Eastern Suburbs Sports Medicine Centre
& Eastside Physiotherapy
ACCELERATED ANTERIOR CRUCIATE LIGAMENT REHABILITATION PROGRAM (Hamstring graft)
Alan Davies & Diane Long (APA Sports Physiotherapists)
The following ACL reconstruction rehabilitation program is our current regime and is based upon current clinical information regarding open and closed chain exercise, early mobilisation, progressive controlled loading of the knee joint and years of experience in returning people back to their previous level of sport or recreation.
The time frame stated in this program should be flexible and act only as a guide. Progression should be based on an individual basis. Factors that may influence expectations of progression include the patient’s age, their attitude to exercise, associated pathology including meniscal, chondral and other ligamentous damage.
STAGE ONE - ACUTE POST OP
Time Frame 0-2 weeks
1. Wound healing (sutures removed approximately day 10).
2. Reduce post operative pain and swelling.
3. Regain full extension.
4. Full weight bearing.
5. Wean off crutches and normalise gait.
6. Promote muscle control.
1. Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise.
2. Patella mobilisation.
3. Active range of motion of the knee joint, calf and gentle hamstring stretching, co-contraction (non weight bearing progressing to standing) to aid in re-gaining range of movement, muscle control and full weight bearing. Aim for full extension within two weeks. Full flexion will takelonger and will generally steadily improve without the effort of focal heavy stretching.
4. Gait retraining encouraging extension at heel strike. Full weight bearing is encouraged.
Nb. As hamstring strains and pain are common in the first six weeks, care needs to be taken with the intensity of hamstring activation on co-contraction exercises. Over emphasis of hamstring contraction may lead to hamstring strain at this stage. Light hamstring loading continues into the next stage with progression of general rehabilitation. Resisted hamstring loading should be avoided until approximately week six.
STAGE TWO - QUADRICEPS CONTROL
Time frame - 2-6 weeks approx.
1. Full active range of movement
2. Normal gait with reasonable weight bearing and walking tolerance
3. Minimal pain and effusion
4. Develop muscular control for a controlled pain free single leg lunge
5. Avoid hamstring strain
6. Develop early proprioceptive awareness
1. Use active, passive and hands on techniques to promote full range of movement.
2. Progress closed chain exercise (quarter squats and single leg lunge) as pain allows. The emphasis is on pain free loading, VMO and gluteal activation.
3. Introduce gym based exercise equipment including leg press and stationary cycle.
4. Once the wounds have healed water based exercise can begin. This can include wading, bicycle action in the water, simple range of motion and gentle swimming (no breaststroke).
5. Begin proprioception exercises including single standing leg balance on the ground and on the mini-tramp. This can be progressed by introducing body movement whilst standing on one leg and including wobble board.
6. Develop a calf strengthening routine including bilateral calf raise progressing to single calf raise and stretching.
7. Refrain from isolated loading of the hamstrings (due to ease of tear). Hamstrings will be progressively loaded through closed chain and also gym based activity during this stage.
STAGE THREE - HAMSTRING/QUADRICEPS STRENGTHENING
Time Frame - 6-12 weeks
1. To begin specific hamstring loading.
2. Increase total leg strength.
3. Promote good quadriceps control in lunge and hopping activity in preparation for running.
1. Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation.
a. Active prone knee flexion which can be quickly progressed to include a light weight and then gradually progressed by increasing the weight.
b. Bilateral bridging off a chair. This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen.
c. Single straight leg dead lift (single bend over) initially active and then can be mademore difficult by adding weights.
Key points with hamstring loading are that to never pushed into pain and volumes and intensities are carefully progressed. Any minor setback of subtle strain or tightness post exercise should be managed with a downgrading of hamstring based exercises.
2. Gym based activity including leg press, light squats and stationery bike can be progressively increased in intensity as pain and control allow. A key point is to monitor effusion post exercise. Any effusion that is exacerbated with exercise should signal a reduction of training intensity.
Once single leg lunge control is good comparable to the other side hopping can be introduced. Hops can be made more difficulty by including variation such as forwards/back, side to side off a step and in a quadrant.
4. Running may begin towards the latter part of this stage. Certain criteria must be met prior to the onset of running.
a. No anterior knee pain.
b. A pain free lunge and hop that is comparable in control to the other side.
c. The knee also must have no effusion.
d. Good control on single hop painfree
e. Good tolerance to distance walking.
Jogging should begin with a walk/jog. Ideally, this is done on a treadmill to monitor landing action and also to carefully monitor effusion post exercise. Again, any increase in effusion following jogging should be met in a reduction in training intensity. Walk/jogging should be attempted for 2-3 times per week for 1-2 weeks before progressing onto jogging alone.
