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ACL Rehabilitation Guidelines

For more information about knee procedures, schedule an appointment with Dr. Fuchs. 

These guidelines have been developed to service the spectrum of ACL injured people (non-athlete ↔ elite athlete). For this reason, example exercises are provided instead of a highly structured rehabilitation program. Rehabilitation specialists should tailor the program to each patient’s specific needs.

Some treatment methods with supporting evidence (e.g., using a high-intensity electric stimulation training program for strength, aquatic therapy) are not included in these rehabilitation guidelines because not all patients have access to these modalities. The treating physical therapist should use these modalities as they see fit, even though they are not specifically documented under these guidelines.

Progression from one phase to the next is based on the patient demonstrating readiness by achieving functional criteria rather than the time elapsed since surgery. The time frames identified in parentheses after each Phase are approximate times for the average patient, NOT guidelines for progression. Some patients will be ready to progress sooner than the time frame identified, whereas others will take longer.

The recommended number of visits to the rehabilitation specialist (including visits merely for evaluation / exercise progression) is 20 to 35 visits with the majority of the visits occurring early (TIW x 4 weeks). However, it is recognized that some patient’s health plans are severely restrictive. Please tailor the number of visits to the patient’s needs.

For a full PDF download, click here.

Phase 0: Pre-operative Recommendations

  • Normal gait
  • AROM 0 to 120 degrees of flexion
  • Strength: 20 SLR with no lag
  • Minimal effusion
  • Patient education on post-operative exercises and need for compliance
  • Educated in ambulation with crutches
  • Wound care instructions

Phase 1: Immediate Post-operative Phase

Approximate time frame: Surgery to 2 weeks. 

Goals

  • Full knee extension ROM
  • Good quadriceps control (≥ 20 no lag SLR)
  • Minimize pain
  • Minimize swelling
  • Normal gait pattern

Crutch Use

  • WBAT with crutches (beginning the day of surgery). 
  • Crutch D/C Criteria:
    • Normal gait pattern
    • Ability to safely ascend/descend stairs without noteworthy pain or instability (reciprocal stair climbing)

Knee Immobilizer

Use hinged knee brace, locked at 10° for 1st week, then locked in full extension after 1st week, until patient is able to do straight leg raise and has good quadriceps control. Patient may then wean out of brace.

Cryotherapy

Cold with compression/elevation (e.g. Cryo-cuff, ice with compressive stocking). 

  • First 24 hours or until acute inflammation is controlled: every hour for 15 minutes
  • After acute inflammation is controlled: 3 times a day for 15 minutes
  • Crushed ice in the clinic (post-acute stage until D/C)

Exercise Suggestions

Range of motion (ROM) exercises include:

  • Extension: Low load, long duration (~5 minutes) stretching (e.g., heel prop, prone hang minimizing co-contraction and nociceptor response)
  • Flexion: Wall slides, heel slides, seated assisted knee flexion, bike: rocking-forrange
  • Patellar mobilization (medial/lateral mobilization initially followed by superior/inferior direction while monitoring reaction to effusion and ROM)

Muscle Activation/Strength exercises include:

  • Quadriceps sets emphasizing vastus lateralis and vastus medialis activation
  • SLR emphasizing no lag
  • Electric Stimulation: Optional if unable to perform no lag SLR Discontinue use when able to perform 20 no lag SLR
  • Double-leg quarter squats
  • Standing theraband resisted terminal knee extension (TKE)
  • Hamstring sets
  • Hamstring curls
  • Side-lying hip adduction/abduction (Avoid adduction moment in this phase with concomitant grade II – III MCL injury)
  • Quad/ham co-contraction supine
  • Prone Hip Extension
  • Ankle pumps with theraband
  • Heel raises (calf press)

Cardiopulmonary: UBE or similar exercise is recommended. 

Scar Massage (when incision is fully healed). 

Criteria for Progression to Phase 2:

  • 20 no lag SLR
  • Normal gait
  • Crutch/Immobilizer D/C
  • ROM: no greater than 5º active extension lag, 110º active flexion

Phase 2: Early Rehabilitation Phase

Approximate time frame: weeks 2 to 6.

