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What is ACL Rehabilitation Phase 1?

The anterior cruciate ligament (ACL) is one of the major ligaments of the knee. It is located in the middle of the knee and runs from the femur (thighbone) to the tibia (shinbone). The ACL prevents the tibia from sliding out in front of the femur. An ACL injury is one of the common injuries of the knee. An injury to the ACL commonly occurs during sports or activities that involve twisting, overextension, landing from a jump incorrectly, and abrupt change in direction or speed of movements.

ACL rehabilitation phase I is a postoperative physiotherapy course conducted in the first two weeks following ACL reconstruction surgery. ACL reconstruction is a surgical procedure to repair or replace a torn or damaged ACL ligament in your knee to restore knee motion and stability. ACL rehabilitation phase I begins immediately following the surgery where a physiotherapist will teach you specific exercises to restore knee mobility, strength, and improve range of motion. Adhering to the goals of the rehabilitation program is important to help you recover and resume your normal activities.

Phase I ACL Rehabilitation

Phase I of post-surgery ACL rehabilitation starts immediately after your reconstruction surgery. Your therapist will recommend strength and mobility exercises that are very crucial to increase blood flow around the knee to boost healing, strengthen muscles, and increase range of motion.

Phase I Goals

  • Achieve full knee extension or straightening of your knee
  • Walk normally
  • Reduce swelling
  • Good control of the quadriceps muscles

Phase I ACL Rehabilitation Guidelines

Bruising, swelling, and discomfort are a common part of recovery post ACL surgery.

Bruising around the knee may last a couple of weeks after surgery. It may be purplish or yellowish and bring about additional tenderness.

There are many ways to manage the swelling and discomfort to ease your recovery. These include rest, ice and elevation, and use of crutches.

Regaining Strength and Mobility

In every stage of your recovery, your physiotherapist will recommend exercises to improve your knee strength and mobility. These exercises are divided into primary, alternate, and optional exercises and adhering to them are critical for a successful rehabilitation.

Primary exercises are the minimum advised for accomplishing a successful recovery.
Alternate exercises accomplish the same goal as primary exercises and are only used if you are uncomfortable with the primary exercise position.
Optional exercises offer additional conditioning and strength to your knee.

Consult your rehabilitation team to find out which exercises are best for you, especially if you are experiencing increased swelling and pain.

Phase I Mobility Exercises

Achieving full knee extension (straightening) is an important goal in Phase I.

Primary Daily Knee Extensions

  • When resting lying or sitting down, extend your operated leg in front of you.
  • Keep your leg straightened as much as you can with your knee straight up.
  • Let gravity gently continue to straighten your knee.
  • Do this for 20 to 30 minutes 3 to 4 times a day.

Primary Supine Knee Extensions

  • Lie supine (on your back) with your knee in a straight position, and a small towel roll placed below your heel.
  • Hold this position for 20 to 30 minutes, 3 to 4 times a day.

Primary Ankle Pumps

  • Sit or lie down with your legs straightened out and a towel roll placed under your ankle.
  • Bring your toes up and then back down as if you are lifting on and off a gas pedal.
  • Complete 15 repetitions each hour.

Primary Heel Slides - Knee Flexion and Extension

  • Lie on your back with the knee in a bent posture and ensure the foot remains in contact with the surface or floor.
  • Now, slide the foot to straighten the knee to keep it mobile and try to improve the range of motion.
  • Do repetitions of 10 to 20 times 3 to 4 times a day.

Alternate Prone Knee Extensions

  • Lie prone (on your stomach) with a small flat towel roll placed just above your knee on the thigh.
  • Let your foot hang off the end of the table or bed for 20 to 30 minutes 3 to 4 times a day.

Alternate Seated Passive-Assisted Knee Extensions

  • Seated in a chair put the foot of your nonsurgical leg underneath the knee of the operated leg just behind the foot.
  • Slowly use your nonoperative leg to lift your operative leg out as straight as you could while keeping your operative leg relaxed.
  • Return back to your starting position.
  • Repeat 10 to 20 times 2 to 3 times a day.

Phase 1 Strength Exercises

Primary Quadriceps Set

Quadriceps exercise is crucial to restore the strength of your quadriceps. It is also the bedrock for several other exercises as you advance. You need to focus on correct muscle activation (tense and then relax) and technique.

  • Sit or lie on your back with your legs straight out.
  • Tighten the front of your thigh as if you are pushing your knee against the surface. This tightening must cause your kneecap to move toward your hip.
  • You need to focus on the quadriceps, not your hamstrings or gluteal muscle. If you feel the quadriceps muscle engaging, then pause, reset and re-focus on contracting the quadriceps.
  • Hold the muscle tight for five seconds and do 12 repetitions, 3 times a day.

Hamstring Sets

You have 4 hamstring muscles located along the back of your thigh. These muscles assist in controlling the knee while performing many activities including walking and climbing stairs. Restoring hamstring strength is just as crucial as it is for the quadriceps on the front of your thigh. These hamstring sets can help improve muscle activation on the back of your thigh.

