ACL Reconstruction- Rehabilitation and Return to Sports

ROM & Flexibility
⦁ Mobilizations if needed to achieve end ranges

Muscle Strength & Endurance
Quadriceps:
⦁ Terminal extension with tubing – forward and backward facing
⦁ Shuttle: full and inner range squats, 2 🡪 1 leg, increasing resistance
⦁ Walking in Bungee cord forward/backward/side step with slow control on return
⦁ Lunging in Bungee – forward/backward/diagonal
⦁ Step-ups 6-8”step forward/lateral (vertical trunk, watch for hip hiking or excessive ankle dorsiflexion)
⦁ Eccentric lateral step down on 2 🡪 4 🡪 6″ step with control (watch for hip hiking or excessive ankle dorsiflexion)(15)
⦁ Static Lunge (¼ – ½ range) 🡪 progress to dynamic lunge step (¼ – ½ range) with proper trunk and leg alignment
⦁ Full wall squats to 90°
⦁ Initiate isokinetic program if patient is appropriate and equipment is available
(see reference for timelines and ROM restrictions)(37)**

6-9 WEEKS continued

Hamstrings/Gluteals:
⦁ Continue hip strengthening with increased weights/tubing resistance
⦁ Supine on floor legs on swiss ball: bridging plus knee flexion (heels to buttocks)
Prone active hamstring curls – progress with 1-2 lb weights
⦁ Standing hamstrings curls – when able to attain 90° ROM against gravity add 1-2 lb weights
⦁ Sitting hamstring curls with light tubing/pulley system for resistance
⦁ Fitter: hip abduction and extension (poles for support)
⦁ Shuttle standing kick backs (hip/knee extension)
⦁ Tubing kickback (mule kicks)
Calves:
⦁ Shuttle heel drops 2 🡪1 leg
⦁ Mini trampoline: weight shift heel drops/bouncing

Proprioception
⦁ Continue on wobble boards and begin to add basic upper body skills (i.e. throwing)
⦁ Mini trampoline: single leg stance, +/– Bodyblade above/below head
⦁ BOSU marching: progress with high knees
⦁ Progress Dynadisc or BOSU 1 leg balance with/without support
⦁ Dynadisc or BOSU squats (60-90°)
⦁ Dynadisc or BOSU stand on 2 legs, with throwing to Rebounder™

Hydrotherapy / Pool
⦁ Knee ROM
⦁ Walking forward/backward, static lunge, lunge walking, squats, side shuffles, step up/down, calf raises (2-1 foot)
⦁ Hip extension/flexion, adduction/abduction
⦁ Deep water: stride walking, cycling, flutter kick

Cardiovascular Fitness
⦁ Bike, increasing time or resistance
⦁ Stairmaster: forward/backward – progress to no hand support
⦁ Swim – Flutter kick only
⦁ Pool jogging – deep water jogging
⦁ Treadmill – walking, increase speed +/– visual (mirror) or auditory (metronome) feedback(12,20)

⦁ GOALS
⦁ Continue flexibility exercises

9-12 WEEKS
LEFS range: 55-66

⦁ Quadriceps strength progression
Address documented hamstring strength deficits (high speed, eccentric 95-60°)(23)
⦁ Continue lower chain concentric/eccentric strengthening of quadriceps & hamstrings, both inner range (60–95°) & full range
⦁ Proprioceptive progression
⦁ Sport specific cardiovascular fitness

⦁ EXERCISE SUGGESTIONS
Muscle Strength & Endurance
Quadriceps:
⦁ Progress resistance of Shuttle: full ROM and inner range (60-95°), working on strength & endurance, 2 🡪 1 leg
⦁ Static Lunge (full range) 🡪 dynamic lunge 🡪 lunge walking all with proper trunk and leg alignment
⦁ Backward step up 4-6-8”step
⦁ Clock face lunges with Bungee using mini pylon markers
⦁ Quick walk forward/backward with Bungee
⦁ Quick side stepping with Bungee
⦁ Quick lunge forward with control (upright trunk, no forward thrust, no hip hiking)
⦁ Eccentric Bungee
⦁ Eccentric step down with control on 6 🡪 8” step
⦁ Shuttle jumping (low resistance) 2 legs 🡪alternate legs (jogging) 🡪single leg
⦁ Shuttle ski hops (side-to-side)
⦁ Continue / progress isokinetic program if patient is appropriate and equipment is available (see reference for timelines and ROM restrictions)(37)**
Hamstrings/Gluteals:
⦁ Prone/standing pulley knee flexion
⦁ Chair walking
⦁ Prone eccentric hamstrings with pulleys/tubing, alternating inner range and full range
⦁ Hydrafitness (hamstrings & quadriceps): 90-30°, resistance 1-3
⦁ Continue hip strengthening with increased weights/tubing resistance
⦁ Sitting and standing hamstring curls – Bungee/pulleys/ weights sitting and standing positions – address full range concentrically and inner range from 95-60° eccentrically and high velocity (if pain free & without difficulty)
⦁ Supine eccentric hamstrings with knee in extension
Calves:
⦁ Eccentric heel drops

