Dr. Jonathan Mulford, Orthopaedic Surgeon, NSW Australia Total Knee Replacement, NSW Australia
Sports Knee Ligament Reconstruction, NSW Australia
Knee Arthroscopy, NSW Australia

ACL Reconstruction Rehabilitation

Program formulated in Conjunction with James Sutherland (Physiotherapist Balmain Sports Physiotherapy)

Rehabilitation Protocol is based on evidence based Rehabilitation (See Evidence-based rehabilitation following ACL reconstruction - Knee Surg Sports Traumatol Arthrosc 2009)

ACL reconstruction information regarding the injury, surgical technique, risks of surgery and what to expect in the early postoperative period can be found in patient information at www.myorthopod.com.au

The Objectives of Knee Rehabilitation are:

  • To protect the joint in the early stages from further mechanical injury by using braces or crutches if required
  • To reduce internal swelling as soon as possible to allow full mobilisation and reduce discomfort
  • To minimise inflammation, to avoid scar tissue formation
  • To restore range of motion (ROM) to prevent later permanent limitation
  • To maintain muscle responsiveness and limit inhibition in the early phases and actual wasting in the later stages
  • To free adhesions so that they do not organise into thicker scar tissue, which might stiffen up the joint
  • To rebuild muscle strength to restore function , stabilise the joint and protect it from further injury
  • To restore gait patterns to prevent strain in the back or hip or the other leg
  • To restore proprioception or internal spatial awareness in the knee, to prevent damaging it again
  • To build endurance to return to target activities eg sport

Notes Regarding ACL Rehabilitation

Graft Protection:

The new graft is weakest between 6 and 12 weeks post-operatively. Therefore, BE CAREFUL DURING THIS PERIOD. (This is incorporated into your rehab program).

Early mobilisation: Has advantages such as maintenance of articular cartilage nutrition and bone mineralisation.

Closed chain exercises: Rather than open chain exercises are utilised and designed to minimise load on the ACL graft.

With an ACL injury there is loss of ACL mechanoreceptors: Therefore, there is a large emphasis on proprioceptive work in the rehab.

Terminology

Positions

  • Prone: lying on your stomach
  • Supine: lying on your back

Range of Motion (ROM)

  • ROM: Range of Motion; amount of bending and straightening of the knee
  • Flexion: bending
  • Extension: straightening
  • FWB: Full Weight Bearing
  • CKC: Closed Kinetic Chain; exercise with the foot in contact with a surface, ie: leg press, squats, lunge
  • OKC: Open Kinetic Chain; exercise when the lower leg is moving freely ie: leg extension

Muscle Groups

  • Quadriceps: muscles on the front of the thigh
  • Hamstrings: muscles in the back of the thigh

Specific types of Exercises

  • Concentric: the muscle is shortening while it is contracting (‘positive contraction”)
  • Eccentric: the muscle is lengthening while it is contracting (‘negative contraction”)
  • Isometrics: tightening/contracting of a muscle without movement of the leg
  • Plyometrics: exercises that enable a group of muscles to reach a maximum strength in as short a time as possible. It tries to bridge the gap between speed and strength trainings

Time Period: Day 1 to Day 10-14

Goals:

  • Increase ROM
  • Decrease pain
  • Minimise swelling

Activities:

Gait:

  • Weight bearing as tolerated with crutches
  • The physiotherapist will determine progression of 2 to 1 crutch
  • Must have full knee extension and walk without a limp beforewalking without crutch use
  • Our goal is to be off crutches after 10-14days

ROM:

Bike circles: high seat 1/2 circles backwards first then forward -> full circles -> lower seat Slider board; Heel slides; Ankle pumping; Prone leg hangs

Modalities:

Ice (I will provide you with a knee ice pack - you can use for 20 minutes every 3-4 hours while awake) Compression - tubigrip stocking
Muscle stimulation

Flexibility:

  • Calf stretches seated with towel
  • Standing hamstring stretches (with knee as extended as possible)
  • Supine hip flexor stretches

Balance/Proprioception:

1 foot standing 30-60 seconds eyes open->closed.

Strength:

Quads: CKC exercises – quadriceps tightening (isometrics) seated and in standing, weight shifting, sit to stand, static lunge, mini squat,

Hamstrings: isometrics , prone knee flexion, Outer range hamstring "flicks" at 0-30 degrees.

