ACL Reconstruction

Anatomy and Methods

ACL Tear Anatomy1

ACL Repair Anatomy

Patellar Tendon Graft

Ipsilateral middle third patellar tendon.1

Hamstring Graft

4-strand gracilis/semitendinosus tendons1

Arthroscopy pictures In tact ACL Torn ACL

ACL RepairPatellar Tendon vs Hamstring

Pros Cons

Patellar Tendon More Likely to have normal Lachman, Pivot Shift.2,3

Fewer results of knee flexion loss.3

High result in Anterior Knee Pain & Osteoarthritis 2,3,4

Greater Loss in knee extension.2,3,5

Less Quad torque in 1st 4-8 months.2

Decrease in Skin Sensativity 4

Hamstring Less pain when kneeling/Less Anterior knee pain.2,3,4

Greater ROM in extension.2,3,5

Greater Quad Torque after 1 year.6

Flexion Loss in 1st 24 months.2,3

Increased laxity anterior (Lachman’s, Pivot Shift) & side to side (KT-1000).2,3

Femoral Tunnel Widening.2,4

ACL Reconstruction

Timeline and Goals+

Rehabilitation exercises

General Guidelines

• Conservative and Accelerated programs– Accelerated programs are today’s trend7

• Supervised or Home physical therapy for 6-9 months – Differences found in supervised versus home physical

therapy were insignificant.8

• Accelerated program timeline 9

– Phase I = 0-2 weeks – Phase II = 2-8 weeks– Phase III = 2-6 months– Phase IV = 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)

Braces

Phase I (1-2 weeks)ROM exercises:• Knee flexion: heel slides, seated pull backs, wall slides, prone quad stretch (10,11)

• Knee extension: prone hangs, heel prop, manual knee extension (10,11,12)

• Patella mobs: superior/inferior, medial/lateral (10,11,12,13)

Strengthening:• Quadriceps: quad sets, knee extension isometrics (60° & 30°) (10,11,13,14,15,16,17)

• Hamstrings: standing hamstring curls (10,12,13)

• Hip: flexion, extension, abduction, adduction (10,11,14,15,16,17)

• Calves: heel toe rocking sitting/standing (10,11,13)

Proprioception:• Weight shifts: side to side, diagonal, front/back (11,12)

• Gait training with crutches (12,13,17)

Cardiovascular conditioning:• Upper body ergometer (UBE) – 10-30min depending on the sport of the athlete

Phase II (3-12 weeks)• Protect graft fixation points by avoiding quick motions in any

direction at the knee and avoiding using heavy weights• Avoid all rotational motions of the knee• 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

Phase II (3-4 weeks)ROM exercises:• Continue previous exercises as needed• Hamstring & calf stretching (11)

Strengthening:• Knee extension (AROM 90-30°): concentric & eccentric (10,12,13,15,16,18)

• Terminal knee extension (TKE) with sports cord (10,11,13)

• Step-ups: forward & lateral (10,11,13,18)

• Leg press: double leg (0-60°) (12,15,16,17,18,19)

• Mini PWB squats (0-45°) with wall / swiss ball (10,13,17,18,19)

Proprioception:• Single leg stance: eyes open/closed, foam, plyoback (11,12,17,18,20)

• Gait training without crutches (12,13,17)

Cardiovascular conditioning:• Stationary bike, if knee flexion > 100° (10,11,13,17,18)

• Aquatic jogging (10,18)

Phase II (5-8 weeks)ROM exercises:• Quadriceps, hamstrings, and calf stretchingStrengthening:• Hamstrings: machine – prone & seated curls (10,11,12,13,17)

• Multi-hip: machine – flexion, extension, ABD, ADD (10,11)

• Leg press: double leg eccentric, single leg (11,15,16,17,18,19)

• Calf: heel raises (standing; DL/SL) (10,11,13,17,18)

• Vertical FWB squats @ 0-60° (10,13,17,18,19)

• Step-downs: forward & lateral (11,13)

Proprioception:• Single leg stance: foam with plyoback and ball toss (11,17,18,20,21)

• Gait training: treadmill walking; backward and lateral stepping (12,13)

Cardiovascular conditioning:• Stationary bike, aquatics• Stair stepper: forward/retro (10,11,12,13,17)

Phase II (9-12 weeks)ROM exercises:• Continue previous exercisesStrengthening:• Leg press: eccentrics & single leg (11,18,19)

• Cable/sports cord: retro walking & lateral stepping (10,11,13)

• Lunges: anterior & lateral (10,11,13)

Proprioception:• Single leg stance: foam with plyoback and ball toss, perturbation (11, 17, 18, 21)

• Lateral hops: single and multiplane (11,17,18)

Cardiovascular conditioning:• Stationary bike, stair stepper, aquatics• Slide board & jump ropes (11,12,13)

Running program:• Treadmill jogging (7, 10, 13, 17, 18)

Phase III (4-6 months)• Avoid overstressing the graft by avoiding quick lateral motions

and avoiding quick rotational motions at the knee• 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 stretchingStrengthening:• Continue exercises from week 11-12Proprioception:• Lateral hops: multiplane with rotation, multiplane with sports cordCardiovascular conditioning:• Continue with stationary bike, stair stepper, and/or joggingPlyometrics: (10, 11, 19, 22, 23)

• Level I: 4-5 exercises, 50-60 foot contacts, 3x6reps• Level II & III: 4-5 exercises, 80-100 foot contacts, 5x5repsAgility drills: (10, 11, 19, 24)

• 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

Phase III (13-18 weeks)

Agility drills:• Level I: Ladder drills, high knees, butt kicks, skipping, backward striding,

lateral shuffles, figure 8’s, 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.25

• Isokinetic testing for full strength– 90% quadriceps strength25

• Full pain free ROM• Physician’s release from rehabilitation to return to sport• Educate patient on any possible future risks or complications

– Verified graft failure rate = 2% 7

– Recent outcome measures show a decline in sport participation after 2-3 years26

• Factors include surgical details, physical therapy, and social and psychological factors

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