Anterior Cruciate Ligament Reconstruction phase 4
Date issued: April 2020
For review: April 2022
Ref: A-432/AJ/Physiotherapy/Anterior Cruciate Ligament Reconstruction phase 4
PDF: Anterior cruciate ligament Reconstruction phase 4 final April 2020.pdf [pdf] 606KB
Phase 4 Rehabilitation (week 12-24)
Criteria to progress on to phase 4;
- Full ROM of the knee
- Excellent unsupported single leg stand
- Good strength
Goals to be achieved before moving to next phase of rehabilitation
- Build up power and aerobic capacity
- Encourage functional retraining
- Comfortable sitting on back of heels (week 16)
- Able to jog 30 minutes (active patients only) by 24 weeks
Guideline
- If the patient displays full ROM, good muscle control and no swelling, you may return to light, uncompetitive sport (light aerobics)
- Heavy manual job, they may return to work (3 months +) as agreed with your consultant
Precautions
- no twisting/pivoting for 6 months
Strengthening Programme
- Deep squats with resistance as needed
- Single leg squats
- Eccentric Hamstrings
- Open chain quads (at 4 months)
Deep squats with resistance as needed
Stand straight with your feet hip width apart and facing forwards. Slowly bend your knees as far as is comfortable and then return to the starting position. 10-15 reps, 2-3 times a day
Progression:-
Hold a weight (weighted ball, barbell, dumbbell in each hand) whilst performing the same exercise.
Single leg squats (Crossley et al 2011)
Support your un-operated leg behind you on a chair/bench. Squat with your operated leg to 70 degrees. Count one second to squat down and one second to come up. Do not fully extend your knee try to keep it slightly flexed/soft.10-15 reps, 2-3 times a day
Progression
- Squat without the un-operated leg on a chair
- Hold a weight (weighted ball, barbell, dumbbell in each hand) whilst performing the same exercise.
Eccentric Hamstrings
Kneel on a soft surface/mat. Have a partner hold onto your ankles. Slowly lean forwards as far as you can whilst controlling your body weight with your hamstring muscles without losing your balance or control. Return to the start position and repeat. 5-10 reps, 2-3 times a day
At 4 months you can start open chain quads if needed such as kicking a football. You must have full hamstring and quads control.
Open chain quads
Sitting on a chair/bench with a small ankle weight attached to your operated leg at the ankle. Pull your toes up, tighten your quadriceps (thigh) and straighten your knee. Hold for 3 seconds then slowly lower. 10-25 reps 2-3 times a day
The same exercise can be performed on an extension machine with low weight.
Proprioceptive/Balance and Coordination Programme
- Arabesque
- Lateral Lunge
- Lunges
- Resisted jog forward/back
Arabesque
Stand on your operated leg with a soft knee (slightly flexed). Maintaining a straight back slowly flex (bend) at the waist extending your un-operated leg back. Your shoulder and heel should move simultaneously forming a straight line. 5-10 reps, 2-3 times a day
Lateral Lunge
Stand with feet wide apart and toes pointing forward. Step out to the left, keeping your toes pointing straight ahead and your feet flat. Squat by bending the left knee. Keep your right leg straight and the weight on the left foot. Squat as low as possible, keep your right leg straight and hold this position for 2 seconds. Return to the starting position and repeat. Then alternate with your opposite leg. 10-15 reps, 2-3 times a day
General Mobility and Cardiovascular Programme
Once it has been established that you have adequate muscle strength, endurance and control a running program can be commenced. Initially you would start by running in a straight line, then in a circle and finally a figure of eight.
Be sure to have good running shoes.
Start with a 5 minute jog/walk program as pain and discomfort allow. Pace increase in distance as able.
Progress by building up your pace from half to three-quarters to full.
When you are able to run for 30 minutes pain free and can manage 2km’s in less than 12 minutes you can commence sprint drills if required.
DO NOT progress with running if experiencing pain, swelling or other symptoms. Remember the programme is just a guideline and not everybody is expected to be at this level.
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.
