Rehabilitation
after ACL reconstruction
Pichet Yiemsiri
Over views
Incidence: exact incidence is unknown
United States:
200,000 are torn each year
100,000 ACL reconstructions are done each year
associated with menisci tear in 50% of case
Rehabilitation Considerations
after ACL Reconstruction
Evidences base
ACL Reconstruction
Rehabilitation
Guideline on anterior cruciate ligament injury
A multidisciplinary review by the Dutch Orthopaedic
Association
Acta Orthopaedica 2012; 83 (4): 379–386
What is the outcome of different nonoperative treatment modalities?
Scientific evidence
Level 1:
 Balance and proprioception
Fitzgerald et al. 2000,
Cooper et al. 2005,
Trees et al. 2005, 2007
What is the outcome of different nonoperative treatment modalities?
Scientific evidence
Level 2:
 Addition of open-chain strength training
Zatterstrom et al. 2000,
Perry et al. 2005,
Tagesson et al.2008
Supervised training
Zatterstrom et al. 1998, 2000
What is the outcome of different nonoperative treatment modalities?
Scientific evidence
Level 3:
 wearing a knee brace
Swirtun et al. 2005
What is the optimal postoperative treatment ?
Scientific evidence
Level 1:
 Wearing a knee brace has no additional
treatment value after an ACL reconstruction
Wright and Fetzer 2007,
Anderson et al. 2009
Closed-chain exercise
Trees et al. 2005,
Wrightet al. 2008,
Anderson et al. 2009
What is the optimal postoperative treatment?
Scientific evidence
Level 2:
 Addition of neuromuscular training
Risberg et al. 2007
Early open-chain exercises will lead to more laxity
with hamstring grafts
Heijne and Werner 2007
Pain & effusion management
Cryo-therapy
Elevation
Compression
Anti-inflammatory medication
ROM exercise
Knee extension to 0 degrees after surgery while
avoiding hyperextension
Prevent a flexion contracture
Hip AROM exercise 4 planes
Continuous Passive Motion
CPM is not warranted to improve rehabilitation
outcome
Protocols after ACL reconstruction
Time frames and guidelines after ACL reconstruction
vary widely.
Most protocols emphasize
Early motion
Developing quadriceps control early
Obtaining full passive extension
Controlled weight bearing
Initiation of closed-chain exercises
Preoperative Phase
Goals
Diminish inflammation, swelling, and pain.
Restore normal ROM (especially knee extension).
Restore voluntary muscle activation.
Provide patient education to prepare patient for
surgery.
Preoperative Phase
Exercises
Ankle pumps.
Elastic wrap or knee
Passive knee extension to 0°.
sleeve to reduce swelling.
Passive knee flexion to
Weight-bearing
tolerance.
SLR: three-way, flexion,
As tolerated with or
abduction, adduction.
without crutches.
Closed-kinetic chain
exercises: 30-degree minisquats, lunges, step-ups.
Brace
Preoperative Phase
Muscle Stimulation
Patient Education
Review postoperative
Electrical muscle
stimulation to quadriceps
rehabilitation program.
during voluntary quadriceps
Review instructional
exercises (4-6 hr/day)
video (optional).
Cryo-therapy/Elevation
Select appropriate
surgical date.
Apply ice 20 min of every
hour, elevate leg with knee
in full extension (knee must
be above heart).
Phase 1: Immediate Postoperative-Days 1-7
Day 1
Brace
Transitional hinged brace locked
in full extension during ambulation
(Protonics Rehab System as
directed by physician).
Weight-bearing
Weight-bearing as tolerated with
two crutches.
Phase 1: Immediate Postoperative-Days 1-7
Day 1
Exercises
Ankle pumps.
Overpressure into full passive knee extension
Active and passive knee flexion (90° by day 5)
SLR (flexion, abduction, adduction).
Quadriceps isometric setting.
Hamstring stretches.
