Anterior Cruciate

Ligament
Reconstruction
Prehabilitation

www.plymouthhospitals.nhs.uk/ourservices/clinicaldepartments/physiotherapy/Pages/Home.aspx

Physiotherapy Department/LB/AJ
Date issued: August 2015
For review: August 2016
Anterior Cruciate Ligament

The Knee joint is a complex weight bearing joint

that relies on the interplay of ligaments and
muscles to provide stability. The Anterior
Cruciate Ligament (ACL) is one of the most
important and commonly injured ligaments
within the knee. Extremely strong the ACL
restricts the tibia (lower leg long bone) moving
forward on the femur (thigh bone) and in
conjunction with the Posterior Cruciate Ligament
restricts internal rotation of the tibia towards the
opposite leg.

An ACL rupture (completely torn ligament) is

likely to cause instability as the restraining
mechanism to movement will have been
significantly damaged. This can cause problems
with even the most basic activities of daily living
(washing, dressing, stairs, walking..).

ACL injuries may not occur in isolation with other

structures in the knee also being damaged
commonly the Tibial or Medial collateral
ligament (MCL), Medial Meniscus (Cartilage), Posterior Cruciate Ligament and the articular
surfaces (Condyles).

You’ve suffered an ACL injury

The ACL is designed to withstand large forces, forces far greater than those that we impart
on it on a daily basis. When we have an accident or play sport we significantly increase the
forces we put through the knee which in certain circumstances overloads the ACL causing
full or partial rupture.

Commonly injured through awkward landing from a jump or planting the foot to take a shot
or change direction in cutting or pivoting sports for example football & netball. Injury can
also be the result of a collision tackle (rugby) or a sudden twist either sporting (skiing,
basketball) or accidentally in everyday life. ACL injuries can also occur due to non-impact
injuries and twists alone – though less common.

Patients often report a “pop” sensation, sudden onset of pain with an immediate swelling of
the knee preventing any further participation in recreational activity. The knee may “give
way” or “buckle” particularly noticed on turning activities.

Associated ‘soft tissues’ (ligaments, muscles, tendons, joint capsule etc) surrounding the
knee may also be damaged which causes inflammation or swelling. This is the bodies
natural response to injury, completely normal and the first phase of the healing process.
Referred to as the ‘inflammatory phase’ it should last for 3-5 days however if poorly
managed can last longer causing pain, restriction of movement and loss of mobility.

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Implementing the principles of POLICE (outlined below) as close to injury as achievable will
help reduce inflammation and prevent further pain and movement dysfunction.

Further assessment and treatment cannot be achieved until inflammation is successfully

managed.

Immediate treatment following ACL injury & reconstruction surgery

Following acute injury the aim of any treatment is to:-

 reduce swelling,
 regain range of knee movement
 regain normal basic functional activity over several weeks.

It is important to reduce swelling as soon as possible for pain relief, restoration of knee
range of movement and to allow muscular control at the knee to re-establish.

The mnemonic POLICE (Protect Optimal Loading Ice Compression Elevation) is helpful in
remembering the important elements of inflammation management.

Protection – you may be assessed for elbow crutches and encouraged to weight bear
through the injured leg as pain allows. Where greater damage to the stability of the knee
has occurred (muscles, ligaments, cartilage..) a brace may be applied. Protecting the knee
prevents further injury occurring therefore allowing the healing process to begin.

Optimal Load – Putting as much weight through the knee as comfortable/pain allows. This
means not pushing into or through the pain. Walk as normally as possible using elbow
crutches if required to maintain correct muscle recruitment patterns. This will stimulate the
healing process and gauged correctly can help reduce swelling through muscle contraction.
Optimal load will also prevent further joint and muscle stiffness as well as any deficits to
control/balance (proprioception).

It is important to find a balance between resting your knee and loading/exercising. Too
much exercise and movement can prolong the inflammatory phase whereas not enough can
result in a stiff weak knee. Rest with your injured leg elevated on a bed with pillows under
the calf and foot. Do not place a pillow under the injured knee as this may slow the
recovery of knee extension. Exercises and knee movement should be maintained in a pain-
free range repeated little and often.

