ACL Recnstructin Guideline The utcme f this evidence-based ACL rehabilitatin prgram fllwing an arthrscpic ACL recnstructin is t return individuals t the desired activities with full participatin safely and as quickly as pssible. This prtcl is criterin-based and the time frames in each phase will vary depending n many factrs including patient demgraphics, gals, and individual prgress. 1 Mdificatins t the prtcl may be necessary dependent n type f graft used, primary recnstructin versus ACL revisin, r cncmitant injuries r prcedures perfrmed. The therapist must mdify the prgram apprpriately depending n the individual s gals fr activity fllwing recnstructin. The ACL recnstructin prtcl is intended t prvide the treating clinician with a guideline fr rehabilitatin. It is nt intended t substitute fr making sund clinical decisins regarding the patient s pst-perative care based n exam/treatment findings, individual prgress, and/r the presence f pst-perative cmplicatins. If the clinician shuld have questins regarding pst-perative prgressin, they shuld cntact the referring physician. General Guidelines/Expectatins Therapist will mnitr pain and swelling and adjust prgram apprpriately Weight bearing will begin immediately unless restricted by cncmitant prcedure Level 1 Return t Play testing (see appendix) between 12-16 weeks pst-p N impact activities until full ROM, n swelling, adequate strength and bimechanics are demnstrated Prgressin t running prgram at 12-16 weeks based n physician preference, when able t demnstrate sufficient symmetry and shck absrptin with running mechanics and level 1 testing activities Level 2 Return t Play testing (see appendix) at 6-8 mnths pst-p Return t full sprt activities when able t cmplete Level 2 Return t Play testing at game speed with sufficient bimechanics (45/50 scre), cnfidence in limb, and/r release by physician. Preperative Rehabilitatin (2-4 weeks prir t surgery) Nte: Achieving pre-perative gals enhance pstsurgical utcmes 2 Pre-perative gals Full knee range f mtin (ROM) Minimal t n swelling present Minimal t n pain Nrmalized gait mechanics Pstperative Rehabilitatin (6-9 mnths depending n patient gals and prgress) Phase I Immediate-Early Pstperative Phase (Weeks 0-6) Phase IA Gals: Initiatin f ROM and muscle activatin (weeks 0-3) Milestnes and Advancement criteria Prper perfrmance f Level 1 MPI prtcl (see appendix) Active Quad cntractin
Ambulate withut assistive device ROM Symmetrical extensin ROM t 120 degrees flexin NO Extensin lag Bilateral symmetrical heel raises FWB (25 reps) Recmmended number f visits per week: 1-3; Ttal: (4-12) Exercises Ankle pumps Quad sets (NMES t quads fr re-educatin) SLR (flexin, prgressing t abductin and extensin) Passive knee extensins t zer by week 1, symmetrical extensin by week 3 Standing weight shifts Bike fr prgressive ROM MPI level 1 (reps, prgressing t static hlds f 1 minute hlds) Clamshells SDLY hip abductin Fire hydrants Standing exercise prgressin Mini-squats Mini-lunges Step ups Duble leg prpriceptin exercises Gait training with brace pened t available ROM (90 degree max) Hurdle step vers (lateral and frward) Manual Therapy Patella mbilizatins Assisted stretching with emphasis n extensin stretching with manual assistance Phase IB Gals: Restratin f ROM and prgressin f weight bearing activatin (weeks 4-6) Milestnes and Advancement criteria Prper perfrmance f Level 2-3 MPI Prtcl (see appendix) Full extensin ROM (equal t cntralateral side) and flexin ROM within 10 degrees Nrmalized gait symmetry (step length and WB) Prper Gluteal activatin Reciprcal stair climbing Recmmended number f visits: 4 Visits; Ttal (8-16) Ntice If full passive extensin (equal t the cntralateral side) has nt been fully restred by the end f this time frame, extensin ROM shuld be the primary fcus f therapy and the prgram shuld nt be advanced until it has been achieved. Exercises Cntinue with previus exercises Bike fr ROM stimulus and endurance Leg press (0-60) Wall sits (0-70 degrees) Calf Raises Stair master Elliptical Prgressive flexin ROM while maintaining full extensin ROM Prpriceptin training Duble leg training n prgressively unstable surfaces with perturbatin Rcker and scter bard Single leg balance training n stable surfaces with and withut perturbatin MPI level 2 Static squat with hlds Surfer squats with hlds
