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Date issued:  April 2020

For review: April 2022

Ref: A-429/AJ/Physiotherapy/Anterior Cruciate Ligament Reconstruction

PDF:  anterior cruciate ligament reconstruction.pdf [pdf] 469KB

Phase 1 Immediately Post-operative (IPO) Rehabilitation (1-3 weeks)

 

Returning to work and sport

This is a guideline as to how soon you can return to particular activities. Your return will be guided by your surgeon and Physiotherapist.

Work

To be agreed with Surgeon

 

Work                                                             Return

Light work, such as office job                          4 - 6 weeks

Medium, physical job                                      2 months

Heavy, manual job (roofs and Ladders)          3-4 months +

Suggest phased return for any manual job.

 

Driving                                                         4 – 6 weeks

DVLA guidelines state the patient must be safe and competent to return to driving. Are they able to do an emergency stop?

 

Physical activity

To be agreed with surgeon or physiotherapist

 

Sport                                                            Return

ACL class or supervised exercises                 6 weeks

Swimming without flippers or aids                  2 months

(No breast stroke)

Light individual sports/non-competitive   

Without rotation                                             3 to 4 months

Start slow running                                         3 months

Twisting/pivoting activities                              6 months

Contact/high performance including impact

and rotation (football, rugby, skiing)                9-12 months

    

These times are guidelines. The exact progression may vary depending on the individual. Rehabilitation will be monitored by your physiotherapist and surgeon. You are advised not to return to full activity too early. Over stressing the graft too early may increase the risk of graft failure.

Each phase of exercises will work on-

• Range of Movement/Stretching
• Strengthening
• Proprioception/Balance/coordination
• General mobility and Cardiovascular

 

Phases of Rehabilitation

• Phase 1 (1-3 weeks)
• Phase 2 (3-6 weeks)
• Phase 3 (6-12 weeks)
• Phase 4 (12-24 weeks)
• Phase 5 (6 months onwards)
• Return to sport

Phase 1 Immediately Post-operative (IPO) Rehabilitation (1-3 weeks)

Goals to be achieved before moving to next phase of rehab

• Ensure adequate pain control
• Minimal swelling (Jakobsen et al 2010)
• Comfortable walking with crutches FWB
• Aim to achieve full extension as soon as possible (Adams et al 2012)
• Flexion as comfortable, should limit to 90 degrees for the first 2 weeks. (Norkin & White 1995)

 

Guidelines for IPO

Patient to take pain killers and anti-inflammatory medications as prescribed

Rest the knee with leg elevated as much as possible when not performing physiotherapy exercises

Use your crutches for the first 2 weeks

Ice knee if swelling not settling

 

Post op precautions so not to stress graft

No open chain quads activities (Quads extensions), i.e. straightening the knee with the foot out of contact with a surface.

No running, twisting, pivoting, jumping or open chain resistance work

Remember this programme is just a guideline. You may progress more rapidly or slowly through the programme as guided by your surgeon, therapist and your pain.

Range of Motion and Stretching Programme

• Gravity assisted knee flexion
• Straightening/Extension
• Bending/Flexing in sitting
• Straightening/extension in lying
• Quads in standing

 

Gravity assisted knee flexion

Sitting on edge of bed let gravity pull the knee into a flexed/ bent position. Repeat 3-4 times a day

 

Straightening/Extension

Sit with your knee unsupported and foot on a raise or on a stool. Allow the weight of your leg to straighten your knee. Hold for 10 minutes, 2 times a day

 

Bending/Flexing in sitting

Sitting with your back supported. Slide your heel towards your bottom, use a belt or towel under your foot to assist you. Hold for ten seconds, repeat 10 times 3-4 times a day

Rest in full extension, even if flexion is more comfortable

Static quads

Aim to achieve full quads active extension

Sitting with leg supported, tighten your thigh muscle until your leg is straight and your knee cap moves towards your hip.Hold 10 seconds 15 reps, 3-4 times a day

 

Quads in standing

Stand with feet hip width apart. Tighten up your thigh muscle and press the knee out straight. 15 reps, 3-4 times a day

 

General Mobility

Walking with crutches

Fully weight bear as pain allows.

Place your crutches forward, step forward with your operated leg, brace your knee straight and step through with the other leg. Limit your walking to necessary activities.