You will benefit from being signed off work for two weeks.

Ice – Effective at reducing inflammation ice should be applied as soon after injury as
possible and continued for twenty minutes every two hours whilst you are awake. At least
five times a day and continued until inflammation settles usually 12 – 72 hours post injury.
Protect your skin from ice burn by wrapping a damp towel around the bag of ice before
placing on the injured knee

Compression – Apply continuous compression (Compression stocking, Tubigrip or

elasticated bandage) from thigh to ankle following ice therapy. Compression helps to
control inflammation formation and can be utilised whilst inflammation exists.

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Elevation – Immediately as is practical and for at least the first 24 hours following injury try
to keep the injured leg elevated ideally lying down so your knee is higher than your heart.
Do not sit for long periods with your foot lower than your body as this will cause increased
swelling in your knee, lower leg and ankle.

Discuss utilising non-steroidal anti-inflammatory medication with your GP or Pharmacist

alongside ice therapy to help control pain and swelling.

As pain and swelling decrease 7-10 days after injury you can start to spend more time up on
your feet using elbow crutches. Once muscular control of the knee has been regained, you
can walk normally carrying all your weight and you are safe you will be weaned off the
elbow crutches.

Diagnosing an ACL injury

The diagnosis of an ACL injury can often be suspected based upon the history or event.
The clinician will be interested in the direction of impact to the knee, the direction the knee
moved, what position the leg finished in and any noises that occurred. Whether you have
any pain and if so how much, where and has it changed since the injury. Rapid swelling
(inflammation) within minutes or slower onset over hours can help determine the diagnosis.

A clinical examination will involve specific ligament stress tests which indicate the extent of
laxity or damage the ACL has suffered. Both knees will be assessed to gain comparisons.
A stiff and inflamed knee will be difficult to assess accurately and PRICE guidelines above
should be followed.

X-ray or MRI scans are sometimes useful though not essential. These may be employed to
confirm diagnosis and assess if other structures have been damaged.

Do I need to have surgery to repair / reconstruct my ACL?

The ACL cannot heal or be stitched back together therefore you have two options one, to
have ACL Reconstruction (surgical repair) in which your own muscle tendons are used to
form a new ACL or option two, not to have a ACL Reconstruction and manage without.

It is not uncommon to manage without a functioning ACL especially if you are happy to
modify/reduce certain activities and have no desire to play sports that involve twisting or
turning (football, netball, skiing etc). Guided appropriate rehabilitation over several months
will aid development of muscle tone and knee control which compensates the loss of the
ACL. A home exercise programme will need to be continued indefinitely to maintain good
knee control and stability.

If you intend to continue with rotational or contact sports or feel that you may like the option
to in the future then it is likely that you will need to have your ACL reconstructed. Your age
is not the determining factor for having an ACL reconstruction but the level of physical
activity you aspire to regain is.

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There is no evidence to suggest that having an ACL reconstruction will reduce the risk of
developing osteoarthritis in later life.

Whichever option you decide a course of expert guided rehabilitation or prehabilitation

(rehabilitation before surgery) by a Chartered Physiotherapist is advisable.

When should I have my ACL reconstructed?

It is advisable that you have recovered from the acute injury before surgery is undertaken.
Physiotherapy rehabilitation can aid this process.

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 Prehabilitation
Prehabilitation following initial injury and prior to reconstructive surgery is very important to
aid your recovery back to health.

The goals/aims are to:

 increase range of motion (ROM) and restore full knee extension
 Achieve good muscle tone, control, strength, flexibility and proprioception
(balance)
 Achieve an increased level of cardio-vascular fitness
 Achieve an increased awareness of your knee

The rehabilitation required will provide a seamless progression into exercise following
surgery and be less of a shock to the system!