5. Proprioception exercises are made more difficult with more aggressive manoeuvres in standing leg balance, wobble board and also by progressing hopping based activity.
6. Expand calf routine to include eccentric loading.
STAGE FOUR - SPORTS SPECIFIC
Time Frame - 3-6 months
1. Increase total leg strength.
2. Develop running endurance speed, change of direction.
3. Advanced proprioception.
4. Neuromuscular training, developing good landing mechanism on jump and hop activity and PEP style activity
5. Preparing for a return to sport and recreational lifestyle.
1. These activities should build in intensity and volume over this time frame. Controlled sport specific activities should be included in the progression of running and gym loads through this time frame. Increasing effusion post running that isn’t easily managed with ice should result in a reduction of running loads.
2. Advancing neuromuscular and proprioception to include controlled hopping, jumping and landing (soft landing with adequate knee flexion and ankle dorsiflexion and good knee in line with toe alignment) , running with change of direction and balance correction.
3. Continue to increase intensity with training loads of gym based exercise program.
4. Monitor potential problems associated with increasing loads.
5. No open chain resisted leg extension unless authorised by your surgeon.
STAGE FIVE - RETURN TO SPORT
Time Frame - 6 months plus
1. A safe return to sport and normal recreational lifestyle.
1. Full training for 1 month prior to active return to competitive sport.
2. Preparation for body contact sports. Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training.
3. To develop running endurance as to be able to handle a normal training session.
4. Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity. Strength estimates to within 10% of other side on multiple testing involving quads, hamstrings and calves.
5. Single leg hop and multiple hops for distance within 10% of other side
6. PEP and FIFA 11+ are examples of programs that have been shown to reduce ACL injury rates. These kinds of programs or variants with sport specific additions should be incorporated into warm ups longer term to reduce risk of recurrence. Australian Netball have produced an excellent version of this that is netball specific
7. Psychological readiness for return to sport comes with thorough late stage rehabilitation. ACL-RSI is a useful measurement tool (App or online) to determine psychological readiness
8. Reinjury rates are higher in reconstruction patients under 18 years old and also in those returning to sport inside of 12 months post op. Consideration should be given to holding back return to sport in this group however this may depend on individual circumstances and how high risk the sport is in managing return to sport
1. Infection. The patient may complain in the acute post op period of significantly increased pain (constant throbbing in nature), fever and be generally unwell. The knee may present with increased swelling and demonstrate heat. The surgeon should be contacted immediately.
2. Deep venous thrombosis. Increased swelling, tenderness to palpation and pain particularly in the calf may be signs of a DVT. Again, this should be assessed immediately by the surgeon.
3. Functional instability. Poor quadriceps control and too early removal of crutch usage may result in the patient feeling that their knee gives way or feels unstable. This is not related to a structural instability but rather a lack of quadriceps control due to pain and swelling associated with the surgery.
4. Hamstring strain and pain. As hamstring tendons (semi-tendinosis and gracilis) are utilised as a graft donor site, hamstring soreness is typical in the acute post op period. Over zealous rehabilitation and daily activity can lead to hamstring strain which can delay progression and require modification of rehabilitation.
5. Poor range of motion. Current surgical techniques usually allow for relatively quick restoration to full range of movement. Fortunately, arthrofibrosis is quite rare. Delaying surgery for several weeks following initial injury can reduce the risk of arthrofibrosis. Regaining full extension and muscle control in end range of extension is a priority early in rehabilitation. This is essential in the restoration of a normal gait. Exercise, calf and hamstring stretching, gentle extension stretches, soft tissue techniques and patella mobilisation will promote full extension. Flexion will usually progress with rehabilitation and only require to be pushed in later stages if full flexion has not been restored.
6. Recurring effusion. Persistent or recurring joint swelling may be a problem through the mid-late stages of rehabilitation. Typically, it may happen in those patients who have had meniscal and/or chondral pathology or those who spend long periods in standing. It is also common with significant progressions in running and training intensity. Anti-inflammatory medication and ice following rehab can also be useful strategies to manage the persistent effusion. A cautious approach to rehab and running progression is also essential.
7. Anterior knee pain. This can be a problem at any stage through rehabilitation. Poor VMO, too rapid progression of closed chain exercise, over zealous daily activity, abnormal gait (flexed knee at heel strike), too early return or too sudden progression of running loads may overload the patellofemoral joint and/or patella tendon and cause irritation.
8. Poor landing mechanism. Patients with reduced quadriceps control on lunging and hopping activity (reduced knee flexion on landing) are not ready to resume running and doing so usually results in altered running action causing joint soreness and potentially patella tendonitis or patellofemoral pain.
9. Graft failure. Graft failure can occur. The risk of graft failure should not prevent a person from returning to their pre-injury level of sport or activity once full function of their knee is restored.