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Date issued:  April 2020

For review: April 2022

Ref: A-431/AJ/Physiotherapy/ Anterior Cruiate Ligament Reconstruction phase 3

PDF:  Anterior cruciate ligament reconstruction phase 3 [pdf] 935KB

Phase 3 Rehabilitation (week 6-12)

Whilst the graft is healing to the bone at this time, the graft itself may be at its weakest. Therefore take great care to avoid falls etc.

Regular Physiotherapy supervised rehab should be starting at this point. Ideally the patient should be enrolled in an ACL class.

Criteria to progress to phase 3: Full extension

Goals to be achieved before moving to next phase of rehabilitation

• Build up on leg strength
• Improve balance and coordination

Guidelines

• Pace increase in activity
• If the patient does a sedentary job they may return to work (week4-6)

Precautions

• At this stage their graft is at its weakest. Progress your activities gradually and continue to avoid any twisting, running, pivoting, jumping and any open chain quads exercises.

 

 

ROM and Stretching Programme

Continue as before. Think about introducing the following as needed

• Runners calf stretch
• Soleus Stretch
• Groin stretch
• Hamstring stretch

Runners calf stretch

Stand facing a wall. Put your operated leg behind you with the other leg bent in front of you. Lean your body forwards towards the wall, keeping the heel of the operated leg down and the knee straight. Feel the stretch on the calf of the straight leg. Hold for 30 seconds 3 reps, 2 times a day

Hamstring stretch

Sitting, maintain a straight body position, with your operated leg out in front of you, reach forward and attempt to grasp your ankle or your toes. Feel a stretch at the back of your leg. Hold for 30 seconds 3 reps, 2 times a day

Groin stretch

Sitting maintain a straight back. Slowly open the legs and lean forward slightly from the waist. Feel the stretch in your groin

Hold for 30 seconds 3 reps, 2 times a day

Soleus Stretch

Stand with the leg to be stretched behind the other leg. Push your heel down, while bending the knee to stretch your Achilles tendon. Hold for 30 seconds 3 reps, 2 times a day

 

Strengthening Programme exercises

Static QuadsCalf raise’s over stepSquatsStep ups forward and sidewaysHamstringsGluteals. 10-15 reps, 2-3 times a day

 

Hamstrings in sitting using resistance band

Sit on a chair with your knee straight and a rubber exercise band around your ankle. Pull the band by bending your knee 10-15 reps, 2-3 times a day

 

Hamstring in prone

Prone lying,  with a light ankle weight around your ankle. Move your heel towards your buttocks as far as possible under control and slowly lower to the start position. 10-15 reps, 2-3 times a day

Sit to stand

Stand up from sitting and sit down again without using your arms.

Progression

Use a lower chair

Hold a weight

15-20 reps, 2-3 times a day

 

Single leg bridge

Lie on your back with both knees bent, tighten your quads and hamstrings, squeeze your buttocks together and lift your bottom off the floor. Now lift your non-operated leg off the floor and bring your knee to your chest, repeat with the other limb. 10-15 reps, 2-3 times a day

Seated leg press with resistance band

Sit with resistance band around your foot. Hold the ends in your hands. Push your leg from 90 degrees to an almost straight position. Every fifth repetition hold your leg straight for 15 seconds. 30-40 reps, 2-3 times a day

If you have access to gym equipment:-

• Seated hamstring curl
• Leg press
• Multi-hip machine- adduction, flexion, abduction, extension

 

No open chain quads

Proprioceptive/balance and coordination programme

Single Leg Stands Line walking 

Variations:-

• Bounce a ball against the wall
• Standing on the operated knee, raise the other leg off the floor bounce a ball off a wall or throw and catch with a partner.
• Practice dribbling ball around operated leg
• Standing on the operated knee, raise the other leg off the floor dribble a ball around the operated leg clockwise then anti-clockwise
• Sport specific variations
• Rugby passes, Tennis volleys

Progressions:-

• Stand on trampette/cushion
• Reduce visual compensation. Close 1 or both eyes.
• Throw and catch a ball.
• Arms folded across your chest.
• Place a beanbag on your head.

 

Line walking

5-10 metre course.

Walk slowly along a line, placing one foot in front of the other (as if on a tightrope) keeping to the line.

 

2 minutes each, 2-3 times a day.

Variations:-

• Fold your arms across your chest.
• Walk backwards.
• Walk sideways.
• Close 1 or both eyes.
• Place small obstacles in your path and step over them
• High knees
• Tip-toe walking.

General Mobility and cardiovascular Programme

• Static bike
• Aqua jog/walk
• Treadmill walk with incline
• Swim front crawl and back crawl
• Rowing
• Step machine
• Cross Trainer 

 

30mins, 60-80 rpm and increase as tolerated once a day.

 

Static Bike – Single leg cycling

Take one leg out from the pedal and place it on the frame.

 

Week 10

 

Treadmill walk with incline

Begin slowly taking normal strides.

Incline no greater than 12 degrees, 20-30mins 2-3 times a week.

 

Swimming

Front crawl and back crawl only – NO BREAST STROKE OR BUTTERLY. 20-30mins, 2-3 times a week

Rowing

Begin with low resistance and ease into the stroke by not fully extending the knee or flexing beyond 90 degrees. 15-20mins, 1-2 times a week.                                                                                                                                                                  

Stepper

Begin with low resistance and short step motion maintaining slightly flexed soft knees.  Never allow your knees to fully extend, feet come off the pedals or allow the pedals to hit the bottom. 20-30mins, 1-2 times a week

Cross Trainer

Ease into training by not fully extending your knees. 15-20mins, 1-2 times a week

                                                                                                                                                      

The reference list below was used to develop this protocol.  If you are interested in learning more these 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.