Rehabilitation of Primary and Revision Anterior Cruciate Ligament Reconstruction

Clinical Concepts

The two anterior cruciate ligament (ACL) postoperative rehabilitation protocols described in this chapter consist of a careful incorporation of exercise concepts supported by the scientific data presented in Chapter 10 . The protocols are evaluation based; that is, progression through the program is based on continual evaluation using the principles of anatomy, physiology, biomechanics, and surgery, with an understanding that the overall goals of the reconstruction and rehabilitation are to:

• Regain normal knee stability: less than 3 mm of increased anteroposterior (AP) displacement on knee arthrometer testing, negative or trace pivot shift

• Control joint pain, swelling, and hemarthrosis

• Regain a normal range of knee motion

• Restore a normal gait pattern and neuromuscular control for ambulation

• Recover normal lower limb muscle strength

• Regain normal proprioception, balance, coordination, and neuromuscular control for desired activities

• Achieve optimal functional outcome based on orthopedic and patient goals

Each patient is taken through the appropriate program at a rate that takes into account sports and occupational goals; the condition of the articular surfaces, menisci, and other knee ligaments; concomitant operative procedures performed with the ACL reconstruction; the type of graft used; postoperative healing and response to surgery; and biologic principles of graft healing and remodeling. The protocols are divided into seven phases according to the time period postoperatively (e.g., phase I comprises postoperative weeks 1 and 2). Each phase has four main categories that describe the factors evaluated by the therapist and exercises performed by the patient:

• General observation of the patient's condition

• Evaluation and measurement of specific variables, with goals identified for each variable

• Treatment and exercise program according to frequency and duration

• Rehabilitation goals that must be achieved to enter into the next phase

The first protocol is designed for patients who undergo primary ACL bone-patellar tendon-bone (B-PT-B) autogenous reconstruction and desire to return to strenuous sports or work activities as soon as possible after surgery. All patients are warned that the return to strenuous activities early postoperatively carries a risk of either a reinjury to the ACL-reconstructed knee or a new injury to the contralateral knee. These risks cannot be scientifically predicted, and patients are cautioned to return to strenuous activities carefully and avoid any activity in which pain, swelling, or a feeling of instability develops. Patients who develop postoperative problems, such as knee motion complications, chronic effusion, patellofemoral pain, or patellar tendinitis, are advised to slow the rate of progression until the problems are resolved. The following criteria exclude a patient from this protocol:

• Concomitant major operative procedures, such as complex meniscal repair or transplantation, other ligament reconstruction, patellofemoral realignment, articular cartilage restorative procedure, and osteotomy

• Prior ACL reconstruction that failed

• Residual muscular atrophy with chronic instability

• Magnetic resonance imaging (MRI) or arthroscopic evidence of major bone bruising or articular cartilage damage

A second protocol, designed to delay or diminish knee joint and graft loading, is used for patients who undergo ACL revision reconstruction (with either allogeneic or autogenic tissue), primary ACL allograft or semitendinosus and gracilis autograft reconstruction, or complex B-PT-B autogenous reconstruction in which major concomitant operative procedures were performed or in whom significant articular cartilage lesions were found during the operation. Delays in return of full weight bearing, initiation of certain strengthening and conditioning exercises, initiation of running and agility drills, and return to full sports activities are incorporated. This protocol is designed to protect healing concomitant meniscal or ligament repairs or allograft tissues and avoid exacerbating articular cartilage deterioration or symptoms.

Specific criteria are evaluated throughout both rehabilitation programs to determine if the patient is ready to progress from one phase to the next. Both protocols incorporate a home self-management program, along with an estimated number of formal physical therapy visits ( Table 11-1 ). For most patients, a total of 11 to 21 postoperative visits is expected to produce a desirable result. A few more supervised sessions may be required between the sixth and twelfth postoperative months for patients who undergo advanced training to return to strenuous activities. A specific neuromuscular retraining program (e.g., Sportsmetrics) is advocated for all patients returning to high-risk activities (see Chapter 14 ). For all patients, the following signs are continually monitored postoperatively: joint swelling, pain, gait pattern, knee motion, patellar mobility, muscle strength, flexibility, and AP displacement. Any individual who experiences difficulty progressing through the protocol or who develops a complication is expected to require additional supervision in the formal clinic setting.

