NEBRASKA ATHLETIC MEDICINE

ACL REHABILITATION

PREHAB PHASE

A week to 10 days prior to surgery, it is usually helpful to begin quad setting, straight leg raising and crutch training. Our belief is that we can use this time to reduce post trauma swelling, assist the athlete to help minimize post-surgical muscle atrophy and allow some early muscle education.

PHASE I -- Weeks 1 & 2

General observations -- Athletes are told the main focus is to control swelling and to

  1. maintain terminal extension and patellar mobility
  2. regain/maintain minimum of 90 degrees knee flexion
  3. Facilitate control of quads to reduce atrophy.

Please realize that all time frames are expressed as guidelines and cannot be utilized for all athletes all times. Athletes are advanced based on physician’s and therapist/trainers preferences, status in weeks post-op, and ability to meet goals stated.

ACTIVITIES

    1. Quad setting; sets of ten with biofeedback unit
    2. Quad setting with straight leg raises, sets of ten
    3. Wall slides, set of ten (active flexion with gravity assist)
      Wall slides
    4. "Jane Fondas", hip ext, flex, ab-adduction; sets of twenty each plane
    5. Ankle pumps, continuous through out day. Prone hangs as necessary
    6. "Gait checks", trainer observes athlete performing backwards ambulation encouraging full extension in brace
    7. Russian electromuscular re-education muscle stimulation
    8. Patellar glides, trainer assisted and athlete self-mobilizations
    9. Long Sitting for extension aid. Also helps to stretch hamstrings. Reach to toes 5-10 minutes every 2-4 hours, try to keep knee down
    10. Ice, compression and elevation after all sessions to control pain/swelling. Electromodalities- trainers/therapists choice through entire rehab program.

Utilize twice-daily sessions. Break routine into 2 sessions to reduce irritation

NO PILLOWS UNDER THE KNEE!!! EVER!!

GOALS BEFORE ADVANCING TO PHASE II
  1. Reduce/control swelling. Protect graft
  2. Extension to zero or better (Match unaffected side)
  3. Flexion to 110 degrees ( 90 degrees if meniscus repaired)
  4. Leg control - active quad contraction with biofeedback
  5. Hip SLR's in abduction, adduction, extension, and flexion
  6. Patellar mobility, decrease fibrosis. Stimulate collagen healing
  7. Weight bearing as tolerated with crutches
  8. Brace independence, doffing and donning brace alone

PHASE II -- Weeks 3 & 4

General observations -- - Maintain work on ROM - Start to focus on closed chain strengthening with attention to pain, swelling or loss of motion. NU therapists prefer use of Protonics with closed chain activity in this phase to reduce chances of patellofemoral problems. Continue to use post-op brace—Can be "broken down" to change size of brace if applicable. As with ALL post surgical exercises, insist that all exercises be performed absolutely correct. There is no substitute for exercises done properly. Trainer/therapist must insist on good form or the exercise may not be beneficial and may in fact be detrimental. Adjust program as necessary

ACTIVITIES
  1. Continue with SLR’s, sets of 10 with weights
  2. Prone hangs if necessary. Patellar mobes PRN
  3. Mini-squats (0-30 degrees) start with sets of 10. Allow "knees over tip of toes" PAINFREE.
  4. Mini-Squats with sports cord as appropriate
  5. Single leg mini-squats ("weight shifts" )
  6. Continue Jane Fondas with resistance
  7. Step ups (concentric) Start with sets of 10, 3" step, advance height as athlete needs/tolerates
  8. Eccentrics (step downs) Sets of ten as indicated
  9. Heel-toe calf raises sets of 10, toes straight ahead, toes in, toes out
  10. Start proprioceptive work, closed chain. Advance to single leg stands, BAPS board as athlete needs/tolerates
  11. Begin bike, Stairmaster, treadmill (walking) Pool work if incisions are healed well. Start with walking forwards/backwards, side walks (see program)

