1. Rehabilitation after ACL reconstruction
Pichet Yiemsiri

2. Over views Incidence: exact incidence is unknown United States:
200,000 are torn each year
100,000 ACL reconstructions are done each year
associated with menisci tear in 50% of case

3. Rehabilitation Considerations after ACL Reconstruction

4. ACL Reconstruction Rehabilitation
Evidences base
ACL Reconstruction Rehabilitation

5. Guideline on anterior cruciate ligament injury A multidisciplinary review by the Dutch Orthopaedic Association
Acta Orthopaedica 2012; 83 (4): 379–386

6. What is the outcome of different non-operative treatment modalities?
Scientific evidence
Level 1:
Balance and proprioception
Fitzgerald et al. 2000,
Cooper et al. 2005,
Trees et al. 2005, 2007

7. What is the outcome of different non-operative treatment modalities?
Scientific evidence
Level 2:
Addition of open-chain strength training
Supervised training
Zatterstrom et al. 2000,
Perry et al. 2005,
Tagesson et al.2008
Zatterstrom et al. 1998, 2000

8. What is the outcome of different non-operative treatment modalities?
Scientific evidence
Level 3:
wearing a knee brace
Swirtun et al. 2005

9. What is the optimal postoperative treatment ?
Scientific evidence
Level 1:
Wearing a knee brace has no additional treatment value after an ACL reconstruction
Closed-chain exercise
Wright and Fetzer 2007,
Anderson et al. 2009
What is the optimal postoperative treatment (after the first postoperative check-up, concerning rehabilitation, resumption of sports, and physiotherapy)?
Trees et al. 2005,
Wrightet al. 2008,
Anderson et al. 2009

10. What is the optimal postoperative treatment?
Scientific evidence
Level 2:
Addition of neuromuscular training
Early open-chain exercises will lead to more laxity with hamstring grafts
Risberg et al. 2007
(after the first postoperative check-up, concerning rehabilitation, resumption of sports, and physiotherapy)
Heijne and Werner 2007

11. Pain & effusion management
Cryo-therapy
Elevation
Compression
Anti-inflammatory medication

12. ROM exercise
Knee extension to 0 degrees after surgery while avoiding hyperextension
Prevent a flexion contracture
Hip AROM exercise 4 planes

13. Continuous Passive Motion
CPM is not warranted to improve rehabilitation outcome

14. Protocols after ACL reconstruction
Time frames and guidelines after ACL reconstruction vary widely.
Most protocols emphasize
Early motion
Developing quadriceps control early
Obtaining full passive extension
Controlled weight bearing
Initiation of closed-chain exercises

15. Preoperative Phase Goals Diminish inflammation, swelling, and pain.
Restore normal ROM (especially knee extension).
Restore voluntary muscle activation.
Provide patient education to prepare patient for surgery.

16. Preoperative Phase Brace Weight-bearing Exercises Ankle pumps.
Passive knee extension to 0°.
Passive knee flexion to tolerance.
SLR: three-way, flexion, abduction, adduction.
Closed-kinetic chain exercises: 30-degree mini-squats, lunges, step-ups.
Brace
Elastic wrap or knee sleeve to reduce swelling.
Weight-bearing
As tolerated with or without crutches.

17. Cryo-therapy/Elevation
Preoperative Phase
Muscle Stimulation
Electrical muscle stimulation to quadriceps during voluntary quadriceps exercises (4-6 hr/day)
Cryo-therapy/Elevation
Apply ice 20 min of every hour, elevate leg with knee in full extension (knee must be above heart).
Patient Education
Review postoperative rehabilitation program.
Review instructional video (optional).
Select appropriate surgical date.

18. Phase 1: Immediate Postoperative-Days 1-7
Brace
Transitional hinged brace locked in full extension during ambulation (Protonics Rehab System as directed by physician).
Weight-bearing
Weight-bearing as tolerated with two crutches.

