ACL Reconstruction 2020

REHABILITATION AFTER ACL
RECONSTRUCTION
The Cruciate Ligaments (ACL) &(PCL)
➢ ACL attaches on anterior condylar area of the
tibial plateau, to attach on medial side of the
lateral femoral condyle.
▪ It is taught when knee approaches full extension .
➢ PCL attaches from the posterior inter-condylar
area of tibia to the lateral side of the femoral
medial condyle.
▪ It is taught in extreme flexion,(pulled taught by
hamstring contraction and subsequent posterior slide of tibia).
▪ PCL is a shorter and less oblique structure than the
ACL, with a cross-sectional area greater than that of the ACL.
MONA SELIM
The ACL functions
1- The primary restraint against anterior translation of the tibia on the femur (or the
posterior translation of femur on the tibia).
2-Resisting hyperextension of the knee.
3-The secondary restraint against either Varus or valgus and medial rotation with
PCL)
4- contribute to the proprioception of the knee.

(with PCL)
5- create an anterior gliding force on the femoral
condyles during flexion (arthrokinematics function).
MONA SELIM
The Role of muscles surrounding the knee joint in
minimizing strain in the ACL.
The hamstring muscles
The soleus muscle
In contrast, activation of both the gastrocnemius

and the quadriceps muscles
Thus in rehabilitation following injuries over strengthening of

hamstrings is an essential component
MONA SELIM
MONA SELIM
MONA SELIM
Mechanisms of ACL injury
1. External rotation of tibia with valgus

stress.
2. External rotation of tibia with varus
stress
3. Internal rotation of tibia with valgus
stress
4. Hyper extension of the knee
5. Violent quadriceps contraction
Predisposing Factors
Bad landing The shoe-surface interaction
Bad running mechanics
Increased joint laxity
strong quadriceps
Flat feet is a big cause of knee valgus position.
Bad Changing the direction Bad Decelerating or stopping
Signs and symptoms
• Does your knee pop"?

• Does your knee ever give way and/or lock?
• Did your knee swell as soon as you were injured Or did the swelling come later?
Anterior drawer test:
Is based on the fact that ACL provide 85% of

passive resistance to anterior translation of
tibia, so the test is performed with pulling the
tibia forward in knee flexed 90 degrees.
Anterior translation of 8 mm or 1/3 inch is indicative of a positive

ACL injury.
It may be masked by hamstring spasm (limiting anterior drawer of
tibia).
ANTERIOR DRAWER
LATERAL PIVOT SHIFT
LACHMAN
Management of ACL tears
• Activity level of the patient is probably the most important aspect in determining mode of
treatment.
• Non-operative treatment
1. Low demand patients
2. Patients willing to change from high to low demand activities

Non-operative treatment of torn ACL
➢Activity modification,
➢Patient education to prevent re-injury:
➢patients were advised not to engage in activities that require cutting and pivoting or
that produce recurrent episodes of instability.
Progressive rehabilitation program
1. Hamstring set exercises

2. Quadriceps set exercise
3. Isometric exercise for the quadriceps with the knee at 90 degrees
1. Hamstring and quadriceps co-
contraction
2. SLR exercises
3. Hamstring curl exercise (OKC)
4. Quadriceps curl exercise (short arc)
5. CKC exercises
6. Proprioceptive training.
7. Functional training
ACL reconstructive surgery:
• Complications:
• joint stiffness
• quadriceps weakness ( Extension lag)
• chronic knee effusion
• donor site pain
Post-Op Rehabilitation
❑Protocol is built on criteria based progression

rather than time based progression.
•Compression & Cold to prevent hemarthrosis
• CPM provides elevation & gently maintains available
ROM (0-90)
•Isometric hamstring contraction may begin
immediately
•Isometric knee extension at angles in the range of 0 to
45 degrees should not be during the first year following
ACL reconstruction.
• Hinged brace set at 20 to 70 degrees of flexion can be initially used, Patient is
weaned from brace between the 2nd to 4th weeks.
Day 1 to day 5
➢Bed rest except for bathroom
➢Heel Prop extension exercices 10 min 6x/day
➢Prone Hang Exercise
➢Flexion exercises 6x/day (OKC) (from prone)
➢SLR
➢Quad Sets
➢CPM & Cryo/Cuff worn continually except during exercises to
prevent a hemarthrosis
• Without a hemarthrosis –
oObtaining full ROM is easier
o Knee is less painful
oQuad control can be obtained easier
2nd Week Postoperative:
• Full hyperextension is achieved

by:
1. Heel Prop Exercise
2. Prone Hang Exercise
3. Hamstring Stretching Exercise
• I Heard a “Pop,” Did I Tear My Graft

