Dr James Coulthard
Rehabilita*on Protocol for Anterior Cruciate Reconstruc*on with Hamstring
autogra9 or allogra9
The anterior cruciate ligament (ACL) is an important structure providing sagi9al plane and rotatory
stability to the knee.
Loss of ACL func?on will adversely affect ?biofemoral contact forces in the knee, and knee stability.
This can lead to progressive damage to the joint either through macro or microtrauma.
Reconstruc?ve surgery aims to restore knee stability, and protect the knee from further injury. Longterm observa?onal studies of delayed reconstruc?on have shown delayed surgery may be associated
with a significantly greater rate of damage to the meniscus, the ar?cular car?lage or both (Frobell, et.
al. 2010). Data from Brambilla’s (2015) retrospec?ve cohort study shows, how medial meniscal tear
prevalence increases, especially aOer 12 months in non-reconstructed knees. They concluded that
for each month of delay of ACLR, increased the risk of intra-ar?cular damage by 0.6%.
Poten?al problems following surgery include infec?on, graO rupture, arthrofibrosis, knee s?ffness,
ongoing swelling, DVT, cosme?c issues and the various risks with general anesthesia. The decision
whether to reconstruct is a complex one determined by weighing up the risks and benefits, as well as
considering if the pa?ent is prepared to par?cipate in an intensive rehabilita?on for approximately
12 months.
Rehabilita?on can be challenging. Twenty to thirty individual physiotherapy consulta?ons, and over
200 hours of rehabilita?on may be required, par?cularly for athletes wan?ng to return to pre-injury
status.
Not all reconstructed knee return to pre-injury ac?vity. Pa?ents oOen expect full return to pre-injury
func?on, but this is unrealis?c for many. To summarise some of the literature:
•
42 - 65% of all pa?ents return to pre-injury sport (Wellsandt, Failla, Axe & SnyderMackler, 2018, Ardern, Taylor, Feller & Webster, 2014)
•
83% of elite athletes return to pre-injury sport (Lai, Ardern, Feller & Webster, 2017)
•
22 - 30% have a second ACL injury on Return to Sport ((Mar?n et al., 2022, Paterno,
Rauh, Schmi9, Ford & Hewe9, 2014)
Delaying return to sport to at least 9 months and restoring normal muscle strength results in lower
re-injury rates. (Grindem et al., 2014)
This protocol aims to provide a general guide for post-opera?ve management of anterior cruciate
ligament reconstruc?on. It is wri9en for health care professionals, primarily Physiotherapists and is
not intended to be distributed to pa?ents. Varia?ons in the protocol may be specified depending on
other procedures performed such as meniscal repair, meniscectomy, anterolateral ligament
augmenta?on, and other pa?ent specific and surgery specific factors.
This is a guide only, and therapist will have to s?ll make their own clinical decisions based on factors
such as available equipment, pre-injury requirements, and individual pa?ent progress. It is a
conserva?ve protocol and assumes up to 12 months to return to high level ac?vity. This protocol
applies to hamstring autograOs and allograOs. Notes have been included with this protocol and are
important.
Stage 1 Recovery from Surgery – Weeks 1 and 2.
Aims:
-
Manage post opera?ve pain/swelling
Minimise muscle inhibi?on and reac?vate quadriceps
Start regaining range of mo?on
Maintain patellofemoral mobility
Gradually improve walking and weightbearing
Criteria for progression to stage 2
-
Full or nearly full passive knee extension
Knee flexion to 100 degrees
Straight leg raise without lag
Swelling 0 – 1+
Stage 2 Strength and Neuromuscular Control - 3 – 6 weeks.
Aims:
-
Further reduce post opera?ve pain/swelling
Quadriceps and glute strengthening
Maintain patellofemoral mobility
Normal walking and weightbearing
Criteria for progression to stage 3
-
Nearly full flexion (within 10 degrees of other leg)
Full extension
Swelling 0 -1+
Stage 3 – Strength and Neuromuscular Control - 7 – 12 Weeks.
Aims:
-
Con?nue strength and condi?oning and gradually add hamstring strengthening
Maintain full knee range of mo?on
Criteria for progression to stage 4
-
Quadriceps, hamstrings, and glutes test to >80% with dynamometry
Normal sit to stand
Single leg squat to 90 degrees
Symmetrical star excursion with good control
No instability symptoms
No swelling
Stage 4 - 13 Strength and Func2onal Recovery 13 – 26 weeks.