The first postoperative week represents a critical time period for all patients in regard to control of knee joint pain and swelling, demonstration of adequate quadriceps muscle contraction, initiation of immediate knee motion exercises, and maintenance of adequate limb elevation. A bulky compression dressing is used for 48 hours and then converted to compression stockings with an additional Ace bandage if necessary. Patients are encouraged to remain recumbent and elevate the limb above the heart for the first 5 to 7 days, rising only to perform exercises and attend to personal bathing issues. Prophylaxis against deep venous thrombosis includes one aspirin daily for 10 days, ambulation (with crutch support) six to eight times daily for short periods of time, ankle-pumping every hour that the patient is awake, and close observation of the lower limb by the therapist and surgeon. Knee joint hemarthroses require aspiration. Nonsteroidal antiinflammatory drugs are used for at least 5 days postoperatively. Appropriate pain medication is prescribed to provide relief and allow the immediate exercise protocol described below to be performed.

Rehabilitation Protocol for Primary ACL B-PT-B Autogenous Reconstruction: Early Return to Strenuous Activities

Modalities

In the immediate postoperative period (1-3 days), knee effusion must be controlled to avoid the quadriceps inhibition phenomenon. Electrogalvanic stimulation or high-voltage electrical muscle stimulation (EMS) may be used to augment the ice, compression, and elevation program to control swelling. This treatment uses the concept of like charges repelling. The effusion or swelling has a negative electrical charge, so using the negative electrodes at the knee and the positive (dispersive) electrode on either the low back or opposite thigh will assist the body in removing the fluid from the joint to be reabsorbed. The treatment duration is approximately 30 minutes; the intensity is set to patient tolerance; and the treatment frequency is three to six times per day. Once the joint effusion is controlled, functional EMS is begun for muscle reeducation and quadriceps facilitation ( Table 11-2 ).

TABLE 11-2

Cincinnati SportsMedicine & Orthopaedic Center Rehabilitation Protocol for Primary Anterior Cruciate Ligament Reconstruction: Early Return to Strenuous Activities

	POSTOPERATIVE WEEKS					POSTOPERATIVE MONTHS
	1-2	3-4	5-6	7-8	9-12	4	5	6	7-12
Brace: immobilizer for patient comfort	X	(X)
Range-of-motion minimum goals:
0-110 degrees	X
0-120 degrees		X
0-135 degrees			X
Weight bearing:
50% body weight	X
100% body weight		X
Patella mobilization	X	X	X
Modalities:
EMS	X	X	X
Pain/edema management (cryotherapy)	X	X	X	X	X	X	X	X	X
Stretching: hamstring, gastrocnemius-soleus, iliotibial band, quadriceps	X	X	X	X	X	X	X	X	X
Strengthening:
Quadriceps isometrics, straight-leg raises, active knee extension	X	X	X	X
Closed-chain: gait retraining, toe raises, wall-sits, mini-squats	X	X	X	X	X
Knee flexion hamstring curls (90 degrees)	X	X	X	X	X	X	X	X	X
Knee extension quadriceps (90-30 degrees)	X	X	X	X	X	X	X	X	X
Hip abduction-adduction, multihip	X	X	X	X	X	X	X	X	X
Leg press (70-10 degrees)	X	X	X	X	X	X	X	X	X
Balance/proprioceptive training:
Weight shifting, cup walking, Biodex Balance System	X	X	X	X
Biodex Balance System, Biomechanical Ankle Platform System, perturbation training, balance board, minitrampoline				X	X	X	X	X
Conditioning:
UBC	X	X	X
Bike (stationary)		X	X	X	X	X	X	X	X
Aquatic program		X	X	X	X	X	X	X	X
Swimming (kicking)				X	X	X	X	X	X
Walking				X	X	X	X	X	X
Stair-climbing machine			X	X	X	X	X	X	X
Ski machine			X	X	X	X	X	X	X
Elliptical machine				X	X	X	X	X	X
Running: straight					X	X	X	X	X
Cutting: lateral carioca, figure-eights						X	X	X	X
Plyometric training						X	X	X	X
Full sports							X	X	X