ROM and Flexibility

(Here are some ideas of exercises to be undertaken daily throughout the day)
 Extension hangs in sitting or prone lying
 Heel slides
 Bike pendulums: high seat half circles forwards/backwards leading to full
revolutions on lower seat
 Seated calf stretch with towel – knee bent (Soleus) knee straight
(Gastrocnemius)
 Seated hamstring stretch (back straight)

Extension hangs in sitting or prone lying

Sit with your knee unsupported and foot on a
raise or on a stool. Allow the weight of your
leg to straighten your knee.

Hold for 10 minutes, repeat 2 times a day

Heel Slides
Sitting with your back supported. Slide
your heel towards your bottom, use a belt
or towel under your foot to assist you.

Hold for 10 seconds, repeat 10 times 3-4

times a day

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Bike pendulums
High seat half circles forwards/backwards
leading to full revolutions on a lower seat.

2-3 minutes, repeat 3 times a day

Seated calf stretch (Soleus muscle)

With your knee flexed/bent 30° and using
a towel, belt or scarf, slowly pull your toes
up toward your shin.
Feel the stretch in your lower calf

Hold for 30 seconds, repeat 3 times 3-4 Seated calf stretch (Gastrocnemius
times a day muscle)
With your knee straight and using a
towel, belt or scarf, slowly pull your toes
up toward your shin.
Feel the stretch in your upper calf

Hold for 30 seconds, repeat 3 times 3-4

times a day

Seated hamstring stretch

Sitting, maintain a straight body position,
with your operated leg out in front of you,
reach forward and attempt to grasp your
ankle or your toes. Feel a stretch at the
back of your leg

Hold for 30 seconds, repeat 3 times 2

times a day

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 Muscle strength and endurance
 Static Quads
 Bridging
 Sit to stand
 Static Lunge forwards and to the side
 30° Squats
 Side lying abduction/adduction
 Gluteal squeezes supine or standing
 Prone hip extension
 Standing hip flexion/extension, abduction/adduction
 Ankle pumping
 Standing calf raises with/without support

Static Quads
Sitting with leg supported, tighten your
thigh muscle until your leg is straight and
your knee cap moves towards your hip.
Hold 10 seconds

15 repetitions, 3-4 times a day

Bridging
Lie on back with both knees bent. Tighten
your quads and hamstrings, squeeze your
buttocks together and lift your bottom off
the floor. Progress exercise by lifting both
hands in the air.

10-15 reps, 2-3 times a day

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 Sit to stand
Stand up from sitting and sit down again without using your
arms.

15-20 reps, 2-3 times a day

Static lunge
Stand with erect posture and your legs hip width apart.
Take a step forward with the operated leg and squat
down. Return to the starting position and repeat.
Then alternate with your opposite leg.

10-15 reps, 2-3 times a day

Lateral lunge
Stand with feet wide apart and toes pointing forward.
Step out to the left, keeping your toes pointing straight
ahead and your feet flat. Squat by bending the left knee.
Keep your right leg straight and the weight on the left foot.
Squat as low as possible, keep your right leg straight and
hold this position for 2 seconds. Return to the starting
position and repeat.
Then alternate with your opposite leg.

10-15 reps, 2-3 times a day

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30° squat
Stand with feet hip width apart. Slowly
bend knees to about 30 degrees, keeping
knees lined up over feet and then
straighten up to standing position, and
repeat.

10 reps, 3-4 times a day

Standing Hip extension

Stand next to a bench and lean over it.
Bend the operated knee to 90 degrees
and then lift the whole leg behind you a
little and lower it again. Keep your buttock
tight throughout!

10-15 reps, 2-3 times a day

Proprioception (Balance)

Single leg standing 30 – 60 seconds, 1-2 times a day

Wobble boards
Wobble cushion and Trampette

Single leg standing

Standing on the operated leg, lift the
other leg off the floor and try to balance.