Goals

  • Full ROM
  • Improve muscle strength
  • Progress neuromuscular retraining

Exercise Suggestions

Range of motion (ROM) exercises include:

  • Low load, long duration (assisted prn)
  • Heel slides/wall slides
  • Heel prop/prone hang (minimize co-contraction / nociceptor response)
  • Bike (rocking-for-range → riding with low seat height)
  • Flexibility stretching all major groups

Strengthening exercises include:

  •  Quadriceps:
    • Quad sets
    • Mini-squats/wall-squats
    • Steps-ups
    • Knee extension from 90o to 40o
    • Leg press
    • Shuttle Press without jumping action
  • Hamstrings:
    • Hamstring curls
    • Resistive SLR with sports cord
  • Other Musculature:
    • Hip adduction/abduction: SLR or with equipment
    • Standing heel raises: progress from double to single leg support
    • Seated calf press against resistance
    • Multi-hip machine in all directions with proximal pad placement

Neuromuscular training:

  • Wobble board
  • Rocker board
  • Single-leg stance with or without equipment (e.g. instrumented balance system)
  • Slide board
  • Fitter

Criteria for Progression to Phase 3:

  • Full ROM
  • Minimal effusion/pain
  • Functional strength and control in daily activities
  • IKDC Question # 10 (Global Rating of Function) score of ≥ 7

Phase 3: Strengthening & Control Phase

Approximate time frame: weeks 7 through 12

Goals

  • Maintain full ROM
  • Running without pain or swelling
  • Hopping without pain, swelling or giving-way

Exercise Suggestions

Strengthening exercises include:

  • Squats
  • Leg press
  • Hamstring curl
  • Knee extension 90o to 0o
  • Step-ups/down
  • Lunges
  • Shuttle
  • Sports cord
  • Wall squats

Neuromuscular Training:

  • Wobble board / rocker board / roller board
  • Perturbation training
  • Instrumented testing systems
  • Varied surfaces

Cardiopulmonary:

  • Straight line running on treadmill or in a protected environment (NO cutting or pivoting)
  • All other cardiopulmonary equipment

Criteria for Progression to Phase 4:

  • Running without pain or swelling
  • Hopping without pain or swelling (Bilateral and Unilateral)
  • Neuromuscular and strength training exercises without difficulty

Phase 4: Advanced Training Phase

Approximate time frame: weeks 13 to 16. 

Goals

  • Running patterns (Figure-8, pivot drills, etc.) at 75% speed without difficulty
  • Jumping without difficulty
  • Hop tests at 75% contralateral values (Cincinnati hop tests: single-leg hop for distance, triple-hop for distance, crossover hop for distance, 6-meter timed hop)

Exercise Suggestions 

Aggressive strengthening:

  • Squats
  • Lunges
  • Plyometrics

Agility drills:

  • Shuffling
  • Hopping
  • Carioca
  • Vertical jumps
  • Running patterns at 50 to 75% speed (e.g. Figure-8)
  • Initial sports specific drill patterns at 50 – 75% effort

Neuromuscular Training:

  • Wobble board / rocker board / roller board
  • Perturbation training
  • Instrumented testing systems
  • Varied surfaces

Cardiopulmonary:

  • Running
  • Other cardiopulmonary exercises

Criteria for Progression to Phase 5:

  • Maximum vertical jump without pain or instability
  • 75% of contralateral on hop tests
  • Figure-8 run at 75% speed without difficulty
  • IKDC Question # 10 (Global Rating of Knee Function) score of ≥ 8

Phase 5: Return-to-Sport Phase

Approximate time frame: weeks 17 to 20.

Goals

  • 85% contralateral strength
  • 85% contralateral on hop tests
  • Sport specific training without pain, swelling or difficulty

Exercise Suggestions

Aggressive Strengthening:

  • Squats
  • Lunges
  • Plyometrics

Sport Specific Activities:

  • Interval training programs
  • Running patterns in football
  • Sprinting
  • Change of direction
  • Pivot and drive in basketball
  • Kicking in soccer
  • Spiking in volleyball
  • Skill / biomechanical analysis with coaches and sports medicine team

Return-to-sport Evaluation Recommendations

  • Hop tests (single-leg hop, triple hop, cross-over hop, 6 meter timed-hop)
  • Isokinetic strength test (60°/second)
  • Vertical jump
  • Deceleration shuttle test

Return-to-sport Criteria:

  • No functional complaints
  • Confidence when running, cutting, jumping at full speed
  • 85% contralateral values on hop tests
  • IKDC Question # 10 (Global Rating of Knee Function) of ≥ 9

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