Aims:
-
Progress strengthening
-
Introduce early sports specific drills
Introduce func?onal, neuromuscular and balance exercises including
o Teach correct landing mechanics
o Low intensity straight line running
o Hopping exercises
Criteria to progress to Stage 5 – 6 months+ aOer surgery
-
Quadriceps, hamstrings, and glutes test to >90% with dynamometry
Hamstring: quadriceps ra?o >70%
Normal straight line running gait
Normal triple hop test
Normal balance
Stage 5 – Progressive return to Full Func2on - 6-12 Months following surgery. Aims:
-
Progress strengthening
Normalise sports specific movements
Return to full sport
Criteria to progress to full return to full ac?vity
-
Normal clinical examina?on
100% strength and endurance
Normal Lachman’s and Pivot shiO
Normal landing mechanics if required
Normal Hop test ba9ery (hop for distance, ver?cal hop, side hop)
Pre-injury running gait and speed restored if required
Normal func?onal tes?ng in a fa?gued and non-fa?gued state
Normal general fitness
Normal psychological state and confidence (ACL RSI)
Minimum 9 months since surgery
Stage 6 - Preventa2ve Programming.
There are several ACL injury preven?on programs which aim to maintain or improve neuromuscular
control during func?onal tasks. These include
•
•
•
•
•
Sportsmetrics Program
The FIFA 11+ Warm Up
The PEP Program •
The KNEE Program - Netball Australia •
The FootyFirst Program - AFL
Appendix: Descrip2on of test measures
Knee range of mo2on. This is measured using a long-arm goniometer. Bony landmarks: greater
trochanter, lateral femoral condyle, and lateral malleolus.
Swelling grades. Using stroke test:
Zero: no wave produced on downstroke
Trace: small wave on medial side on downstroke
1+: Large bulge on medial side on downstroke
2+: Effusion spontaneously returns to medial side aOer upstroke
3+: So much fluid it is impossible to move effusion out of the medial aspect of the knee
Hop test ba9ery. There are numerous versions of hop test. These are most relevant in the return to
sport seong, and performing several of these is recommended. Examples are described below.
Triple Hop Test (Noyes 1991). Subjects are required to hop forwards three consecu?ve ?mes on one
foot. The total distance is measured and the average of 2 valid tests is recorded. Measure from toe at
takeoff to heel at landing. Arms are free to swing. A limb symmetry index is calculated by dividing the
mean distance (in cm) of the involved limb by the mean distance of the non-involved limb, then
mul?plying by 100. The goal is 95% compared with the other side.
Side Hop Test (Gustoavsson et al,. 2006) Subjects stands on test leg with hands behind the back and
jumps from side to side between two parallel strips of tape, placed 40 cm apart on the floor. Subject
jumps as many ?mes as possible during 30sec. The number of successful jumps performed, without
touching the tape is recorded. The goal is 95% compared with the other side.
1. Ardern, C. L., Taylor, N. F., Feller, J. A., & Webster, K. E. (2014). Fifty-five per cent
return to competitive sport following anterior cruciate ligament reconstruction
surgery: an updated systematic review and meta-analysis including aspects of physical
functioning and contextual factors. British Journal of Sports Medicine, 48(21), 1543–
1552. doi:10.1136/bjsports-2013-093398
2. Brambilla, L., Pulici, L., Carimati, G., Quaglia, A., Prospero, E., Bait, C., … Volpi, P.
(2015). Prevalence of Associated Lesions in Anterior Cruciate Ligament
Reconstruction. The American Journal of Sports Medicine, 43(12), 2966–2973.
doi:10.1177/0363546515608483
3. Cooper, R., Hughes. M., (n.d.). Melbourne ACL rehabilitation guide 2.0. Melbourne,
Vic.
4. Frobell, R. B., Roos, H. P., Roos, E. M., Roemer, F. W., Ranstam, J., & Lohmander,
L. S. (2013). Treatment for acute anterior cruciate ligament tear: five-year outcome of
randomised trial. BMJ, 346(jan24 1), f232–f232. doi:10.1136/bmj.f232
5. Gustavsson, Alexander, et al. "A test battery for evaluating hop performance in
patients with an ACL injury and patients who have undergone ACL
reconstruction." Knee Surgery, Sports Traumatology, Arthroscopy 14.8 (2006): 778788.
