Early Post-Operative Treatment

Following Anterior Cruciate

Ligament Reconstruction
Aaron Reynolds, PT, OCS, CSCS
Elite OrthoSport Physical Therapy and Performance
Los Angeles, CA
I have nothing to disclose.
Objectives
• Review foundational principles to prepare for successful
ACLR rehab
• Identify potential risk factors leading to complications in
later stages of ACLR rehab
• Provide current clinical practice techniques and concepts
related to early ACLR rehab
• Demonstrate manual techniques used in ACLR rehab
 Scenario

• Player injured, holding knee

• Felt/heard pop
 Scenario
• On field assessment
• Subjective info
• ROM, diagnostic testing, etc.

• Rule out fracture, vascular injury

• Meniscus injury? Cartilage injury?
• Assist in walking off playing field
Scenario

🤷🏻‍♂️
Scenario
• What happens next?
• X-Ray/imaging
• Schedule with ortho
• MRI, diagnosis
Scenario
• What happens next?
• Before appt with ortho
• Crutches/AD
• Manage swelling, pain, maintain ROM
• Normalize extension for optimal quad activation
• If suspect meniscal or cartilage involvement, do not force
flexion ROM
Scenario
• ACL rupture is confirmed
• What now?
• Discuss meaning with athlete/patient, family, coaches, etc
• Schedule surgery
• Establish short term pre-op goals
Scenario
• ACL rupture is confirmed
• What now?
• Discuss post-op rehab
• Short term goals and milestones
• Long term goals and milestones
• Return to play
 Pre-op Rehab

“preoperative exercises not only prevented quadriceps weakness, but also

accelerated the recovery of muscle strength”
Pre-op Goals
• Minimize pain and swelling
• Normalize ROM
• Improve quad activation
• Normalize gait
• Education
Pre-op Goals

• Prepare patient for post-operative status

• Daily exercises prior to post-op outpatient rehab
• Home
• School
• Work
Pre-op Goals
• Minimize pain and swelling
• Modalities
• Rest
• Cryotherapy
• Compression
• Elevation
• Kinesiotape
• Manual therapy
• Effleurage
Pre-op Goals
• Normalize ROM
• Extension
• Terminal knee extension required for optimal
quadriceps activation
• Allows for normal gait mechanics
• May be inhibited by hamstring guarding/spasm
Pre-op Goals
• Normalize ROM
• Flexion
• Get MRI report from surgeon – cartilage fragment,
meniscus tear blocking flexion?
• If no MRI available – what is the end feel?
• Swelling will inhibit flexion
 Pre-op Goals
• Quadriceps Activation
• Pain and swelling inhibit quadriceps activation

“…effused knee and painful knee groups demonstrated quadriceps muscle

dysfunction…strength deficits were not magnified when these 2 stimuli were
present simultaneously.”
 Pre-op Goals
• Quadriceps Activation
• Pain and swelling inhibit quadriceps activation

“Patients presenting to physical therapy after ACL injury should be treated

with high-intensity neuromuscular electrical stimulation to help normalize this
activation.”
Pre-op Goals
• Quadriceps Activation
• Requires terminal knee extension
• Quad sets – use NMES with volitional contraction
• Allows for SLR without lag → heel strike at initial contact
Pre-op Goals
• Normalize Gait
• Must have terminal knee extension
• Quad activation & SLR
• Proprioception (must be able to balance in SLS)
 Pre-op Goals
• Education
• Graft selection
• Were options given to patient?
• Function/anatomy of ACL
• Visual models (athletes often
visual learners)
Pre-op Goals
• Education
• Goals following surgery
• Return to or avoiding sport?
• Time frames/milestones post-operatively
• Lay out expectations for patient
• Duration/frequency of physical therapy
• May not have realistic understanding of post-operative rehab
Pre-op Goals
• Prepare for post-operative status
• Home modifications
• Stairs, rugs, meals, etc
• Work modifications
• Plan ahead – surgery Friday, resume work early following
week?
• Able to work from home?
• Allotting time for post-op rehab during work/school week?
Pre-op Goals
• Travel modifications
• Handicap placard
• Realistic expectations for driving (R vs. L leg)
• Post-op rehab accommodations
• What times/days of week will work with patient’s
schedule?
• Prepare for duration of post-op rehab
Pre-op Goals
• Prepare for post-operative status
• Home exercise program for p/o week 1
• Ankle pumps
• Hamstring stretch
• Calf stretch
• Knee extension stretch
• Quad set
• Heel slides (or does surgeon prescribe CPM?)
• DO NOT place pillow under knee (prop up heel instead)
Pre-op Goals
• Prepare for post-operative status
• Home exercise program for p/o week 1
Post-op Rehab
• Evaluation
• Get the operative report
• Investigate cartilage health, involvement of meniscus, etc.
• Axillary Crutches
• Check/correct sizing, crutch training
• Immobilization brace
• Locked in extension? 0 ≠ full extension
• No brace? Gait training is even more critical
Post-op Rehab
• Evaluation
• Weight bearing
• WBAT if isolated ACLR
• Stitches
• Typically removed 10-14 days p/o
• Circulation
• Screen for DVT
• Pulses, Homan’s
• Ask questions, educate patient
• Reference Wells’ Score
Post-op Rehab
• Evaluation
• Inspect incision when able to
• Good wound closure
• Measure ROM
• Flexion – do they have a CPM? Often d/c at “90 degrees”
• Girth measurements
• Stay consistent – establish landmarks with yourself and/or
colleagues
 Post-op Rehab

