Physiotherapy Protocol

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Note: it is considered important that patients learn to manage the post-operative exercises before they have surgery.

No lunges or squats in rehabilitation process.

Phase 1: Preoperative phase

Goals:

  • Diminish inflammation and swelling
  • Restore normal range of motion
  • Restore voluntary muscle control

Guidelines:

  • Active and passive knee extension to zero
  • Active and passive knee flexion to tolerance
  • Straight leg raises (3 way, flexion, abduction/adduction and extension)
  • Closed kinetic chain exercises (step ups, mini squat holds etc)
  • Ice and elevation

Phase 2: (Week 0 -1) – post surgery

Goals:

  • Reduce swelling
  • Improve patella mobility
  • Re-establish quadriceps control
  • Gait re-training with crutches
  • ROM exercises
  • (Brace to be worn – usually set at 30-90 degrees – only if medial ligament involvement)

Guidelines:

  • Standing: Commence weight bearing: gait training (with crutches) and VMO contraction (use of bio-feedback)
  • Standing weight shifts. Shift weight from side to side.
  • Sitting: Heel slides. Sliding foot of involved leg backwards. Holding stretch and applying gentle overpressure with uninvolved leg.
  • Manual Therapy: Patella mobilisation
  • Soft tissue therapy for swelling control (quadriceps)
  • Lying: Ankle pumps: progress to use of thera-band
  • Ice (cryotherapy pump) and elevation

Phase 3: (2-6 weeks)

Goals:

  • Increase passive extension ROM
  • Reduce swelling
  • Restore proprioceptive/neuromuscular control
  • Discontinue use of crutches and restore normal gait
  • ROM 0-130 degrees

Guidelines:

  • Lying: Straight leg raises: (abd and flex)
  • Standing: Weight shift: increase to gentle single leg standing
  • Quarter squats: Back against wall, hold, and pulse (knee flexion to remain >90)
  • Double leg bridging: focus on pelvic stability and control – progress to single leg bridging
  • Double leg bridging with feet on chair: upper hamstring strength. May progress (from week 6) to eccentric hamstring strengthening as tolerated
  • Balance work: single leg standing on involved leg and tap foot of uninvolved leg out to side, in front and back.
  • Stationary bike – low resistance, if pain and ROM allow
  • Open chain hamstring strength: E.g Hamstring curls – gradual weight increase as tolerated

Phase 4: (6-12 weeks)

Goals:

  • Full ROM
  • Progression of squat strength form ¼ – ½
  • Improve proprioceptive and neuromuscular control
  • Increase hamstring strength

Guidelines:

  • Standing: Quarter squats: pulses
  • Lateral stepping
  • Commence jogging (on flat surface, no hills)
  • Stationary bike (low resistance to start)
  • Stretching: Quadriceps, Gastrocs, Soleus and Hamstrings
  • Leg press: Gradually increase weight and progress to single leg (0-60degrees)
  • Backward running/stride: focusing on deceleration
  • Lying: Bridging: Single leg bridging and progress to Swiss ball bridges double leg to single leg bridges

Phase 5: (12 weeks – 5 months)

Goals:

  • Incorporate more sport specific exercises
  • Incorporate agility and reaction time into proprioceptive work
  • Increase total leg strength

Guidelines:

  • Jumps: double leg, soft landing, ½ turns and repeat
  • Hopping: front/back – sideways
  • Shuttle runs: E.g. zig-zag, side steps, grapevine, interval running with alternating speeds
  • Strides and landing: soft and unstable surface

Phase 6: (5 – 6 months)

Goal:

  • Return to sport

Guidelines:

  • Begin open chain leg extensions for Quadriceps muscle
  • Emphasis on plyometric strength
  • Proprioceptive skills: focusing on landing skills and use of wobble board (single leg)
  • Sport specific drills, training and cardiovascular fitness