Phase 1: Immediate Postoperative-Days 1-7
Day 1
Muscle Stimulation
Used during active muscle exercises (4-6 hr/day).
Continuous Passive Motion
As needed, 0-45/50 degrees (as tolerated by patient and
directed by physician).
Ice and Elevation
Ice 20 min out of every hour and elevate with knee in full
extension (elevated above the heart with pillows below the
ankle, not the knee).
Phase 1: Immediate Postoperative-Days 1-7
Days 2-7
Goals
Restore full passive knee extension.
Diminish joint swelling and pain.
Restore patellar mobility.
Gradually improve knee flexion.
Reestablish quadriceps control.
Restore independent ambulation.
Phase 1: Immediate Postoperative-Days 1-7
Days 2-7
Brace
EZ Wrap
brace/immobilizer, locked
at O-degrees extension for
ambulation and unlocked
for sitting (or Protonics
Rehab System as directed
by physician).
Weight-bearing
As tolerated with two
crutches.
Range of Motion
Brace removed during
ROM exercises 4-6 times
a day.
Phase 1: Immediate Postoperative-Days 1-7
Days 2-7
Exercises
Multi-angle isometrics and 90° and 60° (knee extension).
Knee extension 90-40 degrees.
Overpressure into extension.
Ankle pumps.
SLR (three-way).
Mini-squats and weight shifts.
Standing hamstring curls.
Quadriceps isometric setting.
Proprioception and balance activities.
Phase 1: Immediate Postoperative-Days 1-7
Days 2-7
Muscle Stimulation
Continue electrical muscle
stimulation 6 hr/day.
Continuous Passive Motion
0 - 90° as needed.
Ice and Elevation
 Ice 20 min of every hour
and elevate leg with full
knee extension.
Phase 2: Early Rehabilitation-Weeks 2-4
Criteria for Progression to Phase 2
Quadriceps control (ability to perform good quad
set and SLR).
Full passive knee extension.
Passive ROM 0-90 degrees.
Good patellar mobility.
Minimal joint effusion.
Independent ambulation.
Phase 2: Early Rehabilitation-Weeks 2-4
Goals
Maintain full passive knee extension.
Gradually increase knee flexion.
Decrease swelling and pain.
 Muscle training.
Restore proprioception.
Patellar mobility.
Phase 2: Early Rehabilitation-Weeks 2-4
Brace
Discontinue at 2-3 wk.
Weight-bearing
As tolerated (goal is to discontinue
crutches 10 days after surgery).
Range of Motion
Self-ROM stretching exercises four to five
times daily, emphasis on maintaining full
passive ROM.
Swelling Control
Ice, compression, elevation
Week 2
Phase 2: Early Rehabilitation-Weeks 2-4
Week 2
Exercises
Muscle stimulation to
quadriceps exercises.
Isometric quadriceps sets.
SLR (four planes).
Leg press.
Knee extension 90-40°
Half squats (0-40°).
Weight shifts.
Front and side lunges.
Hamstring curls
Bicycling.
Proprioception training.
Overpressure into
extension.
Passive ROM 0-50
degrees.
Patellar mobilization.
Well-leg exercises.
Progressive resistance
program: start with 1
pound and progress I
pound per week.
Phase 2: Early Rehabilitation-Weeks 2-4
Range of Motion
Continue ROM stretching
and overpressure into
extension.
Exercises
Continue all exercises as in
week 2.
Passive ROM 0-115°.
Bicycling for ROM stimulus
and endurance.
Week 3
Pool walking program
Eccentric quadriceps
program 40-100° (isotonic
only).
Lateral lunges.
Lateral step-ups.
Front step-ups.
Lateral step-overs (cones).
Stair-stepper machine or
elliptical trainer.
Progress proprioception
drills, neuromuscular control
drills.
Phase 3: Controlled Ambulation-Weeks 4-10
Criteria for Progression to Phase 3
Active ROM 0-115°.
Quadriceps strength 60% of contralateral side
(isometric test at 60 degrees knee flexion).