PHASE 1: WEEKS 1-2
General Observation	50% weight bearing with two crutches when: Postoperative pain controlled Hemarthrosis controlled Voluntary quadriceps contraction achieved
Factors Evaluated (Goal)	Pain (controlled) Hemarthrosis (mild) Patellar mobility (good) ROM (minimum, 0-110 degrees) Quadriceps contraction and patella migration (good) Soft tissue contracture (none) Joint arthrometry day 14 (<3 mm)
Activity	Frequency	Duration
ROM	3-4 ×/day, 10 min
Passive (0-90 degrees)
Patella mobilization
Ankle pumps (plantar flexion with resistance band)
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec each
Strengthening	3 ×/day, 15 min
Straight-leg raises (flexion, extension, abduction, adduction)		3 sets × 10 reps
Active quadriceps isometrics (full extension)		1 set × 10 reps
Knee flexion (active, 0-90 degrees)		3 sets × 10 reps
Knee extension (active assisted, 90-30 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Closed-chain: minisquats (0-45 degrees, 50% weight bearing)		3 sets × 20 reps
Balance Training	3 ×/day, 5 min
Weight shift side-side and forward-back		5 sets × 10 reps
Aerobic Conditioning
UBC	1-2 ×/day, 5 min
Modalities	As required
EMS		20 min
Cryotherapy		20 min
Goals	ROM 0-110 degrees Adequate quadriceps contraction Control inflammation and effusion 50% weight bearing

PHASE 2: WEEKS 3-4
General Observation	Full weight bearing with one crutch when: Pain controlled without narcotics Effusion controlled ROM 0-100 degrees Muscle control throughout ROM
Factors Evaluated (Goal)	Pain (mild) Effusion (mild) Patellar mobility (good) ROM (minimum, 0-120 degrees) Muscle control (3/5) Inflammatory response (none) Joint arthrometry, day 28, 20 lb (<3 mm)
Activity	Frequency	Duration
ROM	3-4 ×/day, 10 min
Passive (0-120 degrees)
Patella mobilization
Ankle pumps (plantar flexion with resistance band)
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec each
Strengthening	2-3 ×/day, 20 min
Straight-leg raises (flexion, extension, adduction, abduction)		3 sets × 10 reps
Isometric training, multiangle (90, 60, 30 degrees)		1 set × 10 reps
Heel raise/toe raise		3 sets × 10 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension (active, 90-30 degrees)		3 sets × 10 reps
Closed-chain:
Wall-sits		5 reps
Minisquats		3 sets × 20 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Balance Training	3×/day, 5 min
Weight shift side-side, forward-back		5 sets × 10 reps
Balance board, two legged
Cup walking
Single-leg stance (level surface)		5 reps
Aerobic Conditioning	2×/day, 5 min
UBC
Water walking
Stationary bicycling (patellofemoral precautions)
Modalities	As required
EMS		20 min
Cryotherapy		20 min
Goals	ROM 0-125 degrees Muscle control Arthrometer within 3 mm Control inflammation, effusion 100% weight bearing

PHASE 3: WEEKS 5-6
General Observation	Independent ambulation when: Pain controlled Effusion controlled ROM 0-120 degrees Muscle control throughout ROM
Factors Evaluated (Goal)	Pain (no CRPS) Effusion (minimal) Patellar mobility (good) ROM (0-135 degrees) Muscle control (4/5) Inflammatory response (none) Gait, symmetric
Activity	Frequency	Duration
ROM	3 ×/day, 10 min
ROM passive (0-135 degrees)
Patella mobilization
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	1-2 ×/day, 20 min
Straight-leg raises (ankle weight, <10% of body weight)		3 sets × 10 reps
Straight-leg raises with rubber tubing		3 sets × 10 reps
Isometric training, multiangle (90, 60, 30 degrees)		2 sets × 10 reps
Heel raise/toe raise		3 sets × 20 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension (90-30 degrees, with resistance)		3 sets × 10 reps
Closed-chain:
Wall-sits		5 reps
Minisquats		3 sets × 20 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Balance Training	3 ×/day, 5 min
Balance board, two legged
Lateral step-ups, 2- to 4-inch block
Aerobic Conditioning (Patellofemoral Precautions)	2 ×/day, 10 min
UBC
Water walking
Stationary bicycling
Stair machine (low resistance and stroke)
Ski machine (short strike and level, low resistance)
Modalities	As required
EMS		20 min
Cryotherapy		20 min
Goals	ROM 0-135 degrees Control inflammation and effusion Recognition of complications (motion loss, CRPS, increased anteroposterior displacement) Muscle endurance Recognition of patellofemoral changes Full weight bearing, normal gait

