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3rd Year Physical Therapy Notes

ACL REHAB
Tommy Brennan

© Institute of Physical Therapy and Applied Science

LEARNING OUTCOMES:
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 Describe the mechanism of injury commonly associated with ACL injuries
 Recognise and explain the principals of ACL rehabilitation.
 Demonstrate exercises used in the rehabilitation of ACL injuries.

What is the ACL?

The ACL is one of the two cruciate ligaments. It is named in relation to its attachment to the tibia.
The two cruciates- ACL and PCL are crucial in providing knee stability. It is essential in controlling
pivoting movements. If the ACL is not functional the tibia may rotate under the femur when a
person attempts to land from a jump, pivot, or stop suddenly.The ACL has two primary functions:
 It prevents forward movement of the tibia under the femur
 It controls rotational movement of the tibia under the femur

Tearing your ACL- how does it happen?

Most ACL tears, 60-80%, happen in non-contact situations. ACL injuries occur most frequently in
field sports involving landing from jumps, side-stepping, turning sharply and decelerating, e.g GAA,
soccer , rugby, basketball.

A valgus knee position where the knee falls medial to the foot and hip leads to ACL tear.
The typical ACL injury occurs when the knee is externally rotated, slightly flexed and in a valgus
position as the sportsperson takes off from the planted foot and internally rotates their upper body
with the aim of suddenly changing direction. In this maneuver the ground reaction force falls medial
to the knee joint and this added force may tax an already tensioned ACL and lead to failure.
Similarly in the landing injuries the knee is close to full extension and the ACL is tensioned.

© IPTAS Notes 2
Why does the ACL suddenly tear?
A question often asked is why the ACL tears in maneuvers that the sportsperson has completed
successfully many times in the past. The sportsperson could be off balance, be pushed/nudged by
an opponent, have adopted an unusually wide foot position. Inadequate muscle protection, poor
neuromuscular control, fatigue and loss of concentration may also be relevant factors. That’s one
of the reasons why general conditioning in prehab programmes and ACL rehab is important.

© IPTAS Notes 3
FEATURES OF AN ACL TEAR.
History takes often reveal the following:

 A description of valgus knee position at time of injury, a landing, cutting maneuver.

 Patient can hear a ‘pop’ or ‘click’ or something ‘going out of place and then going back’.
 Most tears are extremely painful.
 Players are usually unable to continue playing.
 There can be relatively immediate swelling (2hrs)
 Patients experience a feeling of instability in the knee.

ACL examination.
Most sportspeople will present to your clinic 24-48 hrs after injury. Testing at this time may prove
difficult due to pain and swelling. The examination is easier either 1 hour or 4/5 days after injury.
The Lachman’s test is positive in ACL tears and is the most useful single test.

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Do all ACL tears require surgery?
The short answer to this is no, but it depends on a number of factors. Evidence for non-surgical
ACL rehabilitation only is emerging. One study by Frobell and Roos et al compared two treatment
groups- rehab plus early ACL surgery and rehab alone. After two years there was no difference in
terms of knee function and return to sport and 40% of the group treated with initial rehab only
needed ACL reconstruction.
Possible factors include:
 Age
 Degree of instability in function
 Associated knee injuries- (e.g MCL, meniscal tear)
 Patient’s desire to return to jumping and pivoting sports
 Occupation

Episodes of ‘giving way’ (certainly after 3 months) indicate functional instability and this is likely to
be a reliable predictor that there is an increased likelihood of needing surgery.

After the operation ppl generally return to desk based occupation after two weeks but if your job
requires mobility it may be three months before patients are able to return.

TYPE OF SURGERY:
The aim of ACL surgery is to replace the torn ACL with a graft that reproduces the normal function
of the ligament. In some cases allografts are used (transplant of cadaver tissue) but most often
autografts are used- patella or hamstring tendon from ipsilateral limb. There are pros and cons for
both and the type of graft used has implications for the rehabilitation programme.