MPI level 3 Single leg wall pushes with hlds Stand n invlved leg, cntralateral hip flexed t 90 degrees, push lateral knee ut int ER with abductin Standing clamshells Pl therapy Gait training ROM prgressin Clsed chain strengthening Manual Therapy Patella mbilizatins Assisted flexin stretching Phase II- Intermediate Pst-perative Phase (weeks 7-16) Gals: Expsure t prper hip and shck absrptin strategies Nte: Level I Return t Play testing by week 16 (when adequate cntrl and mvement strategies are demnstrated) Milestnes and Advancement criteria Full AROM/PROM as cmpared t the cntralateral limb Able t sit n heels r prne lying heel t buttck tuching Prgressin f Phase 1 Strengthening Prper perfrmance f Level 4-5 MPI prtcl (see appendix) Jint effusin f trace r less Demnstrate nrmal gait mechanics (full cycle) Nrmal Step Dwn mechanics x 10 reps frm 8 step SLS less than 100 mm excursin r 30 secnds eyes clsed Gal: Quad strength 70-80% cmpared t cntralateral limb Gal: Gluteal strength within 10% cntralateral limb Initiate Running prgram when demnstrate nrmalized step-dwn, nrmalized hip strength, gait symmetry (16 weeks) Satisfactry perfrmance n Return t Sprt Test Level I including the abve criteria and bimechanical readiness tests Recmmended number f visits: 10-12; Ttal (18-28) Exercises Cntinue abve PRE Light hamstring curls (may begin earlier if BTB r allgraft) Prgressin tward single leg based strengthening as strength and cntrl allws Single leg wall sits Leg press Table squats Prgressive single leg prpriceptin training n unstable surfaces with perturbatin MPI level 4 Barbell squats Kettle bell / dumbbell squats Crab (lateral walks with band at knees) walks Frward lunges full depth MPI level 5 Bench lunges (Bulgarian split squats) Single leg (superman) squats Single leg RDL s Kaiser (r TB) single leg squat pulls Standing clamshells (reps) Pelvic drps Deep step frward step ups Frward cntrlled step dwns
Return t Sprt Bimechanical Readiness Level 1 Test (apprximately 4 mnths pst-p) Begin training fr Level 1 testing as cleared by MD (apprximately 12-14 weeks See appendix Referral t Return t Perfrmance prgram upn satisfactry scring n Level 1 testing (average 1-2 sessins per week) If patient elects t cntinue independently, they will be prvided an individualized prgram t be cmpleted at a facility with apprpriate strengthening equipment Phase III- Advanced Mvement and Impact Phase (mnths 5-6) Gals: Advancement f hip and shck absrptin strategies Milestnes and Advancement criteria Cntinue t prgress strength and endurance while adding advance lading activities Demnstrate apprpriate cntrl f Level 6-7 MPI Prtcl (see appendix) Nrmalized Running mechanics Adequate Drp jump mechanics Adequate Lateral Shuffle mechanics Adequate Triple Jump mechanics Adequate deceleratin mechanics Adequate cutting mechanics Pass Return t Sprt Test Level II (if the abve criteria fr are met) Recmmended number f visits: 8 Visits; Ttal (26-36) Exercises Cntinue previus exercises MPI level 6 squat jumps with bands frward jumps with bands bx jumps with bands ladders with n bands side t side ver small hurdles skater drills lateral bunding MPI level 7 lateral bunding single leg lateral jump ver bject frward deceleratin/backpedal single hps single bxes 4-6 up and landing frward jumping triple hps side step cut Return t Sprt Bimechanical Readiness Level 2 Test (apprximately 6-8 mnths)
