Dr. David A Parker, Orthopaedic Knee Surgeon NSW
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ACL Rehabilitation Protocol

Information for Patients

Terminology

CKC Closed Kinetic Chain; exercise with the foot in contact with a surface, ie: leg press, squats, lunge
Concentric The muscle is shortening while it is contracting (‘positive con traction”)
Cybex Test Strength testing machine that can measure force, work, and power of muscle groups.
Eccentric The muscle is lengthening while it is contracting (‘negative contraction”)
Extension Straightening
Flexion Bending
FWB Full Weight Bearing
Hamstrings muscles in the back of the thigh
Isometrics tightening/contracting of a muscle without movement of the leg
OKC Open Kinetic Chain; exercise when the lower leg is moving freely ie: leg extension
Plyometrics exercises that enable a group of muscles to reach a maximum strength in as short a time as possible. It tries to bridge the gap between speed and strength training.
Prone lying on your stomach
Quadriceps muscles on the front of the thigh
ROM Range of Motion; amount of bending and straightening of the knee
Supine lying on your back

Timeline 0-2 weeks

Goals

  • Patient education +++ re: gait, ice, strength of repair, do’s & don’ts, Increase ROM (0-90 degrees), Decrease pain and swelling

  • Maintain flexibility of lower extremity; Balance/proprioceptive re-education Strengthening: quadriceps, hamstrings, hip, calves

Gait

Weight bearing as tolerated with crutches between 2- 6 weeks. The physiotherapist will determine progression of 2 to 1 crutch. Must have full knee extension and walk without a limp before walking without crutch use.

ROM

Bike circles: high seat ½ circles fwd/back -> full circles -> lower seat Slider board; Heel slides; Ankle pumping; Prone leg hangs

Modalities

Ice; Interferential current therapy; Muscle stimulation

Flexibility

Calf stretches seated with towel; Seated hamstring stretches; Supine hip flexor stretches Balance/Proprioception: 1 foot standing 30-60 seconds eyes open->closed.

Strength

  • Quads: CKC exercises – Quadriceps tightening (isometrics) seated and in standing, weight shifting, sit to stand, static lunge, mini squat, squats on shuttle

  • Hams: Isometrics , prone knee flexion, standing knee flexion to 90 degrees Hip: standing flexion/extension/abduction/ adduction, prone hip extension, side lying adduction/abduction

  • Calves: Standing heel raises 2->1 foot, shuttle heel raise

Timeline 3-6 weeks

Goals

  • Achieve near or full flexion and extension
  • Continue flexibility exercises
  • Normal FWB gait
  • Maintain cardiovascular fitness
  • Continue strengthening hams, quads, hip, calves
  • Add on balance/proprioception

ROM

  • Continue as outlined
  • Pool - walking, squats, knee flexion, step-ups & downs

Flexibility

Continue as outlined

Gait

Normalize to full weight bearing

Cardio

Bike ,Stairmaster , Pool: swim/jog (no whip kick)

Strength

  • Quads: Step ups 4-6-8” step fwd/lateral, ½ wall squats, shuttle leg press 2->1 leg, bungy lunge, squats with pul leys

  • Hams: Seated chair walking, standing knee flexion with weight/pulleys, seated knee flexion with bungy cord, seated ham curls, reverse stairmaster

  • Hip: Standing abduction/adduction/extension with pulleys/ tubing

  • Calves: Heel drops, shuttle drops, mini-tramp bouncing, single heel raises

Balance/Proprioception

Standing 1 foot eyes closed -> balance board, wobble board


Timeline 6-9 weeks

NB: Graft is at the weakest point now, Avoid OKC exercises

Reasons why open kinetic chain (OKC) exercises (ie: leg extensions especially with weight) are contraindicated after ACL reconstruction

  • When the quadricep muscle contracts with the above exercises, the lower leg (tibia) is pulled forward (shears) in relation to the upper leg (femur)

  • This shear directly stresses the reconstructed ACL graft

  • It is believed that these shearing forces may lead to stretching of the ACL graft that may result in increased laxity

  • Shearing is minimized if the force is maintained down the whole leg during muscle contraction (i.e. foot is fixed), and therefore CKC exercises are recommended

Goals

  • Full pain free ROM Increase cardio fitness
  • Continue to strengthen hip and calves
  • Intermediate proprioception
  • Functional quads strength
  • Concentric-eccentric hams strength

Cardio

Bike, fitter, stairmaster, swim (flutter kick only), pool, jogging , treadmill power walking

Strength

  • Quads: Stairmaster fwd/bkwd, bungy lunge in different directions, clock face lunges, squats with pulleys increasing weight