• Evaluation
• Assess quad activation
• Inhibited by:
• Pain
• Swelling
• Knee extension deficit
• Hamstring guarding
• Posterior tibial glide
 Post-op Rehab
• Evaluation
• Patellar mobility
• Inferior, medial, superior
typically most limited
• Patellar tendon mobility
• Important if BTB autograft

PT mobility Patellar mobility

Post-op Rehab
• Week 1 GOALS
• Reduce/mobilize swelling
• Symmetrical knee extension
• Good quad activation w/ posterior tibial glide
• SLR without minimal to no lag
• Unlock brace when lag is absent
Post-op Rehab
• Week 1 GOALS
• Mobilize patella and patellar tendon
• Gradual increase in knee flexion
• Normal gait with unlocked brace and 1-2 axillary crutch
• Begin glute/core strengthening
Post-op Treatment Strategies – Week 1
• Reduce/mobilize swelling
• Contrast bath
• Ice in dependent position
• Heat in extension (heel propped)
• Effleurage in dependent position
 Post-op Treatment Strategies – Week 1
• Reduce/mobilize swelling
• Compression
• Compression sock
• Ace bandage for more significant swelling
• Look at ankle/foot
• Kinesiotape
• Post-treatment squid tape
• Other considerations:
• Alcohol, diet (Na+)
 Post-op Treatment Strategies – Week 1
• Symmetrical Knee Extension
• Beware of cyclops lesion
• Proliferative fibrous nodule formation in intercondylar notch
• Loss of terminal knee extension
• ~10% of post-ACLR population
• Anterior knee pain (deep to infrapatellar fat pad)
Post-op Treatment Strategies – Week 1
• Symmetrical Knee Extension
• Hamstring guarding/spasticity
Post-op Treatment Strategies – Week 1
• Symmetrical Knee Extension

“Good prediction of QF atrophy in the first postoperative

month can be made from studied variables, with isometric
endurance and knee extension ROM deficit being the most
significant contributors.”
Post-op Treatment Strategies – Week 1
• Symmetrical Knee Extension
• Posterior thigh soft tissue
mobilization:
• Hamstring guarding/spasticity
• Gastrocnemius, popliteus
guarding/spasticity
• Stretching:
• Hamstring
• Gastrocnemius
• Knee extension with overpressure
Post-op Treatment Strategies – Week 1
• Symmetrical Knee Extension
• Joint mobilization:
• Posterior tib-fem glide/tilt
Post-op Treatment Strategies – Week 1
Posterior tib-fem glide
Post-op Treatment Strategies – Week 1
Posterior tib-fem tilt
Post-op Treatment Strategies – Week 1
• Good quad activation
• Should demonstrate posterior tibial glide with quad set
• NMES w/ volitional quad set
• Sequencing matters
• Perform once maximum knee extension is achieved on that day
• After manual treatment, stretching, etc
• NMES w/ straight leg raise (SLR)
• Once good volitional quad set is performed, and SLR observed
without extensor lag
Post-op Treatment Strategies – Week 1
• SLR with minimal to no extensor lag
• Criteria* to unlock post-op immobilizer with ambulation
• Requires:
• Full passive knee extension
• Good quadriceps activation with posterior tibial glide
• SLR with extensor lag → increased load across PFJ and PT
Post-op Treatment Strategies – Week 1
• Mobilize patella
• Prioritize inferior, medial, superior mobilization
• Inferior glide:
• Reduces strain on PT incision
• Improves knee flexion ROM
• Superior glide:
• Improves quad activation
• Be mindful of superior mobilization with PBTB autograft
• Medial glide:
• Often tight laterally (TFL/ITB, VL)
Post-op Treatment Strategies – Week 1
• Gradual increase in knee flexion
• Must mobilize patella (prioritize inferior mobility)
• Seated at edge of table with leg supported
• Patient will be more relaxed than in supine
• Facilitate use of gained knee flexion in pre/early swing
• Heel slides at home
Post-op Treatment Strategies – Week 1
• Gradual increase in knee flexion
• Must mobilize patella (prioritize inferior mobility)
Post-op Treatment Strategies – Week 1