3 minutes practicing, 2-3 times a day

Variations - Hold wall with one hand

Fold arms across chest
Close 1 or 2 eyes

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Wobble Boards (two legs)
Stand on the wobble board. Practice
balancing and do not let the sides of the
board touch the floor

3-5 minutes, 1-2 times a day

Wobble Cushion
Standing on the operated leg, lift the other
leg off the floor and try to balance.

3-5 minutes, 1-2 times a day

Gait (walking)
Weight shifting side-to-side and forward/backward
Progress from two crutches to one maintaining a normal walking pattern.

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Surgical Techniques

The Orthopaedic Knee Surgeons at Plymouth Hospitals NHS Trust commonly use one of
the patients own hamstring tendons to form the ligament graft.

Taken from the same injured leg the surgeon harvests the hamstring through a small
incision on the inner aspect of the leg just below the knee. The remainder of the operation is
performed using an arthroscope (keyhole surgery) removing the damaged ACL, drilling
tunnels and positioning the new hamstring graft. The hamstring graft is tensioned and fixed
into place with a screw and end button.

The new graft does not immediately function in the same way as a natural ACL. The graft
undergoes many changes during its recovery being most vulnerable to damage over the
first three months. Expert guided rehabilitation by a Chartered Physiotherapist is vital to the
ongoing recovery process and a successful outcome.

To successfully rehabilitate an ACL you must strike a balance between exercise and
mobility. The correct amount of exercise and mobility will develop knee control and prevent
stiffness or soft tissue contracture. Too much mobility or exercise may place undue stress
or strain on the graft causing complications. Your Chartered Physiotherapist will expertly
guide you through each stage of your recovery

Post Operative Physiotherapy:

At all times rehabilitation should be governed by common sense. If exercises cause knee
swelling (an effusion) then there may be something wrong; probably overdoing the
exercises, and you should return to a lower level of exercise and seek advice from your
Physiotherapist or Surgeon.

During the first six weeks the graft is going through a healing phase when hopefully it is
binding to the bone. Thereafter we believe that it starts to develop a blood supply. It may be
however that the graft is weakest at about six weeks post op (6-12 weeks)Butler et al (1989),
and then progressively strengthens. The stimulation of rehabilitation is important at this
time. From twelve weeks onward the knee can gradually be pushed harder, introducing
running. Between four and six months post op, cutting and turning can be introduced with
sport specific training starting at six to nine months, and a return to sport at nine to twelve
months. Obviously, not everyone aspires to sport, and your rehab should be tailored to your
requirements, but rehab is important for everyone!

During the first six weeks do your own regime daily. Your physiotherapist will advise you
how much and how frequently you should exercise, but in general aim to work through an
exercise schedule at least three times per day. From six weeks onward, your rehab protocol
becomes more intensive (with limitations), and you should aim to work five days a week
resting completely for two days.

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Knee Bracing:
Knee braces or splints are not routinely prescribed following ACL reconstruction unless
indicated. You may find that a Tubigrip support or elasticated bandage (available at the
chemist) gives you confidence, and there is nothing wrong with using this. Make sure it is
not too tight.

ACL REHABILITATION
Returning to work and sport
This is a guideline as to how soon you can return to particular activities. Your return will be
guided by your surgeon and Physiotherapist.

Work
To be agreed with Surgeon

WORK RETURN
Light work- such as office job 4 - 6 weeks
Medium- physical job 2 months
Heavy- manual job (roofs and Ladders) 3-4 months +
Suggest phased return for any manual job.

Driving 4 – 6 weeks
DVLA guidelines state the patient must be safe and competent to return to driving. Are they
able to do an emergency stop?

Physical activity
To be agreed with surgeon or physiotherapist

SPORT RETURN
ACL class or supervised exercises 6 weeks
Swimming without flippers or aids 2 months
(No breast stroke)
Light individual sports/non-competitive
Without rotation 3 to 4 months
Start slow running 3 months
Twisting/pivoting activities 6 months
Contact/high performance including impact
and rotation (football, rugby, skiing) 9-12 months

These times are guidelines. The exact progression may vary depending on the individual.
Rehabilitation will be monitored by your physiotherapist and surgeon. You are advised not
to return to full activity too early. Over stressing the graft too early may increase the risk of
graft failure.