9-12 WEEKS continued

Proprioception
⦁ On boards/Dynadisc/BOSU/foam roller/mini trampoline: catch and throw (2 hands/1hand) at varying angles and directions with partner or using rebounder
Dynadisc or BOSU throwing on rebounder feet side-to-side, forward/backward, 2-1 foot
⦁ Perturbation drills(8,42) with tubing on boards/ Dynadisc/BOSU /foam roller/mini trampoline
⦁ Single leg stance on Dynadisc or BOSU with unaffected leg performing kicking drills +/– tubing/pulleys
⦁ Single leg stance on Dynadisc or BOSU performing kicking drills +/– tubing/pulleys
⦁ Single leg stance on Dynadisc or BOSU performing higher end upper body skills

Hydrotherapy / Pool
⦁ Increase time, speed, repetitions of exercises
⦁ Pool running

Cardiovascular Fitness
⦁ Bike: increased resistance and time parameters
⦁ Fitter: slalom skiing without ski pole support
⦁ Treadmill walk +/– incline(29) 🡪 quick walk

⦁ GOALS

12-16 WEEKS
LEFS range: 55-66

⦁ Continue with flexibility exercises for the lower chain
⦁ Continue strengthening of the lower chain
Sport specific quadriceps & hamstrings strengthening
⦁ Sport specific proprioception training
⦁ Sport specific cardiovascular fitness

⦁ EXERCISE SUGGESTIONS
Muscle Strength & Endurance
⦁ Continue with concentric and eccentric strengthening of hamstrings and quadriceps, working through full & inner range
⦁ Backward lunge – progress to backward lunge walking (with proper trunk and leg alignment)
⦁ Bungee jogging – progress to running
⦁ Split squat jumps – progress to BOSU
⦁ Single leg drop landing 2” step

Agility is the ability to move, and change direction and position of the body quickly and effectively with control.
Agility
⦁ Ladder drills – forward/backward, side-to-side (focus on footwork/speed/timing)
⦁ 2 legged lateral and forward jumping
⦁ Side step-overs (hurdle) – progress to side hop-overs
⦁ Carioca patterning
⦁ Tuck jumps
⦁ Skipping
⦁ Initiate 2 legged hop tests (hop for distance, 6-m timed hop, triple hop, crossover hop) prior to single leg hop tests in next stage – ensure patterning and landing is proficient prior to 1 leg progression

Proprioception
⦁ Mini trampoline: 2 feet jump & land 🡪jogging 🡪1 leg hopping (1L/1R, 2L/2R, 3L/3R…)
⦁ Continue progressing skill difficulty
⦁ Single leg stance – tap down clock drill with mini pylons
⦁ Dynadisc or BOSU: 1 leg balance with upper body or opposite leg skill i.e. throwing, phantom kicking with Bungee resistance, hockey shot….

12-16 WEEKS continued

Hydrotherapy / Pool
⦁ Progress to plyometrics: 2 leg hopping, forward/backward/side-to-side
⦁ Split squat jumping

Cardiovascular Fitness
⦁ Bike – standing with interval training
⦁ Sport specific cardiovascular training: aerobic vs. anaerobic training
⦁ Jogging – straight on flat ground, no cuts/no downhill
⦁ Treadmill – jog 🡪 interval running🡪 running
*Note: Progression to running may only occur once a symmetric and proficient pattern has been attained to prevent abnormal tissue/joint loading in the lower extremity. Running should NOT be initiated if swelling, loss of motion or patello-femoral pain is present.

⦁ GOALS

16-20 WEEKS
LEFS range: 61-76

⦁ Sport specific quadriceps, hamstrings and lower chain strengthening progressing to plyometrics
Proprioception training
⦁ Sport specific cardiovascular fitness

⦁ EXERCISE SUGGESTIONS
Muscle Strength & Endurance
⦁ Continue with lower extremity strengthening with specific emphasis on client–specific deficits
⦁ 2 🡪 1 leg progression for all exercises

Plyometrics are exercises that enable a group of muscles to reach maximal strength in as short a time as possible. They help bridge the gap between speed and strength training. Adequate concentric & eccentric strength is essential before initiating plyometrics. If needed, start them in the pool in shallow water to decrease stress on the tibiofemoral and patellofemoral joints; otherwise initiate on land as tolerated.
Agility drills should commence by introducing proper footwork, timing and speed. Once the client is able to successfully and appropriately run in a straight line,without difficult, non-linear activities may be initiated, such as cutting and pivoting. These drills should commence by introducing large angles and low speeds (ie. large figure 8s) and progress to more advanced drills with sharper angles and increasing speeds(20)
Plyometrics and Agility
⦁ Ladder drills – incorporate lateral movements/diagonals, adding single leg and crossover patterns
⦁ Running/lunging/vertical jump/ run-plant-sidestep with Bungee – may incorporate upper/lower body skill – kicking, jumping, catching, pass & shoot
⦁ Shuttle hopping 2 – alt – 1 (high resistance, increased speed)
⦁ Shuttle Ski hops (high resistance, increased speed)
⦁ Carioca ¾ jog
⦁ Mini trampoline: 2 leg jump off – 2 leg land with progression to one leg land on/off balance pad/BOSU (watch for proper landing mechanics)
⦁ Single leg forward and lateral hopping
⦁ Hop tests: single hop, 6-m timed hop, triple hop, crossover hop
⦁ Vertical jumps – single leg
⦁ Box hop up /down
⦁ Box jump down with sprint forward
⦁ Box drop jump 2 legs with proper form may progress to drop jump with vertical hop for maximum height
⦁ Single leg drop landing 4-6-8-10” step