19. Phase 1: Immediate Postoperative-Days 1-7
Exercises
Ankle pumps.
Overpressure into full passive knee extension
Active and passive knee flexion (90° by day 5)
SLR (flexion, abduction, adduction).
Quadriceps isometric setting.
Hamstring stretches.

20. Phase 1: Immediate Postoperative-Days 1-7
Muscle Stimulation
Used during active muscle exercises (4-6 hr/day).
Continuous Passive Motion
As needed, 0-45/50 degrees (as tolerated by patient and directed by physician).
Ice and Elevation
Ice 20 min out of every hour and elevate with knee in full extension (elevated above the heart with pillows below the ankle, not the knee).

21. Phase 1: Immediate Postoperative-Days 1-7
Goals
Restore full passive knee extension.
Diminish joint swelling and pain.
Restore patellar mobility.
Gradually improve knee flexion.
Reestablish quadriceps control.
Restore independent ambulation.

22. Phase 1: Immediate Postoperative-Days 1-7
Brace
EZ Wrap brace/immobilizer, locked at O-degrees extension for ambulation and unlocked for sitting (or Protonics Rehab System as directed by physician).
Weight-bearing
As tolerated with two crutches.
Range of Motion
Brace removed during ROM exercises 4-6 times a day.

23. Phase 1: Immediate Postoperative-Days 1-7
Exercises
Multi-angle isometrics and 90° and 60° (knee extension).
Knee extension degrees.
Overpressure into extension.
Ankle pumps.
SLR (three-way).
Mini-squats and weight shifts.
Standing hamstring curls.
Quadriceps isometric setting.
Proprioception and balance activities.

24. Phase 1: Immediate Postoperative-Days 1-7
Muscle Stimulation
Continue electrical muscle stimulation 6 hr/day.
Continuous Passive Motion
0 - 90° as needed.
Ice and Elevation
Ice 20 min of every hour and elevate leg with full knee extension.

25. Phase 2: Early Rehabilitation-Weeks 2-4
Criteria for Progression to Phase 2
Quadriceps control (ability to perform good quad set and SLR).
Full passive knee extension.
Passive ROM 0-90 degrees.
Good patellar mobility.
Minimal joint effusion.
Independent ambulation.

26. Phase 2: Early Rehabilitation-Weeks 2-4
Goals
Maintain full passive knee extension.
Gradually increase knee flexion.
Decrease swelling and pain.
Muscle training.
Restore proprioception.
Patellar mobility.

27. Phase 2: Early Rehabilitation-Weeks 2-4
Brace
Discontinue at 2-3 wk.
Weight-bearing
As tolerated (goal is to discontinue crutches 10 days after surgery).
Range of Motion
Self-ROM stretching exercises four to five times daily, emphasis on maintaining full passive ROM.
Swelling Control
Ice, compression, elevation

28. Phase 2: Early Rehabilitation-Weeks 2-4
Exercises
Muscle stimulation to quadriceps exercises.
Isometric quadriceps sets.
SLR (four planes).
Leg press.
Knee extension 90-40°
Half squats (0-40°).
Weight shifts.
Front and side lunges.
Hamstring curls
Bicycling.
Proprioception training.
Overpressure into extension.
Passive ROM 0-50 degrees.
Patellar mobilization.
Well-leg exercises.
Progressive resistance program: start with 1 pound and progress I pound per week.

29. Phase 2: Early Rehabilitation-Weeks 2-4
Range of Motion
Continue ROM stretching and overpressure into extension.
Exercises
Continue all exercises as in week 2.
Passive ROM 0-115°.
Bicycling for ROM stimulus and endurance.
Pool walking program
Eccentric quadriceps program ° (isotonic only).
Lateral lunges.
Lateral step-ups.
Front step-ups.
Lateral step-overs (cones).
Stair-stepper machine or elliptical trainer.
Progress proprioception drills, neuromuscular control drills.

