MO

OON ACL Rehabilitatio

R
on Guideline
es
MULTICEENTER ORTHOPAEDIC
C OUTCOMES NETWO
ORK

eral Informa
ation: The fo
ollowing ACL rehabilitation guideline
es
Gene
are ba
ased on a re
eview of the randomized
d controlled trials
t
related
d to
ACL rehabilitation
r
n. For manyy aspects of ACL rehabillitation there
e are
eitherr no studies that qualify as
a best-evid
dence or the number off
studie
es is too few
w for conclusions to be drawn with co
onfidence. In
these
e circumstances, the reco
ommendatio
ons are base
ed upon the
guida
ance of the MOON
M
panel of content experts.
e
g
ha
ave been de
eveloped to service
s
the spectrum
s
of ACL
A
The guidelines
injure
ed people (no
on-athlete elite athlette). For this reason,
exam
mple exercis
ses are provided instead
d of a highly structured
rehab
bilitation prog
gram. Atten
nding rehab
bilitation specialists sh
hould
tailorr the progra
am to each patients
p
sp
pecific need
ds.
The multicenter
m
n
nature
of the MOON grou
up necessita
ates that the
e
MOON ACL Reha
abilitation Prrogram only include trea
atment methods
that can
c be emplo
oyed at all sites without purchasing expensive
equip
pment. Conssequently, so
ome treatme
ent methodss with supporrting
evidence (e.g. using a high-in
ntensity elecctric stimulation training
progra
am for stren
ngth, aquaticc therapy) are not include
ed in the
progra
am because
e the expert panel believves that it is unreasonab
ble to
expecct all sites to
o carry out su
uch treatmen
nts.
Progrression from one phase to the next is based on the patient
demo
onstrating rea
adiness by achieving
a
functional criiteria ratherr
than the time ela
apsed since
e surgery. The
T timefram
mes identifie
ed in
paren
ntheses afterr each Phase are approxximate timess for the ave
erage
patien
nt, NOT guid
delines for progression. Some patie
ents will be re
eady
to pro
ogress soone
er than the timeframe identified, whe
ereas otherss will
take longer.
r
ed number of
o visits to the
e rehabilitatiion specialisst
The recommende
(including visits merely
m
for evvaluation and
d/or exercise
e progression) is
g early
16 to 24 visits witth the majority of the visits occurring
eekly x 6 we
eeks). Howe
ever, it is reccognized tha
at some patiients
(Biwe
health
h plans are severely
s
restrictive. Forr this reason, the minimu
um
numb
ber of post-A
ACL reconstrruction visits to a rehabilitation speciialist
has been
b
set at 6 visits for th
he MOON grroup patientss.

Sports Medicin
ne
UNIVERSITY OF CO
OLORADO

If therre are any questions reg

garding the MOON
M
ACL Rehabilitatio
on
Guide
elines, then please
p
conta
act Dr._____
__________
___________
___
or the
e Sports Med
dicine Cente
ers Rehabilittation Liaiso
on:
_____
__________
__________
___________
__________
______.

MULTICENTER ORTHOPAEDIC OUTCOMES NETWORK

ACL Reha
abilitation Guidelines
G
s

PHASE 0: Pre-operrative Recom

mmendations

Norm
mal gait

ARO
OM 0 to 120 degrees
d
of flexion

Stren
ngth: 20 SLR
R with no lag
g

Minim
mal effusion

Patie
ent education
n on post-op
perative exerrcises and need
n
for com
mpliance

Educ
cated in amb
bulation with crutches

Wound care instrructions

Educ
cated in MOO
ON follow-up
p expectatio
ons

PHASE 1: Immediate Post-ope

erative Phas
se
ery to 2 weekks)
(Approximate time frrame: Surge
GOALS

Full knee
k
extension ROM

Good
d quadricepss control (> 20
2 no lag SL
LR)

Minim
mize pain

Minim
mize swelling
g

Norm
mal gait patte
ern

U
WBAT
T with crutches (beginnin
ng the day of surgery)
Crutch Use:
Crutch D/C
D Criteria
a:

Norm
mal gait patte
ern
Abilitty to safely ascend/desc
a
cend stairs without
w
notew
worthy pain or
o instability
(recip
procal stair climbing)
c

Knee Im
mmobilizer: None (Exception: First 24
2 hours afte
er a femoral nerve blockk)
Cryothe
erapy: Cold with
w compre
ession/elevattion (e.g. CryyoCuff, ice with
comp
pressive stoccking)

First 24 hours orr until acute inflammation

i
n is controlle
ed: every hour for 15 min
nutes

Afterr acute inflam

mmation is controlled:
c
3 times a dayy for 30 minu
utes

Crushed ice in th
he clinic (posst-acute stag
ge until D/C))