Primary Hamstring Set While on the Back

  • Lie on your back and bend your knee to bring your calf to 90 degrees.
  • Now, push your heel down into the surface with mild to moderate pressure.
  • Hold for 6 seconds and then relax.
  • Do 12 repetitions 1 to 3 times a day.

Alternate Hamstring Set While on the Stomach

  • Lie on your stomach with a towel placed under the front lower part of your thigh.
  • Now, bend your knee to bring your calf up to 90 degrees from the floor or table.
  • Do 12 repetitions 1 to 3 times a day.

Alternate Hamstring Set Standing

  • Stand on both feet with both crutches.
  • While supported with crutches, do a gentle hamstring curl, bending your knee upward behind you.
  • Hold for 6 seconds and then relax.
  • Do 12 repetitions, 1 to 3 times a day.

Primary Quadriceps/ Hamstring Co-Contraction

Quadriceps and hamstring co-contraction helps to activate (tense and then relax) both muscles together. This is crucial for standing up, sitting down, walking, and taking stairs.

  • Lie down on your back with your surgical leg straight out. You may bend your nonsurgical leg up to 90 degrees for comfort.
  • Now, push your heel down into the table as if you are trying to “dig.” Once you feel these muscles contracting, tighten your quadriceps muscle by attempting to straighten your leg. Push firmly but not so hard you lift your body off the table.
  • Hold this contraction of both sides of the thigh for 5 seconds and then relax.
  • Do this exercise 12 repetitions 3 times a day.

Primary Straight Leg Raises

This will be the main exercise in your postoperative rehabilitation. Straight leg raises helps to develop quadriceps strength and function for return to walking and daily activities. Start these after you have made adequate progress with quadriceps sets and can do a straight leg raise.

  • Lie on your back with your nonsurgical leg bent to 90 degrees.
  • Push the knee of your operative leg flat against the surface to tighten the top of the thigh.
  • Hold the thigh muscle tight. Lift your leg until your knee reaches the height of your other knee. Use a slow and controlled motion.
  • Hold your knee as straight as possible to avert “Quad Lag.” Lag is when you bend your knee slightly as you start lifting your leg.
  • Return your leg to the surface slowly.
  • Do 12 repetitions 3 times a day.

Primary Double-Leg Heel Raises (Calf Press)

Heel raises enhance calf strength. This will assist you to walk and, later in your rehabilitation, to run and jump.

  • Stand with your hands on a table for support.
  • Place your feet shoulder-width apart.
  • Keep your weight the same on both legs.
  • Keep your toes on the ground and lift your heels using a 2-second count.
  • Hold this position for a short period, then slowly lower it for 4 seconds.
  • Do 12 repetitions 1 to 3 times a day.

Alternate Prone Hamstring Curls

Prone hamstring curls exercise is employed for strengthening and to improve range of motion (the capacity to bend your knee).

  • Lie down on your stomach. Place a pillow or towel roll under your thigh for comfort while moving your knee.
  • Now, bend your surgical knee to advance your heel up toward your back. Do this motion smoothly and deliberately.
  • Hold the bent-knee posture for 5 seconds and then lower the foot to its original position gently.
  • Do 12 repetitions 3 times per day.

Optional Standing Hamstring Curls

Once you are comfortable doing prone hamstring curls and able to bear weight on your surgical leg with control, standing hamstring curls can improve hamstring strength.

  • Stand with your hands on a stable surface for support.
  • Maintain an upright posture. Now try to shift your weight slightly to your uninjured leg.
  • Bend the knee of your other leg to bring your heel up toward your back.
  • Hold for 5 seconds and slowly return to the starting position.
  • Perform sets of 12 repetitions 1 to 3 times a day.

Primary Double-Leg Quarter Squats

Double-leg quarter squats enable a crucial transition to strengthen your hamstrings, quadriceps, and gluteal muscles further and also improve weight-bearing movements through your knees.

  • Stand with your feet shoulder-width apart.
  • Bend slightly at your hips, then at your knees.
  • Keep your trunk straight and limit any tilt forward.
  • Lower your buttocks down about 6 inches like you are going to sit in a chair.
  • Straighten your legs and hips to return to standing.
  • Keep your weight evenly on both legs. Avoid transferring weight to the nonsurgical leg.

Primary Patellar Mobilisation (Medial and Lateral)

Patellar mobilisation aids in more easily bending and straightening your knee. It also helps to reduce knee tightness symptoms.

  • Ensure your surgical knee is relaxed and straight.
  • Use your index and thumb finger to find the edges of your kneecap.
  • Place your thumb on one side of your kneecap and your index finger on the other side.
  • Now, move your kneecap firmly from side to side. Try not to irritate the skin or any incisions.
  • Move it side to side about 20 times.

Primary Side-Lying Hip Abduction

Side-lying hip abductions improve muscle strength in the back and side of your hip. This helps you walk and with other activities.

  • Lie on your nonsurgical side on a table or flat surface.
  • Straighten the top part of the operative leg and hold it straight throughout the exercise.
  • Now, slowly lift the top leg using your hip, not your side or back
  • Lower your leg back to starting position and keep the hips aligned throughout the exercise.
  • Do 12 repetitions, 1 to 3 times a day.