ACL Reconstruction Rehabilitation Protocol
The following rehabilitation protocol has been developed for the patient and clinician following an anterior cruciate ligament (ACL) reconstruction surgical procedure. This procedure is normally performed on an athlete following acute injury to the ligament. The ACL is the primary restraint to anterior tibial translation and can be compromised in sports/movements that require explosive pivoting, cutting, or jumping.
Post-operative rehabilitation is a key component of the recovery process in order to achieve a successful (and safe) return to sport or activity, preferably at the same level as previous. There is evidence that inadequate rehabilitation combined with a premature return and improper objective testing may limit overall performance and increase risk of subsequent injury.
Graft Selection and Concomitant Procedures
Graft selection is often a joint-decision between the surgeon and patient. Common graft choices are:
- Patellar tendon
- Quadriceps tendon
- Hamstring bundle
- Achilles allograft (donor)
Each graft choice has associated pros/cons and should be a consideration in post-operative care.
Further, concomitant procedures can include:
- Meniscectomy
- Meniscus repair
- Articular cartilage repairs
- Multi-ligament reconstructions/repairs (MCL, LCL, PCL)
Communication with the surgeon and review of the operative note are necessary to understand all procedures performed and possible alteration in the rehabilitation timeline.
Timeline and Supervision
A typical ACL reconstruction rehabilitation can take upwards of 9–12 months. Timeline varies depending on demands of the sport, level of play, and the patient’s desired functional goals. Physical therapy should be initiated within 7–10 days post-op with referral from the surgeon.
The supervised rehabilitation is to be supplemented by a home exercise program provided by the Physical Therapist. Multiple studies indicate that aggressive or accelerated return to sport is often associated with a large increase in risk of reinjury. The Physical Therapist and patient should work together to determine the parameters of supervised rehab with attention to insurance or financial limitations that may inhibit consistent in-person participation.
Rehabilitation Goals
The overall goals of ACL reconstruction and its corresponding rehabilitation are to:
- Control pain and inflammation
- Allow for adequate tissue healing and maturation
- Regain normal lower extremity range of motion and strength
- Correct movement or mechanical faults and maximize consistency with proper knee alignment
- Achieve the patient’s desired level of function and performance
Note: While the rehabilitation process may be lengthy, adherence to a structured recovery program is crucial for return to sport. With compliance to rehabilitation, return to sport rates are as high as 80%.
Important Considerations
There are not a lot of things that we can do to speed the process of healing, but there are things that we can do to slow it down:
- Healing is a process; the graft is functionally at its weakest around weeks 4–8 — this is not the time to test things
- Do not push through painful movements
- Open-kinetic chain (OKC) activities such as knee extensions should be considered with strong caution as adverse stress through the graft can be present, especially in knee angles above 50° and especially with resistance