ACL Injuries – Physiotherapy assessment format and Plan of care

ACL Injuries (Post reconstruction / Conservative)

Name: Age/Sex:

Occupation:

OPD No:

Address:

1. Patients brief Summary:

a. Chief complaints
b. Mechanism of injury ( If conservative)
c. Previous Injuries ( relevant )
d. Surgical History (associated ligament & meniscal injuries / type of
graft)
e. Comorbidities
f. Activity level before injury & objectives if any
g. Emphasis on (pain, mobility, instability, swelling (occurrence))
h. Presentation of problems at activity / sports (pre, during, post)
2. Observation
a. General – ( whole body appearance)
b. Local –Swelling, Colour (Surgical Incision – if applicable)
c. Position of limb comfort – if relevant*
d. Posture
3. Examination
a. Pain
b. FLAGs – trauma to bones and other ligament
c. Limb Oedema
d. Joint effusion ( grading)
e. Special test ( only if indicated , NOT done in reconstruction and
immediately after injury)
f. AJROM ( observe the Quantity, Movement pattern, Muscle activity
(inhibition / number of muscle fibres recruited), kinematics, protective
mechanism
i. Knee ( Flex and Extension)
ii. Ankle (DF/PF /Eversion) – Precaution in Peroneal graft (avoid
In/Ev)
iii. Hip ( SLR/Abd/extension/ Add)

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 1/10
ACL Injuries – Physiotherapy assessment format and Plan of care

g. PJROM (Knee – TF/PF) - (with special precautions as per guidelines)

i. End feel
ii. List the structures limiting the movements
iii. Observe for tibia rotation during extension and flexion
iv. Ankle (DF/PF /Eversion) – Precaution in Peroneal graft (avoid
In/Ev)
v. Hip ( SLR/Abd /extension/ Add)
h. Strength ( Quadriceps / VMO/ Hamstrings / Hip Abductors)
i. Isometric strength testing (Muscle activity (inhibition / number
of muscle fibres recruited)*
ii. MMT / 1or 10 RM after 3 weeks ( once stability of joint is
achieved)
iii. Dynamometer (OPD, after 2 weeks)
iv. Functional- combined (CKC) – ( After 2 weeks)
i. PSFS ( patient specific functional scale)
j. Balance (Relate with the possible factors (proprioception / strength /
control)
k. Functional Movement analysis ( relate with normal pattern, identify
the possible structure )
l. Core muscle strength (upper body and spine)
m. Gait Analysis
i. Function / Gait status – Level of independence.
4. Joint support status during mobility – ( Not supported / on Brace / on
Dynamic brace (mention range))

ICF- (OPD)

Measurem
ICF domain Assessment summary
ent used
- Structure (Lower limb & Upper limb) related
to movement
Body structure - Musculoskeletal structure related to
movement. (Swelling /effusion /scar/ Muscle
wasting/ Hip&Knee / Bony alignments)

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 2/10
ACL Injuries – Physiotherapy assessment format and Plan of care

- Sensation of pain
- Mobility of Knee joint
- Stability of knee
Body function - Muscle power
- Motor control / proprioception
- Muscle endurance
- Gait pattern
- Walking
- Moving around
- Driving
Activity &
- Sports activity
Participation
- Community Life
- Activities at work
- Recreation and leisure
- Products and technology for personal use in
daily living
Environment
- Construction and building and technology of
buildings for public use

5. Summary of findings.
6. Functional Diagnosis / Areas of concern

Clinical Reasoning

Clinical relevance /
contributing factors / Important information
Hypothesis / Reasoning

Healing / strength / mobility /

Age
degenerative / activity / sports
participation
- Relate with injury
Chief List the reported symptoms
/surgery/procedure
Complaints (Pain, Mobility, instability)
- Identify Flags
Surgical History – Incision / type Past relevant injuries
Surgical
of graft , associated injuries &
history and
repair Previous Functional status
comorbidities
Relevant medical conditions

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 3/10
ACL Injuries – Physiotherapy assessment format and Plan of care

