Paraic Murray - Galway Clinic

Paraic Murray
MSc, MCh(Orth), FRCSEd(Orth)
Consultant Orthopaedic Surgeon
Physiotherapists Post-Operative
Guidelines for Anterior Cruciate
Ligament Re-construction

Contents
Rehabilitation Guidelines 4
Phase 0 – Pre-operative Recommendations 5
Phase 1 – Immediate Post Operative Phase 6
Phase 2 – Early Rehabilitation Phase 8
Phase 3 – Strengthening and Control Phase 10
Phase 4 – Advanced Training Phase 12
Phase 5 – Return to Sport Phase 13

Rehabilitation Guidelines
The following Anterior Cruciate Ligament (ACL) reconstruction rehabilitation guidelines are
based on a review of the randomised controlled trials related to ACL rehabilitation. For the
many aspects of the ACL rehabilitation where there are either no studies that qualify as “best
evidence” or the number of studies are too few for confident conclusions to be drawn, the
recommendations are based upon the guidance of the Multicenter Orthopaedics Outcomes
Network (MOON) panel of content experts.
The guidelines have been developed to service the spectrum of ACL injured people from
the non- to the elite athlete. For this reason the guidelines are not prescriptive and example
exercises only are given. Each programme should be tailored to meet the individual needs
of the patient.
Progression from one phase to the next is based on the patient demonstrating readiness by
achieving functional criteria rather than the time elapsed since surgery. The timeframes
quoted here after each phase are approximate times for the average patient, NOT guidelines
for progression. Some patients will be ready to progress sooner while others will take longer.
Phase 0: Pre-operative Recommendations
• Normal Gait
• Active Range of Movement (ROM) 0 to 120 degrees
• Strength: Can Straight Leg Raise (SLR) with no lag x 20
• Minimal effusion
• Patient education on post-operative exercises and need for compliance
• Education in mobilisation with crutches
• Wound care instructions *
* Wound Care: Wool and crepe bandage is reduced on Day 1.
The primary dressings remain in situ even if blood stained, and must remain dry, until Day 10
The aim is to ensure that the sterile wound and any exudate remain sterile. A dressing when
dry even though blood stained acts as an efficient barrier to microbes.
4 5

Phase 1: Immediate Post-operative Phase
(approximate time frame 1 day to 2 weeks Post-operation)
Goals
• Full knee extension
• Good quadriceps control (> 20 no lag SLR)
• Minimize pain
• Minimize swelling
• Normal Gait pattern
Crutch Use: Partial weight bearing
Crutch Discharge:
Criteria: Normal Gait pattern.
Ability to ascend/descend stairs without noteworthy pain or instability
(reciprocal stair climbing)
Cryotherapy: First 24hrs or until acute inflammation is controlled: every hour for 15mins.
After acute inflammation is controlled: 3 times a day for 15 minutes
Exercise suggestions
ROM
• Extension: Low load, long duration (~ 5 minutes) stretching (e.g. heel prop, prone hang
minimizing co-contraction and nocioceptor response)
• Flexion: Wall slides (see squats), heel slides, seated assisted knee flexion,
bike: half revolutions for range
Muscle Activation/Strength
• Quadriceps sets emphasising vastus lateralis and vastus medialis activation
• SLR emphasising no lag
• Double-leg quarter squats (< 45° only) against the wall
• Standing theraband resisted terminal extension – closed kinetic chain
• Standing theraband, *hamstrings – closed kinetic chain
• Side-lying hip adduction/abduction (avoid adduction movement in this phase with
concomitant grade I-II Medial Collateral ligament injury)
• Quadriceps and Hamstring co-contraction supine
• Prone hip extension
• Ankle pumps with theraband
• Heel raises (calf press)
• Calf stretches
* Avoid hamstring curls (open chain) x 3–4 weeks
Criteria for progression to Phase 2
• 20 x no lag SLR
• Normal independent gait
• Active ROM 0-110 degrees
6 7

