ACL Reconstruction- Rehabilitation and Return to Sports
A Comprehensive Guide to ACL Rehabilitation
Rehabilitation following Anterior Cruciate Ligament Reconstruction (ACLR) is critical for achieving a full recovery. This guide aims to provide detailed instructions, direction, and rehabilitative guidelines to help patients and physiotherapists navigate the recovery process. Physiotherapists should use their professional judgment to tailor this protocol to each patient’s needs, considering the variability in individual progress and pre-operative conditions. Adjustments to exercises may be necessary based on the available equipment at each facility. It is important to customize this protocol to ensure the best possible recovery, especially when additional injuries such as meniscal tears, cartilage damage, bone bruising, or other ligament injuries are present.
This rehabilitation protocol extends over six months and is divided into seven timelines. Each timeline includes goals and exercise suggestions across several domains: range of motion and flexibility, strength and endurance, proprioception, gait, and cardiovascular fitness. Progression criteria within each timeline are based on achieving specific goals and the patient’s Lower Extremity Functional Scale (LEFS) score. Early rehabilitation focuses on regaining range of motion, normalizing gait, and activating the quadriceps muscle. To ensure a safe return to pre-injury activity levels, it is crucial to follow the protocol for the entire six months. The emphasis of rehabilitation should be on the 4-6-month period, where crucial skills such as plyometric training, agility drills, take-off and landing mechanics, patterning drills, and functional testing are introduced to assess readiness for returning to sport or activity.
The Rehabilitation Process
ACL rehabilitation typically involves several stages, each focusing on different aspects of recovery:
Immediate Post-Injury Phase: Managing pain and swelling, restoring range of motion, and beginning muscle activation exercises.
Early Rehabilitation Phase: Progressing to weight-bearing exercises, increasing strength and endurance, and enhancing proprioception.
Advanced Rehabilitation Phase: Incorporating functional exercises, sport-specific drills, and agility training.
Return to Sport Phase: Preparing the athlete for the demands of their sport through high-intensity training and psychological readiness.
Re-injury Risks and Prevention
Re-injury rates for ACL tears can be significant, especially if the return to sport is premature or if the rehabilitation process is incomplete.
• 0-2 WEEKS (LEFS Range14-24):
Goals:
. Patient education, re weight bearing status
. Decrease Pain and Swelling
. Increase range of motion and restore full extension
. Maintain flexibility of hamstrings, calves
. Quadriceps activation
. Proprioceptive, Balance Re-education
. Maintain cardiovascular fitness
EXERCISES
a.ROM & Flexibility:
-Heel slides
-Supine with legs up wall-heel slides with gravity assisted
-Bike pendulums: High seat ½ circles forward/backward > full circles lower seat-Sitting passive leg extension with roll under heel or prone leg hangs off end of bed or plinth
-Seated calf stretch with ball/towel(soleus), knee straight(gastrocnemius)
-Seated hamstring stretch (back straight)
b. Muscle strength & Endurance:
Quadriceps/Hamstrings:
Quadriceps and Hamstrings co-contraction
Quadriceps Isometrics in sitting, sitting, lying- stimulation or biofeedback
Sit to stand-progress by gradually decreasing height of seat
Static lunges forward/ side, Mini wall squat 30 degrees
Hip & Gluteal:
Side lying abduction or adduction
Gluteal squeezes supine or standing
Prone hip extension
Standing hip flexion/extension, abduction/adduction
Calves: Ankle pumping +/- with leg elevation, Standing calf raises with/without support
c. Proprioception:
With balance drills on unstable surfaces, be aware of and correct poor balance responses such as hip hiking with INV/EVER and trunk extension with DF/PF.
GOAL: maintain stance on board regardless of ability to control board position(20)
Proprioception
Single leg stance 30-60 seconds
Wobble boards with support (table, bars, poles) through full ROM: side-to-side, forward/backward
d. Gait
If patient has an antalgic gait pattern with use of 1 crutch, keep patient on 2 crutches until they can exhibit normal gait with 1 crutch.
Weight shifting: side-to-side and forward/backward(28)
Progress from 2 crutches to 1, always maintaining normal walking pattern
e. Modalities
Ice 15-25 minutes(24)
Interferential current therapy (pain relief)
Muscle Stimulation(49)
3-6 WEEKS continued
Progression of balance retraining should be from:
looking forward 🡪 looking away, eyes open 🡪 eyes closed, on a stable base 🡪 on an unstable base
Proprioception
⦁ Continue with full ROM on wobble boards with decreased support – progress to maintaining balance on board
⦁ Standing 747 eyes open/closed – progress to mini trampoline
⦁ Dynadisc or BOSU(round) 2 leg balance 🡪 weight shift forward/backward, side-to- side, eyes open/closed 🡪 progress to mini squats (0-30°)
⦁ Standing on ½ foam roller: balance🡪 rocking forward/backward
*Full knee extension is needed for normal gait.
