Jesse C. DeLee, M.D.

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Rehabilitation Protocol for ACL Reconstruction

Goal of Rehabilitation Protocol

GOAL:
To restore range-of-motion (ROM), strength, and confidence to the knee while protecting the anterior cruciate ligament (ACL) graft from stretching or rupturing.

FACTS Guiding Rehabilitation Protocol

It requires at least 4 to 6 months for the ACL graft to be transformed into a strong and durable ligament.
If the graft should rupture or stretch during this time period it is not repairable and a new graft has to be inserted.
This protocol must be followed throughout the first four months to prevent graft injury.
Any deviation from this regimen may unnecessarily compromise the final result.

Facts Regarding Rehabilitation
The rehabilitation program is a four month, vigorous, structured program. The end-result depends to a great extent on the patients' discipline, motivation, and perseverance in performing the exercise program. Without commitment from the patient, the surgery is assured to fail to meet expectations. With cooperation and dedication, the patient has an excellent chance to regain the strength, stability, and confidence in the knee that existed before injury.

Many patients are too busy with the demands of work and family to participate in a formal physical therapy program that requires regular attendance at therapy sessions at inconvenient times during the day. Fortunately, in the majority of cases, rehabilitation can be done at home or while traveling using a stationary bicycle, pool, or exercise equipment at a health club. The following exercise program is a sample program. A detailed protocol will be designed specifically for you, and your trainer or physical therapist.

TIMING OF POST-SURGICAL VISITS:

WEEK 1 (7-12 days)
WEEK 4
WEEK 8
WEEK 16 (X-rays prior to visit: single-leg hop test)
6 MONTH
ONE YEAR

Your progress will be monitored at each of these visits. Rarely, it may be necessary to perform a manipulation of the knee or an additional arthroscopy to assist you in regaining motion or to remove adhesions.

GENERALIZED REHABILITATION PROGRAM

WEEK 0-2

ROENTGENOGRAMS: An x-ray of your knee is obtained before your visit. The placement of the graft tunnels and fixation devices will be reviewed.

WEIGHT BEARING: Bear weight on the operated leg as tolerated with the emobilizer on and crutches after the first week. Crutches may be discarded when the knee is comfortable enough to walk on.
RANGE OF MOTION: Increase active motion using heel slides and contralateral leg bends. Extension is restored using "KFC" exercises.
STRENGTHENING: Strengthen the knee using straight-leg-raises and isometric quadriceps and hamstring exercises. The hip is strengthened by doing abduction, adduction, flexion, and extension exercises.
WOUND CARE: Keep the wound dry until your first follow up visit. Do not soak the knee in a bath tub, hot tub, or swimming pool. Don't be surprised if bruising develops 3 to 7 days after the operation in the back of the thigh, calf, and ankle.
GOAL: By two weeks the knee should move from 0 to 90 degrees .

WEEK 2-4

WEIGHT BEARING: The crutches can be discarded between 1 and 3 weeks after surgery. Usually, you will be fitted with a ACE Brace to wear while weight bearing.
RANGE OF MOTION: Increase ROM using the stationary bicycle. Begin with the seat elevated and initially do not apply any resistance to the wheel. Lower the seat as motion increases and add resistance as tolerated. Try to bicycle twice a day for 10 to 15 minutes.
STRENGTHENING: The patient may walk unlimited distances and swim as your comfort permits.
GOAL: By four weeks the knee should extend equal to the opposite knee and flex to at least 120 degrees. It is not unusual to still have some fluid or swelling in the knee which may limit motion. Do not be discouraged if some fluid persists.

WEEK 4-8

STRENGTHENING: Continue strengthening exercises as tolerated. Use lower weight and a higher number of repetitions (20 to 30) to build endurance. Try to exercise 1 hour a day.
GOAL: By eight weeks the range of motion of the knee should equal the normal side and feel well enough to resume light jogging, golf, shooting baskets, and agility training (i.e. forward and backward running, and sideways running or cross overs)

WEEK 8-16

STRENGTHENING: Continue to use any exercise equipment available to you in your home, gym, and health club. Do not use knee extension exercises against resistance. Increase the weight and resistance on the exercise machines. Long bike rides are encouraged. It's safe to run on a level surface; increase the distance first and then the speed.
GOAL: By 16 weeks the knee should feel well enough to resume full unrestricted daily activities and begin sports specific activities as presented.

WEEK 16 to 24

Continue strength and agility training.
At 6 months a KT 1000 measurement (to test stability of the knee) will be completed.
If measured strengths are equal to the unaffected knee, return to sports is allowed at 24 weeks.
COMMENT: It may take between six months and a year to regain full confidence in the reconstructed knee. Confidence can only be regained by using the knee and subjecting it to the demands of the sport that you desire to return to.