Introduction
Anterior Cruciate Ligament reconstruction (ACL-R) is a common surgical procedure that often necessitates extensive rehabilitation to help patients achieve their functional goals.
The quality of rehabilitation and effective communication between the orthopaedic surgeon and therapist are vital for a successful recovery.
This guide offers an overview of evidence-based practices for managing patients post-ACL-R.
It is important to note that this document serves as a general resource; individual circumstances and recovery progress can vary significantly from one patient to another. Therefore, always consult with your own therapist for personalized advice and guidance.
Terminology
- ACL-R: Reconstruction of the Anterior Cruciate Ligament of the knee is carried out when a patient has torn their ligament and surgical intervention is indicated. A graft is commonly taken from either the hamstrings or patella tendon of the patient.
- ROM: Range of motion of a joint. The range that the joint is able to move through without restriction. Referred to in degrees.
- Effusion: Swelling present within a joint.
- OKC: Open kinetic chain. An exercise where the patient is moving their lower limb and their foot is not fixed to the floor.
- Plyometric drills: Exercises where a patient is commonly jumping or hopping and exerting high levels of force.
- Y-Balance: A physical test of a patients control and balance standing on one leg.
- RTS: Return to Sport – In this context this is often criteria based. i.e. when the patient is able to achieve specified testing scores and sufficient time has passed since surgery then they will be advised that they are fit to return to sport.
- ACL-RSI: Anterior Cruciate Ligament – Return to Sport Index. A questionnaire based outcome measure that measures a patient’s readiness to return to sport .
- TSK-11: Tampa Scale of Kineseophobia-11. A questionnaire based outcome measure which identifies a patient’s level of fear relating to movement and re-injury .
- Hop Test Battery: A series of hop tests that help the clinician to decide if a patient is ready to return to sport. Commonly includes a single hop for distance, a triple hop for distance, a timed 6 meter hop and a triple cross over hop.
- IKDC: International Knee Documentation Committee Questionnaire – a questionnaire that is designed to evaluate a patient’s overall knee function.
- FIFA 11 / AFL FootyFirst: Established programs within the literature that are designed to prevent/minimise soft tissue injuries in athletic populations.
- Side hop endurance test: Side hop endurance test – two strips of tape are applied to the floor 30cm apart. The patient hops (single leg) side to side over the tape for 30 seconds. Their score is the number of successful hops without touching the line and the scores for left and right limbs are compared.
Guideline
- Key Principles: The aim of this document is to provide a framework for the medical team and therapists in the management of patients who have undergone an ACL-R to ensure the best and safest outcome is achieved. The patient should progress through the individual stages of the rehabilitation as they meet the criteria that has been defined.
This is a guidance document only and each patient’s individual circumstances and situation must be taken into account when progressing through the stages to ensure that their rehabilitation is individualised appropriately
- Pre-operative
- Focus: Effusion control / muscle activation / restore ROM
- Physiotherapy: Compression / home rehab / pool exercises
- Conditioning: Off-feet / bike as tolerated
- Progression: Surgery date / Identified ability to cope without surgical intervention
- Medical Review: Only fit for surgery if full pre op extension, minimum 120deg ROM. Explain milestone based rehabilitation to meet long term goals and overall timeframes.
- Stage 1: Post Surgery (~0 – 6/8 weeks)
- Focus: Effusion control and tissue healing / restore ROM (Ensure full extension) / good patella mobility / Single leg static balance / muscle activation (quadriceps, hamstrings, calf complex – closed chain initially) / wean off crutches when gait normalised
- Physiotherapy: Early stage home rehab / pool exercise when wounds healed / ice & compression if required
- Conditioning: Upper body only – seated or lying
- Progression: 120 degrees flexion / Full extension / No quads lag / Parallel squat / Minimal effusion / normalised gait pattern (Note: restrictions may be in place if a patient has had a concurrent meniscal repair)
- Red flags: Wound not healing as expected / Poor patella mobility / Lacking full extension at 6 weeks / no quads control at 6 weeks. Contact medical team if these are present
- Medical Review: Wound check & Review: Reiterate surgical findings and goals over next 6 weeks; If meniscal repair > protected weight bearing/brace ~ 4 weeks; Reiterate importance of full extension & brace at night in extension if needed-next review at 8 weeks (or sooner if extension an issue).
