The aim of this protocol is to supply agreed guidelines so that, following a technically successful ACL reconstruction, by six months the patient is returned to their pre-injury level of sporting participation or occupation.
The aim is to produce a full range of motion, normal muscle strength and agility, maximise proprioception and fully educate the patient about the likely future for their knee.
Isokinetic training and assessment prior to discharge, are useful but not essential.
The pre-operative phase
This is probably the most important phase of rehabilitation.
Patients should be fully educated about expectations and likely outcomes.
They should be drilled in their post-operative exercises and if patient compliance seems to be, or is likely to be, a problem the surgeon should be informed.
Pre-operative muscle power and ROM should be documented.
Deficits in flexibility and soft tissue compliance should be corrected.
Warn they need to avoid deep squats/low chairs for 12 weeks. Discuss when driving and occupation can be returned to.
Achieve full hyperextension and 90 degrees of flexion
Normal gait pattern
Being regaining muscle strength
Local treatment of swelling with cryotherapy etc
Passive hyperextension - heel of operated leg rested on doubled pillow with rest of the leg unsupported, allow gravity to let knee sag - 10 minutes every waking hour
Heel slides or prone hamstring curls
Weight bearing as tolerated, may need crutches for the first few days
5 minutes every waking hour (current work suggests that stimulus for the graft to undergo "ligamentisation" is best "little and often"
Co-contractions (particularly when lifting operated leg to get out of bed etc). Hamstrings first and then quads.
Half squats (20-70) - progress more weight over operated leg as discomfort allows until single leg half squat can be performed. Should be performed with hands on back of settee or table in case of sudden quads relaxation.
Dips - operated leg on telephone directory or bathroom scales other leg at 45 degrees, lower until heel touches floor and then back up. To begin re-introducing proprioception these can be done with the eyes shut.
Cycling - can be safely introduced as soon as wounds are stable. Keep seat high to avoid too much flexion.
Maintain calf muscles, hip abductors, hamstrings etc and maintain flexibility.
Advise surgeon immediately if increasing pain, signs of infection or signs of DVT
ROM - full extension to almost full flexion
Return to normal ADL
Prone hangs, passive sitting extensions, hamstring curls
Increase load with squats and dips
Cycling (keep seat high)
Leg press 0-90
Rowing (avoid extreme flexion)
Swimming (avoid breaststroke)/aquajogging
Theraband work to improve control and proprioception
AB/Adductor/glutens medius work
Full range of motion
Increasing functional activity level
Avoid open chain quads for 9 weeks with BPTB and 12 weeks with hamstring reconstructions.
Introduce jogging when muscle strength and control allow. As function increases can introduce some jogging in and out of cones from about 10 weeks. This should be a smooth rather than sudden change of direction.
Work on proprioception. Rope walking is a simple way of doing this - walking barefoot, forward and backwards along a 10m length of 9mm rope. This can be shaped into curves to make things more difficult and then can be done with eyes shut. Wobble board work (instrumented balance platforms such as the Biodex are useful but not essential).
To return to pre-injury level sport/occupation at 6 months
Fully educated about the future of the knee
Progressive sport specific programme
Sort specific strength work
Progressive sport specific agility and speed work. No sudden twisting/turning work until 4 months. Plyometrics - quality not quantity. Introduce gradually once strength maximised.