Knee Rehabilitation ACL Protocol

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ACL Rehabilitation Guidelines

Phase O: Pre-operative Recommendations

• Normal gait
• AROM 0 to 120 degrees of flexion
• Strength: 20 SLR with no lag
• Minimal effusion
• Patient education on post-operative exercises and need for compliance
• Educated in ambulation with crutches
• Wound care instructions
• Educated in MOON follow-up expectations

Phase 1: Immediate Post-operative Phase (Approximate time-frame: Surgery to 2 weeks)

Goals

• Full Knee extension ROM
• Good quadriceps control (> 20 no lag SLR)
• Minimize pain
• Minimize swelling
• Normal gait pattern

Crutch Use: WBAT with crutches (beginning the day of surgery)
Crutch D/C Criteria: Normal gait pattern
Ability to safely ascend/descend stairs without noteworthy pain or
Instability (reciprocal stair climbing)

Knee Immobilizer: None (Exception: First 24 hours after a femoral nerve block)

Cryotherapy: Cold with compression/elevation (e.g. Cryo-cuff, ice with compressive stocking)

• First 24 hours or until acute inflammation is controlled: every hour for 15 minutes
• After acute inflammation is controlled: 3 times a day for 15 minutes
• Crushed ice in the clinic (post-acute stage until D/C)

EXERCISE SUGGESTIONS ROM

• Extension: Low load, long duration (~5 minutes) stretching (e.g., heel prop, prone hand minimizing co-contraction and nocioceptor response)
• Flexion: Wall slides, heel slides, seated assisted knee flexion, bike: rocking-for-range
  
• Patellarmobilization (medial/lateral mobilization initially followed by superior/inferior direction while monitoring reaction to effusion and ROM)

Muscle Activation/Strength

• Quadriceps sets emphasizing vastus lateralis and vastus medialis activation
• SLR emphasizing no lag
• Electric Stimulation: Optional if unable to perform no lag SLR

Discontinue use when able to perform 20 no lag SLR

• Doug-leg quarter squats
• Standing theraband resisted terminal knee extension (TKE)
• Hamstring sets
• Hamstring curls
• Side-lying hip adduction/abduction (Avoid adduction moment in this phase with concomitant grade II – III MCLinjury)
• Quad/ham co-contractionsupine
• Prone HipExtension
• Ankle pumps with theraband
• Heel raises (calf press)

Cardiopulmonary

• UBE or similar exercise is recommended Scar Massage (when incision is fully healed) CRITERIA FOR PROGRESSION TO PHASE2
• 20 no lag SLR
• Normal gait
• Crutch/Immobilizer D/C
• ROM: no greater than 5° active extension lag, 110° active flexion

PHASE 2: Early Rehabilitation Phase (Approximate time-frame: weeks 2 to 6)

GOALS

• Full ROM
• Improve muscle strength
• Progress neuro-muscular retraining

EXERCISE SUGGESTIONS ROM

• Low load, long duration (assisted prn)
• Heel slides/wall slides
• Heel prop/prone hand (minimize co-contraction / nocioceptor response)
• Bike (rocking-for-range – riding with low seat height)
• Flexibility stretching all major groups

Strengthening

Quadriceps:

• Quadsets
• Mini-squats/wall-squats
• Step-ups
• Knee extension from 90° to 40°
• Legpress
• Shuttle Press without jumping action

Hamstrings:

• Hamstringcurls
• Resistive SLR with sports cord

Other Musculature:

• Hip adduction/abduction: SLR or with equipment
• Standing heel raises: progress from double to single leg support
• Seated calf press against resistance

Multi-hip machine in all directions with proximal pad placement Neuromuscular training

• Wobble board
• Rocker board
• Single-leg stance with or without equipment (e.g. instrumented balance system)
• Slideboard
• Fitter

Cardio-pulmonary

• Bike
• Elliptical trainer
• Stairmaster

CRITERIA FOR PROGRESSION TO PHASE 3

• Full ROM
• Minimal effusion/pain
• Functional strength and control in daily activities
• IKDC Question # 10 (Global Rating of Function) score of > 7)

PHASE 3: Strengthening & Control Phase (Approximate time-frame: weeks 7 through 12)

GOALS

• Maintain full ROM
• Running without pain or swelling
• Hopping without pain, swelling or giving-way

EXERCISE SUGGESTIONS

Strengthening

• Squats
• Legpress
• Hamstringcurl
• Knee extension 90° to 0°
• Step-ups/down
• Lunges
• Shuttle
• Sportscord
• Wallsquats

Neuromuscular Training

• Wobble board / rocker board / roller board
• Perturbation training
• Instrumental testing systems
• Varied surfaces

Cardio-pulmonary

• Straight line running on treadmill or in a protected environment (NO cutting or pivoting)
• All other cardio-pulmonary equipment

CRITERIA FOR PROGRESSION TO PHASE 4

• Running without pain or swelling
• Hopping without pain or swelling (Bilateral and Unilateral)
• Neuromuscular and strength training exercises without difficulty

PHASE 4: Advanced Training Phase (Approximate time-frame: weeks 13 to 16)

GOALS

• Running patterns (Figure-8, pivot drills, etc.) at 75% speed without difficulty
• Jumping without difficulty
• Hop tests at 75% contra-lateral values (Cincinnati hop tests: single-leg hop for distance, triple-hop for distance, crossover hop for distance, 6-meter timed hop)

EXERCISE SUGGESTIONS

Aggressive Strengthening

• Squats
• Lunges
• Plyometrics

Agility Drills

• Shuffling
• Hopping
• Carioca
• Vertical jumps
• Running patterns at 50 to 75% speed (e.g.Figure-8)
• Initial sports specific drill patterns at 50 75% effort

Neuromuscular Training

• Wobble board / rocker board / roller board
• Perturbation training
• Instrumented testing systems
• Variedsurfaces

Cardiopulmonary

• Running
• Other cardio-pulmonary exercises

CRITERIA FOR PROGRESSION TO PHASE 5

• Maximum vertical jump without pain or instability
• 75% of contra-lateral on hop tests
• Figure-8 run at 75% speed without difficulty
• IKDC Question # 10 (Global Rating of Knee Function) score of > 8

PHASE 5: Return-to-Sport Phase (Approximate time-frame: weeks 17 to 20)

GOALS

• 85% contra-lateral strength
• 85% contra-lateral on hop tests
• Sport specific training without pain, swelling or difficulty

EXERCISE SUGGESTIONS

Aggressive Strengthening

• Squats
• Lunges
• Plyometrics

Sport Specific Activities

• Interval training programs
• Running patterns in football
• Sprinting
• Change of direction
• Pivot and drive in basketball
• Kicking in soccer
• Spiking in volley ball
• Skill / bio-mechanical analysis with coaches and sports medicine team

RETURN-TO-SPORT EVALUATION RECOMMENDATIONS:

• Hop tests (single-leg hop, triple hop, cross-over hop, 6 meter timed-hop)
• Isokinetic strength test(60°/second)
• VerticalJump
• Deceleration shuttle test
• MOON outcomes measure packet (mandatory; should be completed post-testing)

RETURN-TO-SPORT CRITERIA:

• No functional complaints
• Confidence when running, cutting, jumping at full speed
• 85% contra-lateral values on hop tests
• IKDC Question # 10 (Global Rating of Knee Function) of > 9