Rehabilitation following an ACL repair is necessary for complete recovery and to reduce the risk for an injury recurrence. The process is long and arduous, but the goal is to get each patient back into shape for all of the demands they will face both on and off the field.
ACL Graft Selection Considerations
There are a few things that can affect how your acl physical therapy will progress. The first thing to be aware of is where the tissue graft for the ACL comes from. Graft selection is surgeon dependent and they should advise you of which graft they hope to use prior to surgery. An autograft is a repair that uses a piece of tissue from the patient receiving the surgery. This tissue usually comes from the patellar tendon, quad tendon, or hamstring tendon. An allograft comes from a piece of tissue from a donor body.
- Considerations for hamstring tendon autograft: Delays ability to strengthen hamstrings for about 12 weeks
- Considerations for allografts: Increased time to revascularization: Time on crutches generally increases
Concurrent Injury Considerations
Other considerations following surgery are given if there was a secondary injury to a meniscus when the injury occurred. Depending on the type of injury to the meniscus, the surgeon may decide to do a menisectomy (removal) or meniscal repair during the ACL surgery. This can have an impact on the rehabilitation plan.
- Considerations with meniscal repairs: Use of crutches with weight bearing restrictions for 6 weeks
- Considerations following menisectomy: Likely no impact on rehabilitation for the ACL
ACL Physical Therapy Repair Protocol: Weeks 1-6 ACL Rehab Exercises
Generally, the first few weeks of rehabilitation include protecting the graft and controlling inflammation, mobility exercises to restore range of motion, and promote muscle activation throughout the quad muscles. It is crucial to follow a home program dedicated to improving range of motion during this phase. Movement will promote increases in motion, reduction in swelling and stiffness, and can also help with relieving pain and discomfort.
The other goal of this time period is to improve muscle activation throughout the quads and other muscles surrounding the knee joint. The sooner muscle activation and quad control improves, the sooner crutches can be removed for ambulation (except for surgeries with a meniscus repair). Sometimes if the quads are not activating as expected (which can happen due to nerve blocks used during surgery or pain), electrical stimulation is used to promote a contraction within the muscle.
Benchmarks: Full extension ROM; reduced swelling, reduced pain, no extension lag during straight leg raise
ACL Physical Therapy Repair Protocol: Weeks 6-10 ACL Rehab Exercises
Range of motion will continue to be progressed during this phase of rehab following an ACL repair. The goal will be to attain full flexion range of motion, and to continue working on extension as well, although most patients will have achieved full extension ROM by this point.
Strengthening will progress in this phase with emphasis on weight bearing exercises including squats, lunges, and step-ups. Special attention will be paid to the quads during strengthening, as these muscles are usually affected most following the surgery. Single leg exercises are likely to be performed as there will be a deficit, but it is important to work the other side at home when possible as there is research that there can be carry over to the affected side when exercising the uninvolved side.
Balance exercises will be initiated in order to begin improving your proprioception. Proprioception is your joint sense of how it is performing in various activities. There are sensors within all of the tissues surrounding your joints that give your brain information about how much tension and load is on each tissue as well as what position the joint is in. This joint sense is extremely important for successful completion of most activities including running, cutting, and jumping.
Benchmarks: Full range of motion, normal gait mechanics, reduced pain with weight bearing activities
ACL Physical Therapy Repair Protocol: Weeks 10-16 ACL Strengthening Exercises
Strengthening, balance, and proprioceptive exercises will begin to get more challenging during this phase to further progress back towards functional activities. Increases in loading will be used throughout strengthening exercises with the goals of getting the surgical leg stronger so the strength deficit from side to side continues to decrease.
Balance and proprioceptive exercises will be prescribed to have the patient move outside of straight plane movements to ensure that the knee is able to stabilize with more complex movements.
Running is likely to be initiated during this phase for most patients. Focus will be on correct form vs. speed or pace. We follow a return to run protocol developed by the JOSPT to progress our patients through the running phase. We also follow the soreness rules laid out in the article to ensure that running is being tolerated and progressed appropriately.
Benchmarks: Full ROM, normal gait/running mechanics, improved strength
ACL Physical Therapy Repair Protocol: ACL Rehab Exercises 3-6 Months
Progression into hopping, cutting, change in direction and agility. This phase is used to begin progressing our patients to return to sport and prior activities. Movements may include box jumps, the use of the agility ladder, shuttle runs, running against resistance, etc. During this phase our patients finally feel like the finish line is in sight.
Hop testing and functional capacity measures will be performed during this phase as a benchmark for successful return to sport-specific activities. These benchmarks including hop testing and a single leg squat test allow our clinicians to determine how much of a strength and stability deficit continues to remain. This allows us to determine a more accurate return to sport guidelines while reducing the risk for an injury recurrence.
Benchmarks: Passing all functional testing measures
ACL Physical Therapy Repair Protocol: ACL Rehab Exercises 6 months
Progression into sport specific drills and reintegration into on-field sport training. This stage is generally carried out independently by the patient and with coordination with the coaching staff. Our therapists will remain in contact with our patients during this time to ensure successful reintegration into sport and function.