Anterior Cruciate Ligament Reconstruction

AFTER THE OPERATION

Phase 1 (Weeks 0-2 )

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 & pain with ice, elevation, co-contractions and pressure pump.

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

● 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.

The main aim of the first 2 weeks is to keep swelling and pain to a minimum and to maintain some muscle tone and flexibility. This can be achieved in the following ways:

  • Mr Damasena uses cryotherapy (iceman3 can be rented) machine which supplies continuous cooling to the knee and has ben shown to reduce swelling and post-operative pain requirements.

  • When applying ice, keep the leg in elevation. Sitting with your leg up on a stool is not adequate, you need to have the whole leg above the level of your heart. For example, lie on floor/bed with foot up on chair/pillows etc.

  • There should be little or no pain associated with the exercises. Ease off on the exercises if they cause increased pain or swelling.

  • Do not rest with a pillow crossways under your knee. It should rest completely straight.

When to Wear Your Splint

  • Only if your surgeon has indicated you need to wear a splint

  • Only when walking for the first 2 weeks or until review with your surgeon.

Ambulation

  • Use crutches and partially weight bear through operated knee for the first 2 weeks. You may start to fully weight bear as you feel comfortable.

  • Try to return to a normal gait (walking) pattern by 2 weeks.

Frequency of Exercises

  • 3-4 times per day, unless otherwise indicated.

IF YOU HAVE ANY DIFFICULTIES OR CONCERNS PLEASE CONTACT YOUR SURGEON OR PHYSIOTHERAPIST

Phase 2 (Weeks 2-6)

Strength and Coordination - Phase 2

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 (eg leg extension machine and a freestyle swimming kick). Intermittent episodes of increased swelling may occur, and if so exercises and loads 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. Use of 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 decrease loads

● Hamstring strengthening progresses with the increased complexity and repetitions of co-contractions eg 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 gluteal 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.

Stage 3- Hamstring/Quadriceps Strengthening (6-12 Weeks)


Goals

  1. Begin specific hamstring loading

  2. Increase total leg strength

  3. Promote good quadriceps control in lunge and hopping activity in preparation for running


Treatment Guidelines

  1. Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation

    • Active prone knee flexion which can be quickly progressed to include a light weight and gradually increasing weights

    • Bilateral bridging off a chair. This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen

    • Single straight leg dead lift initially active with increasing difficulty by adding dumbbells

    • With respect to hamstring loading, they should never be pushed into pain and should be carefully progressed. Any subtle strain or tightness following exercises should be managed with a reduction in hamstring based exercises

  2. Gym based activity including leg presses, light squats and stationary bike which can be progressively increased in intensity as pain and control allow. It is important to monitor any effusions following exercise and if it is increasing then exercise should be toned down

  3. Once single leg lunge control is comparable to the other side hopping can be introduced. Hops can be made more difficult by including variations such as forward/back, side to side off a step and in a quadrant

  4. Running may begin towards the latter part of this stage. Prior to running certain criteria must be met:

    • No anterior knee pain

    • A pain free lunge and hop that is comparable to the other side

    • The knee must have no effusion

    • Before jogging start having brisk walks, ideally on a treadmill to monitor landing action and any effusion. This should be done for several weeks before jogging properly

  5. Increased proprioceptive manoeuvres with standing leg balance and progressive hopping based activity

  6. Expand calf routine to include eccentric loading


Stage Four-Sport Specific (3-6 Months)


Goals

  1. Improve leg strength

  2. Develop running endurance speed, change of direction

  3. Advanced proprioception

  4. Prepare for return to sport and recreational lifestyle


Treatment Guidelines

  1. Controlled sport specific activities should be included in the progression of running and gym loads. Increasing effusion post running that isn't easily managed with ice should result in a reduction in running loads

  2. Advanced proprioception to include controlled hopping and turning and balance correction

  3. Monitor potential problems associated with increasing loads

  4. No open chain resisted leg extension exercises unless authorised by Dr Parker

Stage Five-Return to Sport (6 Months Plus)


Goals
A safe return to sporting activities

Treatment Guidelines

  1. Full training for 1 month prior to active return to competitive sport

  2. Preparation for body contact sports. Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training

  3. To improve running endurance leading up to a normal training session

  4. Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity. Circumference measures of thigh and calf to within 1 cm of other side.