- Stage 2: Progressive loading (~6 – 12 weeks)
- Focus: Return to single leg loading (no plyometrics) / Single leg dynamic balance and proprioception / Double leg jumping and landing if appropriate
- Physiotherapy: Progression of rehab (static > dynamic balance) / Pool rehabilitation / Early plyometrics - Force production and acceptance drills / Hamstring graft - OKC from 4+ weeks 90-45o WITHOUT resistance. Gradually increase working range weekly.
- Conditioning: Bike (once flexion >100o) / Rower / Pool
- Progression: 10s Single leg Stand (5+45 deg knee flexion) / 20+ Single leg calf raises / 15+ Single leg Squat (to bench) / 15+ Single leg bridges / 1.5 x Body Weight leg press (body weight +50%)
- Surgical Review: Around 8 weeks; Ensure full extension, progressing flexion ~120deg +; out of brace/crutches, normal gait. First Assessment of graft-feel for Lachman Grade & End Point, No Pivot. Ideally minimal/no effusion.
- Stage 3: Unilateral load acceptance (~12 – 24 weeks)
- Focus: Return to running (settled knee, 20+ single leg squats, 20+ single leg calf raises) / controlled multi-directional movements / decelerations
- Physiotherapy: Progression from stage 2 (strength training ++) / Introduce decision making drills / Plyometric drills / Hoping and change of direction can be commenced in the pool
- Conditioning: Full lower body weights program / running drills / skipping
- Progression: Y-balance test normal / 1.8 x Body Weight leg press (body weight + 80%) / Quadriceps & Hamstring strength aiming for 80% of unaffected leg (if testing available)
- Surgical Review: Around 4 months. Allow running after only if minimal Effusion, Full ROM, Stable Knee (reassess graft), good quads tone and >80% bulk/circumference symmetry. Adequate single leg squat.
- Stage 4: Sport Specific Task Training (~24 – 40 weeks)
- Focus: Strength based / Multi-directional plyometric drills / Sport specific drills / High speed running
- Physiotherapy: Isokinetic strength training / Increased demand and complexity with multi-directional tasks / Increase running drills intensity (accelerations and decelerations)
- Conditioning: Non-contact sport drills / Full speed running
- Progression: Acute: chronic workload ratio achieved (<1:2) / Side hop endurance test 95%+ / Quads and Hamstring strength aiming for 90%+
- Surgical Review: Only have surgical review around 6 months if high risk candidate/not met milestones at 4 months/not progressing. If concern re ongoing swelling/any pain/loss of range, consider further MRI.
- Stage 5: Return to Sport (~40 – 52 weeks)
- Focus: High level plyometric drills as required / return to sport specific running
- Physiotherapy: Contact drills (possibly with club physio) / High demand plyometric drills / RTS testing / FIFA 11+ (or similar) for on-going knee care
- Conditioning: Full squad training / Reintroduction to contact drills as required (liaise with club physio)
- Progression: RTS testing satisfactory – Hop test battery, Strength assessment (all 90%+), subjective testing (TSK-11 (aiming for <18), ACL-RSI (aiming for >80%) / Earliest return 40 weeks, preferably 52 weeks for return to competition
- Surgical Review: RTS allowed after minimum 40 weeks (52 weeks if high risk/juvenile), and successful completion of RTS assessment. Has confidence, trust, fitness, stability, range. Re-test RTS if any deficiencies. Educate about fatigue management, long term injury prevention (FIFA 11, AFL FootyFirst)