Overview
In my previous blog, I briefly discussed ACL surgical reconstruction versus conservative, exercised based treatment alone. Ultimately the end goals for ACL pre-surgery / prehab, ACL post-surgery rehab and non-surgical, conservative rehab are all similar. The path to those goals can differ though. Having a physiotherapist and an orthopedic surgeon in your corner will ensure you are guided down the correct path and any variations in your case are treated appropriately whether that is a concurrent meniscus injury, secondary low back pain or a previous ligament tear. The type of surgical repair performed can very between autograft and allograft. Autografts are when the patient's own tissue from another body part is used to reconstruct the ACL. Common grafts used are the patellar and hamstring tendons. Depending on the approach used, early rehab can differ and affect which exercises are selected by your physio. Below are general goals of rehab after ACL reconstruction surgery that are followed but should be supervised with your physio! Your surgeon may provide a more specific protocol given your case.
GOALS OF ACL REHABILITATION
Weeks 0-2: Immediate Post-Operation
Focus – Reduce swelling and improve RANGE OF MOTION (ROM)
Reduce swelling and pain with exercise, cryotherapy, and electrotherapy
Improve knee flexing (bending) to 100 degrees with exercise and manual therapy
Improve knee extension to a straight position with exercise and manual therapy
Activate the quadriceps muscles followed by hamstrings, glutes, calves and abs with exercise and neuromuscular electrical stimulation (NMES or EMS)
Regaining full weight bearing on the surgical leg with gait retraining exercises
Weeks 2-4: Early Post-Operation
Focus – Improve ROM and initiate BALANCE exercises
Minimal to no swelling
Knee bending up to 115 degrees by week 3
Full hamstring flexibility
Continued muscle activation and starting balance exercises
Quadriceps strength >50% of the other leg
Maintain cardiovascular fitness
Weeks 4-12: Intermediate Post-Operation
Focus – Improve STRENGTH/ENDURANCE gradually, continue with balance
Full knee range of motion
Quadriceps strength 80% of the other leg
Full squat
Good balance
Unrestricted walking
Increase cardiovascular fitness towards end of the phase
Month 3-6: Advanced Phase
Focus – Normalizing exercise, preparing for return to sport
Full lower leg strength and power
Return to running and agility drills
Sport specific drills and increase cardiovascular fitness
Month 6-12: Return to Sport/Activity
Focus – Overall conditioning and remaining deficits before full return
High level sport specific exercises
Gradually progressive return to sport
Bottom Line
Whether you have undergone ACL surgery or gone the conservative, non-surgical approach, certain goals should be met in a timely manner. Exercise will be one of the most important pieces of your rehab, and your physical therapist will select the most appropriate ones for you. Your physio can also provide adjunct, complimentary treatments to facilitate your recovery such as manual therapy, modalities (cryotherapy, electrotherapy) and education/guidance.
References
Brukner, P. & Khan, K. (2012). Clinical Sports Medicine (4th ed.). Sydney, AU: McGraw-Hill.
Douglas, A., Logerstedt, D., Hunter-Giordano, A., Axe, M., & Synder-Mackler, L. (2012). Current conceps for anterior cruciate ligament reconstruction: A criterion-based rehabilitation progression. Journal of Orthopedic & Sports Physical Therapy, 42(7):601-12.
Physiotherapy following ACL reconstruction protocol. (2015) Retrieved from http://www.fowlerkennedy.com