Post-Operative Functional ACL Reconstruction Rehab Program
Phase 1
Goals for Phase 1 of the Post-operative Functional ACL Reconstruction Rehab program include restoration of ROM and mobility, management of pain and edema, and initiation of strengthening with emphasis on the quadriceps. The post-operative brace may be removed for treatment. Closed chain exercises should be performed in the protected range of 0-45° of flexion and open chain exercises should stay in the protected range of 90-60° of flexion.
Exercises should include, but are not limited to:
- Quad Sets and 4-Way Straight Leg Raises
- Heelslides, Stationary Bicycle
- Stretching (as necessary)
- Leg Press (Unilateral and Eccentric)
- Terminal Knee Extension, Hamstring Curls, Calf Raises
- Patella-Femoral and Tibiofemoral Mobilizations
- Neuromuscular Electrical Stimulation
- Forward and Lateral Step-Ups and Step-Downs
- Step-and-Holds
- Lunges in the Sagittal, 45°, and Frontal Planes
- Single Leg Stance
o Eyes open and closed, on stable and unstable surfaces
- Balance and Reaches, Star-Excursion Drills
- Perturbation Training
- Gait Training
o Treadmill Walking
o Forward Weight-shifts/Nose Reaches
o Romanian Deadlifts/Staggered Stance Hip flexion with Knees Flexed
o Hip Excursion Drills
- Singe Leg Squats
- Monster Walk, Resisted Side-Stepping, Resisted Staggered Stance Walk
Criteria to Advance to Phase 2:
1. Patient must be at least 12 weeks post-surgery
2. MD Clearance
3. Able to perform 70% of single leg 1 Rep Max on leg press vs. uninvolved
4. Able to perform 10 single leg squats from 0-45° of flexion without loss of balance, muscle quivering, or varus/valgus moments (patella moving out of the sagittal plane)
5. Able to perform 30 consecutive forward step-and-holds from the uninvolved to involved leg without loss of balance, muscle quivering, or varus/valgus moments (patella moving out of the sagittal plane)
6. Able to tolerate 15 minutes of fast walking on treadmill without onset of antalgic gait pattern (speed should be set so that it’s just short of jogging)
Phase 2
When strengthening, closed chain knee flexion may go >45° after post-op week 16 unless the patient complains of patellofemoral pain. Running should be initiated on a treadmill at slow, comfortable speeds for short durations and distances. The patient may progress in speed, time and distance as long as there is not an onset of new signs/symptoms of inflammation. When the patient can tolerate 1 mile of treadmill jogging without any new signs/symptoms of inflammation, they may begin running on a track and treadmill independently, jumping (movement that starts and concludes with both feet), forward/backward shuttle runs, and lateral
side-stepping. Jump length should begin at the patient’s stride length and progress as tolerated. When the patient can jump forward 50% of their height, vertical jumps and jumping can be initiated in the frontal and transverse planes. Frontal plane jump length should begin at 1 foot and progress in distance as symptoms allow. Transverse plane jumps should begin at 45° clockwise and counterclockwise and progress in rotation as symptoms allow. Vertical jumps should begin at 1 foot above the patient’s standing reach and progress as symptoms allow. Forward/backward shuttle runs and lateral side-stepping exercises should begin at 25% of maximum speed and progress to 50% as symptoms allow.
Exercises from Phase 1 should be continued and progressed to increase both power and endurance.
New exercises for Phase 2 include but are not limited to:
- Lunges in the sagittal, 45°, frontal, and transverse planes
o Progress from # of repetitions to lunges to fatigue, to step and lunge, to walking lunges in all planes
- Running on treadmill
o Goal is to tolerate 1-2 miles without the onset of signs/symptoms of inflammation
- Side Shuffling
o ≤50% speed
- Forward/Backward Shuttle
o ≤50% speed
- Jumping
o Preparation for jumping includes tolerating multi-plane single leg stance activities, balance and squats on the tramp, and skipping
o All jumps should be jumping and landing with both feet
o All jumps should be single, not consecutive
o All jumps should be practiced at 25% then 50% of patient’s height according totolerance
Criteria to Advance to Phase 3:
1. MD Clearance
2. Tolerating Phase 2 exercises without signs/symptoms of inflammation. Patient must be able to tolerate jumping vertically, and in all 3 planes of motion before beginning unilateral hops
4. Single leg 10 Rep Max on leg press 85% of uninvolved
5. Able to perform 10 single leg squats with 75% resistance of uninvolved leg (body weight + dumbbells)
6. Able to run 2 miles on track or road signs/symptoms of inflammation
Phase 3
Jumping will progress from single jumps to consecutive jumps in all planes of motion. Hops (movement that starts and concludes with one foot) will be initiated in Phase 3. Dynamic strengthening of the lower extremity and core, and agility exercises from Phase 2 should be continued and progressed to 75-100% effort/speed as tolerated. New exercises include but are not limited to:
- Standing Broad Jump (2 feet)
o Goal is to progress to 80-90% of height for females, 90-100% of height for males
- Consecutive Broad Jumps
o Sagittal, frontal, transverse planes
- Consecutive Vertical Jumps
- Hops
o Sagittal plane, frontal plane, clockwise, and counterclockwise
o Hops for Speed
o Hops for Distance – Goal is to progress to 70-80% of height for females, 80-90% of height for males
- Vertical Hops
- Single Leg Triple Hops
- Single Leg Zig-Zag Hops
- Plyometric Drills
- Ladder Drills
- Carioca
Criteria to Advance to Phase 4:
1. MD clearance
2. Tolerating all of Phase 3 exercises without any new signs/symptoms of inflammation
3. Single leg 10 Rep Max on leg press ≥90% than uninvolved
4. Able to perform 10 single leg squats with 85% resistance of uninvolved leg (body weight + dumbbells)
Phase 4
Rehabilitation in Phase 4 is focused on preparing for return to sport (RTS). Jumping and hopping should be consecutive and performed in all planes of motion. Running and sprinting should be initiated and progressed to 100% speed with emphasis on cutting, pivoting, cut and spinning, and stop and go reactions. Sport specific exercises should be included and progressed to include opposition.
New exercises should include but are not limited to:
- All exercises from Phases 1-3 at 100% effort (speed/power/distance)
- Forward/backward shuttle, side shuffling drills, and carioca at 100% effort focusing on eccentric control and push-off of involved lower extremity
- Cutting drills
o Begin with “rounded S-cuts” and progress to quicker “Z-cuts”
- Cut and Spin drills in both directions
- 10 meter single leg hopping (timed)
- Sprinting
o Progress from 50% sprinting, to 75% sprinting, to 100% sprinting. Begin with short distances, to 40 yard dash, to sprinting to fatigue
- Sport-specific drills
o Progress to sport-specific drills with opposition
- Preparation for Return to Sport Testing Protocol
Criteria to Take Return to Sport Testing:
1. MD Clearance
2. Patient tolerates all exercises for strengthening, agility, running, sprinting and plyometrics at 100% effort with no reports of instability, pain or signs/symptoms of inflammation.
3. Single leg 10 Rep Max on leg press ≥95% than uninvolved
4. Able to perform 10 single leg squats with 90% resistance of uninvolved leg (body weight + dumbbells)