Each phase of exercises will work on-

Range of Movement/Stretching
Strengthening
Proprioception/Balance/coordination
General mobility and Cardiovascular

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The reference list below was used to develop this protocol. If you are interested in learning more these resources may be a
good place to begin.

References and Bibliography

Butler, DL, Kappa Delta Award paper. (1989) Anterior Cruciate Ligament: its normal response and replacement ;7:910-921

Beynnon, BD., Fleming, BB., (1998) Anterior cruciate ligament strain in-vivo: a review of previous work. Journal of Biomechanics. 31(6),
519-25.

Fitzgerald, GK, Lephart, SM, Hwang, JH, Wainer, MR., (2001) Hop tests as predictors of dynamic knee stability. Journal of
Orthopaedic Sports Physical Therapy. 31:588-597

Heijne, A., & Werner, S., (2007) Early versus late start open kinetic chain quadriceps exercises after ACL reconstruction with patellar
tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 15:402-414.

Hickey, KC., Quatman, CE., Myer, GD., Ford, KR., et al., (2009) Methodological report; Dynamic field tests used in an NFL combine
setting to Identify lower extremity functional asymetries. Journal of strength and conditioning research. 23(9) 2500.

Herrington, L., Myer, G., & Horsley, I. (2013) Task Based rehabilitation protocol for elite athletes following Anterior Cruciate ligament
reconstruction: a clinical commentary. Physical Therapy in Sport. 14, 188-198.

Hiemstra, LA., Webber, S., MacDonald, PB., Kriellaars, DJ., (2000) Knee strength deficits after Hamstring and patella tendon ACL
reconstruction. Medicine and Science in Sports and Exercise. 32(8):1472-1479

Myer, G., Paterno, MV., Ford, KR., Quatman, CE., & Hewett TE., (2006) Rehabilitation after anterior cruciate ligament reconstruction:
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Myer, G., Ford, K., & Hewett, T., (2008) Tuck jump assessment for reducing anterior cruciate ligament injury risk. Athletic Therapy Today.
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Myer, G., Chu, DA., Brent, J., & Hewett, T., (2008) Trunk and hip control neuromuscular training for the prevention of knee joint injury.
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Myer, G., Paterno, MV., Ford, K., & Hewett, T., (2008) Neuromuscular training techniques to target deficits before return to sport after
anterior cruciate ligament reconstruction. Journal of Strength and Conditioning Research. 22, 987-1014.

Noyes, FR., Braber, SD., & Mangine, RE., (1991) Abnormal lower limb symmetry determined by functional tests after anterior cruciate
ligament rupture, American Journal of sports medicine, 19 513-518.

Padua, DA., Marshall, SW., Boling, MC., Thigpen, CA., Garrett, WE Jr., Beutler, AI., (2009) The Landing Error Scoring System (LESS) is
valid and reliable clinical assessment tool of jump landing biomechanics: The JUMP-ACL study. American Journal of Sports Medicine. 37,
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Perry, MC., Morrissey, MC., King, JB., Morrissey, D., & Earnshaw, P., (2005) Effects of closed versus open kinetic chain knee extensor
resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate
ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 13(5), 357-69.

Pauole KK, (1996) The physical performance T-Test as a measure of speed, Power, and agility in females. Long Beach, CA: California
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Shiraissha M, Mizuta H, Kubota K, Otsuka Y, Nagamoto N., (1996) Stabilomatric assessment in the ACL-reconstructed knee. Clinical
Journal of Sport and Medicine. 6(1):32-39

Tyler TF, McHugh MP, Gleim GW, Nicholas SJ., (1998) The effect of immediate weight bearing after ACL reconstruction. Clinical
Orthopaedics and Related Research. Dec (357): 141-148

Whatman C, Hing W, Hume P. (2012) Physiotherapist agreement when visually rating movement quality during lower extremity functional
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