Phase 2: Early Rehabilitation Phase
(Approximate time frame: 2 to 6 weeks)
Goals
• Full ROM
• Improve muscle strength-able to perform a unilateral step down to 45 degrees knee
flexion, with neutral pelvic alignment
• Progress neuromuscular retraining-able to maintain on a soft surface, a single leg mini dip,
knee unlocked for 15 seconds
Exercise sugestions
ROM
• Low load, long duration stretch (assisted as necessary)
• Heel slides, wall slides
• Heel prop/prone hang (minimize co-contraction/nociceptor response)
• Bike (half revolutions for range > riding with low seat height)
• Flexibility stretching all major groups
Strengthening
Quadriceps:
• Mini-squats/wall squats
• Step up’s
• Step downs low step
• Leg press
• Quadriceps terminal knee extension with theraband-standing
Hamstrings:
• Hamstring with theraband, closed kinetic chain
Other Musculature:
• Hip adduction/abduction: SLR or with equipment
• Standing heel raises: progress from double to single leg support
• Seated calf press against resistance
• Multi- hip machine in all directions with proximal pad placement
Neuromuscular Training
• Wobble board
• Rocker board
• Single-leg stance with or without equipment (e.g. instrumented balance system)
• Sliding board
Cardiovascular
• Bike
• Elliptical trainer
Criteria for progression to Phase 3
• Full ROM
• Minimal effusion/pain
• Functional strength and control in daily activities
• International Knee Documentation Committee (IKDC) Question 10 (global Rating of
Function) score of >7
8 9

Phase 3: Strengthening & Control Phase
(Approximate time frame; 7 to 12 weeks)
Goals
• Maintain full ROM
• Running without pain or swelling
• Hopping without pain, swelling or giving way
• Limb Symmetry Index (LSI) of knee flexors up to 70% of non-operated side( Divide 1
repetition Maximum (1RM)of involved by 1RM of uninvolved leg)
Exercise sugestions
Strengthening
• Squats
• Leg press
• Hamstring closed kinetic chain with theraband
• Knee extension 90-0 degrees
• Step ups
• Step downs
• Lunges
• Shuttle
• Sports cord
• Leg press
• Wall squats
Neuro-muscular Training
• Wobble board/rocker board/roller board
• Perturbation training
• Instrumented testing systems
• Varied surfaces
Cardio-vascular
• Straight line running on treadmill or in a protected environment (NO cutting or pivoting)
• All other cardio-vascular equipment
Criteria for progressing to Phase 4
• Running without pain or swelling
• Hopping without pain or swelling (bilateral and unilateral)
• Neuromuscular and strength training exercises without difficulty
10 11

Phase 4 : Advanced Training Phase
(Approximate time frame:13 to 18 weeks)
Goals
• Running patterns (Figure of 8, pivot drills, etc) at 75% speed without difficulty
• Jumping without difficulty
• Hop tests at 75% contralateral values (Cincinnati hop tests: single-leg hop for distance,
triple-hop for distance, crossover hop for distance, 6 metre timed hop)
Exercise sugestions
Aggressive Strengthening
• Squats
• Lunges
• plyometrics
Agility Drills
• Shuffling
• Hopping
• Vertical jumps
• Running patterns at 50–75% speed (e.g. Figure-8)
• Initial sports specific drill patterns at 50–75% effort
Neuromuscular Training
• Wobble board/rocker board/roller board
• Perturbation training
• Instrumented testing systems
• Varied surfaces
Cardiovascular
• Running
• Other cardio-vascular exercises
Phase 5: Return to Sport Phase
(Approximate timeframe: 5 to 6 months)
Goals
• 85% contralateral strength
• 85% contralateral on hop tests
• Sport Specific training without pain, swelling or difficulty
Exercise sugestions
Sport Specific activities
• Interval training programs
• Running patterns in football
• Sprinting
• Change of direction
• Pivot and drive in basketball
• Kicking in soccer
• Spiking in Volleyball
• Skill/biomechanical analysis with coaches and sports medicine team
Return to sport evaluation recommendations:
• Hop tests (single-leg hop, triple hop, cross-over hop, 6 meter timed-hop)
• Isokinetic strength test
• Vertical Jump
• Deceleration shuttle test
• MOON outcome measure packet
12 13

14
Return to sport criteria
• No functional complaints
• Confidence when running, cutting, jumping at full speed
• 85% contra-lateral values on hop test
• IKDC Question No.10 (Global Rating of Knee Function) of > 9
References
Multicenter Orthopaedics Outcomes Network (MOON) group.
Special thanks to: The Galway Clinic Physiotherapy Department
Authors: Jane Campbell – Chartered Physiotherapist,
Paraic Murray – Consultant Orthopaedic Surgeon

16
Mr Murray’s suite is situated on the second floor of
the Galway Clinic. On entering the main hospital
entrance, the lifts to the suites are on your left.
Once exiting the lifts on the second floor, suite 32
is straight ahead and second suite on the right.
GALWAY CLINIC
Galway
Airport
Western
Motors
Galway
Clinic
N6
To Galway City
Quality Inn
Hotel
N6
Martin
Roundabout
To Galway City
Coast Road
To Claregalway
(Sligo)
N6
To Oranmore
To Dublin
N18
Suite 32 (Second Floor), Doughiska, Galway
Tel: (091) 720160 Fax: (091) 720161
www.galwayclinic.com