KNEE/LCA

When does rehabilitation start after an ACL reconstruction?

On the day of surgery. Patients are given a set of exercises to start immediately in the recovery room.

Will I need to be on crutches after surgery?

Yes, but only initially and only for comfort. Full weight bearing is gradually increased as tolerated by the patient. It typically takes seven to 10 days after the procedure, until the patient is comfortable without the assistance of a crutch. An exception to this rule is if the patient also underwent a meniscal repair or other reconstruction of an additional ligament. In these cases, weight bearing may be restricted for several weeks.

What do I do in the first few weeks after surgery?

The first two weeks after surgery concentrates on decreasing the swelling in the knee and regaining knee extension, with less concern about knee flexion. This is accomplished by elevating/icing the leg and riding the stationary bike.

Two weeks after surgery, the goal is for patients to achieve and maintain full knee extension and increase quadriceps muscle function. While knee flexion of only 90 degrees is the goal for this stage, obtaining full extension is more of a priority.

When can I drive?

Usually by two weeks after surgery, patients are off crutches and demonstrate adequate muscle function, mobility, and comfort to allow driving. This is dependent on what leg has been operated on and how fast the patient recovers.

How is rehabilitation after an ACL reconstruction typically structured?

Although different surgeons and therapists will have slightly different protocols, the goal for all forms of post-operative ACL rehabilitation is the same: to return the patient to a normal and complete level of function in as short a time possible without compromising the integrity of the surgically reconstructed knee.

In order to achieve this goal, therapy is typically broken down into stages (or phases) of activity, with goals for each stage. Here is an example of a standard four-phase protocol:

Phase I - First two weeks after surgery

Emphasis:

• Control of inflammation
• Range of motion - full extension, and 90 degrees of knee flexion
• Achievement of quadriceps control
• Education of patient about rehabilitation process
• Crutches - usually seven to 10 days until patient is comfortable
• Patellar Mobilization - to prevent patellar tendon shortening/contracture and loss of knee motion

Phase II - two to six weeks after surgery

Emphasis:

• Strengthening - light weights and sports cords
• Full range of motion
• Continued protection of the graft from stresses
• Improvement of endurance and proprioception - use of treadmill, step machine and elliptical trainer

Phase III - six weeks to three to four months after surgery

Emphasis:

• Improve patient's confidence in the knee
• Progression in strength, power, and proprioception - preparing for return to sport
• Jogging typically allowed at three months
• Straight ahead running

Phase IV - four to six months after surgery

Emphasis:

• Possible return to sport, depending on type of sporting activity and type of graft
• Full pain free range of motion should be present
• Sufficient strength and proprioception should be present
• Typically, patient is advanced to initiate advanced lifting exercises
• Phase is typically customized to the patient's activity level and competition level in sport.

Phase V - return to sport, usually at six months

Emphasis:

• Patient must meet all the criteria for return to sports
• No soft tissue or range of motion complaints
• Physician must clear the patient to resume full activities
• The goal is safe return to sports
• Education of patient about possible limitations
• Maintenance of strength, endurance, and proprioception
• Functional bracing may be recommended by some physicians for the first one to two years after surgery for psychological confidence.

OTHER QUESTIONS  

Will I need a brace after ACL reconstruction?

Bracing after ACL surgery is purely dependent on patient and surgeon preference. Some surgeons never use bracing, some always use a brace, and others just use a brace during the immediate post-operative or rehabilitation phases. This topic still remains the subject of much debate in sports medicine literature. However, to this date, no long-term benefits have been found with regard to knee laxity, range of motion, or function following ACL surgery. Bottom line: If you feel more comfortable in a brace, then one will be ordered for you.

What type of follow-up is done after an ACL reconstruction?

You will be seen within the first week, at two weeks, six weeks, three months and six-eight months. Specifically, the physician will look at and measure:

• The presence of continued pain and swelling
• Range of motion of the knee
• Laxity of the graftStrength of the leg
• Knee function during routine activities of daily living

What are the possible complications of ACL surgery?

As with any invasive surgical procedure, infection and bleeding are always surgical risks. Infection rates for arthroscopic ACL reconstructions are among the lowest for surgical procedures, with average infection rates typically cited at 0.2 percent. As for bleeding complications, the rates are much less than one percent, and consist mostly of isolated case reports.

Loss of motion following ACL reconstruction is the most commonly cited complication. This can range from minor and inconsequential to severe. Prevention is the first and most effective method for treatment of loss of motion. This is why compliance with post-operative rehabilitation is so vital to the outcome of the procedure, and why range of motion is started immediately post-operatively.

Another risk of ACL reconstruction surgery is continued anterior knee pain post-operatively. Anterior knee pain following ACL reconstruction also has been closely associated with loss of motion. Therefore, range of motion, quadriceps strengthening and patellar mobility are of primary concern during the first two weeks following surgery.

ACL Reconstruction: Hamstring and Bone-Patella Bone Autografts

Weeks 1-3 Begin:__________________

**DO NOT PUSH FLEXION PAST 90 DEGREES FOR THE FIRST SIX WEEKS!

Goals:

1. 90 degrees flexion ROM, full extension

2. Independent quad contraction

3. Gait without crutches by end of week 2

Exercises:

 1. Continue with post-op program, add weight to SLR if

no extension lag

2. Add bike for ROM, strength, and cardio benefit;

pedal as tolerated

3. 4-way hip machine, initiate closed kinetic chain CKC to

include toe and heel raises, dynamic terminal extension,

mini-squats

4. Gait training with mini-hurdles to restore normal 

Weeks 4-6 Begin:__________________

**DO NOT PUSH FLEXION PAST 90 DEGREES FOR THE FIRST SIX WEEKS!

Goals: 

1. ROM 0-120 as tolerated

2. Normal gait cycle by weeks 3-4

3. KT 1000 at 6 weeks post-op

Exercises: 

1. Continue with post-op exercises as home exercise program

2. Advance CKC program to: step-ups, modified lunges

3. Initiate isotonic weight machines

a. Leg extension 90-30 degrees (BPTB – eccentric x 6

weeks, HS concentric starting at week 3)

b. Hamstring curls (start with standing HS curls at week 3

for hamstring graft; progress to weight machine)

c. Leg press

4. Initiate proprioceptive program – single leg stance,

balance board

Weeks 7-12 Begin:__________________

Goals:

 1. Full ROM

2. Swelling < 1-2 cm at midpatella

3. Prevent patella femoral pain with exercises

Test: 1. KT 1000 and isokinetic test at week 12

Exercises: 

1. Continue with above program

2. Leg extension can be concentric 90=30 after week 6 for BPTB

3. Begin isokinetics 90-30 degrees, practice starting at week 8

with progression from fast speed (300d/sec) to slow speed

(60d/sec), practice once per week only

5. Add shuttle for plyometrics at week 10

Return to Activity

Treadmill walking..................week 7

Elliptical .............................week 9

Rowing ...............................week 10

Outdoor biking ....................week 10

Swimming ..........................week 12

Stair stepper .......................week 12

Golf....................................week 16

Running, skiing, basketball ....month 5

Tennis, football, soccer ..........month 6