Knee Rehabilitation ACL Protocol
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