An Exercise Program to Prepare for ACL Surgery

If you have an anterior cruciate ligament (ACL) tear and are considering surgery, you may benefit from physical therapy exercises prior to surgery. Preparing for your surgery with your physical therapist has been shown to improve overall outcomes with your knee after your ACL repair.

An ACL sprain can cause a variety of symptoms, and your physical therapist can help you get back to optimal function after the injury. Symptoms of an ACL sprain may include:

- Knee pain

- Knee swelling 

- Limited knee range of motion (ROM)

- Loss of strength in your quadriceps or hamstring muscles

- Feeling of instability around your knee joint

- Difficulty performing basic functional tasks like climbing stairs, walking, or running

If you suspect you have an ACL tear, you should visit your doctor to get an accurate diagnosis. Your doctor will likely perform special tests to determine if you have an ACL tear, and an MRI may be ordered to confirm the suspected diagnosis. If you do have an ACL tear, surgery may be recommended.

Physical therapy prior to ACL repair surgery has been shown to improve your overall outcome with the procedure. So what components and exercises are typically included in a PT program for pre-op ACL care?

Goals of PT prior to ACL surgery may include:

- Restore normal knee ROM

- Improve quadriceps and hamstring strength

- Improve hip strength and stability

- Maximize balance and proprioception

- Control pain and swelling in your knee

Your physical therapist may use various modalities to help control your knee pain and swelling and to improve muscular function as part of your ACL prehab. But exercise is your main tool in maximizing knee function prior to ACL surgery.

Here is a sample exercise program that your physical therapist may prescribe for you to do prior to your ACL surgery. Your PT can show you how to do the exercise properly.

Be sure to check in with your doctor before starting this, or any other, exercise program for your knee.

1
Quad Sets and Short Arc Quads

Photo of a young woman stretch her thigh.
You can stretch your quads just about anywhere. Cultura RM Exlcusive/Jordan Lutes/Getty

 After an ACL injury, you may find that your quadriceps muscle on the front of your thigh isn't functioning properly. One of the primary goals of pre-op ACL therapy is to restore normal function and strength to your quad muscle so that it supports your knee properly.

Exercises that your PT may prescribe to improve quad function may include:

  • Quad setting exercises: Lie on your back and place a small towel under your knee. Tighten your quads by pressing the back of your knee into the towel. Hold for 5 seconds, and then relax.
  • Short arc quads (SAQ): Lie on your back and place a ball underneath your knee. Straighten your knee fully, keeping the back of your knee against the ball.
  • Straight leg raises: Tighten your quad muscle on the top of your thigh, and then slowly lift your straight leg up about 12 to 15 inches. Hold for 2 seconds , and then slowly lower your leg down.

Exercises should be performed in a pain free motion; stop any quad exercises that cause increased pain in your knee.

2
Improving Knee Range of Motion

Restoring knee range of motion should be one of your primary goals prior to ACL surgery. If your knee is bending and straightening fully before surgery, it is likely to quickly recover full ROM after surgery. Exercises that may be done may include:

  • Heel slides: Lie on your back and slowly bend your knee and slide your heel up towards your buttocks.
  • Prone hang for knee extension: Lie on your stomach and hang your leg over the edge of a bed, allowing your knee to hang in a fully straightened position.
  • Stationary bicycling: Use a bike at the gym or PT clinic to gently get your knee bending and straightening.

Be sure to move your knee with control and slowly and purposefully, and stop the exercise if you feel pain.

3
Hamstring Strengthening

Your ACL helps to stabilize your knee by preventing forward slippage of your shin bone underneath your thigh bone. Your hamstrings, by nature of their attachment points behind your thigh and knee, can also help to add stability to your knee joint.

Your physical therapist may prescribe hamstring strengthening exercises during your ACL prehab. Exercises may include:

  • Hamstring sets: Lie one your back with your knee bent. Slowly press your heel into the floor, tightening your hamstring as you do so. Hold the position tight for 5 seconds, and then relax.
  • Prone knee bends: Lie on your stomach, and slowly bend your injured knee up, using your hamstring on the back of your thigh.
  • Seated hamstring curls with a resistance band: Obtain a resistance, and sit in a chair with the band around your ankle of your injured leg. The other end can be held by a friend or attached to a doorknob. Then, slowly bend your knee, allowing the resistance band to provide resistance. Hold your knee bent for a few seconds, and then slowly return to the starting position.

Strengthening your hamstrings should not cause any pain; if you feel pain during the exercise, stop it and check in with your PT.

