ACL Rehabilitation: General Concepts in Physical Therapy
The anterior cruciate ligament (ACL) of the knee is one of the key ligaments that help to stabilize the knee joint. ACL tears typically occur through either contact or non-contact injury in high-risk sports such as soccer, football, basketball, and skiing. When ACL tears are severe, they require surgical reconstruction to restore stability of the knee. Professional athletes and a majority of recreational athletes will likely require surgery, followed by an extensive period of physical therapy in order to return to their prior level of activity. Rehabilitation following ACL reconstruction is generally based on the following phases:
- Protection and range of motion: The initial post-operative rehab period involves protecting the surgical repair, improving knee range of motion, normalizing walking pattern, reducing pain and joint swelling, and initiating balance exercises. Patients can expect to wear a brace and utilize crutches until they are walking normally and can demonstrate good quadriceps strength by raising their injured leg without a “lag” or bend of their knee (if no other associated meniscal or ligament injuries were present and repaired by your surgeon). Exercises and activities in this phase include heel slides to improve knee bending, knee extensions to improve straightening, mini squats, step-ups, single leg balance, and various hip/core strengthening activities. The physical therapist may also elect to use modalities such as icing and electrical stimulation to help reduce swelling and improve muscle recruitment, respectively.
- Strength, endurance, and neuromuscular control: After the protection phase, physical therapy goals shift towards progressing the patient’s strength, building muscle endurance, and improving control of the surgical leg. At this point, the patient will no longer use a brace or crutches. Improving quadriceps strength is especially important in this phase, so the patient can expect to perform exercises like squatting, lunging, step-up/downs, and leg press. Balance exercises will be progressed to include more dynamic activities using even and uneven surfaces. Hip and core strength will also be progressed in this phase.
- Power and agility: In the power and agility phase, the patient will continue to progress single leg strength in preparation for impact activities like running and jumping. Usually, running is initiated about 12 weeks after surgery, while jumping activities are initiated around week 16. The patient can expect to perform activities like agility ladder, shuffling, and plyometrics in this phase in addition to progressive strengthening.
- Return to sport: This phase of ACL rehabilitation is meant for athletes who have a desire to return to their previous level of sporting activities. The physical therapy program is aimed at aggressive strengthening to address any imbalance between the surgical and non-surgical leg, maximum effort plyometrics in multiple directions and planes, progression of cutting/pivoting, and increasing the speed of running and agility. Rehab is sports-specific to ensure that the athlete is being trained in the mechanics of his or her specific sport. It is highly recommended that an athlete who had an ACL reconstruction undergoes a functional sports assessment and gets clearance from his/her surgeon and physical therapist before returning to sport.
About the author
By Danielle Morency, PT, DPT, CSCS
Physical Therapist, Certified Strength and Conditioning Specialist
Midwest Orthopaedics at Rush