Graft Type Possible complications Implications for

rehabilitation
Patella tendon Kneeling pain Soft tissue therapy
Patellar tendonosis Patella tendon
Reduced patella mobility strengthening
Patella taping
Hamstring Slower graft healing time Less aggressive soft
tendon tissue work
No isolated hamstring
strengthening for 8
weeks

The patella graft follows an accelerated rehab programme compared to the hamstring graft. The
main difference in relation to hamstring graft rehab is to move slower through the phases
(especially the earlier phases) of rehab and delay plyometrics and return to running.

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ACL SURGERY:

© IPTAS Notes 6
ACL REHABILITATION:
Exercises included in the rehab programme fall into the following catagories:
 ROM
 Progressive muscular strengthening
 Proprioception
 Neuromuscular control
 Functional drills
 Return to running
 Sports specific drills

PRE-OPERATIVE PHASE

Patients who comply to a pre-operative rehabilitation phase generally have better outcomes and
move easier through the post-op phases, especially the earlier phases.

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Brukner & Khan: Rehab following ACL reconstruction.

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PRINCIPALS OF ACL REHABILITATION :
Guidelines for therapist in ACL rehab:
 Full passive knee extension
 Restore Patellar mobility
 Reduce post-op inflammation
 Restore ROM
 Re-establish voluntary quadriceps control
 Restore Neuromuscular control
 Gradually increase applied loads
 Progress to Sport-specific training.

Full Passive Knee Extension:

The most common cause of poorer outcomes following ACL reconstruction is motion loss
especially full knee extension.

The inability to fully extend the knee results in:

 Abnormal joint mechanics
 Scar tissue formation
 Increase in patellofemoral/tibiofemoral joint contact pressure.

The goal is to aim for hyperextension in the first few days after surgery. The degree of
hyperextension is dependent on the asymptomatic knee. E.g. 10 degrees on good side-aim for 7
degrees on injured leg and restore remaining degrees in following weeks.

Specific exercises:
 PROM exercises by therapist
 Supine hamstring stretch
 Gastro stretch with towel
 Passive overpressure 2-4.5kg proximal to patella for low load long duration stretch. 15
mins x 4 reps i.e. 60 mins/day

Passive overpressure: prone and supine

Research articles feel that hyperextension is imperative to a successful outcome and an

asymptomatic knee.

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RESTORE PATELLAR MOBILITY:
There can be a loss of patella mobility due to scar tissue, fat pad restrictions and using the patella
tendon for ACL graft.
Loss of patella mobility can lead to
 ROM complications
 Difficulty activating quads

Mobilisations by the therapist and patient at home are required. (medial to lateral, superior to
inferior)

REDUCE POSTOPERATIVE INFLAMMATION:

Control post-op pain , inflammation and swelling. Pain leads to muscle inhibition in the quads.
Young et al examined quad activity in patients with a painful knee and discovered that there was
30-76% inhabitation in control group compared to 5-31% inhibition in patients with local
anesthesia.

Pain and swelling can be controlled by:

 Cryotherapy
 Medication
 Electrical stimulation
 PROM
 Joint compression

© IPTAS Notes 10
The speed progressed through the weightbearing programme needs to be assessed to ensure no
increase in symptoms.
2 crutches are used for first 7-10 days progressing onto 1 crutch and full weight bearing at 10-14
days.

ROM:
Immediate motion is essential and the primary focus is on extension. Flexion is gradually
progressed by 10 degrees each week so that full flexion is achieved by 4-6 weeks.

The rate of progression depends on the individual patient’s response- move slower in the first 5-7
days and focus on reducing the pain and swelling rather than push flexion at the expense of
increasing the symptoms.

Assisted knee flexion exercises: Active Knee flexion exercises:

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RE-ESTABLISH VOL. QUAD CONTROL:

Inhibition of the quad muscle is common after ACL surgery . Using NM electrical stimulation
combined with exercise was more effective at improving quad strength than exercise alone. (Kim
et al) i.e. electrical stimulation while performing isometric and Inhibition of the quad muscle is
common after ACL reconstruction. Kim et al concluded that exercise and electrical stimulation is
more effective in isotonic exercises. E.g.
 VMO activation
 straight leg raise
 mini-squats
 hip abduction
 mini lunge

Patients are instructed to actively contract their quad muscle.

