Written by: Joseph Villena, PT, MPT, OCS, CSCS, COMT
Most athletes who suffer an ACL injury will undergo surgical reconstruction. Expectations for rehab professionals are to utilize an evidence-based approach when determining appropriate exercises and progressions for treatment. What goes into developing a successful post-operative ACL rehabilitation program? Here are 3 key factors that you must consider:
1. Aim to achieve full knee ROM within 12 weeks after surgery.
The most common complication after ACL surgery that can lead to poor functional outcomes is the loss of knee ROM. Full knee ROM as defined by the American Orthopaedic Society for Sports Medicine and the International Knee Documentation Committee are:
- Knee extension < 2° (which includes hyperextension)
- Knee flexion < 5°
Research by Sachs et al5 showed that a flexion contracture can contribute to patellofemoral pain and quadriceps weakness. Additional research by Shelbourne and Gray6 showed that 3° to 5° loss of knee extension adversely affected the subjective and objective results after surgery. These are post-surgical complications that can affect the patient’s function in the short-term. However, one important long-term consequence from not achieving full knee ROM would be the increased likelihood of the patient developing osteoarthritis7.
2. Train for equal weight bearing with basic and advanced squat activities.
ACL post op patients are at high risk for sustaining a second ACL injury to their contralateral side within 24 months of return to sport even with excellent functional testing and isokinetic scores3,8. Why you might ask? One research article showed that post-operative ACL subjects unloaded their affected limb with basic squatting up to 48% of their body weight between the first 1 ½ to 4 months post-operative and 28% between 6 to 7 months2. The difference in loading response was worse with adding external weight or with performing a deeper squat.
This type of compensation compromises the affected limb’s abilities to develop appropriate strength and stability while increasing the work load and risk of injury of the unaffected side. To mitigate this, train squatting with equal weight bearing early in the rehab. Some easy and effective ways to know if they are weight bearing equally are to use low-cost weight scales to get measures of weight distribution or use a mirror to monitor for their body position.
Check Out These Videos:
Utilize a combination of Open Kinetic Chain (OKC) knee exercises and Closed Kinetic Chain (CKC) knee exercises to achieve full quadriceps and hamstring strength.
The primary concern for those apprehensive of utilizing OKC knee exercises is loosening of the healing ACL graft via excess strain at the tibiofemoral joint. Clinical trials on this topic were investigated in three systematic reviews and one meta-analysis4. The results of these studies showed that there were no significant differences in anterior tibial laxity, strength, patient-reported function, or physical function with early or late introduction of OKC knee exercises in those who have had ACLR4. Any modifications for OKC knee exercises at different ROMs should be based on graft-site pain and patellofemoral stress considerations, but should not be made based on perceived strain on the ACL graft1.
Check Out This Video:
OKC Knee Extension Exercise Combined with Blood Flow Restriction Training
You can learn more about developing a successful program from my upcoming live stream course Advanced Concepts in ACL rehabilitation on June 28th from 12:30 pm – 3:45 pm US/Eastern. Click here to register!
About Summit Professional Education
Summit equips Physical Therapists, Occupational Therapists and SLPs with better continuing education courses that provide CEUs while impacting patient outcomes. Find high-quality on-demand CE along with the largest offering of live options — including live webinars, live streams, and in-person courses. Want to deep dive on a topic? Summit offers hundreds of 6-hour courses for the most in-depth learning!
References:
- Brinlee, A. W., Dickenson, S. B., Hunter-Giordano, A., & Snyder-Mackler, L. (2022). ACL reconstruction rehabilitation: clinical data, biologic healing, and criterion-based milestones to inform a return-to-sport guideline. Sports Health, 14(5), 770-779.
- Neitzel, J. A., Kernozek, T. W., & Davies, G. J. (2002). Loading response following anterior cruciate ligament reconstruction during the parallel squat exercise. Clinical Biomechanics, 17(7), 551-554.
- Paterno, M. V., Rauh, M. J., Schmitt, L. C., Ford, K. R., & Hewett, T. E. (2014). Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. The American journal of sports medicine, 42(7), 1567-1573.
- Perriman, A., Leahy, E., & Semciw, A. I. (2018). The effect of open-versus closed-kinetic-chain exercises on anterior tibial laxity, strength, and function following anterior cruciate ligament reconstruction: a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy, 48(7), 552-566.
- Sachs, R. A., Daniel, D. M., Stone, M. L., & Garfein, R. F. (1989). Patellofemoral problems after anterior cruciate ligament reconstruction. The American journal of sports medicine, 17(6), 760-765.
- Shelbourne, K. D., & Gray, T. (2009). Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. The American journal of sports medicine, 37(3), 471-480.
- Shelbourne, K. D., Urch, S. E., Gray, T., & Freeman, H. (2012). Loss of normal knee motion after anterior cruciate ligament reconstruction is associated with radiographic arthritic changes after surgery. The American journal of sports medicine, 40(1), 108-113.
Sousa, P. L., Krych, A. J., Cates, R. A., Levy, B. A., Stuart, M. J., & Dahm, D. L. (2017). Return to sport: Does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes?. Knee surgery, sports traumatology, arthroscopy, 25(5), 1356-1363.