Rehabilitation of Acl Injuries

By: Gerry Van Dyke

Anterior cruciate ligament (ACL) tears are one of the most debilitating and common knee injuries in sports. Deciding on the best course of treatment, surgery vs. non-surgery, rehab vs. no rehab, can be confusing. In general, athletes opt for surgical reconstruction and rehab since studies show athletes with ruptured ACL's seldom regain their prior level of functioning (skills). Even non-athletes have considerable long term functional deficits and are at greater risk of further injury if they do not have surgical reconstruction. There are several surgical considerations including using a graft from the patient (autograft) vs. using a graft from a donor (allograft). The most common technique uses the middle 1/3 of the patients patellar tendon for the reconstruction. For the sake of this article, I will assume the most common surgical procedure has been performed (and by a highly skilled surgeon).

Early movement is the key to rehab. Since modern surgical techniques provide very good fixation (anchoring), bending (flexion) and straightening (extension) the knee can begin immediately after surgery. A constant passive motion (CPM) machine is recommended if the patient won't be starting physical therapy immediately. The initial range of motion (ROM) goal is full extension and 110 degrees of flexion. Early movement helps strengthen the graft and reduces the formation of deleterious scar tissue. It also helps prevent breakdown of healthy tissue such as the joint surfaces (cartilage). ROM can also be improved by use of a stationary bike and/or swimming pool.

Controlling fluid (edema) build up in the knee early is very important. Our goal (before full weight bearing is allowed) is 1cm or less. Edema interferes with muscle activation and ROM. Compression via a bandage or sleeve, along with ice/cryotherapy machine are commonly used after surgery. Massage, ultrasound, and various forms of electrical stimulation can be utilized during physical therapy.

Keeping pain low is also key. Pain interferes with healing and motivation. Medications, cryotherapy, massage all can help reduce pain.

Achieving good quad muscle activation early is also important. Weight bearing should not be allowed until the patient can perform a straight leg raise with full extension, otherwise the patient is at increased risk of developing patellar-femoral pain. The body shuts down the muscles around the knee (primarily the quads) after a traumatic event (surgery). Getting the muscles to work properly again, is the focus of rehab once ROM goals have been met and edema is under control. Patients that are instructed in quad exercises prior to surgery usually can achieve good quad muscle activation within a day or so of the operation.

Exercises are designed to improve strength, endurance, flexibility, and balance. The measure of a good rehab program is how quickly a patient is able to return to full functional status. A patient should be progressed when the tissue is ready, instead of waiting a predetermined amount of time. All people heal at different rates. Everyone should be progressed as quickly as their tissues will allow it. In general, our goal is for patients to resume sport specific training within 2-3 months after surgery...that means they have normal strength, ROM, and endurance, no pain or edema, and can run and jump without problems. Often, our patients return to their sports in better condition than prior to their injury due to the comprehensive and intensive rehab program.

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