6. Lai, C. C. H., Ardern, C. L., Feller, J. A., & Webster, K. E. (2017). Eighty-three per
cent of elite athletes return to preinjury sport after anterior cruciate ligament
reconstruction: a systematic review with meta-analysis of return to sport rates, graft
rupture rates and performance outcomes. British Journal of Sports Medicine, 52(2),
128–138. doi:10.1136/bjsports-2016-096836
7. Martin, R. K., Wastvedt, S., Pareek, A., Persson, A., Visnes, H., Fenstad, A. M., …
Engebretsen, L. (2022). Predicting subjective failure of ACL reconstruction: a
machine learning analysis of the Norwegian Knee Ligament Register and patient
reported outcomes. Journal of ISAKOS, 7(3), 1–9. doi:10.1016/j.jisako.2021.12.005
8. Noyes, Frank R., et al. "A training program to improve neuromuscular and
performance indices in female high school basketball players." The Journal of
Strength & Conditioning Research 26.3 (2012): 709-719
9. Noehren, B., & Snyder-Mackler, L. (2020). Who’s Afraid of the Big Bad Wolf?
Open-Chain Exercises After Anterior Cruciate Ligament Reconstruction. Journal of
Orthopaedic & Sports Physical Therapy, 50(9), 473–475.
doi:10.2519/jospt.2020.0609
10. Paterno, M. V., Rauh, M. J., Schmitt, L. C., Ford, K. R., & Hewett, T. E. (2012).
Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after
primary ACL reconstruction and return to sport. Clinical Journal of Sport Medicine,
22(2), 116–121. doi:10.1097/jsm.0b013e318246ef9e
11. Wellsandt, E., Failla, M. J., Axe, M. J., & Snyder-Mackler, L. (2018). Does Anterior
Cruciate Ligament Reconstruction Improve Functional and Radiographic Outcomes
Over Nonoperative Management 5 Years After Injury? The American Journal of
Sports Medicine, 46(9), 2103–2112. doi:10.1177/0363546518782698
ACL RECONSTRUCTION WITH AUTOLOGOUS
HTG
To the end of week
no tubigrip due to risk of DVT.
ROM approximate goals:
0-100° note 1
0-125°
0-full°
Weight-bearing:
25 - 75% body weight. Note 2
75 - 100% body weight. Note 2
Patella Mobilisation: Note 3
Modalities:
Electromuscular stimulation. Note 4
Pain/oedema Management (cryotherapy)
Stretching:
quadriceps, hip flexors. Note 5
hamstrings. Note 6
Gastrocnemius-soleus
Strengthening:
Quads isometrics, SLR, active knee extension
DVT preventative exercises
gait retraining, walking, and running. Notes 7,8
toe raises, mini-squats, TRX assisted squats
Knee flexion hamstring curls, bridging
Knee extension quadriceps (0 - 90)
Hip abduction-adduction, extension. Note 9
Leg press (70°- 0°)
leg press (0 - 100)
full squat or full leg press
Balance/proprioceptive training:
Weight-shifting,
single leg balance
Y-excursion
balance, perturbation, neuromuscular
Conditioning:
arm ergo, bike, rowing, aquatics, elliptical
Elliptical machine
core strengthening
Running straight: note 12
Cutting, carioca, figure-eights, hopping. Note
10
Plyometric training. Note 10
Full sports. Note 11
2
4
6 8 12 16 20 26 30 34 40
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1. If a pa?ent has persistent flexion contracture a zimmer can be worn at night for a few weeks.
Aim to achieve full extension by 1-2 weeks.
2. Crutches and or a zimmer splint are some?mes recommended un?l gait is safe, and full knee
extension has been achieved, and a consistent, comfortable, locked straight leg raise can be
demonstrated
3. Patella mobilisa?ons can be con?nued for longer if there is persistent loss of patellar
mobility.
4. Very li9le evidence but probably a dose response rela?onship. 3 x 20 min/per day
5. Quads stretches only possible with near full knee flex range of movement
6. Hamstring stretches are very gentle in the early phase and are used to minimise adhesions
7. Start running retraining. Lower limb strength should be at 95% or above, full knee ROM, 95%
on Y-excursion and minimal knee effusion. 95% Lyshom knee score
8. Emphasise full knee extension at heel strike.
9. Gluteus maximus is an important external rotator of the hip. Deficits may predispose to
injuries
10. Commence plyometrics and mul? direc?onal movements only when back to full strength,
full y excursion and no knee effusion. 95% Lyshom knee score
11. Full strength, ROM, 100% Lyshom knee score, 100% Y-excursion c.f. to other limb, 100%
single hop and 3 hop tests, full cardiovascular fitness, on field, sports specific drills, Good
performance on drop ver?cal jump (no valgus, > 72 degrees knee flexion (Hewi9 2005), no
excessive trunk sway)
12. Commence running when full strength and no effusion