ACL Reconstruction

Timeline / Goals / Exercises for Rehabilitation

Takeshi Kitamura, WSU MSAT

General Guidelines
Conservative and Accelerated programs
Accelerated programs are todays trend (Kvist,2004)

Supervised or Home physical therapy for 6-9 months

Differences found in supervised versus home physical therapy were insignificant (Grant,2010)

Accelerated program timeline (Pizzari, 2005)

Phase 1 = 0-2 weeks Phase 2 = 2-8 weeks Phase 3 = 2-6 months Phase 4 = 6 months to released

Phase I (1-2 weeks)

Educate patient on the goals of each phase of rehabilitation Crutches for 1 week and non-weight bearing; then add weight bearing as tolerated up to full weight bearing by 2 weeks No driving for 1 week with surgery on left knee and 4 weeks with surgery on right knee Brace locked in full extension for 1 week, then kept on unlocked Protect the graft Control inflammation (swelling) Full extension PROM by 2 weeks 90 flexion PROM or assisted AROM by 2 weeks Immediately begin quadriceps strengthening open chained and isometrically Patellar mobilization exercises (graft donor site)

Phase I (1-2 weeks)

ROM exercises: Knee flexion: heel slides, seated pull backs, wall slides, prone quad stretch (12, 15) Knee extension: prone hangs, heel prop, manual knee extension (7, 12, 15) Patella mobs: superior/inferior, medial/lateral (2, 7, 12, 15) Strengthening: Quadriceps: quad sets, knee extension isometrics (60 & 30) (3, 5, 6, 7, 9, 12, 15) Hamstrings: standing hamstring curls (2, 7, 12) Hip: flexion, extension, abduction, adduction (3, 5, 6, 9, 12, 15) Calves: heel toe rocking sitting/standing (2, 12, 15) Proprioception: Weight shifts: side to side, diagonal, front/back (1, 7, 15) Gait training with crutches (2, 7, 9) Cardiovascular conditioning: Upper body ergometer (UBE): 20-30min (<65% HR max)

Heel slides

Wall slides

Seated pull back

Prone hangs

Heel prop

Quad sets

SLR (flexion)

SLR (abduction)

UBE

Phase II (3-12 weeks)

Protect graft fixation points Strengthen quadriceps with closed chain exercises and perform a full body weight squat properly Hamstring exercises increased as tolerated Restore normal gait Regain good balance; proprioception exercises Full flexion AROM restored (130) Full extension AROM Avoid rotational motions of the knee

Phase II (3-4 weeks)

ROM exercises: Continue previous exercises as needed Hamstring & calf stretching (15) Strengthening: Knee extension (AROM 90-30): concentric & eccentric (2, 5, 6, 7, 11, 12) Terminal knee extension (TKE) with sports cord (2, 12, 15) Step-ups: forward & lateral (2, 11, 12, 15) Leg press: double leg (0-60) (2, 5, 6, 9, 10, 11) Mini PWB squats (0-45) with wall / swiss ball (2, 9, 10, 11, 12) Proprioception: Single leg stance: eyes open/closed, foam, plyoback (4, 7, 9, 11, 15) Gait training without crutches (2, 7, 9) Cardiovascular conditioning: Stationary bike, if knee flexion > 100 (2, 9, 11, 12, 15) Aquatic jogging (11, 12)

Terminal knee extension

Step downs

Step ups

Leg press

Swiss ball squat

Aquatic exercise

Phase II (5-8 weeks)

ROM exercises: Quadriceps, hamstrings, and calf stretching Strengthening: Hamstrings: machine prone & seated curls (2, 7, 9, 12, 15) Multi-hip: machine flexion, extension, ABD, ADD (12, 15) Leg press: double leg eccentric, single leg (5, 6, 9, 10, 11, 15) Calf: heel raises (standing; DL/SL) (2, 9, 11, 12, 15) Vertical FWB squats @ 0-60 (2, 9, 10, 11, 12) Step-downs: forward & lateral (2, 15) Proprioception: Single leg stance: foam with plyoback and ball toss (4, 8, 9, 11, 15) Gait training: treadmill walking; backward and lateral stepping (2, 7) Cardiovascular conditioning: Stationary bike, aquatics Stair stepper: forward/retro (2, 7, 9, 12, 15)

Phase II (9-12 weeks)

ROM exercises: Continue previous exercises Strengthening: Leg press: eccentrics & single leg (10, 11, 15) Cable/sports cord: retro walking & lateral stepping (2, 12, 15) Lunges: anterior & lateral (2, 12, 15) Proprioception: Lateral hops: single and multiplane (9, 11, 15) Single leg stance: foam with plyoback and ball toss, perturbation (8, 9, 11, 15) Cardiovascular conditioning: Stationary bike, stair stepper, aquatics Slide board & jump ropes (2, 7, 15) Running program: Treadmill jogging (2, 7, 9, 11, 12)

