Downtown Physical Therapy treats many conditions related to the knee, this includes post-surgical Anterior Cruciate Ligament (ACL) repairs. Here is what to expect after ACL surgery.
WHAT IS AN ANTERIOR CRUCIATE LIGAMENT (ACL) INJURY?
The ACL is a ligament that runs diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur, as well as provides rotational stability to the knee. One of the most common knee injuries is an anterior cruciate ligament sprain or tear. Athletes who participate in high demand sports are more likely to injure their anterior cruciate ligaments. An injury to an ACL, may require surgery to regain full function of your knee.
WHEN IS AN ACL SURGERY PERFORMED?
The surgical procedure is performed by an Orthopedic surgeon after testing has been performed to determine the severity of the injury. This testing can include a physical test, x-rays, and MRI’s.
Most ACL tears cannot be sutured back together. To surgically repair the ACL and restore knee stability, the ligament must be reconstructed. Your orthopedic surgeon will replace your torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on.
Grafts can be obtained from several sources. Often they are taken from the patellar tendon, which runs between the kneecap and the shinbone. Hamstring tendons at the back of the thigh are a common source of grafts. Sometimes a quadriceps tendon, which runs from the kneecap into the thigh, is used. Finally, cadaver graft (allograft) can be used.
There are advantages and disadvantages to all graft sources. You should discuss graft choices with your own orthopedic surgeon to help determine which is best for you.
HOW LONG IS THE RECOVERY PROCESS AFTER ACL SURGERY?
Most procedures are performed in outpatient facilities, meaning the patient can return home same day. While recovery time is on a case per case basis, one can expect up to 6 months before returning to full activity.
WHAT SHOULD I EXPECT WITH PHYSICAL THERAPY AFTER ACL SURGERY
Immediately after post-op
Goals:
1) Protect ACL reconstruction
2) Reduce swelling & inflammation
3) Control Pain
4) Restore & maintain full extension
5) Gradually restore knee flexion
6) Activate quadriceps muscle
7) Independent ambulation
8) Patient education & protect graft harvest site
POST-OP DAY 1
Brace: Brace locked at zero degrees extension for ambulation
Weight Bearing Two crutches as tolerated (at least 50 % WB)
Range of Motion – Full passive extension (0-90 degrees)
Exercises
*Ankle pumps
* Passive knee extension to zero
* Straight leg raise (flexion)
* Hip Abd/Adduction
* Knee Extension 90-40 degrees
* Quad sets with Neuromuscular Stimulation
* No Hamstring stretching **
Ice, Compression, Elevation (ICE): Game Ready x 15’ w/elevation
Home ICE 3-4x/day 20’/session
POST-OP DAY 2 through 7
Brace: Locked at zero degrees extension for ambulation
Weight Bearing Two crutches as tolerated
Range of Motion Patient out of brace 4-5 times daily to perform self ROM 0-90/100
Degrees
Exercises
* Intermittent ROM exercises (0-90 degrees)
* Patellar mobilization
* Ankle pumps
* Straight leg raises (4 directions)
* Standing weight shifts and mini squats [(030) ROM]
* Knee extension 90-40 degrees
* Continue quad sets with Neuromuscular Stimulation
Manual Therapy
Passive ROM
Patellar Mobs
Edema Massage
ICE: Game Ready x 15’ w/elevation
Continue Home ICE 3-4x/day 20’ Sessions
MAXIMUM PROTECTION PHASE (Week 2-9)
Goals:
1) Absolute control of external forces and protect graft
2) Nourish articular cartilage
3) Decrease swelling
4) Prevent quad atrophy
Week Two
Brace: Locked at zero degrees for ambulation only, unlocked for self ROM (4-5
times daily)
Weight Bearing: As tolerated (goal to discontinue crutches 7-10 days post op)
Range of Motion: Self-Assisted Heal Slides (4-5 times daily), emphasis on maintaining zero degrees
passive extension
Precautions
* No Hamstring curls
* No Hamstring Stretches
Exercises
*Straight Leg raises (4 planes)
* Knee extension 45-10 degrees
* Mini squats (0-45)
*Weight shifts
*TKE’s
*Clamshells
* Shuttle Leg Press (Double Leg Only) 0-60 degrees
* PROM/AAROM 0-100 degrees
* Patellar mobilization
* Proprioception training
*Exercises to challenge non-surgical leg
* PRE Program start with 1 lb., progress 1 lb. per week
*Elliptical/Stationary Bike (No resistance)
Neuromuscular Stimulation with Quad Sets x 10’
ICE: Game Ready w/elevation 15’
Continue home RICE 3-4x/day 20’/session
Week Four-Five
Brace: Unlock to 45 degrees flexion for ambulation (Week 4)
Unlock to 90 degrees for ambulation (Week 5)
Range of Motion: Self-Assisted Heel Slides (4-5x daily), emphasis on maintaining zero degrees
passive extension
Exercises
* Same as week two