Mr Damasena implements Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) Calculator. Please click on this link and complete the form prior to your 6 month appointment.

https://orthotoolkit.com/acl-rsi/

ACL RECONSTRUCTION EXERCISES

(Exercises to be done 3 times per day, These can start straight after surgery)

Ankle Exercises
Move foot up and down and around in circles. Repeat 10 times in Each direction every hour, for the first few days.

Calf Stretch
Use towel or belt around foot to pull toes towards face. Hold for 20 seconds, relax, repeat 3 times.

Hamstring Stretch
Keeping knee and back straight, lean forward until you feel a gentle Stretch behind the knee. Hold for 20 seconds, relax, repeat 3 times.

Quad Sets/Extension

  1. Sit or lie on your back with your leg straight.

  2. Press the back of your knee downwards by tightening the muscle on the front of your thigh.

  3. Hold for 5 seconds.

  4. Repeat 3 x 10 times.

Isometric Quadriceps/Hamstring Co-Contraction (long sitting position)

  1. Sit with a rolled up towel under your knee and the thigh rolled outwards.

  2. Dig heel into bed and tighten whole thigh.

  3. Place fingers on inner thigh just above kneecap to feel quadriceps/Vastis medialis muscle contracting.

  4. Hold contraction for 5 secs, rest for a few seconds.

  5. Repeat 3 x 10 times.

  6. You can also do this sitting

Bent Leg Raise

  1. With knee bent to about 30 degrees, lift leg off bed.

  2. Keep your knee flexed at 30° throughout the exercise.

  3. Hold for 5 seconds, then relax.

  4. Repeat 3 x 10 times.

FLEXION EXERCISES

Passive Flexion in Sitting

Commence now.

  1. Wrap a towel around the ball of your foot of your operated leg.

  2. Holding the ends of the towel in your hands, gently pull the ends of the towel so that your knee bends with it.

  3. Hold at the comfortable limit of flexion for 5 seconds.

  4. Continue slowly 10 times. Gradually increase to 30 times.

Passive Flexion in Prone

Commence in 1-2 days.

  1. Lie on stomach.

  2. Place foot of unoperated leg underneath shin of operated leg.

  3. Gently assist the injured leg to bend as far as comfortable by pushing up with the unoperated leg.

  4. Hold at the limit of flexion for 5 seconds.

  5. Continue slowly for 10 – 30 times.

  6. Continue to do Passive Flexion in Sitting exercise before this one.

EXTENSION EXERCISES

Supine Hangs
Commence now.

  1. Sit or lie with foot up on a ball/bolster/rolled towel.

  2. Relax knee in straight position for 30 seconds.

  3. Continue for a total of 5 minutes.

Prone Hangs

Commence in 1-2 days. ** Only do this extension exercise. Stop doing the Supine Hangs**

  1. Lie on stomach with knee-caps over the edge of a firm bench or bed.

  2. Let operated knee gently hang over the end of bench/bed.

  3. Hang for 1 minute, lift slightly up with good leg to rest for 30 seconds.

  4. Continue for a total of 5 minutes.

Advanced Prone Hangs

Commence in 5-7 days. ** Only do this extension exercise. Stop doing the Prone Hangs**

  1. Lie on stomach with knee-caps over the edge of bench or bed.

  2. Let operated knee gently hang over the end of bench/bed.

  3. Rest the foot of your good leg over the ankle of your operated leg, to gain a greater stretch.

  4. Hold position for 1 minute, then ease pressure off by lifting good leg off for 30 seconds.

  5. Continue for a total of 5 minutes.

Patella Mobilisation

With knee straight and relaxed, gently move kneecap from side to side (A) and up and down (B).