GOALS

  1. Athlete should be off crutches with normal gait, no limp
  2. Full extension with flexion gains to 120 degrees
  3. Mini-squats progress to 3 sets of 3 minutes with heavy sports cord
  4. Step ups and step downs 3 sets of 3 minutes each (eccentrics)
  5. Stairmaster 10 minute or better, bike 15 minutes or better, treadmill (walk) 15 minutes or better
  6. Tolerates pool exercise program with no increased symptoms
  7. No increase in swelling, pain, or symptoms with any activities

PHASE III -- Weeks 5 - 8

General observations – Must monitor effusion, watch for patellar tendonitis. If athlete has progressed as expected, we will do an isokinetic (Cybex) test in the 5th to 6th week—Must be done with 20 degree extension block at 180 and 240 degrees/second. If athlete can reach 70% of normal strength in affected knee, may begin walk-jog program. Continue using Protonics with squatting/leg press activities. Will now begin to alternate activities. Suggest aerobic activity such as pool and stationary on M-W-F and weight work on T-TH.

ACTIVITIES:

  1. Continue squats with sports cord. Athlete is instructed to go into squat with feet shoulder width apart, hips and knees over toes. Can go as deep as pain permits.
  2. Begin single and double leg press. Trainer/therapist monitor for emphasis on form versus weight. Start with sets of 10, then 20. As athlete progresses, resume PRE as per trainers’ choice. DAPRE, DELORM etc
  3. Begin jogging program. No cutting, twisting movements yet (see program for suggestions. Trainer/therapists choice for distance and reps. Can do back-pedals and side-stepping
  4. Continue to use Stairmaster and stationary bike for aerobics
  5. Intensify balance/proprioception work
  6. Continue with single leg step downs
  7. Open chained extension, with 30 degree block
  8. Can vary running with more aggressive swim program as needed.

    GOALS PHASE III WEEKS 5-8

    1. No patellar-femoral aggravation, no intensified effusion
    2. Tolerates all activities without increased pain
    3. Continues to strengthen quads and hams, co-contraction
    4. Maintain hip/ankle strength and flexibility
    5. Start running program to tolerance if tests at 70% of uninjured quad
    6. Maintain general body fitness

      PHASE IV -- Weeks 8 - 12

      General observations -- This phase is when the athlete begins to do more functional activities. Physician may consider fitting for an activity brace

      ACTIVITIES:

        All the PHASE III plus....
      1. Begin more aggressive lateral work- carioca,zig-zags, plants and back up
      2. Full arc isokinetic testing at 12 weeks
      3. Sliding board, "Fitter" activities, lateral work with sports cord resistance
      4. Start "weight room" squats at 10 weeks. We utilize a "safe squat" bar that emphasizes form and weight placement on heels, NOT on toes
      5. Maximize proprioceptive work as above

        GOALS
        1. Tolerates all lateral work - Slide board, shuffles, carioca, zig-zags, plant and back-ups with no increase in symptoms
        2. Able to full arc isokinetic test (no block) at 12 weeks, 80% or better injured quad to non-affected quad
        3. Able to start squat exercise, emphasis on form NOT weight at 10 weeks
        4. Continue other strength, balance, and endurance activities

          PHASE V -- Weeks 12 – 16 to 24 weeks (6 months)

          General observations -- Athlete should be advanced enough to begin sport specific skill training, start running for speed, functional agility, power and explosion (jumping)

          ACTIVITIES Same as above (phase IV)
          1. Continue with intense Proprioceptive work
          2. Add functional activity, sport specific activity as appropriate. Monitor for aggravated symptoms
          3. Isokinetic test, full range

          GOALS

          1. Isokinetic tests in the 80% range - want to see improvement in endurance, and total work done - Time to peak torque approaching normal
          2. Jumping, bounding, cutting and change of direction, full speed sprints with no increase in symptoms

             

          Please remember that these suggestions are for very high level athletes. These are not necessarily suggested as guidelines or a "cookbook" approach to rehabilitation the ACL deficient knee. Your orthopedic surgeon, your therapist or your trainer should monitor all advances and changes in your program.

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