Gait
⦁ “Cup walking”(14): forced exaggeration of knee and hip flexion during the swing phase of gait rather than a rigid knee with a compensatory hip hike (may use plastic cups/mini pylons/foam rollers to walk over to accentuate hip/knee flexion)
⦁ Progress from a single crutch to full weight bearing. Ensure NO antalgic gait pattern
Cardiovascular Fitness
⦁ Bike with increasing time parameters
⦁ May start elliptical trainer and progress to Stairmaster(36) if adequate strength has been achieved (must have no hip hiking when pressing down on step)
6-9 WEEKS
LEFS range: 45-59
⦁ Full and pain free knee range of motion
⦁ Functional quadriceps strength
Initiate isokinetic quadriceps strengthening in a specific & limited range(37)
**only if: ROM is full, no swelling, adequate muscle control, and no meniscal or patellofemoral pathology
⦁ Address documented quadriceps strength deficits (high and low velocity, concentric and eccentric, 0-95°)(23)
⦁ Continue strengthening lower extremity muscle groups, specifically through full range hamstrings/quadriceps (without pain at donor site)
⦁ Advance proprioception exercises
⦁ Increase cardiovascular fitness
⦁ EXERCISE SUGGESTIONS
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
16-20 WEEKS continued
Proprioception
⦁ Continue progressions e.g. mini trampoline with upper skills
⦁ Forward hop and lateral hop – maintain balance for 5 sec on landing
Cutting drills with quick stop and maintain balance
⦁ Bungee run plant/push off L&R
Cardiovascular Fitness
⦁ Increase distance, duration or intensity with bike, Stairmaster, treadmill, outdoor running/cycling depending on the demands of the particular sport
⦁ Treadmill: running 🡪 sprinting: assess sprinting form – should have normal pain-free rhythmic stride (audible monitoring of foot contact)(20)
⦁ Jogging and running on an uneven surface
⦁ Jogging with turns 90/180/360°
⦁ Jogging and cutting with 45° change of direction
⦁ Acceleration and deceleration running, add on tight turns and hills as tolerated
⦁ Cycling outdoors
⦁ Swimming – no whipkick
⦁ GOALS
20-24 WEEKS
LEFS range: 61-76
⦁ Adequate cardiovascular fitness, strength, power, agility neuromuscular control, symmetry and stability
Continue with upper body strengthening
⦁ Back to sport practice for upper skills (as able)
⦁ Return to sport skills on own at practice with minimal risk of re-injury
⦁ EXERCISE SUGGESTIONS
Plyometrics and Agility
⦁ Single leg drop jump 6” step
⦁ Large Figure 8’s
⦁ Carioca running full speed
⦁ Last minute decision drills
⦁ 2 and 1 foot hopping with control
⦁ Forward and lateral hop with control and comparable distance L&R
⦁ Triple jump and landing with control and comparable distances L&R
⦁ Single limb hop for distance (within 15% of uninvolved side)
⦁ Single-limb crossover triple hop for distance (within 15% of uninvolved side)
⦁ Single-limb timed hop over 6 m (within 15% of uninvolved side)
⦁ Single limb vertical power hop (within 15% of uninvolved side)
⦁ Single limb drop landing (within 15% of uninvolved side)
⦁ Single limb drop-jump
⦁ 10 second single limb maximum vertical hop (both sides)
1.Inadequate muscle strength, particularly in the quadriceps and hamstrings.
2.Poor neuromuscular control and proprioception.
3.Imbalance between the injured and uninjured leg.
4.Psychological factors, such as fear of re-injury or lack of confidence.
Return to Sport Tests
Determining when an athlete is ready to return to sport is critical and involves several objective tests:
Strength Tests: Evaluating the strength of the quadriceps and hamstrings to ensure symmetry between the injured and uninjured leg. The Limb Symmetry Index (LSI) should be at least 90% for safe return.
Hop Tests: Single-leg hop tests (single hop for distance, triple hop, crossover hop, and 6-meter timed hop) assess power, stability, and confidence in the injured leg.
Agility Tests: Shuttle runs, figure-of-eight runs, and cutting drills mimic sport-specific movements and test dynamic knee stability.
Neuromuscular Control Tests: Functional movement assessments, such as the Y-Balance Test, evaluate balance, coordination, and control.
Psychological Readiness: Questionnaires like the ACL-Return to Sport after Injury (ACL-RSI) scale measure the athlete’s mental readiness and confidence in their knee.
Combining Objective Measures with Clinical Judgement
While objective tests provide valuable data, clinical judgement plays a vital role in the decision-making process.
A comprehensive approach includes:
1.Regular assessments and monitoring throughout the rehabilitation process.
2.Tailoring the rehabilitation program to the individual athlete’s needs and sport.
3.Continuous communication between the athlete, physiotherapist, and sports physician.
Conclusion
Returning to sport after an ACL injury is a complex process requiring a combination of physical rehabilitation, psychological readiness, and careful monitoring. By incorporating rigorous return to sport tests and focusing on injury prevention, athletes can safely return to their sport with reduced risk of re-injury. Effective ACL rehabilitation is not just about recovery but ensuring athletes can perform at their best while minimizing future risks.
For more information on ACL rehabilitation and injury prevention, contact Sahasra Physio Rehab. Our experienced team is dedicated to helping athletes recover and return to their sport safely and confidently