Recovery after ACL reconstruction requires a thorough rehabilitation programme to ensure both optimal function of the knee and prevention of further injury. The long term goal should be both a return to sport, but also correction of preinjury deficits, potentially making the patient a better athlete than before their ACL injury. The rehabilitation program must consider multiple factors. Following implantation the human body will use the ACL graft as a scaffold to remodel into a ligament in a biological process that takes in excess of 12 months[1]. During this time the ACL graft has significantly less strength than a normal ligament, so is vulnerable to injury with low force. Accompanying the “ligamentization” process are significant other deficiencies such as muscular weakness, impaired proprioception, altered muscle reaction times, impaired muscular function, and impaired neuromuscular control. The progress through rehabilitation must respect both the neuromuscular deficiencies and the biological process of healing tissue. We recognise that GOAL based rehabilitation is far superior to TIME based rehabilitation…. but biological healing must also be respected

Phases of Rehabilitation

The recovery after ACL reconstruction can be considered to broadly follow 6 phases. The goals of each phase should be achieved before progression to the next phase.

0. Prehabilitation before surgery

1. Acute Recovery

2. Muscular Control and Coordination

3. Proprioception and Agility

4. Sports Specific Skills

5. Return to Play

Phase 0 – Prehabilitation

There is considerable evidence to demonstrate that rehabilitation before surgery is beneficial to recovery. ACL reconstruction should be performed once the knee has recovered from the acute injury, has a full range of motion, and is pain free in order to optimise the outcome and avoid complications such as knee stiffness. For many this may only take a few weeks, but for some it can be several months. A recent study demonstrated that a 5 week program of preoperative rehabilitation supervised by a physiotherapist improved knee related function and strength following surgery [2] and rate of return to sports at 2 years[3]. Quadriceps strength deficits of more than 20% before surgery are associated with persistent strength differences 2 years after surgery[4]. A thorough prehabilitation, restoring the knee to optimal function before surgery is beneficial on every level, and will lead to a faster recovery after surgery.

Goals of Prehabilitation

1. Regain pain free full range of movement

2. Optimise muscular strength and function

3. Familiarise with basic post operative exercises

4. Prevention of episodes of knee instability which may cause further damage

Treatment Guidelines

● Initial goal is to resolve knee impairments related to swelling and ROM deficits

● Regular icing to reduce effusion and pain

● Commence basic VMO strengthening with use of biofeedback and range exercises

● Once sufficient range of movement is achieved stationary exercise bike is encouraged++

● Once swelling and ROM is achieved then progress to restoration of muscle strength with intensive muscle strength training (increasing resistance, complexity and reps), and controlled plyometric exercises (e.g. balance board, progressing to squats on board)

● Running and jumping sports should be avoided due to risk of knee instability

Phase 1 – Acute Recovery

In the acute period after ACL reconstruction the knee needs some time to recover from the acute trauma of surgery. Basic gentle exercises, regular application of ice and elevation of the knee are beneficial. The grafted ACL sees minimal force with normal daily activities and immediate weight bearing will help facilitate return of functional strength. Most will leave hospital using crutches, which should be used to achieve a normal gait pattern during the first week after surgery. Crutches may also be used to avoid fatigue and alert others to disability. Crutches can be discontinued once walking comfortably.

Goals of Phase 1

1. Achieve primary wound healing

2. Minimise swelling

3. Restore range of motion

4. Establish muscular control

5. Progress off crutches

Treatment Guidelines

● Minimise swelling and pain with ice, elevation, co-contractions and pressure pump

● Return of co-ordinated muscle function encouraged with biofeedback devices

● No use of tubigrip around the knee joint region as may increase risk of blood clots

● Full weight bearing as pain allows

● Active range of motion exercises as swelling permits

● Patella mobilisations to maintain patella mobility

● Gait retraining with full extension at heel strike

● Active quadriceps strengthening is begun as a static co-contraction with hamstrings emphasising VMO control at various angles of knee flexion and progressed into weight bearing positions

● Gentle hamstring stretching to minimise adhesions

● Active hamstring strengthening begins with static weight bearing co-contractions and progresses to active free hamstring contractions by day 14

● Resisted hamstring strengthening should be avoided for at least 6-8 weeks

Phase 2 – Strength and Coordination

During phase 2 exercises can progress from simple muscular control to body weight exercises and then to a gym based program. Any resisted ‘open chain’ quadriceps exercises should be avoided as they can apply a strain to the ACL graft (e.g. leg extension machine and a freestyle swimming kick). Intermittent episodes of increased swelling may occur, and if so exercises and lads may need to be adjusted accordingly.

As the ACL graft progressively remodels into a ligament, its strength and load to failure decrease such that it reaches a low of around 30% of a normal ACL around 3 months, before it then progressively increases in strength over the subsequent 9 months. Caution should be emphasised during this vulnerable phase of healing. Activities that involve speed or height should be avoided. Walking is encouraged. Swimming with a kick may be commenced after 8 weeks. Before that time swimming with a pool buoy between the legs is possible. Road bike commenced after 6 weeks if stationary bike has been mastered, but toe cleats should be avoided.

