Anterior Cruciate Ligament (ACL) Rehabilitation

 

The semitendinosus (hamstring) graft is utilized because of its excellent strength and low
harvest morbidity. The graft is precisely placed in the same location as the original ACL for
optimal healing and mechanical function and for safer rehab. Significant injury to the meniscal
cartilage is repaired if possible. This adds to the stability of the knee and diminishes the risk of
osteoarthritis later. During the rehabilitation period, we expect that patients will return to 0-135°
motion by 4 to 8 weeks. Closed kinetic chain activities and aerobic conditioning are emphasized
with bracing to protect the ACL graft as it heals and matures.

Three basic precautions:
1. Focus on closed kinetic chain activities
2. Only fully extend, or “lock out” your knee with a slow, controlled quad recruitment, or
controlled stretching: i.e. don’t “pop” your knee into full extension.
3. Avoid torsional/twisting/lateral stress during all rehab activity. Remember, cycling is super for
rehab after 6 weeks.

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ACL Rehab Program

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Bracing

1) Lock at 0° for one week (toe-touch weight-bearing and no ROM).
2) Shower without brace at one week.
3) Sleep without brace at one week.
4) Walk with brace locked at 0 degrees for first 6 weeks.
5) No cyclic stresses for 6 weeks.
6) Discontinue brace at five to six weeks with adequate quad strength.
7) Remove brace for stationary biking start after 6 weeks.

ROM/ Strengthening

1) Immediate isometric ham/quad co-contractions.
2) Passive ROM 0-135° (avoid hyperextension).
3) Safeguarded CKC (closed kinetic chain) exercises 0°-100° in rehab brace.
Recommended:
a) Squats
b) Seated toe drags
c) Toe raises
d) Treadmill walking
(inclines)
e) Biking with toe clips (after 6 weeks)
f) Pilates
g) Total Gym
h) Elliptical Trainer (after 6 weeks)
i) Leg Press
4) Incorporate single leg strengthening, balance, and proprioceptive exercises once good
eccentric
quad control is established.
5) Incorporate aquatic therapy where available once incision is well healed and sealed.

Goals

1) 0°-135° ROM by four to eight weeks.
2) Quad/ham strength 80-85% contralateral (opposite) limb by four months.
3) Sports specific training at three to four months with sports brace.
4) Return to sport at six months in sports brace.
5) Run/jog program at 3-4 months upon physician approval.

Troubleshooting

1) With meniscal repair:

Specific Needs

a) Lock brace at 0° for two weeks (increase weight-bearing at 2 weeks post-op).
b) Set brace 0-90 degrees for exercise.
2) With microfracture/mosaicplasty, see prescription for weight bearing timing.
3) Hyperlax patient:
a) Set brace at 10°-100° for exercise.
b) Avoid hyperextension with passive ROM.
4) Slow extension:
a) Adjust brace setting to 10°-100°
for exercise
b) Patellar glides
c) Extension sitting
d) Prone extension
e) Long striding gait
f) Stretch gastroc/hams 5 times a day
g) Remove brace for safe ADLs (optional)
h) Remove brace for passive ROM exercises
i) Soft tissue work to posterior musculature.
5) Slow flexion:
a) Patellar glides
b) Wall slides
c) Chair squats
d) Kneeling squats
e) Cycling
f) Remove brace for passive ROM exercises
g) Scar Mobilization
h) Retro-treadmill walking

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Range of Motion Exercises

FLEXION:

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A) Wall Slides

Lie on your back with your hips flexed 90 degrees and your foot positioned
on the wall. With gravity, slide your heel down the wall as far as possible
(use a sock to decrease friction). Pressure from your other
leg may be helpful.

B) Chair Squats

Sit in a chair with arm rests. With your foot firmly
planted, slide your hips forward while controlling body
weight with arms.

C) Kneeling Squats

While on hands and knees, lower hips backward toward feet.
When you feel a stretch, hold as long as possible.

D) Cycling

You may use a bike to gain range of flexion. Position the seat at a height which
allows you to pedal the bike without lifting off the seat. Progressively lower the
bike seat to achieve greater knee flexion.

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EXTENSION:

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1) Extension Sitting

Sit on floor or table with legs straight. Prop up feet so that knee is hanging
unsupported. Pull back on the foot with a strap while repetitively
contracting your quadriceps (quad sets).

2) Prone Extension

Lie prone with your foot and ankle hanging off the edge
of the bed or top of a staircase. Relax and let gravity
straighten the leg. To increase the stretch, place a light
weight around your ankle. Continue activity for 5 to 10
minutes.

3) Long Striding Gait

Increase your walking distance and also increase
the length of stride as much as possible. Use heel-toe walking.

4) Gastroc/Hamstrings Stretch

Stretch to the point of tension or mild pain. Use frequent repetitions and avoid
brute force! Hold each stretch for 15-30 seconds. Do not bounce or jerk while
stretching.

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Closed Kinetic Chain Exercises

Brace Setting 0°-100°

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Squats

Equal weight-bearing emphasized with knee
flexion no greater than 90°. Do not progress
in resistance or knee flexion if form forces
weight shift to unaffected side.
Single leg squats are recommended with the
Use of pilates, or total gym.

Seated Toe Drags

While seated in a chair, extend leg, point toe,
And press toe to the floor. Drag the toe along
the floor as the knee is bending. Resistance
increases as the toe is pressed more forcefully
to the floor.

Toe Raises

With brace at 0° to control hyperextension, raise
up on the ball of foot and slowly lower. Begin
exercise off the floor and progress to a small step to
allow greater range of motion as strength increases.

Treadmill Walking

With brace, start with 10 minutes and progress 5 minutes
per week until 30 minutes is achieved. Proper form must be
maintained in order to progress on the treadmill. Increase
uphill grade 2° per week until a maximum of 10° is reached.

Biking with Toe Clip

When a symmetrical spin is achieved, progress in time from 15 minutes
to 40 minutes at 5 minutes per week pace. Low load interval work can start
at 6 weeks post-op with 20 seconds on and40 seconds off. RPM is progressed
from 70 to 100 during the work phase.