* ROM 0-125 degrees* Bicycle for ROM stimulus and endurance (non-surgical leg is the driving force, surgical assists motion as tolerated)
*Single leg balance (SLB) on solid surface
* Initiate eccentric quads
*Shuttle Leg press (Double Leg Only) 0-60 degrees
* Emphasize CKC exercise
* Emphasize hip strengthening (Hip ER, Abduction, Extension)
*Initiate Core Program
Manual Therapy
Passive ROM
Patellar Mobs
Edema Massage
Weeks Six-Eight
Brace – Discontinue use of drop locked brace
Exercises
* Same as week four gradually increasing resistance as tolerated
* Standing Hamstring Curl (light resistance)
*Advance SLB to Airex Pad
*Hip Drills (RDLs, Lateral slides, Standing 4-way hip)
* ROM 0-125 degrees
* Emphasize closed chain exercises
* Bicycle/Elliptical/Stairmaster (Increased resistance)
Neuromuscular Stimulation with Quad Sets x 10’
ICE: Game Ready w/elevation 15’
Continue home RICE 3-4x/day 20’/session
Manual Therapy
Passive ROM
Patellar Mobs
Edema Massage
Cross-Friction Massage to incision sites
Manual LE Hamstring/Hip Stretches
Brace: None
MODERATE PROTECTION PHASE (Months 2-3)
Goals:
Maximal strengthening for quads/lower extremity
Maximize ROM
Protect patellofemoral joint
Exercises (8-12 Weeks)
*Continue Previous Exercises with increased resistance
* Knee Extensions 90-0 degrees (Low load)
* Shuttle Leg Press (Initiate Single Leg/Kickbacks) 0-90 degrees
* Forward and Lateral 6-10” Step Ups
* Standing Hamstring curls
* Hip Abd/Add
* Heel raises
* Bicycle
* Stairmaster
* Wall Squats 0-90 degrees
* Lunges
*Woodway Treadmill Manual Walk
* Progress Proprioceptive training
* Continue PRE progression (no weight restriction)
Neuromuscular Stimulation with Quad Sets x 10’
ICE: Game Ready w/elevation 15’
Continue home RICE 1-2x/day 20’/session
Manual Therapy
Passive ROM
Patellar Mobs
Edema Massage
Cross-Friction Massage to incision sites
Manual LE Hamstring/Hip Stretches
Week 12-14
Exercise – Continue prior exercises
Initiate running program (patient must have minimal inflammation/swelling and demonstrate good VMO tone and quad control in order to initiate safely)
*Treadmill walk to light jog
LIGHT ACTIVITY PHASE (Month 4-5)
Criteria to Enter Phase IV
* AROM 0-125 degrees >
* Quad strength 70% of contralateral side, knee flexor/extensor rated 70-79%
* Minimal/no effusion
* Satisfactory clinical exam
Goals:
Development of strength, power, endurance, agility
Begin gradual return to functional activities
Progress running program
Exercises
* Emphasize eccentric quad work
* Continue to advance degree of difficulty of closed chain exercises, step-ups, squats, leg press
* Progress knee extension 90-0 degrees high repetitions low weight
* Hip abduction/adduction
* Initiate plyometric program
* Progress running program
*Woodway Manual Sprint (50-75% exertion)
* Initiate agility program
* Sport specific training and drills
* Hamstring curls and stretches
* Calf raises
* Bicycle for endurance
* Walking program
* Stairmaster
Criteria to Progress
No Pain/Swelling
Satisfactory clinical exam
Functional Drills
* Straight line running
* Jog to run
* Walk to run
Manual Therapy
Continue with previous Manual Therapy
RETURN TO ACTIVITY PHASE (Month 6 – 8)
Goals:
Achieve maximal strength, explosiveness, and endurance
Initiate return to sport activities
Strength
Knee Extensions
Hamstrings Curls
Wall Squats
Calf Raises
Shuttle Leg Press (Single/Double/Side-lying/Kickbacks) 0-90 degrees
Shuttle Jumps (Single/Double)
Step-up Hops
Hip Abduction
Step downs
4-Way Hip
Endurance, Proprioception & Stability
Assault Bike
Manual Woodway Sprint
High Speed Hamstrings
Cone Drills
Ladder Drills
Stairmaster
High Speed Hip Flexion/Extension
Elliptical
Trampoline Balance Drills
Backward running
A-Skips/B-Skips
Hip ER/IR strengthening
Lateral Slides
Manual Therapy
Manual Hip/LE stretches
RETURN TO SPORT PHASE (Months 9-12)
Goals
Perform at sport specific level of activity without limitations
Achieve full confidence
Exercises
*Continue same as previous phase
Strength & Power
Squats
Deadlift
Knee Extension/Curl
Plyometrics
Shuttle Leg Press (Single/Double/Side-lying/Kickbacks) 0-90 degrees
Shuttle Jumps (Single/Double)
Step-up Jumps
4-Way Hip
Endurance, Proprioception & Stability
Assault Bike
Manual Woodway Sprint
High Speed Hamstrings Drills
Stairmaster
Cone Drills
Ladder Drills
High Speed Hip Flexion/Extension
Elliptical
Trampoline Balance Drills
Backward running
A-Skips/B-Skips
Hip ER/IR strengthening
Lateral Slides
Criteria for Return to Sport
Surgical Leg = 95% of opposite leg strength/endurance/stability
*Protocol will be amended per surgeon’s request and patient presentation
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