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What is ACL Rehabilitation Phase 2?

The anterior cruciate ligament (ACL) is one of the four major ligaments of the knee that connects the femur to the tibia and helps stabilise your knee joint. It prevents excessive forward movement of the tibia in relation to the femur as well as limits rotational movements of the knee. An ACL injury is one of the most 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 II is an intermediate postoperative physiotherapy course for recovery after 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 II is conducted 2 to 6 weeks following ACL reconstruction surgery where your 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 fully recover and resume your normal activities.

Phase II ACL Rehabilitation Exercises

Before you begin Phase II ACL rehabilitation exercises, you should:

  • Have gained full range of motion
  • Be off crutches
  • Be able to do straight leg raises without lag
  • Be able to flex your knee (bend) to at least 110 degrees
  • Have achieved a knee extension range of motion of zero degrees

The goals of phase II ACL rehabilitation exercises include:

  • Maintain full extension and restore full flexion (contralateral side)
  • Continue to improve muscle strength with increasing resistance in your exercises
  • Start to resume your normal activities of daily living, including standing, walking, using stairs, and getting in and out of a car

Bruising, swelling, and discomfort are a common part of recovery post ACL surgery. To address these, place a pillow underneath your whole leg (not just the knee) and continue to ice your knee for 15 minutes after exercise sessions.

The phase II exercises aim at further improving range of motion/mobility, strengthening, and balance/proprioception. Phase II 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.

Phase II ACL Strengthening Exercises

Alternate Seated Passive-Assisted Knee Extensions

  • Sit in a chair and place the foot of your nonsurgical leg behind the foot of your surgical leg.
  • Now gently use the good leg to lift your operated leg as straight as you could while holding your operated leg relaxed.
  • Return to the starting position.
  • Do 10 to 20 repetitions, 2 to 3 times a day.

Quadriceps Strengthening

Primary Quadriceps Set

The quadriceps set is crucial in restoring the quadriceps strength. It is also the foundation for several other exercises as you advance.

  • Sit on a chair or lie on your back with your legs straight out.
  • Now, tighten the top part of your thigh as if you are pushing the knee flat against the surface. This tightening should cause the kneecap to move toward the hip.
  • Focus on the quadriceps, not your hamstrings or gluteal (butt) muscle. If you feel otherwise, then you need to pause, reset and refocus on contracting the quadriceps.
  • Hold the muscle tight for 5 seconds and relax.
  • Do 12 repetitions, 3 times a day.

Double Leg Squats

  • Rest your back on a wall with a ball held in between your thighs
  • Now, slowly slide your back down the wall with the ball firmly held between your legs
  • Hold at a 45-degree position for 5 seconds
  • Perform 10 repetitions, 2 to 3 times a day

Alternate Standing Terminal Knee Extension

Standing terminal knee extension boosts quadriceps strength and walking. You will require an exercise or resistance band and a stable item to hold the band.

  • Stand with the resistance band around the back of your surgical knee.
  • Tie the band to a stable item, such as a table to hold the band securely.
  • Start with your knee slightly bent and your heel and foot held firmly on the floor.
  • Keep your trunk straight and straighten your knee utilising the quadriceps muscle.
  • Hold for six seconds and slowly return to the beginning position.
  • Do 2 sets of 12 repetitions up to 3 times a day.

Hamstring Strengthening

You have 4 hamstring muscles located along the back of your thigh. These muscles assist in controlling the knee while doing 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 Side-Lying Hip Abduction

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

Alternate Standing Hip Extensions

Standing hip extensions increase your ability to bear weight on your operative leg while walking. They also strengthen muscles around your hip.

  • Stand firm with your hands on a table or stable surface for support.
  • Now, transfer your weight onto your nonoperative leg.
  • Lift the surgical leg and move it back to a 45-degree angle. Make sure your trunk and pelvis do not rotate.
  • Hold the leg at a 45-degree angle for 2 seconds and slowly return to the starting position.
  • Do 12 repetitions on each leg 3 times a day.
  • Add a resistance band to the surgical leg to do the same as your strength improves with the approval of your physician or physiotherapist.

Phase II Functional Exercises

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.
  • Holding the thigh muscle tight, lift your leg until your knee reaches the height of your other knee in 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 starting position slowly.
  • Do 12 repetitions 3 times a day.

Primary Standing Hip Flexion with Resistance

This is a weight-bearing exercise which is the next step from straight leg raises. Standing hip flexion challenges your single-leg stability on the stationary leg and the strength of your quadriceps and hip flexors of your moving leg.

  • Tie or loop a resistance band around a secure object like a table leg.
  • Place one ankle inside the loop and step away until there is slight tension on the band.
  • Stand upright and stiffen your quadriceps (the front thigh) muscle of the leg in the band, straightening and locking the knee.
  • With stiff quadriceps, lift the leg in the band slightly and kick forward slowly.
  • Return to the starting position slowly.
  • Do 12 repetitions, 1 to 3 times a day, and switch legs.

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 upright and limit any forward tilting.
  • 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 Double-Leg Heel Raises (Calf Press)

Heel raises enhance calf strength. This will assist you to walk and, later in your rehabilitation, 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 them for 4 seconds.
  • Do 12 repetitions 1 to 3 times a day.

Primary Patellar Mobilisation (Medial and Lateral)

  • Patellar mobilisation aids in more easily bending and straightening your knee. It also helps to reduce knee tightness.
  • 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 the 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 Step-Up

This exercise helps to develop strength and stability and is vital for developing lateral and base movement skills.

  • Stand next to a 2- to 6-inch step board.
  • Place your nearest foot up on the step board.
  • Now, lift yourself up on that foot, placing your weight through the heel.
  • Simultaneously, lift your opposite knee in the air to a 90-degree angle.
  • Slowly return to the starting position.
  • Step totally off the step board.

Primary Standing Anterior Reach

Standing anterior reach boosts the strength and stability of your stationary or motionless leg.

  • Stand upright with your hands held just in front of your abdomen.
  • Bend one knee as you reach the other foot forward as far as you can under control.
  • Slightly touch your heel down for additional stability.
  • Return to the standing upright position.
  • Complete the movement 12 times. Moving slowly improves the benefit.
  • Switch legs and do 1 to 3 times daily as directed.