MULTICENTER ORTHOPAEDIC OUTCOMES NETWORK

ACL Reha
abilitation Guidelines
G
s

EXERCISE SUGGESTIONS
ROM

nsion: Low load, long du

uration (~5 minutes)
m
stre
etching (e.g., heel prop,
Exten
prone
e hang minim
mizing co-co
ontraction an
nd nocicepto
or response))

Flexiion: Wall slid

des, heel slid
des, seated assisted kne
ee flexion, bike: rocking--forrange
e

Patellar mobiliza
ation (media
al/lateral mob
bilization inittially followed
d by
supe
erior/inferior direction
d
wh
hile monitorin
ng reaction to
t effusion and ROM)

Muscle Activation/S
A
Strength

Quad
driceps sets emphasizin
ng vastus late
eralis and va
astus medialis activation
n

SLR emphasizing no lag

Electtric Stimula
ation: Option
nal if unable to perform
m no lag SLR
RDiscontinue use
e when able to perform 20
2 no lag SL
LR

ble-leg quartter squats

Doub

Standing Thera-B
Band resistted terminal knee extenssion (TKE)

Hamstring sets

Hamstring curls

Side--lying hip ad
dduction/abd
duction (Avoiid adduction
n moment in this phase with
w
conc
comitant grad
de II III MC
CL injury)

Quad
d/ham co-co
ontraction su
upine

Prone hip extenssion

Ankle
e pumps with Thera-Ban
nd

Heel raises (calf press)

Cardiop
pulmonary

UBE or similar exxercise is re

ecommended
d

Scar Ma
assage (whe
en incision iss fully healed
d)
CRITERIA FOR PRO
OGRESSION TO PHAS
SE 2

20 no
o lag SLR

Norm
mal gait

Crutc
ch/Immobilizzer D/C

ROM
M: no greate
er than 5 active extensio
on lag, 110 active flexio
on

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ACL Reha
abilitation Guidelines
G
s

PHASE 2: Early Rehabilitation

n Phase
(Approximate time frrame: weekss 2 to 6)
GOALS

Full ROM
R

Impro
ove muscle strength

Progress neurom
muscular retrraining

EXERCISE SUGGESTIONS
ROM

Low load, long duration (assisted p.r.n.)

Heel slides/wall slides

s

Heel prop/prone hang (minim

mize co-conttraction / nocciceptor resp
ponse)

Bike (rocking-for-range rid

ding with low
w seat height)

Flexibility stretch
hing all major groups

Strength
hening
Quadrice
eps:

Quad
d sets

Mini--squats/wall--squats

Step--ups

Knee
e extension

Leg press
p

Shutttle press witthout jumping action

Hamstrin
ngs:

Hamstring curls

Resis
stive SLR with sports co
ord

MULTICENTER ORTHOPAEDIC OUTCOMES NETWORK

ACL Reha
abilitation Guidelines
G
s

Other Mu
usculature:

Hip adduction/ab
a
bduction: SLR or with eq
quipment

Standing heel raises: progress from double to single

e leg supportt

Seated calf presss against ressistance

Multi-hip machine in all direcctions with prroximal pad placement

Neuromuscular training

Wobble board

Rock
ker board

Singlle-leg stance
e with or with
hout equipm
ment (e.g. insstrumented balance
b
systtem)

Slide
e board

Fitterr

Cardiop
pulmonary

Bike

Ellipttical trainer

Stairmaster

CRITERIA FOR PRO

OGRESSION TO PHAS
SE 3

Full ROM
R

Minim
mal effusion//pain

Func
ctional streng
gth and conttrol in daily activities
a

IKDC
C Question # 10 (Global Rating of Fu
unction) sco
ore of > 7

10. How
w would you rate the function of yo
our knee on
n a scale of 0 to 10 with
h 10
being normal, excellent
e
fun
nction and 0 being the
e inability to
o perform an
ny of
yourr usual daily
y activities?
?