Phase III (4-6 months)

Avoid overstressing the graft Continue full ROM Improve strength, endurance and proprioception of the lower extremity to prepare for functional activity Progress strengthening exercises to eccentric and advanced closed chain activities Progress to advanced proprioceptive exercises Begin agility drills gently (brace may be recommended) Begin plyometric drills gently

Phase III (13-18 weeks)

ROM exercises: Quadriceps, hamstrings, and calf stretching Strengthening: Continue exercises from week 11-12 Proprioception: Lateral hops: multiplane with rotation, multiplane with sports cord Cardiovascular conditioning: Continue with stationary bike, stair stepper, and/or jogging Plyometrics: (10, 12, 13, 14, 15) Level I: 4-5 exercises, 50-60 foot contacts, 3x6reps Level II & III: 4-5 exercises, 80-100 foot contacts, 5x5reps Agility drills: (10, 12, 15, 16) Level I: focus on mechanics then speed; 10 reps each Level II: focus on speed; 10 reps each

Phase III (13-18 weeks)

Plyometrics:
Level I: Power hops, tuck jumps, 4 corner hops, zig-zag hops, box jumps, squat jumps, SL box push-offs, lateral box push-offs Level II: Split squat jumps, depth jumps, SL jump off box, lateral box shuffle, lateral box jumps, SL power hops, alternating bounding Level III: SL depth jumps, depth jumps with 180 turn, depth jumps with sprint, box-to-box jumps (DL/SL), SL hops and bounding

Split squat jumps

Depth jumps

Lateral box push-offs

Box jumps

Phase III (13-18 weeks)

Agility drills:
Level I: Ladder drills, high knees, butt kicks, skipping, backward striding, lateral shuffles, figure 8s, 45 cone cuts, 3 cone shuffles Level II: Ladder drills, 20 yard shuttle, 45 cone cuts, 3 cone shuffles, box drill, T-drill, 5 cone drills

Phase IV (6-12 months)

Return to sport and full activity Sport specific functional and agility testing (brace may be recommended)
90% single leg hop test (Barber, 2011)

Isokinetic testing for full strength

90% quadriceps strength (Barber, 2011)

Full pain free ROM Physicians release from rehabilitation to return to sport Educate patient on any possible future risks or complications
Verified graft failure rate = 2% (Kvist, 2004) Recent outcome measures show a decline in sport participation after 2-3 years (Feller 2013)
Factors include surgical details, physical therapy, and social and psychological factors

References
1. Risberg M A, Lewek M, Synder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Physical Therapy in Sport 2004; 5(3): 125-145. 2. Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):402-14. 3. Shaw T, Williams MT, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother. 2005;51(1):9-17. 4. Cooper RL, Taylor NF, Feller JA. A randomised controlled trial of proprioceptive and balance training after surgical reconstruction of the anterior cruciate ligament. Res Sports Med. 2005;13(3):217-30. 5. Perry MC, Morrissey MC, King JB, Morrissey D, Earnshaw P. Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13(5):357-69.

References
6. Perry MC, Morrissey MC, Morrissey D, Knight PR, Mcauliffe TB, King JB. Knee extensors kinetic chain training in anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc. 2005;13(8):638-48. 7. Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8(6):337-42. 8. Liu-ambrose T, Taunton JE, Macintyre D, Mcconkey P, Khan KM. The effects of proprioceptive or strength training on the neuromuscular function of the ACL reconstructed knee: a randomized clinical trial. Scand J Med Sci Sports. 2003;13(2):11523. 9. Gerber JP, Marcus RL, Dibble LE, Greis PE, Burks RT, Lastayo PC. Safety, feasibility, and efficacy of negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2007;37(1):10-8. 10. Lorenz D, Reiman M. The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and acl reconstruction. Int J Sports Phys Ther. 2011;6(1):27-44.

References
11. Papandreou MG, Billis EV, Antonogiannakis EM, Papaioannou NA. Effect of cross exercise on quadriceps acceleration reaction time and subjective scores (Lysholm questionnaire) following anterior cruciate ligament reconstruction. J Orthop Surg Res. 2009;4:2. 12. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med. 2005;33(3):347-59. 13. Struminger AH, Lewek MD, Goto S, Hibberd E, Blackburn JT. Comparison of gluteal and hamstring activation during five commonly used plyometric exercises. Clin Biomech (Bristol, Avon). 2013;28(7):783-9. 14. Myer GD, Ford KR, Mclean SG, Hewett TE. The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics. Am J Sports Med. 2006;34(3):445-55. 15. Manske RC, Prohaska D, Lucas B. Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives : Critical reviews in rehabilitation medicine. Curr Rev Musculoskelet Med. 2012;5(1):59-71. 16. Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther. 2006;36(6):385-402.