• – Congratulations! You Are Working Hard
• – Adhesion Tear?
Flexion 110 degrees is accomplished
through:
1. Wall Slide Exercise
2. Heel slide exercise
3. Hamstring curl exercise
4. Multiple angle
hamstring isometric
exercise
Quadriceps muscle leg control is
enhanced by:
1. Quadriceps setting exercise
2. SLR exercises
3. Short-arc quadriceps exercise
4. Quadriceps isometrics with the knee at
90 degrees
Hamstring-Quadriceps Co-contraction
➢The use of weight bearing activities, such as partial squats as a Hamstring-Quadriceps Co-contraction
can significantly reduce the ACL strain compared to quadriceps activity alone.
➢“concurrent shift”: When rising from the squatted position, simultaneous hip and knee extension
occurs.
▪ As a result, the rectus femoris lengthens across the hip as it shortens across the knee , and the hamstrings
lengthen across the knee as they shorten across the hip.
▪ The resultant concentric and eccentric contractions at opposite ends of the muscle produce a “pseudo
isometric” contraction.
▪ This type of contraction is utilized during functional activities and can not be reproduced during isolated
open chain knee extension and flexion exercises.
➢ During simulated squat exercise, the addition of hamstrings load caused a significant decrease
in graft load, especially in the range of 15 degrees to 45 degrees of flexion.
➢both isometric and isotonic quadriceps loads induced the greatest strain in the ligament between 0 degree (full extension)
and about 30 degrees of flexion of the knee.
The actions of the gluteus maximus and soleus muscles can influence knee motion in weight-bearing. Although they do not cross
the knee joint, these muscles are capable of assisting with knee extension
Gait training:
• Patient is non-weight bearing for approximately one week,
• then Weight bearing progresses as tolerated to full weight bearing. ( could start partial weight
bearing immediately)
• Subjects ambulated with 2 crutches for the first 2 weeks
postoperatively.
• One crutches for the 3rd and 4th weeks.
• finally discontinued crutch use by 4 weeks postoperatively.
• The heel-to-toe gait pattern was taught to the subject ( to
avoid shear stress on the graft.
Weeks 3-5 Postoperative:
• Full ROM in the knee is achieved with:

1. Continued Heel Slide Exercise
2. Exercise on a Stationary Bicycle
3. Kneeling Stretch
Muscle Strength is enhanced as following:
•All exercises previously described were continued,
and weighted resistance was applied beginning with
1 lb. and progressing by 1 lb. per week.
1. Resisted SLR
exercises
2. Resisted short-arc
quadriceps muscle
exercise
3. Resisted Hamstring
Curl Exercise
Closed kinetic chain exercises
➢ double-legged mini squat,
➢ double leg press,
➢ and double-legged calf raise exercise.
Weeks 6-12 postoperatively
1. Step-up ex.
2. Single-legged mini squat
ex.
3. Single leg press ex.
4. Single-legged calf raise ex.
5. Exercise on a Stationary
Bicycle
6. Functional training: light
jogging program, and agility
training
can progress into circle running,
figure of eight, single-leg hops, vertical jumps, one- legged
long jumps and zigzag walking.
Guide lines
Knee bracing: appears to be more beneficial than not using a brace in
patients with ACL deficiency. (Evidence Level :B )
Immediate versus delayed Mobilization: (Evidence Level :B )

➢ The use of immediate mobilization following ACL reconstruction to increase
ROM, reduce pain, and limit adverse change to soft tissue structure.
➢ Knee Exercises:
➢ Rehabilitation that emphasizes early restoration of knee extension
and early weight bearing activity appears safe for patients with ACL
reconstruction (Evidence Level :B )
DOES ELECTROTHERAPY
HAVE A ROLE ????
ULTRASONIC
•Several studies have shown the safe use of

ultrasound over metal implants.
•The acoustical energy is dispersed
throughout the metal and is absorbed into
the surrounding tissue.
•NO significant heating within the
implant.
ELECTRICAL STIMULATION
• functional electrical stimulation (FES) is an appropriate intervention. The protocol for
strengthening the quadriceps and improving stability of the knee should consist of stimulation
of the:
HAMSTRINGS IMMEDIATELY BEFORE THE QUADRICEPS TO
PRODUCE COCONTRACTION.
• Stimulating the hamstrings just prior to stimulating the quadriceps will stabilize the tibia and
prevent anterior tibial translation
Thank you

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REHABILITATION AFTER ACL

4- contribute to the proprioception of the knee.

In contrast, activation of both the gastrocnemius

Thus in rehabilitation following injuries over strengthening of

1. External rotation of tibia with valgus

• Does your knee pop"?

Is based on the fact that ACL provide 85% of

Anterior translation of 8 mm or 1/3 inch is indicative of a positive

2. Patients willing to change from high to low demand activities

1. Hamstring set exercises

❑Protocol is built on criteria based progression

• Full hyperextension is achieved

• I Heard a “Pop,” Did I Tear My Graft

• Full ROM in the knee is achieved with:

Immediate versus delayed Mobilization: (Evidence Level :B )

•Several studies have shown the safe use of

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