ACL Rehabilitation

General principles of ACL rehabilitation

ACL rehabilitation emcompasses the initial period after injury and again after reconstruction, when there may be blood or fluid in the joint and the quads muscle is likely to be inhibited, through the early phase of healing when the new ligament is gaining a blood supply, then on into the period of improving range of motion and building muscle strength, right to the final stage of return to full activities and eventually possibly sports.

Focus should be on avoiding stressing the new ligament inappropriately, while the progression of exercise should be appropriate to the phase of healing reached.

• Quote from peer-reviewed paper:

  After ACL reconstruction "....no brace or length of brace wear demonstrated an advantage over another type of brace, another duration of bracing, or no bracing at all. Bracing does not provide any benefit and is not necessary...."

  Citation: Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012 Oct 3;94(19):1737-48. doi: 10.2106/JBJS.K.01246. PMID: 23032584; PMCID: PMC3448301.

• Quote from peer-reviewed paper:

  ....Current evidence suggests average long-term outcomes are similar following management of ACL rupture with [ACL reconstruction] and rehabilitation or with rehabilitation alone...."

  Citation: Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47. doi: 10.1016/j.berh.2019.01.018. Epub 2019 Feb 21. PMID: 31431274; PMCID: PMC6723618.

• Quote from peer-reviewed paper:

  "....guidelines should be followed that allow the rehabilitation specialists to progress the patient as improvements in strength, edema, proprioception, pain, and range of motion are demonstrated...."

  Citation: Cavanaugh JT, Powers M. ACL Rehabilitation Progression: Where Are We Now? Curr Rev Musculoskelet Med. 2017 Sep;10(3):289-296. doi: 10.1007/s12178-017-9426-3. PMID: 28791612; PMCID: PMC5577427.

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Phases of ACL rehabilitation

Acute phase immediately after injury or immediately after reconstruction

This phase of rehab should be started as early as possible, and the focus should be on regaining passive ROM, and starting to overcome quads inhibition to allow reasonable active ROM.

• quadriceps sets
• active straight leg raise
• prone hangs
• heel slides or facilitated heel slides

Intermediate phase some time after injury or reconstruction

In this phase the aim is to help the knee feel reliable again, challenging nervous control and also muscle balance and responsiveness.

• perturbation training training and balance training, such as wobble board
• agility drills, such as figure-of-eight
• plyometrics

Phase of preventing re-injury

Here the focus is on rebuilding strength and agility appropriate to the social and sporting activities the patient is hoping to achieve.

Late phase

Here the focus moves on to strength, power and agility drills, and sports-specific training.

• Quote from peer-reviewed paper:

  "....Prior to returning to sport, specific objective quantitative and qualitative criteria should be met...."

  Citation: Cavanaugh JT, Powers M. ACL Rehabilitation Progression: Where Are We Now? Curr Rev Musculoskelet Med. 2017 Sep;10(3):289-296. doi: 10.1007/s12178-017-9426-3. PMID: 28791612; PMCID: PMC5577427.

• Quote from peer-reviewed paper:

  "....emphasis on posterior chain muscle group strengthening such as the gluteus maximus, gluteus medius, gluteus minimus, and hamstings reduces the load to the ACL by controlling frontal plane motion and improving neuromuscular control...."

  Citation: Raines BT, Naclerio E, Sherman SL. Management of Anterior Cruciate Ligament Injury: What's In and What's Out? Indian J Orthop. 2017 Sep-Oct;51(5):563-575. doi: 10.4103/ortho.IJOrtho_245_17. PMID: 28966380; PMCID: PMC5609378.

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Recognising complications during ACL rehabilitation

If there is a failure to make progress with extension during ACL rehabilitation, one must think of the potential complications of notch impingement and cyclops lesion.

Notch impingement is when the intercondylar notch has not be sufficiently widened to allow easy mobility of the graft during flexion and extension. If the graft keeps catching, it may start to strip a little with each passage and the stripped tissue can bunch up into a cyclops lesion, where a scarred lump can catch on the roof of the notch with each extension.

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Forum discussions

• Robs ACL Allograft Exercise Journal with Timeline

  A comprehensive explanation of a patient's rehabilitation regime, with discussion.

• Calf Pain after ACL Reconstruction (hamstring graft)

  Early-onset calf pain after hamstrings graft for ACL.

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