Time Period: 2-6 weeks

Goals:

  • Increase ROM – aim for 0-130 by 4-6 weeks
  • Increase weight bearing
  • Increase hamstring and quads control

Activities:

ROM:

Continue as outlined.
Pool - walking, squats, knee flexion, step-ups & downs

Flexibility: Continue as outlined

Gait: Normalize to full weight bearing

Cardio: Bike

Strength:
Quads: step ups 4-6-8” step fwd/lateral, 1/2 wall squats, shuttle leg press 2->1 leg, theraband lunge,

Hamstrings: prone hamstring curls

Balance/Proprioception: standing 1 foot eyes closed -> balance board, duradisc/foam.

Time Period: 6 - 12 weeks

NB: Graft is at the weakest point now
Avoid OKC exercises

Reasons why open kinetic chain (OKC) exercises (ie: leg extensions especially with weight) are contraindicated after ACL reconstruction:

  • When the quadricep muscle contracts with the above exercises, the lower leg (tibia) is pulled forward (shears) in relation to the upper leg (femur)
  • This shear directly stresses the reconstructed ACL graft
  • It is believed that these shearing forces may lead to stretching of the ACL graft that may result in increased laxity
  • Shearing is minimized if the force is maintained down the whole leg during muscle contraction (i.e. foot is fixed), and therefore Closed Kinetic Chain (CKC) exercises are recommended

Goals:

  • Improve neuromuscular control and proprioception
  • Strengthen hamstrings
  • Protect graft
  • Improve patient confidence
  • Full pain free ROM

Activity:

Cardio: Bike, fitter, stairmaster, swim (flutter kick only), pool, jogging , treadmill power walking

Strength:
Quads: stairmaster fwd/bkwd, theraband lunge in different directions, clock face lunges,
Hams: backward walking, ham curls progress concentric - eccentric

Balance/Proprioception: balance board progressions, duradisc progressions, trampoline balance

Time Period: 12 weeks - 5 months

Goals:

  • Sport specific cardio fitness
  • Sport specific quad and hamstring strength
  • Sport specific proprioception training
  • Continue with flexibility and strength of lower extremity
  • Incorporate agility and reaction time into proprioceptive work
  • Increase total leg strength
  • Develop patient confidence

Activity:

Cardio:

  • Treadmill jog-> run
  • Land jogging forward without cutting
  • Stationary jog against bungy cord resistance
  • Pool running
  • Bike standing with interval training
  • Mini tramp jumping 2->1 leg

Strength:
Quads/Hams: continue with CKC progressions increasing weight, theraband cord eccentrics - reverse lunges with variable speed, shuttle kick backs, high steps, lunge walking fwd/bkwd, split squats, ham curls all with emphasis on endurance, progress to pool plyometrics deep water ->shallow water

Balance/Proprioception:

Mini-tramp jump and land, 2 ->1 leg balance with upper body or opposite leg skill i.e., throwing on rebounder, phantom kicking with bungy cord resistance, throwing/passing drills, single leg balance clock drill with mini pylons.

Time Period: 5 - 6 months

Goal:

  • Back to sport practice for upper body skills
  • Continue with sport specific proprioception training
  • Continue with specific cardio fitness
  • Return to sport

Activity:

  • Practice Drill Ideas
  • Straight forward and backward running
  • Figure 8s gradually decreasing in size
  • Zig-Zag running
  • Cross over stepping
  • Backward with cutting
  • Stop and go drills

Functional Testing in Clinic:
Lunge walk with control both forward and backward Forward hop and lateral hop with control with comparable distances L and R side One foot hopping with control Triple jump and landing with control with comparable distances L and R side Sport specific demands with adequate skill, speed and control

PEP Program (Prevent Injury Enhance Performance)

This is a warm up exercise routine.
I believe it may help to prevent re-rupture and injury to the other leg ACL.
The program has shown to be effective in ACL rupture prevention in female college athletes.
The program can be found on youtube:

Knee Replacement Surgery, NSW Australia
Sydney Orthopaedic Surgeon, NSW Australia

I am a orthopaedic surgeon that specialises in all aspects of Hip and Knee surgery...

Meet Dr. Jonathan Mulford
Trauma Surgery, NSW Australia
Dr Mulford was awarded a Diploma in Clinical Trials from the University of London in 2008.
Clinical Research
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Revision Knee Replacement, NSW Australia  
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