10

MULTICENTER ORTHOPAEDIC OUTCOMES NETWORK

ACL Reha
abilitation Guidelines
G
s

PHASE 3: Strength
hening & Co
ontrol Phase
e
1
(Approximate time frrame: weekss 7 through 12)
GOALS

Main
ntain full ROM
M

Demonstrate ability to desce

end an 8 ste
ep without pa
ain or deviattion

Runn
ning without pain or swe
elling

Hopp
ping without pain, swellin
ng or giving--way

EXERCISE SUGGESTIONS
hening
Strength

Squa
ats

Leg press
p

Hamstring curl

Knee
e extension 90
9 o to 0o

Step--ups/down

Lung
ges

Shutttle

Sporrts cord

Wall squats

Hopp
ping without pain progression
(Bilatteral hop/jum
mp progressing to single
e leg ending in squat.
Hop and hold witth alignmentt AP, medial-lateral, crosss)

Neuromuscular Tra
aining

Wobble board / rocker

r
board
d / roller board

Pertu
urbation train
ning

Instru
umented tessting systems

Varie
ed surfaces

MULTICENTER ORTHOPAEDIC OUTCOMES NETWORK

ACL Reha
abilitation Guidelines
G
s

Cardiop
pulmonary

Straig
ght line runn
ning on tread
dmill or in a protected en
nvironment
(NO cutting or piivoting)

All otther cardiopu

ulmonary eq
quipment

OGRESSION TO PHAS
SE 4
CRITERIA FOR PRO

Runn
ning without pain or swe
elling

Hopp
ping without pain or swe
elling (Bilate
eral and Unila
ateral)

Neurromuscular and
a strength
h training exe
ercises witho
out difficulty

PHASE 4: Advance
ed Training Phase
(Approximate time frrame: weekss 13 to 16)
GOALS

Runn
ning patternss (Figure-8, pivot drills, etc.)
e
at 75% speed witho
out difficulty

Jump
ping without difficulty

Hop tests at 75%

% contralaterral values
cinnati hop te
ests: single--leg hop for distance,
d
trip
ple-hop for distance,
d
(Cinc
cross
sover hop fo
or distance, 6-meter
6
time
ed hop)

EXERCISE SUGGESTIONS
sive Strengtthening
Aggress

Squa
ats

Lung
ges

Plyom
metrics

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ACL Reha
abilitation Guidelines
G
s

Agility Drills
D

Shufffling

Hopp
ping

Cario
oca

Vertical jumps

Runn
ning patternss at 50 to 75
5% speed (e.g. Figure-8))

Initial sports speccific drill pattterns at 50%

%75% efforrt

Neuromuscular Tra
aining

Wobble board / rocker

r
board
d / roller board

Pertu
urbation train
ning

Instru
umented tessting systems

Varie
ed surfaces

Cardiop
pulmonary

Runn
ning

Othe
er cardiopulm
monary exerccises

CRITERIA FOR PRO

OGRESSION TO PHAS
SE 5

Maximum vertica
al jump witho
out pain or in
nstability

75% of contralate
eral on hop tests

Figurre-8 run at 75%

7
speed without
w
difficulty

IKDC
C Question # 10 (Global Rating of Kn
nee Function) score of > 8

10. How
w would you rate the function of yo
our knee on
n a scale of 0 to 10 with
h 10
being normal, excellent
e
fun
nction and 0 being the
e inability to
o perform an
ny of
yourr usual daily
y activities?
?

10

MULTICENTER ORTHOPAEDIC OUTCOMES NETWORK

ACL Reha
abilitation Guidelines
G
s

PHASE 5: Return-to
o-Sport Pha
ase
(Approximate time frrame: weekss 17 to 20)
GOALS

85% contralatera
al strength

85% contralatera
al on hop tessts

Sporrt specific tra

aining withou
ut pain, swelling or difficu
ulty

EXERCISE SUGGESTIONS
sive Strengtthening
Aggress

Squa
ats

Lung
ges

Plyom
metrics

Sport Sp
pecific Activ
vities

Interv
val training programs
p

Runn
ning patternss in football

Sprin
nting

Chan
nge of directtion

Pivott and drive in

n basketball

Kicking in soccerr

Spikiing in volleyb
ball

Skill / biomechan
nical analysiss with coach
hes and sports medicine
e team

RETURN
N-TO-SPOR
RT EVALUAT
TION RECO
OMMENDAT
TIONS:

Hop tests (single

e-leg hop, triple hop, cross-over hop, 6-meter tim
med-hop)

Isokinetic strengtth test (60/ssecond)

Vertical jump

Dece
eleration shu
uttle test

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ACL Reha
abilitation Guidelines
G
s

RETURN
N-TO-SPOR
RT CRITERIA
A:

No fu
unctional com
mplaints

Conffidence when
n running, cu
utting, jumpiing at full speed

85% contralatera
al values on hop tests

IKDC
C Question # 10 (Global Rating of Kn
nee Function) of > 9

10. How
w would you rate the function of yo
our knee on
n a scale of 0 to 10 with
h 10
being normal, excellent
e
fun
nction and 0 being the
e inability to
o perform an
ny of
yourr usual daily
y activities?
?

10

10