Anterior Cruciate Ligament (ACL) Reconstruction Rehabilitation Protocol

Phase 1: 0 - 2 weeks post-operatively

On Surgical day 0

Cryocuff and elevated knee and leg in extension with support until blocks wear off

DVT stocking and enoxaparin until mobile

Walk normally with 2 x crutches

Initial exercises

• Ankle dorsi and plantar flexion for DVT prophylaxis: 10 repetitions 6 x daily

• Range of motion of the knee as tolerated without restriction – unless dictated by meniscal or other pathology. 10 repetitions 6 x daily

• Quadriceps activation exercises in extension, notably VMO activation. 10 repetitions, 6 x daily

At 14 days post operatively

Assess quadricep control and range of motion. Range of motion is most critical to return to normal as soon as possible.

Phase 1 training

Goal

Reduce swelling and fluid in the knee. Wound healing, Full extension, straight leg raising after 2 weeks. 90 degrees of flexion by 2 weeks.

Action

• Elevate leg with full extension

• Ice and compression

• Gait retraining 2 crutches. Loading as tolerated and with muscular control

• Ankle plantar and dorsiflexion exercises

• Range of motion exercises

• Quadriceps activation exercises

Phase 2 : From 2 - 12 weeks post-operatively

Goal

Attain full range of motion, normal gait, try to aim to normal ADLs (Activities of Daily Living). Attain normalised muscle strength and dynamic stability of knee

Action

• Gradual removal of crutches

• Light ergo cycling

• Gait, stair, and balance training.

• Normalisation of gait pattern

• Balance training. Shift weight forwards, backwards and side to side

• Start gentle strengthening when tolerating loading. 2 x 25 – 30 reps of light load

• Neuromuscular training. Start with stable and move to a dynamic base with increasing visual input

• Strength training to gradual increase in load aiming towards 6 repetitions. Focus on control and strength development

• Direction changing

Criteria to move to the next phase: Near full range of motion, no swelling or pain, good muscular control and strength.

Phase 3: From a minimum of 12 weeks post-operative to 6 months post-operatively

Goals

Achieve full range of motion, increase muscle control and increase loading

Action

• When strength development begins to flatten out strength training can focus towards stability through motion and strength development with increased repetitions. Strength training can push to fatigue including drop sets without pauses.

• When strength and stability allow hopping and landing exercises can be introduced. Focus on stability and soft landing. Also focus on rapid power development. 5 x 5 repetitions

• Light jogging on a treadmill. Requires full range of motion, good quadricep control, and 30 minutes of walking without pain or swelling

Criteria for the next phase

Control full knee extension in high stepping, full knee flexion, no swelling, complete 10 hops on a low step block, run 10 minutes with good stability and without provoking pain or swelling. Strength and hop tests are over 85% of the normal side.

Phase 4: From 6 - 12 months post-operatively

Goal

Return to sporting and work activity

Action

• Push hop and landing training

• Strength training

• Sport specific and activity of daily living specific training

Criteria for return to sport: No swelling or pain with training activities

Test

• Isokinetic strength test >90% compared with the non-injured side

• Four one leg hop test > 90% compared to non-injured side

• Single hop

• Triple zig zag hop

• Six (6) meter hop timed

• IKDC questionnaire > 90%

Recommend waiting to 9 months to return to contact or pivoting sporting activity to minimise the risk of re rupture.