by I PHASE — Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation Progression. JOSPT 2012. 42(7): 601-614. Di Stasi S, Myer GD,
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Massachusetts General Brigham Sports Medicine Rehabilitation Protocol for Anterior Cruciate Ligament ( ACL ) Reconstruction This protocol is intended to guide clinicians through the post – operative course for ACL Reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on complications. If a clinician requires assistance in the progression of a post – operative patient, they should consult with the referring surgeon. The interventions included within this protoco l are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician. Considerations for allograft and hamstring autograft Early weight bearing and early rehabilitation intervention vary for allograft and hamstring autograft. Please reference specific instructions below. Expectations are the early return to sport phase will be delayed. Considerations with concomitant injuries Be sure to follow the more conservative protocol with regard s to range of motion, weight bearing , and rehab progression when there are concomitant injuries (i . e . meniscus repair) . Post – operative considerations If you develop a fever, intense calf pain, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should call your doctor. PHASE I: IMMEDIATE POST – OP (0 – 2 WEEKS AFTER SURGERY) Rehabilitation Goals Protect graft Reduce swelling, minimize pain Restore patellar mobility Restore full extension, gradually improve flexion Minimize arthrogenic muscle inhibition, re – establish quad control , regain full active extension Patient education o Keep your knee straight and elevated when sitting or laying down. Do not rest with a towel placed under the knee o Do not actively kick your knee out straight; support your surgical side when performing transfers (i.e. sitting to laying down) o Do not pivot on your surgical side Weight Bearing Walking Initially brace locked, crutches (per MD recommendation) May start walking without crutches as long as there is no increased pain , effusion, and proper gait o Allograft and hamstring autograft continue partial weight bearing with crutches for 6 weeks unless otherwise instructed by MD May unlock brace once able to perform straight leg raise without lag May discontinue use of brace after 6 wks per MD and once ad equate quad control is achieved When climbing stairs, lead with the non – surgical side when going up the stairs, and lead with the crutches and surgical side when going down the stairs
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Massachusetts General Brigham Sports Medicine 2 Intervention s Swelling Management Ice, compression, elevation (check with MD re: cold therapy) Retrograde massage Ankle pumps Range of motion/Mobility Patellar mobilizations : superior/inferior an d medial/lateral o ** Patella r mobilizations are heavily emphasized in the early post – operative phase following patella tendon autograft ** Seated assisted knee flexion extension and heel slides with towel Low intensity, long duration extension stretches: p rone hang , heel prop Standing gastroc stretch and s oleus stretch Supine active hamstring stretch and supine passi ve hamstring stretch Strengthening Calf raises Quad sets NMES high intensity ( 2500 Hz, 75 bursts ) supine knee extended 10 sec/50 sec, 1 0 contractions, 2x/wk during sessions use of clinical stimulator during session, consider home units distributed immediate post op Straight leg raise o * * Do not perform straight leg raise if you have a knee extension lag Hip abduction Multi – angle isometrics 90 and 60 deg knee extension Criteria to Progress Knee extension ROM 0 deg Quad contraction with superior patella glide and full active extension Able to perform straight leg raise without lag PHASE II: INTERMEDIATE POST – OP (3 – 5 WEEKS AFTER SURGERY) Rehabilitation Goals Continue to protect graft Maintain full extension, restore full flexion (contra lateral side) Normalize gait Additional Intervention s *Continue with Phase I interventions Range of motion/Mobility Stationary bicycle Gentle stretching all muscle groups : prone quad stretch , standing quad stretch , kneeling hip flexor stretch Strengthening Standing hamstring curls Step ups a nd step ups with march Partial squat exercise Ball squats , wall slides , mini squats from 0 – 60 deg Lumbopelvic str engthening : bridge & uni lateral bridge , sidelying hip external rotation – clamshell , bridges on physioball , bridge on physioball with roll – in , bridge on physioball alternating , hip hike Balance/proprioception Single leg standing balance (knee slightly flexed) static progressed to dynamic and level progressed to unsteady surface Lateral step – overs Joint position re – training Criteria to Progress No swelling (Modified Stroke Test) Flexion ROM within 10 deg contra lateral side Extension ROM equal to contra lateral side