Phase IV Speed, Pwer, and Agility Phase (mnth 7-8) Gals: Advanced muscle perfrmance with emphasis n return t play Milestnes and advancement criteria Demnstrate cntrl f level 6-7 MPI prtcl at game speed intensity Nrmalized Running mechanics Nrmalized Drp jump mechanics Nrmalized Lateral Shuffle mechanics Nrmalized Triple Jump mechanics Nrmalized deceleratin mechanics Nrmalized cutting mechanics Scre greater than 45 n Return t Sprt Test full speed Recmmended number f visits: 6-8 Visits; Ttal (32-44) * Prgressin f functinal activities and clearance fr return t sprt is based n bth physical capacity testing (bjective measurements) and verall cnfidence rating n subjective utcme measurement tl (IKDC 2000, etc). References 1. Adams D, et al. Current cncepts fr anterir cruciate ligament recnstructin: a criterin-based rehabilitatin prgressin. JOSPT. 2012 ;(42):601-614. 2. Lewek M, Rudlph K, Axe M, Snyder-Mackler L. The effect f insufficient quadriceps strength n gait after anterir cruciate ligament recnstructin. Clin Bimech (Bristl Avn). 2002;17:56-63. 3. Patern MV, et al. Bimechanical measures during landing and pstural stability predict secnd anterir cruciate ligament injury after anterir cruciate ligament recnstructin and return t sprt. Am J Sprts Med. 2010;(38):1968-1978. Appendix Return t play testing cmprehensive testing perfrmed at the Sanfrd POWER Center that evaluates an athlete s ROM, strength, prpriceptin, and functinal mvement patterns. There are 2 levels f f testing perfrmed based n stage f rehabilitatin. Level 1 Cmpleted 3-4 mnths pstperatively Determine an athlete s level f prgress at the mid-pint f their rehabilitatin and identify impairments that may need further attentin Used t determine athlete s readiness fr the Return t Perfrmance prgram Patient must meet all criteria prir t level 1 testing Physician apprval Full ROM N pain and swelling Weight bearing symmetry Restratin f balance and pstural stability Nrmal gait Hip and pelvic stability 0. >10 step dwns n 8 step with gd frm
Level 2 Cmpleted 6-8 mnths pstperatively Insurance prvider may dictate timing f testing based n the individual s cverage Determine an athlete s level f readiness t return t full participatin based n perfrmance with functinal tests, agility, strength, and prpriceptin. A heavy emphasis has been placed n bimechanical assessment with functinal mvement as impairments have been shwn t increase risk fr ACL injury. 2 Cmpnents f Level 2 testing includes Bimechanical assessment f 1. Frward step dwn 2. Lateral shuffle 3. Drp jump 4. Deceleratin 5. Triple hp 6. Side step cut (90 degree) Assessment f running mechanics Static and dynamic balance Strength and endurance testing 1. Gal: Less than 10% deficit in quads and gluteals (cmpared t cntralateral limb r nrmative data) and 1:1 quad t gluteal rati A scre f 45/50 ttal pints n bimechanical assessment is recmmended prir t return t sprt Mvement Perfrmance Institute (MPI) Prximal Hip Stability Prgressin I. Level One: Nn-weight bearing activatin- Clam shell, Fire hydrant, side-lying hip abductin. II. Level Tw: Weight bearing duble limb supprt- static squat with hlds, surfer squats III. Level Three: Single Limb Supprt- single leg wall pushes, standing clam IV. Level Fur: Duble Limb Supprt, Dynamic- squats with bar, kettle weight squats, crab walks, frward lunges V. Level Five: Single Limb Supprt, Dynamic- bench lunges, single limb squats, Russian dead lifts (RDL s), Kaiser pulls, standing clam, step-ups, pelvic drps, step dwns VI. Level Six: Duble Limb Ballistic- squat jumps with bands, frward jumps with bands, bx jumps with bands, ladders with n bands, side t side ver small hurdles, skater drills, lateral bunding VII. Level Seven: Single Limb Ballistic- lateral bunding single leg, lateral jump ver bject, frward deceleratin/backpedal, single hps, single bxes 4-6 up and landing, frward jumping, triple hps, side step cut VIII. Return t Sprt