ACL Rehabilitation by Mark Corry APA Physiotherapist
Understanding ACL Rehabilitation
An anterior cruciate ligament (ACL) injury can be a life-altering event for anyone, whether you're a professional athlete or an active individual. ACL rehabilitation plays a crucial role in helping you recover fully and safely, restoring function, and getting you back to doing what you love. Whether you're preparing for surgery, in the early days of recovery, or aiming to return to sport, understanding the rehabilitation process will help set realistic expectations and guide your journey to recovery.
What to Expect Before Surgery
If surgery is the chosen course of action for your ACL injury, preparation is key. Before your surgery, your physiotherapist will work with you to ensure you're in the best possible condition for the procedure. This prehabilitation phase will look to achieve the ‘quiet’ knee: minimal pain and swelling, good quad muscle contraction and full (or almost full) range of motion.
Key pre-surgery goals include:
Reducing swelling and inflammation: Ice, compression and elevation may be used to manage swelling. Your physiotherapist will help with techniques to reduce pain and improve function.
Strengthening and conditioning: Strengthening your quadriceps, hamstrings, and glute muscles can help your knee in the post-operative rehabilitation. Eitzen et al., 2009, recommended an individual should have at least 80% quad strength compared to the unaffected side prior to surgery for best outcomes at 2-year follow-up.
Optimizing knee range of motion: It's crucial to have a flexible, well-functioning knee before surgery to promote a smoother post-operative recovery.
While this period can vary from person to person, it’s essential to remain patient and focus on preparing your body for the journey ahead.
Immediately Post-Surgery: The Early Days
After ACL surgery, the recovery process begins with an initial focus on achieving the ‘quiet knee’ which mentioned previously, includes: reducing swelling, controlling pain, facilitating good quad muscle contraction and protecting the surgical repair. This period can last anywhere from the first few days to the first week or two after surgery.
Here’s what you can expect:
Pain management: Pain control will be prioritised to ensure you're as comfortable as possible. Your healthcare team will guide you on the use of medications and other pain relief strategies.
Initial physiotherapy: Early physiotherapy focuses on regaining basic knee movement and preventing stiffness. Passive range of motion exercises, quad muscle activation, and weight-bearing exercises are typically introduced within the first few days.
Managing swelling: Your physiotherapist will advise on techniques to reduce swelling, such as icing, elevating the leg, and using compression.
Bracing and support: In some cases, your surgeon may be advise you to wear a knee brace to provide stability while walking, and crutches will assist in avoiding weight-bearing on the affected leg initially.
Remember that your knee may feel weak or unsteady at first, but gradual improvement will be noticeable as you progress through the rehabilitation stages.
What to Expect During the Rehabilitation Process
Rehabilitation is a gradual process that takes time, commitment, and hard work. Your physiotherapist will work closely with you to guide you through a structured plan that addresses different stages of recovery.
Remember the following example should not be considered as a one-size-fits-all approach to rehabilitation and performing exercises without prescription is not recommended.
Phase 1: Early Rehabilitation (0-4 Weeks Post-Surgery)
Focus: Pain management, reducing swelling, restoring range of motion.
Exercises: Gentle quad sets, ankle pumps, straight leg raises, and knee flexion/extension exercises to regain mobility.
Goals: Restore knee range of motion and start strengthening the quadriceps and hamstrings to support knee stability.
Phase 2: Strengthening (4-12 Weeks Post-Surgery)
Focus: Building strength and muscle endurance around the knee joint.
Exercises: More active exercises such as leg presses, hamstring curls, stationary cycling, and gentle resistance training. Balance exercises to enhance stability are also introduced.
Goals: Strengthen the muscles around the knee and restore normal gait and movement patterns.
Phase 3: Advanced Strengthening (3-6 Months Post-Surgery)
Focus: Increasing strength, endurance, and functional mobility.
Exercises: More challenging exercises like squats, lunges, and step-ups are included, along with sport-specific drills for agility and coordination.
Goals: Enhance functional strength and prepare for more intense physical activity.
Phase 4: Return to Activity (6-12 Months Post-Surgery)
Focus: Transitioning back to normal activities and sport-specific movements.
Exercises: Sport-specific drills, plyometrics (jumping exercises), and agility drills are gradually introduced to prepare for higher-impact activity.
Goals: >90% quad and hamstring strength symmetry, >1.25 – 1.5 x Bodyweight with a single leg press, knee joint stability, and confidence to safely return to everyday activities and light sports.
How Long Does ACL Rehabilitation Take?
The total timeline for ACL rehabilitation depends on several factors, including the severity of the injury, the success of the surgery, and your overall health and commitment to rehabilitation. On average, most individuals can expect to return to light activities within 6 months, but returning to sports such as running, soccer, or basketball can take 9-12 months, or sometimes longer. It’s important to listen to your body, be patient with the process, and follow the guidance of your physiotherapist to avoid re-injury.
Return to Sport Criteria
Before returning to high-level sports, there are certain physical criteria you must meet to ensure your knee is ready for the demands of your chosen activity. These criteria include:
Knee strength: Your quadriceps and hamstrings should be at least 90-100% strength compared to your uninjured leg.
Range of motion: Your knee should have full range of motion, with no significant loss of flexion or extension.
Functional tests: Specific tests, such as hop tests, single-leg squats, and agility drills, are used to assess strength, coordination, and stability.
Knee stability: Your knee should feel stable during normal activities and sport-specific movements, with no feeling of "giving way."
Confidence: Psychologically, you should feel confident in your knee’s ability to perform without pain or fear of reinjury.
It’s crucial not to rush back into sports before meeting these criteria. Premature return to activity can lead to further injury and setbacks.
Conclusion
ACL rehabilitation is a long-term commitment that requires patience, dedication, and careful guidance from your physiotherapy team. By understanding the rehabilitation process and setting realistic expectations, you can ensure the best possible recovery and return to activity. Every step you take in rehabilitation, no matter how small, brings you closer to regaining full function and getting back to the activities you love.
If you’re currently recovering from an ACL injury, your physiotherapist is your best ally in achieving a full and successful recovery. They will tailor your rehab program to meet your unique needs and help you stay motivated throughout the process.
Stay consistent, follow the plan, and trust the journey—before you know it, you'll be back to doing what you enjoy, stronger and more resilient than ever.
References:
1) Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med. 2009 May;43(5):371-6. doi: 10.1136/bjsm.2008.057059. Epub 2009 Feb 17. PMID: 19224907.
2) Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM. Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med. 2011 Apr;39(4):866-73. doi: 10.1177/0363546510395456. Epub 2011 Feb 18. PMID: 21335344.
3) Campanholi Neto, Jose & Cedin, Luisa & Dato, Carla & Bertucci, Danilo & Andrade, Eduardo & Baldissera, Vilmar. (2015). A Single Session of Testing for One Repetition Maximum (1RM) with Eight Exercises is Trustworthy. Journal of Exercise Physiology Online. 18. 74-80.
4) Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991 Sep-Oct;19(5):513-8. doi: 10.1177/036354659101900518. PMID: 1962720.
By Mark Corry APA Physiotherapist