Anterior Cruciate Ligament (ACL) Reconstruction Rehabilitation Protocol

Anterior Cruciate Ligament (ACL) Reconstruction Rehabilitation Protocol
Rehabilitation and Fitness Video ACL Reconstruction Surgical Video
General Considerations:
Progression should be based on careful monitoring of the patient's functional status. Early emphasis on achieving full hyperextension equal to the opposite side. Passive and active range of motion as tolerated. CPM may be used if ROM not progressing. Full weight bearing as soon as tolerated with no limp (unless otherwise indicated). Regular manual treatment should be conducted to the patella and all incisions. Controlled exercises can be performed without the use of the brace; post-op brace issued on individual basis. Exercises should focus on proper patella tracking and recruitment of the VMO. Early recruitment of the VMO using home electrical stimulation unit if necessary. No resisted leg extension machines (isotonic or isokinetic) at any point in the rehab process. Patient should be well aware that healing and tissue maturation continues to take place for one year after surgery. Patients are given a functional assessment/sport test at 3 months, 6 months, and 1 year post-op. Rationale for phases.
PHASE I (Approximately Weeks 1 - 2) - Max Protection Phase:

MD visit Day 1 post-op to change dressing and review home program. MD visit at 8 - 10 days for suture removal and check-up. Icing and elevation as much as able to minimize edema and promote healing. If needed, use of a CPM at home for 4 - 6 hours a day. Gait training to promote best quality of gait with the least amount of assistance. Passive and active range of motion exercises. Balance/proprioception exercises in a protected environment. Well-leg stationary cycling, upper body conditioning, and core conditioning. Soft tissue treatments to posterior musculature, quads, and infrapatellar pouch. Extensive patellar mobilizations, superior/inferior glides and patellar tipping.
***Passive range of motion should be 0 or hyperextension to 90 flexion, minimal pain and edema, and unassisted good, quality gait before moving onto Phase II.
PHASE II (Approximately Weeks 2 - 4) - Moderate Protection Phase:

MD visit at 4 weeks. Patient still needs to be somewhat restful with low impact on knee, must elevate and ice daily. Walking for exercise limited to 15 - 20 minutes per day if no swelling or limping. Continue with range of motion, gait training, soft tissue treatments and balance exercises. Incorporate functional exercises/eccentrics (i.e. squats, bridging, intense core training, and 2" step downs). Leg weight machines PREs (i.e. leg press, hamstring curls, calf raises, abduction/adduction). Aerobic exercises as tolerated (i.e. bilateral stationary cycling, UBE, Elliptical). Pool workouts including deep water running, waist-high fast walking in all directions. ***Range of motion should be equal, extension bilaterally to 120 flexion, normal gait without assist, single-leg balance ability, and no significant edema before moving to Phase III. CPM can be discontinued if ROM goals reached.
PHASE III (Approximately Weeks 4 - 6) - Return to Function/Strengthening Phase:

Continue any necessary soft tissue mobilization required. Emphasize self stretching of both lower extremities. Increase the intensity of functional exercises (i.e. progress cycling, okay for road cycling, increase resistance in exercises, up to 1 hour walking for exercise, add stairs, climber or VersaClimber, increase challenge of proprioceptive training and eccentric exercises (i.e. 4 - 6" step downs). All exercises still in a controlled environment. Greater emphasis on single-leg strength exercises such as leg press and single leg squats. ***Patients should have full hyperextension and 80 - 90% of full flexion, able to do 4" single-leg step down, and bike with minimal+ resistance for 20 - 30 minutes before moving to Phase IV.
PHASE IV - Approximately Weeks 6 - 10 - Progressive Activity Phase:

Add lateral training exercises (i.e. lateral lunges, lateral step-ups, step overs). Begin to incorporate sport-specific training (i.e. volleyball bumping, easy hiking, functional training exercises in ALL planes of motion). No cutting or pivoting. Focus on good, quality eccentric strength and continue to increase challenge and complexity of proprioceptive exercises. ***All activities should be pain free without swelling, descending stairs should be smooth and pain free, single-leg squatting for 30 seconds should be of good quality and pain free before moving to Phase V.
PHASE V - Approximately Weeks 10 - 16 - Training for Sport Phase:
MD visit at 3 months and functional test. Incorporate bilateral, low-level jumping exercises. Watch for compensatory patterns with take-offs or landings. Progress to running if able to demonstrate good mechanics and appropriate strength at 12 weeks. Add appropriate agility training with progressive complexity and challenge still cautious with cutting and pivoting. Patients should be weaned into a home program with exercises specific to their particular activity/sport; aggressive road cycling is encouraged. Fit for functional knee brace if requested by MD. ***Single-leg squat test for 1 minute must be at least 80% of uninvolved leg, moderate resistance biking for 30 minutes should be easily tolerated, patient should be confident with all ADL's and independent in an appropriate gym and outdoor training program before moving to Phase IV. Patient should be well educated on avoiding cutting sports. Conditioning should be emphasized in this phase rather than playing a sport.
PHASE VI (Approximately Months 6 - 12) - Return to Sport Phase:

MD visit and sport test. Progression of program of increasing intensity to return to sports, increasing plyometric training with appropriate progression and emphasis on form. Patient should be adequately informed of higher risk activities and instructed on appropriate training for safest progression to those specific activities such as skiing, basketball, and soccer. ***Patient must pass sport test and MD exam before being released to full athletics
Functional Test at 12 Weeks:
Comparison of involved and uninvolved leg in the following tests: Single-leg squat for 1 minute; comparison of repetitions achieved in 1 minute. Lateral Excursion Test: Patient to stand on test leg attempt to tap (touch toe only) as far out laterally as possible with opposite leg. Distance recorded and compared for 3 attempts on each side. Posterior Excursion Test: Same as above but with patient tapping toe posteriorly. Cariocas: Patient to demonstrate good, quality movement and control with speed cariocas over 40'. Lateral Leaps: Patient to leap laterally at speed touching markers set 3 - 4' apart for 1 minute with excellent control and form.
Sport Test at 6 Months and 1 Year:

to full speed cariocas over 40' with good control and form. Single-leg contralateral reach downs: Patient to stand on test leg, with contralateral hand to touch floor at test legs ankle. Repeat over 1 minute and compare number of successful touches to uninvolved side. Forward Leap: Patient to leap forward (striding) with alternating legs over 40' to see quality and willing of single leg push-off and landing. Lateral Leap with Resistance: Same test as 12 Week but with added resistance cord around waist in line with direction of leap.
At One Year:
Add test of single leg hop for distance; 3 hop trials per leg. Add Change of Direction Drill: Patient to begin running forward and on command, reverse direction to backwards run; on next command, turn and run right; on next command turn and run left, etc. for 1 minute. Evaluate quality and control of movement.
NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.

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Anterior Cruciate Ligament (ACL) Reconstruction Rehabilitation Protocol

Rehabilitation and Fitness Video ACL Reconstruction Surgical Video

PHASE I (Approximately Weeks 1 - 2) - Max Protection Phase:

PHASE II (Approximately Weeks 2 - 4) - Moderate Protection Phase:

PHASE III (Approximately Weeks 4 - 6) - Return to Function/Strengthening Phase:

PHASE IV - Approximately Weeks 6 - 10 - Progressive Activity Phase:

PHASE V - Approximately Weeks 10 - 16 - Training for Sport Phase:

PHASE VI (Approximately Months 6 - 12) - Return to Sport Phase:

Functional Test at 12 Weeks:

Sport Test at 6 Months and 1 Year:

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