Milestones Following ACL Reconstruction

• Minimal swelling 
• Full mobility 
• Good quadriceps control 
• Physical and mental preparation of patient 
• Explain: protocol, objectives and goals 
• Teach post-operative exercise regime (if appropriate) 
• Emphasise importance of maintaining full knee extension and gaining 90 degrees of knee flexion within the first 1-2 weeks
• Teach patello-femoral self-mobilisation 
• Co-contraction exercises for Hamstrings/Quadriceps: supine, sitting, weight bearing, incorporating VMO 
• Measure for crutches (if appropriate) and teach safe use, stairs etc.

The frequency of physiotherapy input can be dependent on the surgeon’s protocol but also depends on each individual.   More intensive monitoring is recommended in the early weeks to ensure good range of movement and to prevent complications. Then the general recommendation is every 2 to 4 weeks until 6 months post-op. After this it is determined by the patients’ specific activity and/or strength deficits. The seven stages involve critical milestones that should be achieved before progressing the patient’s function. In documenting the date of achievement this enables another physiotherapist to easily establish where a patient lies on the rehabilitation ladder.

STAGE I: 0-2 weeks
STAGE II: 2-4 weeks
STAGE III: 4-6 weeks
STAGE IV: 6-10 weeks
STAGE V: 10-12 weeks
STAGE VI: 3-4 months
STAGE VII: 4-9 months

• must see a physiotherapist around 1 -2 weeks post-op 
• essential patient is off work to prevent post-op swelling & complications 
• crutches should be used for the first 5 days but this may depend on surgeons’ own protocol
• must gain terminal extension and 90 degrees flexion in the first week to avoid arthrofibrosis. Arthroscopic debridement may be needed at 4-6 weeks if full extension is not achieved.

OBJECTIVES

• Reduce swelling 
• Ensure mobility of the patella 
• Prevent adhesions developing around the arthroscopy incision sites 
• Check and report to surgeon any signs of infection or other post-op complications such as Deep Vein Thrombosis 
• Gain terminal extension equal to opposite leg 
• Gain 90 degrees flexion, do not push past this as can cause laxity 
• Restore normal gait pattern using crutches if necessary to prevent incorrect movement patterns
• Encourage co-contraction of Quadriceps and Hamstrings to strengthen muscles and begin to regain knee control.

METHOD

• Minimal standing and walking (5 Minutes) 
• Exercise every 1-2 hours 
• RICEM regime (minimum 3 times daily) 
• Massage carefully around incisions and popliteal muscle / posterior capsule 
• Massage and release to any trigger points 
• Patellar mobilisations; medial / lateral and superior / inferior glides 
• Gentle knee mobilisations to facilitate normal joint glide 
• Passive knee extension exercises, unsupported knee hangs, prone knee hangs, standing weight shifts 
• Hamsting / Calf stretches
• Knee Flexion to 90 ° exercises, lying on the back heel slides, over the side of the bed, lying on the front, in sitting – NB all using the other leg for assistance as tolerated 
• Quadriceps strengthening exercises in sitting with Vastus Medialis Obliquus (VMO) emphasis 
• Active knee extension exercises pushing the back of the knee down into the bed, sitting over the side of the bed working through 90°-3 ° with VMO emphasis 
• Active Straight Leg Raise (SLR) – only if there is no quadriceps lag 
• Hip extension exercises in prone and standing 
• Posterior fibres of gluteus medius exercises
• Gym: static bike once the knee allows comfortable turning – may adjust the seat up to facilitate this.

GOAL: To achieve isolated muscle control and initiate a co-contraction of the quadriceps and hamstrings.

MILESTONES

• Safe independent use of crutches; walking and stairs   
• Active isometric co-contraction of quadriceps and hamstrings in both
• long sitting and sitting with knee flexion varied with VMO emphasis
• Full extension with quadriceps control
• Active SLR in 4 directions for 10 secs without quads lag (otherwise use a brace)
• Unsupported 2 legged mini squat with correct knee alignment
• Painfree correct gait pattern on 1 crutch.

