudden change of direction) Acceleration and deceleration running Cycling outdoors Swimming Progression Criteria Return to sport criteria 1. Clearance from the orthopedic surgeon and physical therapist/athletic trainer 2. Progressive testing will be completed Return to sport test - Quads strength within 10% of the uninjured side - 4 single leg hop tests; with no more than 10% difference between sides - Triple hop test - Crossover triple hop test - Hop tests: single hop, 6-m timed hop, triple hop, crossover hop 24-32 weeks after surgery Continue addressing patient’s physical impairment and performance needs based on their work and sport requirements. Patients are safe to return to sports and team practices with/without measures and limitations set by the physical therapist. This may include time, volume or specific activity. References Anderson, M. J., et al. (2016). A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthopaedic Journal of Sports Medicine , 4 (3), 2325967116634074. doi:10.1177/2325967116634074 Beischer. S., Gustavsson. 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