Goals of Phase 2

1. Develop good muscle control

2. Recover basic balance & proprioceptive skills

3. Reduce any recurrent knee swelling

4. Continue to improve total leg strength

5. Improve endurance capacity of muscles

Treatment Guidelines

● Commence use of an exercise bike as soon as tolerated

● Aim for a full range of motion using active and passive techniques

● Progress muscle control by increasing the repetitions, length of contraction and more dynamic positions, e.g. using a reformer, squats, lunges, stepping, resistance bands

● Progressing of strength work, e.g. half squats with resistance, leg press & curls, wall squats, step work on

progressively higher steps, stepper & rowing machine, single leg squats

● In the presence of swelling continue with ice and/or decreased loads

● Hamstring strengthening progresses with the increased complexity and repetitions of co-contractions e.g. bridging. From week 6 eccentric hamstring strengthening is progressed and hamstring curl equipment can be introduced

● Introduce balance exercises, progress from single leg to wobble board

● Consider beyond the knee joint for any deficits, e.g. gluteal control, tight hamstrings, ITB, gastrocs and soleus, etc.

● Core strength is an important component of balance

● Emphasize gluteus maximus strengthening which is strong hip extender and external rotator while in a flexed hip posture. Deficits in gluteal strength are a significant predictors of recurrent ACL injuries[5]

Phase 3 – Proprioception and Agility

Once sufficient strength is achieved during Phase 2, while this needs to be continued, the emphasis can then be directed to improving balance, agility and proprioceptive deficits. This is an imperative phase of recovery and adherence has the potential to dramatically reduce the risks of further injury. Many will have pre-existing poor techniques on jumping and landing that should be corrected. Repeat ACL injuries have been shown to be strongly associated with poor hip rotation control, increased knee valgus, knee flexor and postural control deficits[5]. For jumpers practice good landing technique = knee flexion, no valgus rotation and toe land. Neuromuscular training has been shown to be superior to strength training alone in terms of subjective function and hamstring strength after ACL reconstruction[6, 7].

Goals of Phase 3

1. Resumption of running and jumping skills with good technique

2. Recovery of balance and agility

3. Progression of muscular strength and power

4. Develop confidence

5. Prepare for sports specific skills

Treatment Guidelines

● Running may be progressively commenced once there is good muscular strength and no knee effusion (this is usually around 3 months)

● Proprioceptive work should include hopping and jumping activities and emphasise a good landing technique

● Progressive single limb landing activities can be assessment and training tools e.g. anterior single leg hops, lateral single leg hops

● Hops and jumps can progress by increasing height and complexity – add ball catch

● Agility work may be commenced after basic running and progressed through activities such as shuttle runs, bounding runs, sideways running, skipping, etc.

● Emphasis on good form through change of direction drills (e.g. plant and cut), and hopping, jumping drills.

Refer to “key principles” on knee.netball.com.au website

● Feedback on good techniques using slow motion video from mobile device can be very beneficial for education

● Pool work can include using flippers

● Commence basic components of PEP programme and progress as able (see Phase 4 for detail)

● While the exercises through this phase become more dynamic, strength training should also continue with further development of strength and power

Phase 4 – Sports Specific Skills

Resumption of sports specific drills can be commenced once the goals of Phase 3 have been successfully achieved. It is however imperative to continue building strength with exercise selection targeting speed of force generation/power to better replicate sporting demands. The athlete should be able to confidently run, perform single and double leg jumping and hopping drills, as well as change of direction activities. Consideration of the biology of the healing ACL graft remains important, and as such sports specific skills and drills involving significant speed or height should rarely be considered before 6 months. Several sports specific injury prevention programs have been developed which incorporate excellent drills to perfect. Repeated practice of good jumping, landing and change of direction drills will reinforce muscle memory and good movement patterns. This can significantly reduce the risk of further injury. Netball Australia’s Knee Program has excellent videos demonstrating the key principles.

Goals of Phase 4

1. Perfect jumping, landing and change of direction techniques

2. Regain confidence with sports specific drills and skills

3. Prepare for return to a team training environment

Treatment Guidelines

Several sports specific injury prevention programs have been developed which incorporate excellent drills to perfect. It is recommended that these programs be performed >once per week and continue for at least 6 weeks to maximise effectiveness. Each program should include plyometric and agility drills, single and double leg hops/jumps and change of direction drills. Some sports specific drills should be individualised according to the sports e.g.

● Netball – progress through skill components using Netball Australia’s “Knee Program” https://knee.netball.com.au/

● Soccer – progress through skill components using the FIFA 11+ or PEP program

● AFL – progress through FootyFirst components

● Touch – agilities such as sidestepping through cones or poles, consider FIFA 11+ program

● Rugby codes – progress through burpees, comando rolls, drop and roll

drills tacklebags and then contact drills and tackles. Agilities such as sidestepping through cones or poles, side hurdles, plant and cut and quick feet drills. Refer NSW rugby “Preparation to Perform” program

● Tennis – lateral step lunges, forward and backwards running drills

● Skiing – slide board, lateral box stepping and jumping, zigzag hopping

● Volleyball or Basketball – vertical jumps progressing to jumps with overhead ball catching, consider using netball drills (see below).