  • Hams: Backward walking, ham curls progress concentric - eccentric

  • Hip: Iincrease weight standing abduction/ adduction/ extension with pulleys/tubing, tubing kick backs, fitter

  • Calves: As above with an increase in weight

Balance/Proprioception

Balance board progressions, wobble board progressions, trampoline balance


Timeline 9-12 weeks

Goals

  • Progress quad and hamstring strength
  • Progress proprioception
  • Sport specific cardio fitness

Cardio

Add treadmill quick walk +/- gradiant—>slow jog Stationary jog against bungy cord resistance Pool running Bike and stairmaster interval training

Strength

  • Quads: Continue with CKC progressions, lunge walking forward/backward aggressive pool exercises, bungy cord eccentrics - reverse lunges

  • Hams: Increase weight with pulley ham curls prone and standing – emphasis on full angle (90-130)- focus on eccentric component – strength (high load, low rep) and endurance (low load, high rep), shuttle– kneeling hip/knee extension, shuttle- standing hip/knee extension, Hydrafitness – hamstrings only

  • Hip: Slider, skating machine, fitter, pulleys/tubing with increased weight

  • Calves: Eccentric heel drops 2->1 leg, eccentric toe press 2->1 leg

Balance/Proprioception

Mini-tramp balance -> eyes open->closed


Timeline 12-16 weeks

Goals

  • Sport specific cardio fitness; Sport specific quad and hamstring strength
  • Sport specific proprioception training; Continue with flexibility and strength of lower extremity

Cardio

  • Treadmill jog-> run; Land jogging forward without cutting
  • Stationary jog against bungy cord resistance
  • Pool running Bike standing with interval training; Mini tramp jumping 2->1 leg

Strength

  • Quads/Hams: Continue with CKC progressions increasing weight, bungy cord eccentrics - reverse lunges with variable speed, shuttle kick backs, high steps, lunge walking fwd/bkwd, split squats, ham curls all with emphasis on endurance, progress to pool plyometrics deep water ->shallow water

Balance/Proprioception

Mini-tramp jump and land, 2 ->1 leg balance with upper body or opposite leg skill i.e., throwing on rebounder, phantom kicking with bungy cord resistance, throwing/passing drills, single leg balance clock drill with mini pylons


Timeline 16-20 weeks

NB. Your physical therapist may decide to perform a Cybex test on you at week 16 or later to help define your specific strengths deficits i.e., strength, power, endurance in hamstrings and quads and the balance between the two muscle groups. This can redefine some specific goals for you to work on the next 8 weeks.

Goals

  • Progress sport specific lower extremity strengthening to plyometrics
  • Increasing strength, power and endurance of lower extremity muscles
  • Increase sport specific proprioception training
  • Increase specific cardio fitness

Strength

  • Quads/Hams: If concentric/eccentric strength is adequate, gradually add on plyometrics on land, 2->1 foot progressions– diagonal lunges or running with bungy cord around waist incorporating upper or lower body skill i.e., kicking, jumping, catching, passing, shooting, 2 leg fwd/back/side hops, 4 square hops, 2 square diagonal hops -> progress to single leg, rebounder – jumping, jump & land, shuttle – ski hops (side to side), jumping 2-> alternating-> 1 leg, hopping, skipping, bounding, cutting, box hops 2-4-6” side to side, front to back, jumpdown with fwd sprint, diagonal/lateral cone jumps.

Balance/Proprioception

Continue with sport specific drills as outlined above, cutting drills with quick stopping and maintaining balance

Cardio

Increase distance, duration or intensity with bike, stairmaster, treadmill, outdoor running or cycling depending on the demands of your particular sport. Add on tight turns and hills as tolerated.


Timeline 20-24 weeks

Goals

  • Back to sport practice for upper body skills
  • Functional testing in clinic to determine return to sport skills on own at practice
  • Continue with sport specific proprioception training
  • Continue with specific cardio fitness

Practice Drill Ideas

  • Straight forward and backward running
  • Figure 8s gradually decreasing in size
  • Zig-Zag running
  • Cross over stepping
  • Backward with cutting
  • Stop and go drills

Functional Testing in Clinic

  • Lunge walk with control both forward and backward
  • Forward hop and lateral hop with control with comparable distances L and R side
  • One foot hopping with control
  • Triple jump and landing with control with comparable distances L and R side
  • Sport specific demands with adequate skill, speed and control

Bracing

This is a very controversial topic. Talk to the physiotherapist and surgeon to see if it is recommended for the athlete to use a brace to return to sports/activities.

Realignment Surgery
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