 

Stairs with Crutches

Lean on the crutches and take a step with your healthy leg. Then take a step up with your operated leg and bring the crutches up onto the same step.

To go down put your crutches one step below. Then take a step down with your operated leg. Lean on the crutches and take a step down with your healthy leg onto the same step as your operated leg. ALWAYS GO ONE STEP AT A TIME.

 

Straightening/extension in lying

Lie face down on a bed with your feet over the edge. Let the weight of your leg straighten your knee

 

Hold 10 minutes, 2 times a day

                                        

The reference list below was used to develop this protocol.  If you are interested in learning more these resources may be a good place to begin.

 

References & Bibliography

 

Butler, DL, Kappa Delta Award paper. (1989) Anterior Cruciate Ligament: its normal response and replacement ;7:910-921

 

Beynnon, BD., Fleming, BB., (1998) Anterior cruciate ligament strain in-vivo: a review of previous work. Journal of Biomechanics. 31(6), 519-25.

 

Crossley, K., Zhang, W., Schache, A., Bryant, A., & Cowan, S. (2011), Performance on the single leg squat task indicates hip abductor muscle function. The American Journal of Sports Medicine, 39, 866-873

 

Fitzgerald, GK,  Lephart,  SM, Hwang,  JH,  Wainer,  MR., (2001) Hop tests as predictors of dynamic knee stability. Journal of Orthopaedic Sports Physical Therapy. 31:588-597

 

Heijne, A., & Werner, S., (2007) Early versus late start open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 15:402-414.

 

Hickey, KC., Quatman, CE., Myer, GD., Ford, KR., et al., (2009) Methodological report; Dynamic field tests used in an NFL combine setting to Identify lower extremity functional asymetries. Journal of strength and conditioning research.  23(9) 2500.

 

Herrington, L., Myer, G., & Horsley, I. (2013) Task Based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport. 14, 188-198.

 

Hiemstra, LA., Webber, S., MacDonald, PB., Kriellaars, DJ., (2000) Knee strength deficits after Hamstring and patella tendon ACL reconstruction. Medicine and Science in Sports and Exercise. 32(8):1472-1479

 

Myer, G., Paterno, MV., Ford, KR., Quatman, CE., & Hewett TE., (2006) Rehabilitation after anterior cruciate ligament reconstruction: Criteria-based Progression through return-to-sport phase.  Journal of Orthopaedic & Sports Physical Therapy, 36(6), 385 – 402.

 

Myer, G., Ford, K., & Hewett, T., (2008) Tuck jump assessment for reducing anterior cruciate ligament injury risk. Athletic Therapy Today. 13, 39-44

 

Myer, G., Chu, DA., Brent, J., & Hewett, T., (2008) Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinical Sports Medicin. 27, 425-448

 

Myer, G., Paterno, MV., Ford, K., & Hewett, T., (2008) Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. Journal of  Strength and Conditioning Research. 22, 987-1014.

 

Noyes, FR., Braber, SD., & Mangine, RE., (1991) Abnormal lower limb symmetry determined by functional tests after anterior cruciate ligament rupture, American Journal of sports medicine, 19 513-518.

 

Padua, DA., Marshall, SW., Boling, MC., Thigpen, CA., Garrett, WE Jr., Beutler, AI., (2009) The Landing Error Scoring System (LESS) is valid and reliable clinical assessment tool of jump landing biomechanics: The JUMP-ACL study. American Journal of Sports Medicine. 37, 1996-2002.

 

Perry,  MC., Morrissey, MC., King, JB., Morrissey, D., & Earnshaw, P., (2005) Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 13(5), 357-69.

 

Pauole KK, (1996) The physical performance T-Test as a measure of speed, Power, and agility in females. Long Beach, CA: California State University; 1996

 

Shiraissha M, Mizuta H, Kubota K, Otsuka Y, Nagamoto N., (1996) Stabilomatric assessment in the ACL-reconstructed knee. Clinical Journal of Sport and Medicine. 6(1):32-39

 

Tyler TF, McHugh MP, Gleim GW, Nicholas SJ., (1998) The effect of immediate weight bearing after ACL reconstruction. Clinical Orthopaedics and Related Research. Dec (357): 141-148

 

Whatman C, Hing W, Hume P. (2012) Physiotherapist agreement when visually rating movement quality during lower extremity functional screening tests.  Physical Therapy in Sport. May;13(2):87-96.