PHASE 4: WEEKS 7-8
General Observation	No effusion Painless ROM (0-135 degrees) Joint stability Performs activities of daily living Full weight bearing Can walk 20 min without pain
Factors Evaluated (Goal)	Manual muscle test (hamstrings, quadriceps, all hip muscles; 4/5) Swelling (none) Joint arthrometry, 8 weeks (<3 mm) Patellar mobility (good) Crepitus (none/slight)
Activity	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	1-2 ×/day, 20 min
Straight-leg raises, rubber tubing		3 sets × 30 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension with resistance (90-30 degrees)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Closed-chain:
Wall-sits		5 reps
Minisquats		3 sets × 20 reps
Dynamic hip and core program
Balance Training	3 ×/day, 5 min
Balance board, two legged
Single-leg stance
Resistance band walking
PlyoBack ball toss
Perturbation training
Aerobic Conditioning (Patellofemoral Precautions)	1-2 ×/day, 15-20 min
Stationary bicycling
Water walking
Swimming (straight-leg kicking)
Walking
Stair machine (low resistance and stroke)
Ski machine (short stride and level, low resistance)
Elliptical machine (low resistance)
Modalities	As required
Cryotherapy		20 min
Goals	Increase strength and endurance

PHASE 5: WEEKS 9-12
General Observation	No effusion, painless ROM (0-135 degrees), joint stability Performs ADLs, can walk 20 min without pain Full weight bearing
Factors Evaluated (Goal)	Manual muscle test (4/5) Isometric test, 12 weeks, mean average torque/% deficit in quadriceps and hamstrings (30%) Swelling (none) Joint arthrometry, 12 weeks (<3 mm) Patellar mobility (good) Crepitus (none/slight)
Activity	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	2 ×/day, 20 min
Straight-leg raises with rubber tubing		3 sets × 30 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension with resistance (90-30 degrees)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Closed-chain:
Wall-sits		5 reps
Minisquats		3 sets × 20 reps
Lateral step-ups (2- to 4-inch block)		3 sets × 10 reps
Dynamic hip and core program
Balance Training	3 ×/day, 5 min
Balance board, two legged
Single-leg stance
Resistance band walking
PlyoBack ball toss
Perturbation training
Aerobic Conditioning (Patellofemoral Precautions)	3 ×/wk, 15-20 min
Stationary bicycling
Walter walking
Swimming (kicking)
Walking
Stair machine (low resistance and stroke)
Ski machine (short stride and level, low resistance)
Elliptical machine (low resistance)
Running Program (Straight)	3 ×/wk, 10 min
Jog		mile
Walk		mile
Backward walk		20 yards
Modalities	As required
Cryotherapy		20 min
Goals	Increase strength and resistance

PHASE 6: WEEKS 13-26
General Observation	No effusion Painless ROM Joint stability Performs ADLs Can walk 20 min without pain
Factors Evaluated (Goal)	Isokinetic test (isometric + torque 300 degrees/sec, % difference in quadriceps and hamstrings, tested monthly) Swelling (none) Joint arthrometry (<3 mm) Patellar mobility (good) Crepitus (none/slight) Single-leg function tests (hop distance, timed hop, % difference between involved and noninvolved side)
Activity	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	1 ×/day, 20-30 min
Straight-leg raises, rubber tubing (high speed)		3 sets × 30 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension with resistance (90-30 degrees)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)
Dynamic hip and core program
Balance Training	3 ×/day, 5 min
Balance board, two legged to single legged
Single-leg stance on unstable platform
Aerobic Conditioning (Patellofemoral Cautions)	3 ×/wk, 20-30 min
Stationary bicycling
Water walking
Swimming (kicking)
Walking
Stair machine (low resistance and stroke)
Ski machine (short stride and level, low resistance)
Elliptical machine (low resistance)
Running Program (Straight)	3 ×/wk, 15-20 min
Jog (progress speed from to to full)		to 1 mile
Walk		mile
Backward run		20 yards
Cutting Program (Lateral, Carioca, Figure-Eights)	3 ×/wk	20 yards
Functional Training	3 ×/wk
Plyometric training (box hops, level, double leg)		15 sec, 4-6 sets
Sport-specific drills
Modalities	As required
Cryotherapy		20 min
Goals	Increase strength and endurance