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Hip Abduction with quad activation.

Other early stage strengthening exercises:

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RESTORE NEUROMUSCULAR CONTROL:
(Muscle activation with neural input to gain the desired movement).

Proprioception training can often begin in week 2 depending on the symptoms- WB weight shifting,
mini- squats progressing onto mini squats on an unstable surface e.g foam, tilt board.

Wearing a support strap can have a positive impact on proprioception and joint position sense.
(Kuster MS)

Wilk et al concluded that the greatest level of hamstring and quad contraction occurred at 30
degrees of knee flexion during squats. Improving quad and hamstring coactivation reduces
ligament stress and enhances knee stability.

See pic of mini-squats above. Instruction to client- squat to 30 degrees and hold for 2-3 seconds
while stabilizing.

The Star Balance Test is an excellent exercise that can be used during ACL rehab.
(Please see paper attached)

As proprioception improves progress to preparatory co-activation during functional tasks E.g.

 Single leg balance, stable- unstable surface
 Cone stepping
 Lateral lunge drills

Proprioception exercises are progressed by incorporating movement of either upper extremity or

uninvolved lower extremity to alter the position of the center of mass, to both upper and lower
extremity movements combined.
These exercises promote dynamic stabilization and recruit various muscle groups.
The med ball weight can be increased to further challenge the NM system.

Single-leg stance on foam while performing upper extremity

movements using a 3.2-kg medicine ball. The clinician can
perform a perturbation by striking the ball to cause a
postural disturbance.

Also please see “Example of Lower limb Proprioception Exercises” in notes.

© IPTAS Notes 14
Cone stepping drills and lateral lunges can improve gait training and also
 Enhance dynamic stability
 Train the hip to control forces at the knee

(The hip has a huge role to play in knee function and isolated hip strengthening begins early in
rehab and is progressed throughout the phases in various NM exercises- balance , plyo drills,
landing technique etc).

Cone stepping drills- instructions to patients:

Raise knee to hip level and step over a series of cones landing with a slightly flexed knee.

Lateral Lunges: - instructions to patients:

Lunge to the side and land on slightly flexed knee and hold position for 1-2 seconds before
returning to the start position.
Progression:
 Lateral lunge
 Lateral lunge – multiplanar
 Lateral lunge onto foam/dura disc.
 Add in a ball catch

Perturbation training has been proven to be effective in ACL rehab. It’s used primarily during
double or single-leg balance exercises

E.g. With knee flexed to 30 degrees the patient maintains postural stabilization while catching the
med ball
The therapist can also provide perturbation by striking the tilt board or tapping the patient on the
trunk or hips and also using theraband to shift weight during exercises.

NM training including perturbation training helps restore patient’s confidence in the knee.

Weight-bearing Vs Non-weight bearing exercises.

Both weight bearing exercise and non-weight bearing exercise have been shown to be effective for
rehab and return to sport after ACL surgery. However compared to NWBE, individuals who
preform predominately WBE tend to have less knee pain, more stable knees, generally more
satisfaction with the end result and a quicker return to sport. (Wilk)

Due to differences in ACL loading between WBE and NWBE, focus on WBE.
E.g.
 Squats
 Single leg squats
 Wall squats
 Forward and side lunges
 Leg press

{The leg press with 40% body weight resistance, climbing stairs and forward lunge produced less
ACL strain than performing seated knee extensions with no external resistance. Seated knee ext.

© IPTAS Notes 15
produced the same ACL strain as a single leg sit to stand with the latter exercise also recruiting
more hip and thigh muscles which helps to stabilize the knee and protect the ACL graft
The Lunge. This exercise can be progressed and used throughout ACL rehabilitation
from phase 1 right through to return to play. It can be used to develop core activation, pelvic and
hip NM control as well as glute, quad and hamstring activation and strength

Technique is important- In squatting and lunging, anterior knee translation beyond the toes (esp
more than 8cm) increases ACL load.