30. Phase 3: Controlled Ambulation-Weeks 4-10
Criteria for Progression to Phase 3
Active ROM 0-115°.
Quadriceps strength 60% of contralateral side (isometric test at 60 degrees knee flexion).
Unchanged KT test bilateral values (+ 1 or less).
Minimal or no full joint effusion.
No joint line or patellofemoral pain.

31. Phase 3: Controlled Ambulation-Weeks 4-10
Goals
Restore full knee ROM (0-125°).
Improve lower extremity strength.
Enhance proprioception, balance, and neuromuscular control.
Restore limb confidence and function.

32. Phase 3: Controlled Ambulation-Weeks 4-10
Range of Motion
Self-ROM (four to five times daily using the other leg to provide ROM), emphasis on maintaining 0 ° passive extension.

33. Phase 3: Controlled Ambulation-Weeks 4-10
Exercises
Progress isometric strengthening program.
Leg press.
Knee extension 90-40°.
Hamstring curls.
Hip abduction and adduction.
Hip flexion and extension.
Lateral step-overs.
Lateral lunges.
Lateral step-ups.
Front step-downs.
Wall squats.
Vertical squats.
Toe calf raises.
Biodex Stability System (e.g., balance, squats).
Proprioception drills.
Bicycling.
Stair-stepper machine.
Pool program (backward running, hip and leg exercises).

34. Phase 3: Controlled Ambulation-Weeks 4-10
Exercises
Continue all exercises.
Poor running (forward), agility drills.
Balance on tilt boards.
Progress to balance and board throws.

35. Phase 3: Controlled Ambulation-Weeks 4-10
Exercises
Continue all exercises.
Plyometric leg press.
Perturbation training.
lsokinetic exercises (90-40°).
Walking program.
Bicycling for endurance.
Stair-stepper machine for endurance

36. Phase 3: Controlled Ambulation-Weeks 4-10
Isokinetic Test
Concentric knee extension-flexion at 180 and 300°/sec
Exercises
Continue all exercises.
Plyometric training drills.
Continue stretching drills.

37. Phase 4: Advanced Activity-Weeks 10-16
Criteria for Progression to Phase4
Active ROM degrees or greater.
Quadriceps strength 79% of contralateral side.
Knee extension flexor: extensor ratio %.
No change in KT values (comparable with contralateral side, within 2 mm).
No pain or effusion.
Satisfactory clinical examination.

38. Phase 4: Advanced Activity-Weeks 10-16
Criteria for Progression to Phase4
Satisfactory isokinetic test (values at 180 degrees)
Quadriceps bilateral comparison 75%.
Hamstrings equal bilateral.
Quadriceps peak torque-to-body weight ratio.
Hamstrings: quadriceps ratio %.
Hop test 80% of contralateral leg.
Subjective knee scoring (modified Noyes system) 80 points or better.

39. Phase 4: Advanced Activity-Weeks 10-16
Goals
Normalize lower extremity strength.
Enhance muscular power and endurance.
Improve neuromuscular control.
Perform selected sport-specific drills.
Exercises
Continue all exercises.

40. Phase 5: Return to Activity-Months 16-22
Criteria for Progression to Phase 5
Full ROM.
Unchanged KT 2000 test (within 2.5 mm of opposite side).
Isokinetic test that fulfills criteria.
Quadriceps bilateral comparison ≥ 80%.
Hamstring bilateral comparison ≥ 110%.
Quadriceps torque: body weight ratio ≥ 70%.
Proprioceptive test 100% of contralateral leg.
Functional test ≥ 85% of contralateral side.
Satisfactory clinical examination.

41. Phase 5: Return to Activity-Months 16-22
Goals
Gradual return to full unrestricted sports.
Achieve maximal strength and endurance.
Normalize neuromuscular control.
Progress skill training.

42. Phase 5: Return to Activity-Months 16-22
Exercises
Continue strengthening exercises.
Continue neuromuscular control drills.
Continue plyometrics drills.
Progress running and agility program.
Progress sport-specific training.
6- and 12-Month Follow-up
Isokinetic test.
Functional test.

43. Thank you