• Ideally patient should be off work for 4 weeks, travelling in for intensive treatment or receiving treatment from local practices 
• There must be no signs of infection or other complications – incision wounds should be healing well or may have healed 
• Full extension and 90° flexion should have been attained.

OBJECTIVES

• Swelling MUST be kept to minimum 
• Maintenance of full knee extension 
• Gradually increase knee flexion now but beware of any other surgical procedures. If meniscal repair has been performed, may have restricted weight bearing and limit of knee flexion to 90 degrees for 4-6 weeks. If chrondroplasty performed expect increased pain and irritability
• Progressive strengthening.

METHOD

• Massage around incisions and popliteal muscle / posterior capsule 
• Massage and release to any trigger points 
• Patellar mobilisations; medial / lateral and superior / inferior glides 
• Gentle knee mobilisations to facilitate normal joint glide 
• Hourly flexion and extension exercises 
• VMO strengthening exercises performed often during the day 
• Walking program 
• Proprioception: 1 leg, eyes open / closed, mini-tramp, arms to side +/- weights, wobble board 
• Closed kinetic chain exercises progressed according to pain and swelling 
• Gym: static bike, stair machine, leg press (not leg extension), squats, lunges 
• Adductor & abductor strengthening 
• Passive quadriceps stretch in prone lying using opposite leg 
• Swimming (NOT breaststroke) as soon as scars healed 
• Assess Gluts / hamstrings / erector spinae firing patterns and treatment 
• Hamstring strengthening exercises, prone lying flicks / catches, weights, standing hamstring curls 
• Walk on toes, heels.

GOAL:

1. Independent gait +/- altered pattern (concentrating on heel-toe gait) 
2. Complete all activities of daily living independently.

NB: Driver / Vehicle Licensing Association (New Zealand) mandatory requirement; no driving until 4 weeks as driving reflexes are diminished by 0.2 secs per 5m before this – (Tietjens).

MILESTONES

• Perform mini squat ® weight shift on to affected leg and hold with correct alignment 10 sec
• Stand on affected leg without support 10 sec
• Bridging unsupported 5 x 10 sec hold (hip control activities)
• Step ups – 3 sets of 10 repetitions
• Leading up and down with affected leg

Patient should now be able to drive safely – may be prudent to inform their car insurance company to ensure they are covered.

OBJECTIVES

• Swelling MUST be kept to minimum 
• Maintenance of full knee extension 
• Continue to gradually increase knee flexion (beware of other surgical procedures) 
• Progressive strengthening.

METHOD 

• Hands on treatment as indicated to ensure full range of movement of flexion and extension 
• Closed kinetic chain exercises progressed according to pain and swelling 
• Gym: static bike, stair machine, leg press (not leg extension), squats, lunges, slideboard 
• Progress to include unilateral closed kinetic chain leg exercises 
• Increase walking distance and/or pace.

GOAL:

1. Independent gait pattern with no compensation. 
2. Knee flexion of >90º+ (note: return of knee flexion tends not to be a problem in isolated ligament injuries).

MILESTONES 

• Mini-squat 0-40º on affected leg with correct alignment and end of range extension control
• Step ups – 3 sets of 10 repetitions
• Leading up with affected and down with non affected leg
• Able to stand on affected leg unsupported for 10 sec with eyes closed
• Able to sit ® stand on affected leg only, with arms folded.

The transplanted graft dies then revascularises – this should occur between 8-12 weeks.

OBJECTIVES 

• Swelling MUST be kept to minimum 
• Maintenance of full knee extension 
• Continue to gradually increase knee flexion (beware of other surgical procedures) 
• Progressive strengthening 
• Increase confidence and fitness levels 
• Exercises performed regularly in gym (x 3 weekly) plus daily home program 
• Improve proprioception and co-ordination.

METHOD

• Progress gym work by changing speed and resistance 
• Progress balance exercises using wobbleboard, trampoline.

GOAL: To decrease base of support when exercising therefore increase proprioception.