4
Hip Strengthening

Photo of woman running with hip muscles exposed.
A solid hip exercise program can keep you injury free. Henning Dalhoff / Getty Images

Research indicates that your hips control the position of your knees when walking, running, and jumping. Keeping your hips strong—namely your gluteus medius muscles—can help keep your knees in the best position possible while running and jumping. This can help minimize stress and strain through your knee and ACL.

Hip strengthening exercises may start with straight leg raises, but some other exercises your PT may prescribe as part of your pre-op ACL program may include:

  • Lateral band walks: Place an elastic band around your ankles and slowly walk sideways across the room.
  • Hip hikers: Stand with one leg on a step and the other leg hanging freely down, and then slowly lower your pelvis down, being sure the motions come from your knee.
  • Single leg bridges. Perform a bridge exercise with one knee bent and one knee out straight and lifted off the floor.

By working to keep your hips strong prior to your ACL surgery, you may be able to maximize hip strength after your surgery.

5
Balance and Proprioception

Photo of woman practicing yoga on the beach.
The T-Stance is a great exercise to build better balance. Zero Creatives/Getty Images

 Proprioception is a term that describes your body's ability to understand where it is in your environment. Good balance and proprioception is essential to keeping your knees in the correct alignment when running and jumping, and this can help keep stress and strain off your ACL. Working on you proprioception will likely be a major component of your your rehab after surgery, so making it a part of your ACL prehab may be a good idea.

Your PT may have you perform various balance and proprioception exercises to help you prepare for your ACL surgery. These may include:

  • Single leg standing: Simply stand on one leg and try to hold your balance for 30 to 60 seconds.
  • BOSU exercises: Use a BOSU ball to stand upon it to challenge your balance.
  • BAPS board: Your PT may have you use a device called a BAPS board to challenge your proprioception and balance.
  • The T-Stance exercise: Stand on one leg with you other leg out behind you. Hold both arms out to the side, like a letter "T", and slowly bend forward at the waist, maintaining stable balance.

Remember, to improve your balance you need to challenge your balance. This may be difficult in an ACL-deficient knee prior to surgery, so be careful when selecting the balance and proprioception exercises that you do. Your physical therapist can help determine the best balance exercises for you to do while preparing for your ACL surgery.

6
Neuromuscular Training

Photo of an athlete doing a box jump.
Plyometric training may be a part of your ankle fracture rehab. John Fredele/Getty Images

Neuromuscular training is performing specific motions designed to improve the way your body moves and responds to various forces that are placed upon it. After an ACL tear, research shows that performing neuromuscular training exercises can help improve overall knee function and may reduce the chance of a future ACL problem.

Exercises that your PT may prescribe for neuromuscular training may include:

  • The drop jump exercise: Stand on a 12 to 18 inch stool, and jump down, landing with your knees bent. Then, immediately jump back up as high as possible.
  • Learning to jump and land correctly: Practice jumping up and landing with your feet shoulder width apart and your knees directly over your ankles. Land softly by bending your knees as you come down from your jump.
  • Single leg hopping: Stand on one foot and hop forward for three hops. Be sure to land with your knee slightly bent and directly over your ankle and foot. 

These motions and exercises are challenging, and they may be difficult to perform with your ACL-deficient knee. The key for these exercises is to ensure that your knees are in the proper alignment when performing them. Be sure to check in with your physical therapist to be sure that this type of training is right for you and your specific condition.

7
Putting it All Together

Women running outside
Adam Hester/Getty Images

 An anterior cruciate ligament sprain can be a devastating injury that sidelines you for months. Choosing to have surgery can help you restore normal motion and function to your injured knee.

Engaging in pre-operative physical therapy when preparing for your ACL repair surgery can have positive impacts on your overall recovery. Your prehab should focus on the basics first—restoring normal knee range of motion and optimal quad and hamstring strength. Once your knee is moving well, adding in advanced balance and proprioception exercise and neuromuscular training can help you feel fully prepared for your ACL surgery.

The best way to understand what to do while preparing for your ACL surgery is to work closely with your doctor and physical therapist. They can help guide you through your exercise program and ensure that your knee is ready to go when your ACL repair surgery finally arrives. That way, you can maximize your chances of a full and rapid recovery after surgery.

Sources:

Failla, MJ, etal. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction? A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts. Am J Sports Med. 2016 Oct; 44(10): 2608-2614.

Shaarani, SR, etal. Effect of prehabilitation on the outcome of anterior cruciate ligament reconstruction. AM J Sports Med. 2013 Sep; 41(9):2117-27.

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