Unchanged KT test bilateral values (+ 1 or less).
Minimal or no full joint effusion.
No joint line or patellofemoral pain.
Phase 3: Controlled Ambulation-Weeks 4-10
Goals
Restore full knee ROM (0-125°).
Improve lower extremity strength.
Enhance proprioception, balance, and
neuromuscular control.
Restore limb confidence and function.
Phase 3: Controlled Ambulation-Weeks 4-10
Week 4
Range of Motion
Self-ROM (four to five times daily using the other leg to
provide ROM), emphasis on maintaining 0 ° passive
extension.
Phase 3: Controlled Ambulation-Weeks 4-10
Week 4
Exercises
Progress isometric
strengthening program.
Leg press.
Knee extension 90-40°.
Hamstring curls.
Hip abduction and
adduction.
Hip flexion and extension.
Lateral step-overs.
Lateral lunges.
Lateral step-ups.
Front step-downs.
Wall squats.
Vertical squats.
Toe calf raises.
Biodex Stability System
(e.g., balance, squats).
Proprioception drills.
Bicycling.
Stair-stepper machine.
Pool program
(backward running, hip
and leg exercises).
Phase 3: Controlled Ambulation-Weeks 4-10
Week 6
Exercises
Continue all exercises.
Poor running (forward), agility drills.
Balance on tilt boards.
Progress to balance and board throws.
Phase 3: Controlled Ambulation-Weeks 4-10
Week 8
Exercises
Continue all exercises.
Plyometric leg press.
Perturbation training.
lsokinetic exercises (90-40°).
Walking program.
Bicycling for endurance.
Stair-stepper machine for endurance
Phase 3: Controlled Ambulation-Weeks 4-10
Week 10
Isokinetic Test
Concentric knee extension-flexion at 180 and 300°/sec
Exercises
Continue all exercises.
Plyometric training drills.
Continue stretching drills.
Phase 4: Advanced Activity-Weeks 10-16
Criteria for Progression to Phase4
Active ROM 0-125 degrees or greater.
Quadriceps strength 79% of contralateral side.
Knee extension flexor: extensor ratio 70- 75%.
No change in KT values (comparable with contralateral side,
within 2 mm).
No pain or effusion.
Satisfactory clinical examination.
Phase 4: Advanced Activity-Weeks 10-16
Criteria for Progression to Phase4
Satisfactory isokinetic test (values at 180
degrees)
Quadriceps bilateral comparison 75%.
Hamstrings equal bilateral.
Quadriceps peak torque-to-body weight ratio.
Hamstrings: quadriceps ratio 66- 75%.
Hop test 80% of contralateral leg.
Subjective knee scoring (modified Noyes
system) 80 points or better.
Phase 4: Advanced Activity-Weeks 10-16
Goals
Normalize lower extremity strength.
Enhance muscular power and endurance.
Improve neuromuscular control.
Perform selected sport-specific drills.
Exercises
Continue all exercises.
Phase 5: Return to Activity-Months 16-22
Criteria for Progression to Phase 5
Full ROM.
Unchanged KT 2000 test (within 2.5 mm of opposite side).
Isokinetic test that fulfills criteria.
Quadriceps bilateral comparison ≥ 80%.
Hamstring bilateral comparison ≥ 110%.
Quadriceps torque: body weight ratio ≥ 70%.
Proprioceptive test 100% of contralateral leg.
Functional test ≥ 85% of contralateral side.
Satisfactory clinical examination.
Phase 5: Return to Activity-Months 16-22
Goals
Gradual return to full unrestricted sports.
Achieve maximal strength and endurance.
Normalize neuromuscular control.
Progress skill training.
Phase 5: Return to Activity-Months 16-22
Exercises
Continue strengthening exercises.
Continue neuromuscular control drills.
Continue plyometrics drills.
Progress running and agility program.
Progress sport-specific training.
6- and 12-Month Follow-up
Isokinetic test.
Functional test.
Thank you