MILESTONES 

• Stand on affected leg, mini squat, draw cross 10x with other leg while maintaining alignment
• Stand on affected leg, mini squat, turn non weight bearing flexed hip from 0-90º external rotation (rotation control exercises)
• Bridging unsupported on affected leg only for 5 x 10 sec hold
• Kneel to stand and return on affected leg with concentric and eccentric control                        

STAGE V: 10-12 weeks

The transplanted graft dies then revascularises –this should occur between 8-12 weeks.

OBJECTIVE
Preparation for running

METHOD

• Progress balance exercises using trampette 
• Light plyometric work, jumping / hopping, lateral step ups 
• Increase speed / height of step / height of jump gradually as confidence improves.

GOAL:

1. To start light jogging on a mini tramp. 
2. Progress loaded activities adding in lateral stability work, i.e. slide board.

MILESTONES

Able to achieve 10 slides maintaining knee alignment with no tibial torsion

1. Forward

2. Laterally in and out of abduction

OBJECTIVES

• Confidence in knee stability 
• Maintain motivation 
• Running 
• Improve aerobic fitness.

METHOD
Progress proprioception 
Agility skills, advance plyometrics, cutting, hopping figure 8s 
Increase speed / height of step / height of jump gradually as confidence improves.

GOAL:

1. Safe to introduce open kinetic chain exercises if sport indicated 
2. Patient should have good hip and knee control, proprioception and be free of effusion to initiate running.

MILESTONES    

• To be able to hop in a figure of 8 around chairs 3m apart                                                                              
• Full knee flexion (130º+) or equivalent to non-affected (not vital – ROM equivalent to functional needs)
• Able to perform power based activities – 3 sets of 10 repetitions squat with weight and correct alignment
• Perform independent sport specific exercises.

Shelbourne and Nitz found that the patellar tendon graft remains consistently viable and attains its maximum fibroblastic size and number at 6 months. The ACL graft at 6 months is 50% of normal breaking strength, at 8 months 80% of normal breaking strength. Typically return to full sport specific activity drills at 4-6 months but dependent on: 

• Full range of movement 
• No effusion after exercise 
• Good stability 
• Adequate proprioception 
• Adequate sport specific agility 
• Functionality in a sports specific agility 
• Care with aggressive activity for swelling and maintenance of motion 
• The ability to play at pre-injury level can require 2 months of regular competition. 
• Return to sport may be initiated at 4-6 months but full contact sport not until 9-12 months.

OBJECTIVES 

• Running and rotation activities 
• Sports specific training.

METHOD

• Progress running skills to include changes of speed and direction 
• Advance plyometrics, single leg jumping to / from graduated height.

GOAL:

1. To have control and strength to complete multi-directional activities / running drills. 
2. Ability to control speed with alignment while completing complex skills relevant to individual sport / goals.

MILESTONES 

• Able to run in figure of 8, altering speed and contours (document time and course undertaken)
• Able to run with acceleration / deceleration and change of direction
• Perform controlled opponent situations
• Perform uncontrolled practice sessions
• Competition at lower level
• Competition at full level.

Important treatment factors which are often ignored: 

• Co-contractions (quadricep:hamstring) should be established from day 1 post operatively. 
• Early open chain active extension (-30º to 0º) applies strain to the graft with shearing forces. 
• Tibio-femoral compression stabilises this complex therefore co-contractions and closed kinetic chain exercises in varied positions and degrees of weight bearing are ideal. 
• Passive extension applies no risk to the graft therefore tibio-femoral and patellofemoral joint mobilisations should be used in the early stages to increase mobility. 
• Hamstring activity is not detrimental to repairs but the type of reconstruction used must be taken into account 
• Gait deficiencies need early correction! Do not be too eager to progress the patient off crutches early, this allows compensatory, incorrect patterns to develop. 
• Assessment of pelvic and foot stability is essential, as both these can play an important role in knee alignment and control. 
• Bias hamstring strength over quadriceps strength to decrease stress on ACL 
• Weight bearing as tolerated with early quadriceps activity and a quick resumption of a normal gait pattern actually strengthen the properly placed graft instead of ‘stretching’ the graft.