PHASE 7: WEEKS 27-52
General Observation	No effusion Painless ROM Joint stability Performs ADLs Can walk 20 min without pain
Factors Evaluated (Goal)	Isokinetic test (torque at 180 and 300 degrees/sec, % difference in quadriceps and hamstrings, tested quarterly; isometric if symptomatic patellofemoral joint) (10%-15%) Swelling (none) Joint arthrometry (<3 mm) Patellar mobility (good) Crepitus (none/slight) Single-leg functional test (hop distance, timed hop, % difference between noninvolved and involved side) (≤15%)
Activity	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening
Straight-leg raises, rubber tubing (high speed)	3-4 ×/wk, 20-30 min	3 sets × 30 reps
Hamstring curls (active, 0-90 degrees)		1-2 sets × 8-12 reps
Knee extension with resistance (90-30 degrees)		1-2 sets × 8-12 reps
Leg press (70-10 degrees)		1-2 sets × 8-12 reps
Multihip machine (flexion, extension, abduction, adduction)		1-2 sets × 8-12 reps
Dynamic hip and core program
Balance Training	3 ×/day, 5 min
Balance board, two legged to single legged
Single-leg stance on unstable platform with secondary activity
Aerobic Conditioning (Patellofemoral Precautions)	3 ×/wk, 20-30 min
Stationary bicycling
Water walking
Swimming (kicking)
Walking
Stair machine (low resistance and stroke)
Ski machine (short stride and level, low resistance)
Running Program (Straight)	3 ×/wk, 20 min
Interval training		20, 40, 60, 100 yards
Walk/rest phase (3 : 1 rest/work)		20 yards
Backward run		20 yards
Cutting Program (Lateral, Carioca, Figure-Eights)	3 ×/wk	20 yards
Functional Training	3 ×/wk
Plyometric training (box hops, level, double leg)		15 sec, 4-6 sets
Sport-specific drills
Modalities	As required
Cryotherapy		20 min
Goals	Increase function, strength, and endurance Return to previous activity level

ADLs, Activities of daily living; CRPS, complex regional pain syndrome; EMS , electrical muscle stimulation; ITB , iliotibial band; ROM , range of motion; UBC , upper body cycle; values in parentheses indicate when exercises are to be performed.

The use of EMS to facilitate and enhance an adequate quadriceps contraction is based on the evaluation of quadriceps and vastus medialis oblique (VMO) muscle tone. One electrode is placed over the VMO, and the second electrode is placed on the central to lateral aspect of the upper third of the quadriceps muscle belly ( Fig. 11-1 ). The treatment duration is 15 to 20 minutes. The patient actively contracts the quadriceps muscle simultaneously with the machine's stimulation. A portable EMS machine for home use may be required in individuals whose muscle rating is poor. EMS is continued until the muscle grade is rated as good. Biofeedback is also useful in enhancing hamstring relaxation if the patient experiences difficulty achieving full knee extension secondary to knee pain or muscle spasm. The surface electrode may be placed over the selected muscle component to provide positive feedback to the patient and clinician regarding the quality of active or voluntary quadriceps contraction ( Fig. 11-2 ). The electrode may also be placed over the belly of the hamstring muscle while the patient performs range-of-motion (ROM) exercises.

The most widely used modality after ACL reconstruction is cryotherapy, which is begun in the recovery room after surgery. The cost of various cryotherapy options and patient compliance are two major factors in the successful control of postoperative pain and swelling. The standard method of cold therapy is an ice bag or commercial cold pack, which is kept in the freezer until required. Empirically, patients prefer motorized cooler units ( Fig. 11-3 ). These units maintain a constant temperature and circulation of ice water through a pad, which provides excellent pain control. Gravity flow units are also effective; however, temperature maintenance is more difficult with these devices than with the motorized cooler units. The temperature can be controlled by using gravity to backflow and drain the water, refilling the cuff with fresh ice water as required. Cryotherapy is used for 20 minutes at a time from three times per day to every waking hour, depending upon the extent of pain and swelling. In some cases, the treatment time is extended owing to the thickness of the buffer used between the skin and the device. The motorized units contain a thermostat, which is helpful when cold therapy is used for an extended treatment time. Vasopneumatic devices offer another option for cold therapy. The Game Ready device (Game Ready) allows the clinician to set the temperature as well as one of four different compression levels, depending on patient tolerance. Although this is primarily a clinical treatment tool, it may be used at home. Cryotherapy is typically done after exercise or when required for pain and swelling control and is maintained throughout the entire postoperative rehabilitation protocol.

Postoperative Bracing

The use of postoperative braces after ACL reconstruction is controversial. Screening patients for personality type, pain tolerance, and program compliance may provide insight into the individual who will require brace protection postoperatively. The primary indication for the use of a brace, in our opinion, is protection of the patient during weight bearing in the event of a fall and to initiate early, more comfortable weight bearing during the first few postoperative weeks. The brace should be rigid in nature and the knee held initially at 0 degrees ( Fig. 11-4 ). The brace is opened based on the protocol to allow normal knee flexion during ambulation. Periodic evaluation of the brace and its position on the leg must be done to ensure maximal benefit is achieved. We do not routinely prescribe a derotation or functional knee brace upon return to full activities after ACL reconstruction for patients treated according to this protocol.