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Massachusetts General Brigham Sports Medicine 3 PHASE III: LATE POST – OP (6 – 8 WEEKS AFTER SURGERY) Rehabilitation Goals Continue to protect graft site Maintain full ROM Safely progress strengthening Promote proper movement patterns Avoid post exercise pain/swelling Avoid activities that produce pain at graft donor site Additional Intervention s *C ontinue with Phase I – II I nterventions Range of motion/Mobility Rotational tibial mobilizations if limited ROM Cardio 8 weeks: Elliptical, stair climber, flutter kick swimming, pool jogging Strengthening Gym equipment: leg press machine , seated hamstring curl machine and hamstring curl machine , hip abductor and adductor machine , hip extension machine , roman chair , seated calf machine o Hamstring autograft can begin resisted hamstring strengthening at 12 weeks Progress intensity (strength) and duration (endurance) of exercises * *The following exercises to focus on proper control with emphasis on good proximal stability Squat to chair Lateral lunges Romanian deadlift Single leg progression: partial weight bearing single leg press , slide board lunges : retro and lateral , step ups and step ups with march , lateral step – ups , step downs , single leg squats , single leg wall slides Knee Exercises for additional exercises and descriptions Seated Leg Extension (avoid anterior knee pain): 90 – 45 degrees with resistance Balance/proprioception Progress single limb balance including perturbation training Criteria to Progress No effusion/ swelling/pain after exercise Normal gait ROM equal to contra lateral side Symmetrical J oint position sense (< 5 - degree margin of error) PHASE IV: TRANSITIONAL (9 - 12 WEEKS AFTER SURGERY) Rehabilitation Goals Maintain full ROM Safely progress strengthening Promote proper movement patterns Avoid post exercise pain/swelling Avoid activities that produce pain at graft donor site Additional Intervention s *C ontinue with Phase I I - III interventions Begin sub - max sport specific training in the sagi t tal plane Bilateral PWB plyometrics progressed to FWB plyometrics Criteria to Progress No episodes of instability Maintain quad strength 10 repetitions single leg squat proper form through at least 60 deg knee flexion Drop vertical jump with good control KOOS - sports questionnaire >70% Functional Assessment o Quadriceps index >80%; HHD or isokinetic testing 60d/s o H amstring s ; HHD or isokinetic testing 60 d/s o Glut med, HHD
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Massachusetts General Brigham Sports Medicine 4 PHASE V: EARLY RETURN TO SPORT (3 – 5 MONTHS AFTER SURGERY) Rehabilitation Goals Safely progress strengthening Safely initiate sport specific training program Promote proper movement patterns Avoid post exercise pain/swelling Avoid activities that produce pain at graft donor site Additional Intervention s *Continue with Phase II – IV interventions Interval running program o Return to Running Program Progress to plyometric and agility program (with functional brace if prescribed) o Agility and Plyometric Program Criteria to Progress Clearance from MD and ALL milestone criteria below have been met Completion jog/run program without pain/ effusion / swelling Functional Assessment o Quad/HS/glut index 90%; HHD mean or isokinetic testing @ 60d/s o Hamstring/Quad ratio 66 % o Hop Testing 90% compared to contra lateral side , demonstrating good landing mechanics PHASE VI: UNRESTRICTED RETURN TO SPORT (6+ MONTHS AFTER SURGERY) Rehabilitation Goals Continue strengthening and proprioceptive exercises Symmetrical performance with sport specific drills Safely progress to full sport Additional Intervention s *Continue with Phase II – V interventions Multi – plane sport specific plyometrics program Multi – plane sport specific agility program Include hard cutting and pivoting depending on the individuals goals (~7 mo) Non – (~9 mo) Criteria to Progress Functional Assessment o Quad/HS/glut index 95%; HHD mean or isokinetic testing @ 60d/s o Hamstring/Quad ratio 66 % o Hop Testing 95% compared to contra lateral side, demonstrating good landing mechanics KOOS – sports questionnaire >90% International Knee Committee Subjective Knee Evaluation >93 ACL – RSI Revised 11/ 2021 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References : 1. Adams D, Logerstedt D, et al. Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion – Based Rehabilitation Progression. JOSPT 2012 42(7): 601 – 614. 2. Di Stasi S, Myer GD, Hewett TE. Neuromuscular Training to Target Deficits Associated with Second Anterior Cruciate Lig ament Injury. JOSPT 2013 43 (11): 777 – 792. 3. Glazer DD. Development and Preliminary Validation of the Injury – Psychological Readiness to Return to Sport (I – PRRS) Scale . Journal of Athletic Training. 2009;44(2):185 – 189. 4. Haitz K, Shultz R, et al. Test – restest and interrater reliability of the functional lower extremity evaluation. JOSPT. 2014. 44(12): 947 – 954. 5. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med . 2001;29:600 – 613. 6. Logerstedt DS, Scalzitti D, et al. Knee stability and movement coordination impairments: knee ligament sprain revision 201 7. JOSPT. 2017. 47(11): A2 – A47.
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Massachusetts General Brigham Sports Medicine 5 7. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preven ting Anterior Cruciate Ligament Injuries in Female Athletes: 2 – year follow – up. Am J Sports Med. 2005;33:1003 – 1010. 8. Noehren B, Snyder – – chain exercises after anterior cruciate ligament reconstruction. JOSPT. 2020. 50(9): 473 – 475. 9. Wright RW, Haas AK, et al. Anterior Cruciate Ligament Reconstruction Rehabi litation: MOON Guidelines. Sports Health 2015 7(3): 239 – 243. 10. Wilk KE, Macrina LC, et al. Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries. JOSPT 2012 42(3): 153 – 171.
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Massachusetts General Brigham Sports Medicine 6 Return to Running Program This program is designed as a guide for clinicians and patients through a progressive return – to – run program. Patients should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or meniscus repair). Specifi c recommendations should be based on the needs of the individual and should consider clinical decision making. If you have questions, contact the referring physician. PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES Day 1 2 3 4 5 6 7 Week 1 W5/J1x5 W5/J1x5 W4/J2x5 W4/J2x5 Week 2 W3/J3x5 W3/J3x5 W2/J4x5 Week 3 W2/J4x5 W1/J5x5 W1/J5x5 Return to Run Key: W=walk, J=jog **Only progress if there is no pain or swelling during or after the run PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1 20 min 20 min 20 min 25 min 2 25 min 25 min 30 min 3 30 min 30 min 35 min 35 min 4 35 min 40 min 40 min 5 40 min 45 min 45 min 45 min 6 50 min 50 min 50 min 7 55 min 55 min 55 min 60 min 8 60 min 60 min Recommendations Runs should occur on softer surfaces during Phase I Non – impact activity on off days Goal is to increase mileage and then increase pace; avoid increasing two variables at once 10% rule: no more than 10% increase in mileage per week
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Massachusetts General Brigham Sports Medicine 8 PHASE III: MULTI – PLANAR PROGRESSION Rehabilitation Goals Challenge the Level 1 sport athlete in preparation for final clearance for return to sport Agility *Continue with Phase I – II interventions Box drill Star drill Side shuffle with hurdles Plyometrics *Continue with Phase I – II interventions Box jumps with quick change of direction 90 and 180 degree jumps Criteria to Progress Clearance from MD Functional Assessment o Quad/HS/glut index 90% contra lateral side (isokinetic testing if available) o Hamstring/Quad ratio o Hop Testing 90% contralateral side KOOS – sports questionnaire >90% International Knee Committee Subjective Knee Evaluation >93 Psych Readiness to Return to Sport (PRRS)
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