Inferior Patellar Mobilization

Post-op Treatment Strategies – Week 1
• Normalized gait with brace and AD as needed
• Manual facilitation of proper gait mechanics
• Heel strike/initial contact
• Full knee extension, volitional quad activation
• Loading response/midstance
• SLB, volitional quad activation
• Pre/initial swing
• Passive knee flexion
• Relax rectus femoris/quadriceps
Post-op Treatment Strategies – Week 1
Manual facilitation of proper gait mechanics
Post-op Treatment Strategies – Week 1
• Begin glute/core exercises
• Start day 1 (use brace as needed)

“Rehabilitation including hip strengthening exercises appears to

improve sagittal plane dynamic balance at three months post ACLR as
compared to traditional rehabilitation”
Post-op Treatment Strategies – Week 1
• Begin glute/core exercises
• Start day 1 (use brace as needed)
Post-op Treatment Strategies – Week 1
• Begin glute/core exercises
 Post-op Treatment Strategies – Week 1
• Begin glute/core exercises
• Look for muscular imbalances that
may inhibit gluteal activation
• TFL tightness
• Psoas tightness
• Mobility exercises and/or manual
release for more productive
gluteal strengthening
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training

“In addition to recovering muscle to a greater extent than standard

rehab alone, the addition of BFR to ACL rehab exercises appears to
have a protective effect on bone.”
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training

“The results indicate that the occlusive stimulus effectively diminishes

the post-operation disuse atrophy of knee extensors.”
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training
• Increased strength and hypertrophy with low load
resistance training
• Able to protect graft/repair while maximizing exercise benefits
• Reduce atrophy due to immobilization and decreased WB
• Positive effect on post-operative bone loss
• Benefits shown proximal and distal to cuff
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training
• Can be implemented once good wound closure is
observed (within 7 days p/o)
• Utilize with low load exercises in p/o week 1-2
• Quad sets
• Terminal knee extension
• NWB gluteal exercises (clams, sidelying hip abduction, prone
hip extension)
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training
• 80% of full LE occlusion
• Sets/Repetitions: 30/15/15/15 at 20-30% 1RM
• “Cell Swelling” protocol
• “Ischemic Pre-Conditioning (IPC)” protocol
• Nutrition – ensure adequate protein intake (2g/kg BW)
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training
• Quad Sets
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training

Terminal Knee Extension

Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training
• Benefits both proximal and distal to cuff

“Isokinetic testing showed greater increases in knee extension peak

torque (3% vs 11%)”

“BFR training had similar strengthening effects on both proximal and

distal muscle groups”
Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training

NWB Gluteal Exercises

Post-op Treatment Strategies – Week 1
• Personalized Blood Flow Restriction (PBFR) Training

Kyle Kimbrel
Owens Recovery Science
Post-op Treatment Strategies – Weeks 2-4

• Continue exercises from week 1

• Suture removal (if applicable)
• Initiate stationary bike for ROM
• Gait w/ 1 crutch if ready by week 2-3, wean off by week 3-4
• 1 crutch in uncontrolled, public environment (i.e. school), practice
without crutch in controlled environment (i.e. home, office)
Post-op Treatment Strategies – Weeks 2-4
• Leg press 0-60° by end of week 2
• DL and SL (incorporate BFR)
• Single leg balance
Post-op Treatment Strategies – Weeks 2-4
• Core strengthening (front, side planks if pain-free)
• DL partial squat once good quad control and SLB is observed
• Hinge at hip
• Increase gluteal/posterior chain activation
• Avoid anterior knee translation
• Decrease load across patellar tendon for BTB autografts
• Patellar tendinitis is NOT a complication of a BTB autograft – it is a
CONSEQUENCE of careless rehab!
Post-op Treatment Strategies – Weeks 2-4

DL Squat

1. Hinge at hip
2. Trunk forward
3. Tibias vertical
Post-op Treatment Strategies – Weeks 4-6
• Progress squat to include lateral/diagonal stepping
• Introduces SL excursion
• Be mindful of gluteal compensations (trunk lean, pelvic drop, etc.)
• Progress balance (unstable surface, dual-task, etc.)
• Assisted eccentric SL excursion at week 6 if appropriate
• TRX, tandem, valslide, etc. to provide balance and strength assist
• Eccentric SL control key for successful running
• Elliptical at week 6
Prepare For Jogging
Full body weight jogging at 12 weeks* if:
1. Good eccentric SL control
• Pain-free
• Control knee valgus
• Combined hip/knee strategy
• Pelvic and trunk symmetry (watch for Trendelenburg)
2. Good core strength
• Front/side plank 30+ seconds with good form
3. Elliptical pain-free
References
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