Once the athlete has mastered the sports specific skill components a return to team training may be considered (rarely before 10 months)

Phase 5 – Return to Competitive Team Ball Sports

Over recent years there is increasing evidence that return to competitive team ball sports within 12 months of ACL reconstruction is associated with significant risk of repeat ACL injury.

● From a biological perspective, normal ACL graft strength and stiffness occurs after 8 months, and the remodelling continues beyond 12 months.

● The rate of ACL reinjury has been shown to decrease by 51% for each month a return to sport is delayed until 9 months after surgery (Grindem et al BJSM 2016)

● The rate of another ACL injury after 12 months is 1% per knee per year (equal graft and opposite ACL) (Salmon Arthroscopy, 2005, Bourke AJSM 2012)

● Athletes who successfully pass a specific return to sport criteria have a 4x lower risk of injury (Grindem BJSM 2016 & Kyritsis BJSM 2016)

Our recommended criteria for assessing return to sport is detailed on the following page.

Goals of Phase 5

1. Achieve >90% on Patient Reported Outcome Score (e.g. IKDC Subjective Score)

2. >90% quads strength & >90% hop symmetry

3. Completed on field sports specific rehabilitation & return to team training

4. Athlete has confidence and is comfortable to return to sports

5. Athlete understands the importance of continued injury prevention program while active in

team ball sports

Treatment Guidelines

For the vast majority of athletes we advocate delaying a return to any competitive team ball sports until after 12 months from surgery. This is especially important in those with risk factors such as young age, those with a positive family history and those with a history of multiple ACL injuries. The goals of Phase 5 must be achieved before a return to team ball sports is advocated. Once the athlete is deemed ready to return advice may be needed as to the need for modifications to be able to return to sport, e.g. Football - start back training in short sprigs, or similar shoes with less grip. Will usually return to lower grades initially; Skiing - stay on groomed slopes and avoid moguls and off piste initially. Lower their DIN setting on the bindings. Athletes should be encouraged to play within their individual level of confidence. Repetition of training and skill work, and adherence to prevention programs before play will improve both performance and confidence.

Checklist for Return to Play

Stable knee to physical examination

IKDC subjective score more than 90/100

ACL-RSI score >60

>90% quads strength relative to opposite limb

>90% hop symmetry relative to opposite limb

(hop for distance, triple hop for distance, crossover hop tests)

Good performance on drop vertical jump (no valgus, adequate knee flexion, symmetrical landing)

Completion of sports specific training program

Successful return to team training

Patient understanding and adherence to an ongoing injury prevention program

Consideration of appropriate footwear (i.e. low friction)

ACL-RSI Scale

IKDC Subjective Evaluation

References and Recommended Reading

1. Claes S, Verdonk P, Forsyth R, Bellemans J. The “Ligamentization” Process in Anterior Cruciate Ligament Reconstruction: What Happens to the Human Graft? A Systematic Review of the Literature. Am J Sports Med, 2011

2. Alshewaier S, Yeowell G, Fatoye F. The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: a systematic review. Clinical Rehabilitation 31(1): 34, 2017

3. Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, Huston LJ, Spindler KP, Snyder-Mackler L, Investigation performed at the University of Delaware NDUSA. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction?: A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts. The American Journal of Sports Medicine 44(10): 2608, 2016

4. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. British Journal of Sports Medicine 43(5): 371, 2009

5. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE. Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport. The American Journal of Sports Medicine 38 (10 ): 1968, 2010

6. Risberg MA, Holm I. The Long-term Effect of 2 Postoperative Rehabilitation Programs After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine 37 (10 ): 1958, 2009

7. van Melick N, van Cingel REH, Brooijmans F, Neeter C, van Tienen T, Hullegie W, Nijhuis-van der Sanden MWG. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. British Journal of Sports Medicine 50(24): 1506, 2016

8. Bourke H, Salmon LJ, Waller A, Patterson V, Pinczewski LA. The survival of the anterior cruciate ligament graft and the contralateral ACL at a minimum of 15 years. Am J Sports Med. 2012;40(9):1985-1992.

9. Webster KE, Feller JA. Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Orthopaedic Journal of Sports Medicine 6(4): 2325967118763763, 2018

10. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine. 2016;50(13):804-808.

11. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British Journal of Sports Medicine. 2016;50(15):946-951.

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ACL Protocol

Authors:

Contents

Overview

Phases of Rehabilitation

Phase 0 – Prehabilitation

Phase 1 – Acute Recovery

Phase 2 – Strength and Coordination

Phase 3 – Proprioception and Agility

Phase 4 – Sports Specific Skills

Phase 5 – Return to Competitive Team Ball Sports

Checklist for Return to Play

ACL-RSI Scale

IKDC Subjective Evaluation

References and Recommended Reading

Services

Patient Info

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