Relevant Past history (Body Assisted devices used for

Function status / sports supports, transfers and
participation/contributing factors mobility
that may influence the exercise
planning)
BMI
General – ( whole body To understand obesity /
Observation
appearance) overweight contributing to
exercise planning
Healing (stages-
Local – Surgical Incision, inflammatory/ remodelling
Swelling, Colour etc.,)
Scar (grading)
knee FFD / Valgus / Varus /
Tibia position / Patella
Position of comfort adaptation*
position
Posture
Posture ( Sagittal and
frontal)
Pain
Type , Intensity , duration
( identity FLAGs, relate to
Examination and frequency, during
surgical history, tissue healing,
movement
medication)
Movement pattern, quantity,
muscle activity, kinematics,
protective mechanism)
Active SLR – ( to measure
knee functional lag)
Identify
AJROM
- Lag
Knee ( Flex and Extension –
- Muscle inhibition
Short arc / High sitting ( only
- Muscle power
perform if good control over joint
Note :Immediately after
during movement)
surgery , most of the clients
may not be able to perform
Ankle(DF/PF/INV/EV)
movements at knee due to
pain / inhibition / surgical
incision (as it requires to
generate a greater amount of
torque to produce
movements)

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 4/10
ACL Injuries – Physiotherapy assessment format and Plan of care

PJROM ( in all plane)

(Knee , Hip and Ankle) - (with Quantity, end feel
special precautions as per
guidelines) (avoid Hyper extension /
- End feel excessive anterior translation
- List the structures limiting the of tibia during extension)
movements
Strength
Knee - Quadriceps
Knee – (isometric strength
Hamstrings
testing) – Progress to
Hip muscles ( checked with
Dynamometer and 1RM (closed
knee locked in brace at 0
kinematic chain) at the later stage
degrees)
when indicated.
Ankle muscles
With reference to activities
PSFS ( patient specific functional as reported by client
scale) - Identify the functional
limitation
Balance
Relate with the possible factors (
standing / perturbation
proprioception / strength /
instability)
- Sit to stand
- Squat (mini)
- Walking
Functional Movement analysis
- Stair climbing
- Stepping ( normal / over
( relate with normal pattern,
obstacles)
identify the possible structure)
- Running
- Jumping
- Side translations
Kinematic / Temporal /
Gait Analysis ( OPD)
spatial parameters
Sit to stand /
Squatting / jumping (if
Movement analysis
applicable)
Kicking
Total assist/
Function / Gait status – Level
max/mod/min assist /
of independence
Independent
Movement pattern at

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 5/10
ACL Injuries – Physiotherapy assessment format and Plan of care

knee ( available flexion)

Distance walked
(observe for discomfort
during function and gait)
*emphasis during admission as In-patients

PT Plan of care
Pre- op / Prehabilitation

Mode Reasoning
Exercise counselling Gain confidence
Upper limb exercise Assistance in mobility / crutches
Upper body and core muscle Contributes to knee stability and vice
strength versa
Hip Flexors/ iliopsoas ( Avoid in case
Stretching exercises of Hip fractures posted for THR)
hamstrings / calf
Activation and training for Quads/
hams/ Hip Abd / Extensors / Calf
Exercises to Hip / Knee and ankle muscles
( aid in re-education during inhibition
after surgery)
Functional education and training
Sports specific training ( education)
Post op

Week 1-2 Goals

- Brace continued, Weight as tolerated – wean from -Achieve full weight
crutches if good mechanics is observed bearing
- JROM – 0-75 - Achieve PROM (0-
- SLR achieved
90)
- VMO recruitment – emphasis on full active
extension - Decrease swelling
- ST mobilization to Patella / patella tendon / /pain /inflammation
posterior /patella mobilization structure. - Patella mobility
- Cryotherapy
Weeks 2-4 Criteria full
extension /flexion 90
- Wall slides (ST/ Peroneal graft) - Proprioception
- Heel slides ( PTBG) - Complete passive
JSS COLLEGE OF PHYSIOTHERAPY
DEPT OF MUSCULOSKELETAL AND SPORTS Page 6/10
ACL Injuries – Physiotherapy assessment format and Plan of care

- JROM exercises ( 0-110) knee extension

- Functional CKC exercises - Increase strength
- Mini squats / modified lunges ( avoid varus /valgus of Hams and
stress) Quads
- Leg press - Controlled
- Calf muscle exercises ambulation (4-
- Proprioception exercises 10weeks)
- Stationary bike - Static – dynamic
- Upper body conditioning exercises - Balance exercises
- OKC ( 6 weeks)
* If hamstring graft, no active hamstring exercises until
2 weeks and no open-chain resisted hamstring curls
until 4 weeks post-op
If patella tendon graft, no resisted leg extension
machine at any point.
Weeks 6-8
+ lateral training ( side walking )
Weeks 8-10
- 30-80 degrees of knee flexion strengthening
exercise
Weeks 10-12 Criteria - Normal gait
/ full knee extension
& flex 130
Weeks 12-14 Achieve optimal
 Patients can begin jogging at 14 weeks assuming strength
they have adequate quadriceps control and no N-M control
complications. Their first few sessions of running JROM – Full
should be monitored by the clinician for proper Resistance training
mechanics. Plyometric
 At 14 weeks, the patient will have a follow-up Dynamic stability
appointment and a functional test. Jogging ( >13 weeks)
The functional test consists of:
 Ground clock / timed
 Unilateral squat / timed / to 70 degrees of flexion
 Lateral shuffle / leaping
 Two-legged leap / distance
 Jogging
 Unilateral balance
 Other functional test specific to patient’s activity
Increase strength of
Phase 4 (week 16 -22) muscles/balance /
proprioception to

