Rehabilitation Protocol after Surgical Repair of Your ACL

What to expect week-by-week after your ACL surgery

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If you have suffered a sprain of your anterior cruciate ligament (ACL) and have surgery to repair your knee, your doctor may refer you to physical therapy after your surgery. There, you will work on restoring range of motion (ROM) and strength, decreasing pain and swelling, and improving your overall functional mobility.

After your ACL surgery, there are certain things you should and should not do during the rehabilitation process to ensure a safe return to your previous activity level.

Your physical therapist and doctor may follow a specific protocol after surgery to help guide you in your ACL rehabilitation. Post-operative protocols serve as a roadmap to follow during your rehabilitation program.

Many people often ask how closely the ACL rehabilitation protocol should be followed. Every person is different, and everyone heals at different rates. Therefore, the ACL protocol should be used as a general framework on which you and your physical therapist build your rehabilitation program. The protocol should give you an idea of what to expect during your ACL rehabilitation at various stages of the post-operative period. Sometimes, a little deviation from the protocol is necessary depending on your specific situation and healing process.

The most important thing to remember is that you should seek the advice of your doctor and physical therapist before following any post-operative rehabilitation protocol to ensure that it is safe for you to do.

The ACL protocol is divided into four specific phases, with specific goals and rehab exercises to be accomplished at each phase.

Maximal Protection Phase after ACL Repair

During the maximal protection phase after ACL repair surgery, the main goals are to protect your knee so it heals properly, to start to work on restoring ROM to your knee, and to restore normal use of your quadriceps muscle in your thigh.

During this phase you will most likely be using crutches to walk, and you may be wearing a full length brace on your knee. Some surgeons do not require you to wear a knee brace after ACL surgery, as recent evidence indicates that it is not necessary for a successful ACL repair outcome.

Post-op Day 1-3:
In this initial post-operative period, your main focus is learning to walk with your crutches. You may start physical therapy during the first few days after surgery to practice using your crutches for walking on level surfaces and walking up and down stairs.

Your physical therapist may choose to use electrical stimulation called neuromuscular electrical stimulation (NMES) to help improve your ability to contract your quadriceps muscles. Ice may also be used several times a day to help control swelling in your knee.

Basic exercises should be started to help improve your knee range of motion. Exercises to improve your quadriceps muscle contraction are also recommended.

Post-op Week 1-2:

  • Gait training: This involves learning to properly use your crutches to walk on level surfaces and up and down stairs.
  • Therapeutic modalities: Ice should be used to control pain and swelling and NMES may be used to improve your quadriceps contraction.
  • Exercises: Basic knee exercises should be initiated to improve your knee range of motion to 0 degrees extension (fully straight) to 90 degrees of flexion (bending). Prone knee hangs may be used to provide a gentle stretch to your knee to help get it fully straight.

Moderate Protection Phase

During the moderate protection phase of ACL rehabilitation, your swelling should be under control, and you should be able to contract your quadriceps muscles easily. The goal of this phase is to stop using an assistive device and normalize walking while still providing some level of protection for your healing knee.

Week 2:
During your second week of rehab after your ACL repair, your main focus should continue to be on improving your knee range of motion and quadriceps strength. Hip strengthening exercises should be incorporated to start to advance walking with no crutches. Progress from using two crutches to one crutch, and then finally to walking with no assistive device.

  • Gait: You should be able to progress to walking with no crutches during the second or third week after surgery.
  • Therapeutic modalities: Continue with ice daily to control swelling and NMES in the clinic to maximize your quadriceps contraction.
  • Exercises: During week 2, exercises should continue to focus on improving quadriceps control. Performing exercises to improve your hamstring strength can also be incorporated during your second week. You may start using a BAPS board in the seated position to start to improve balance and proprioception.

Week 3:

  • Gait: By the end of week 3, your walking should be almost normal. If you have a slight loss of ROM in straightening your knee, then you may still be walking with your knee slightly bent. Continue working on knee ROM to help improve your walking.
  • Therapeutic modalities: Continue with ice for swelling and NMES to improve quadriceps control.
  • Exercises: Start to advance hip strengthening exercises to help improve your walking ability. Straight leg raises can be progressed to include weights to add more resistance. Be sure to properly add resistance with your straight leg raises to prevent too much stress through your knee joint. Advanced hip strengthening exercises may be incorporated. You can progress to performing the BAPS board in the standing position.

Minimal Protection Phase

During the minimal protection phase, you will start increasing the overall strength of your lower extremity, and you will progress from normal walking to light jogging by the end of this phase.

Week 4-6: During week 4, 5 ,and 6 you should be walking normally. Balance exercises should be incorporated, and more resistance type exercises can be started. Gentle wall squats can be initiated, and lunges may be started as well. You should continue with straight leg raises and advanced hip strengthening exercises. By the end of week 6, gentle plyometrics and hopping can be initiated. Modalities like NMES can be discontinued.

Weeks 7-8: During this phase, you should continue with the strengthening exercises from previous weeks. Progressively add resistance to your exercises. Your physical therapist may test the integrity of your ACL at this point using the anterior drawer test. If you have no knee pain and your knee is stable, slow jogging can be started by the end of the eighth week.

Return to Function Phase

During this phase, your focus should be on getting back to normal activity and function. You should be progressing your jogging and starting to progress to running. High level sports that involve a lot of starting and stopping or cutting should still be avoided for a couple more months.

Week 8-12: Continue to advance hip, knee, and ankle strengthening. Your knee should feel stable and pain free. Plyometric exercises should progress from two legs to single leg exercises.

Approximately at the 3-4 month point after your surgery, you may start single leg hop testing. This is used to determine if your knee is stable enough for you to return to high level athletics that require sudden starts and stops or cutting maneuvers. Your doctor and physical therapist should work with you to progress single leg hopping drills and to help you assess your readiness to return to high level sports.

Your knee should be normal after 6 months following your ACL repair surgery. Of course, everyone heals at different rates, and your particular rehab protocol may take as little as 4 months or as long as 9 months to complete.

By working closely with your doctor and physical therapist and by following an ACL rehabilitation protocol, you can have an understanding of what to expect following ACL surgery.

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