Controlling varus and valgus movements at the knee are important- NM control drills
E.g.
 Front step up
 Front step down
 Lateral step down
 Single leg balance

© IPTAS Notes 16
Front step-down movement: during the eccentric or lowering Lateral step down with resistance bands. A resistance band is
phase, the patient is instructed to maintain proper alignment applied around the inner knee to provide resistance and to
of the lower extremity to prevent the knee from moving into control the valgus movement at the knee by recruiting hip
a valgus position. abductors and rotators.

© IPTAS Notes 17
Plyometric Drills for dynamic stabilization and NM control:

Benefits:
 Dissipate forces
 Reduce abduction and adduction movements
 Increase hamstring strength
 Improve hamstring/quad ratio

Plyo drills start 12 weeks after PTG and 16 weeks after hamstring graft.
Instruction of proper jumping and landing technique is crucial.
Instruction:
 Land softly on balls of feet
 Knee flxn
 Hip flxn
 AVOID HYPEREXTENSION AND VALGUS!!

Double-leg plyometric jumping drills in the lateral direction, in which

the patient is instructed to land on the box and flat ground with the
knee in a flexed position. These activities are initiated to allow the
quadriceps musculature to create and dissipate forces at a higher
level prior to returning to sport

Example of drills:
 Ankle hops
 Jumping in place
 Lateral/ diagional/ rotational jumping
 Flat ground
 Plyo boxes
 2 legs- 1 leg

© IPTAS Notes 18
FATIGUE has been shown to diminish proprioceptive and NM control therefore patient needs to
perform NM control drills towards the end of as session after strength/ cardio work to challenge NM
control of the knee joint when the dynamic stabilisers are fatigued.

© IPTAS Notes 19
GRADUAL INCREASE OF APPLIED LOADS:
ROM, strengthening exercises, proprioceptive training, NM control drills, functional drills, running
and sports specific training all follow the basic concept of gradually increasing applied loads
E.g.
 Increase reps/sets/weight or progress the task
 Lunge- multiplanar lunges
 Double leg- single leg work
 Flat surface- unstable surface
 Running in straight lines –cutting & agility drills
 **backwards and lateral running is performed prior to forward running to reduce stress on
the knee**

Progression is based on evaluation by the therapist and the patient’s ability to tolerate functional
progression while following proper technique without increasing pain & swelling.

Progression gradually increases the applied loads to ACL graft resulting in tissue hypertrophy and
better tissue alignment. Stimulate healing tissue without causing damage.

If the patient’s knee is still sore or exibits swelling/stiffness/localized pain after running or activity,
the training is reduced so that it doesn’t cause that reaction.

PROGRESS TO SPORTS SPECIFIC TRAINING:

Development of the many previously used drills.
E.g.
 Cone drills
 Lunge with theraband resistance
 Plyo drills
 Running and agility drills- ziz zag with 45 degree cutting, 90 degree cutting (see examples
below)
 Jump catch ball and land
 Jump catch ball and land with perturbation
 Sprint, cut , shoot- un contested- contested @ 50% / 75% /100% contested play.

© IPTAS Notes 20
Agility Jumps with perturbation. Figure of 8 drill and zig-zag running drill.

CRITERIA FOR RETURN TO PLAY:

1. Satisfactory clinical examination

2. Symmetrical range of motion without pain
3. Isokinetic test parameters
• Quadriceps bilateral comparison (80% or
greater)
• Quadriceps torque-body weight ratio (65% or
greater)
• Hamstrings-quadriceps ratio (>66% for males,
>75% for females)
• Acceleration rate at 0.2 s (80% of quadriceps
peak torque)
4. KT 2000 test within 2.5 mm of contralateral leg
5. Functional hop test (85% or greater of
contralateral side)

© IPTAS Notes 21
You progress patients through stages of rehab right up to on field activity and you can also
conduct the hop tests. (see paper). Isokinetic testing should be done prior to return to full sports.