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 7/10
ACL Injuries – Physiotherapy assessment format and Plan of care

optimal
Functional and Sports
specific exercises

Functional evaluation is performed at 14 weeks, 6 months, and 1 year post-operatively to

objectively assess what specific strength and weakness exist.

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION MENISCUS

REPAIR

General Considerations:
 It is important to recognize that all times are approximate and that
progression should be based on careful monitoring of the patient’s functional
status.
 PROM as tolerated. Early emphasis is on achieving full extension.
 Patients will be in a knee immobilizer for 4 weeks post-op.
 Non-weight bearing for 3-4 weeks
 Closed chain activities initiate at 3-5 weeks post-op and beginning between
20°-70° OR in full extension to avoid stress onto the repair. Avoid sub
maximal CKC exercises for 8 weeks.
 Active hamstring exercises can be initiated at 6 weeks and resistive at 8
weeks.
 No lateral exercises for 10 weeks and no pivoting or ballistic activities for at
least 4 months postop.
 No resisted leg extension machines (isotonic or isokinetic) at any point in the
rehab process
 Patients are given functional assessment test at 14 weeks, 6 months and 1
year postop.
 Program modified based on whether the meniscal injury is simple or
complex.

Week 1:
 Straight leg raise exercises (lying, seated, and standing), quadriceps
/adduction /gluteal sets, gait training.
 Well-leg stationary cycling, abdominal exercises and upper body
conditioning
 Soft tissue treatments to posterior musculature, retro patella and surgical
incisions
Weeks 2 – 4:

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 8/10
ACL Injuries – Physiotherapy assessment format and Plan of care

 Continue with pain control, gait training, and soft tissue treatments.
 Aerobic exercises consisting of UBE, well-leg stationary cycling, and upper
body weight training
Weeks 4 – 6:
 Discontinue use of knee immobilizer if able to demonstrate adequate quad
control
 Incorporate closed-chain exercises (i.e. mini-squats, modified lunges, short
step-ups) between 20°-70° OR in full extension. Avoiding going into the last
15°-20° of extension avoids stress onto the repair.
 Add hamstring curls without resistance*.
 Patients should have full extension and 110 degrees of flexion by the end of
this period
Weeks 6 – 8
 Leg weight machines (i.e. light leg press, calf raises, abduction /adduction).
 Stationary cycling initially for ROM, increasing as tolerated.
 Increase the intensity of functional exercises (i.e. add a stretch cord for
resistance; add weight, increasing resistance of aerobic machines).
Weeks 8 – 12:
 Introduce resistive hamstring curls*.
 Add lateral training exercises (i.e. lateral stepping, lateral step-ups, step
overs
Weeks 12-16
 Progress to running as able to demonstrate good mechanics and appropriate
strength.
 Begin to incorporate sport-specific training (i.e. volleyball bumping, light
soccer kicks and ball skills on contralateral side).
 Patients should be weaned into a home program with emphasis on their
particular activity
Weeks 16-24
 Incorporate bilateral jumping and bounding exercises, making sure to watch
for compensatory patterns and any signs of increased load onto the knee with
take-offs or landings.
 *cautiously introduce hamstring resisted exercises, watching for signs of
joint line/meniscus irritation

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 9/10
ACL Injuries – Physiotherapy assessment format and Plan of care

Home exercise HEP written based on patient goals with special

program (HEP) precautions
- Watch incision for signs of separation and/or infection.
- Protection of the Joint during (OKC) movements and
WBAT
Precautions
- AVOID - beyond patient limits during exercises
- Precautions during multidirectional movements and
dynamic balance exercise training
- Avoid high impact and rapid force exercise
- Improvements in ROM, muscle function, gait, joint
stability and control incrementally according to the
protocol.
Progression
- IF NOT achieved will stay in the previous phase in
criteria
spite of days
- Start plyometric ONLY if good control of joint, normal
muscle power as non-affected side, JROM achieved as
normal.

JSS COLLEGE OF PHYSIOTHERAPY

DEPT OF MUSCULOSKELETAL AND SPORTS Page 10/10