Diagrammatic representation of the series of 4 hop tests: single hop for distance, 6-m timed hop, triple hop for distance,
and crossover hop for distance.
Adapted and reprinted by permission of Sage Publications Inc from: 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;19:513–518. Copyright 1991 by Sage Publications Inc.

Directions for hop tests:

For each hop test, the subjects performed one practice trial for each limb, followed by 2 measured and recorded trials.
Consistent with the original description of the 4 hop tests, no additional warm-up activity was performed. For each set of
tests, the subjects were instructed to begin with the nonoperative limb. To minimize fatigue, a rest period was offered
between types of hop tests (up to 2 minutes) and between individual hop test trials if needed (typically less than 30
seconds was sufficient). Subjects started each test with the lead toe behind a clearly marked starting line. No restrictions
were placed on arm movement during testing, and no instructions were provided regarding where to look. Subjects were
encouraged to wear the footwear they would normally wear during their rehabilitation sessions.
For the hops for distance (single, triple, and crossover) to be deemed successful, the landing must have
been maintained for 2 seconds.

Females and ACL injuries:

The rate of ACL injuries is far higher in females than males and investigation into the following
factors is ongoing:
1. Anatomical
2. Hormonal
3. Shoe/ surface type
4. Neuromuscular

© IPTAS Notes 22
Anatomical:
Smaller intercondylar notch, smaller ACL, wider pelvis and greater Q angle, greater ligament laxity
are differences in females. These factors can’t be changed so there is less focus on this, less
research.

Hormonal :
Most researchers now believe an influential relationship is unlikely. ( Brukner & Khan)

Shoe- surface interface:

Studs, blades, astro, hard/soft ground.

Neuromuscular factors:
The balance of muscle power and recruitment pattern between the quadriceps and hamstring
muscles is crucial to functional knee stability.
Controlling the rotation of the limb under the pelvis in pivoting and landing is crucial in controlling
knee stability and reducing the functional valgus knee. Quadriceps muscle contraction can
increase ACL strain.
 Females are more quad dominant
 Females land with less hip and knee flexion- “ligament dominance”.

ACL PREVENTION PROGRAMMES:

Due to the importance of NM factors in ACL injuries several preventative training programmes
have been established.

The components of these NM training programmes are:

1. Balance training
2. Landing with increased flexion at the hip and knee
3. Controlling body motions especially in deceleration and landing maneuvers
4. Some form of feedback to the sportsperson during training of these activities

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ACL PREVENTION PROGRAMME;

Also see the 11+ warm up. Videos/PowerPoint presentations, cards etc are available for free at
www.fifa.com/medical

© IPTAS Notes 24
References:

Brukner P, Khan K Clinical Sports Medicine 4th Edition. McGraw-Hill

Houglum, P. (2010). Therapeutic exercise for musculoskeletal injuries. USA. Human Kinetics

Wilk et al Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries 2012 Journal of
Orthopaedic & Sports Physical Therapy

Bizzini M et al, Suggestions from the field for return to sports participation following anterior cruciate ligament
reconstruction: soccer. Journal of Orthopaedic & Sports Physical Therapy

Understanding and Preventing noncontact Anterior Cruciate Ligament Injuries: A Review of the Hunt Valley 2 Meeting,
January 2005. The American Journal of Sports Medicine

Padua, D et al The Landing Error Scoring system (LESS) is a valid and reliable clinical Assessment Tool of Jump
Landing Biomechanics. The Jump ACL Study. The American Journal Of Sports Medicine.

Reid A et al, Hop Testing provides a reliable and valid outcome measure during rehabilitation after Anterior Cruciate
Ligament Reconstruction. Journal of the American Physical Therapy Association

Lephart S et al, The Role of Proprioception in the management and rehabilitation of athletic injuries. The American
Journal of Sports Medicine

The Role of Proprioception in

the
Management and Rehabilitation of
in the
Management and Rehabilitation of
Athletic
Injuries

© IPTAS Notes 25