The ACL Rehabilitation Protocol aims to reduce swelling and inflammation, regain range of motion (ROM), improve strength and neuromuscular control, and focus on gait training.
In the later stages of rehabilitation, the focus shifts to full strength and power restoration, sport-specific exercises, and reconditioning.
Patients need to be taught how to manage pain following each workout/session. Ice may be necessary if pain, inflammation, or swelling occurs.
Immediately after surgery, weight-bearing status is determined by any additional injuries, such as meniscal repair. Typically, isolated ACL reconstructions are treated with weight bearing as tolerated, using a brace and/or crutches until adequate quadriceps muscle strength is restored. We expect to remove both crutches and move to full weight bearing within the first two weeks.
The results of ACL reconstruction are generally good, but current techniques can present challenges and potential issues. These include decreased hamstring strength, anterior knee pain, and loss of proprioception. Additionally, there is significant evidence suggesting that ACL reconstruction does not prevent future osteoarthritis.
Return to Running (RTR):
RTR decisions should be individualized for each patient, as there is no universal timeline. Many patients may be ready to RTR around the 8th-16th postoperative weeks, provided there is adequate loading, pain <2 on the visual analogue scale (VAS), 95% knee flexion ROM, full knee extension ROM, and no effusion.
Clinicians may use a variety of tests for individualized clinical decision-making regarding RTR, including strength tests, qualitative performance-based assessments focusing on dynamic knee control, and quantitative performance-based assessments such as hop tests.
Post-operative ACL Rehabilitation Conclusion:
Various types of bracing have been evaluated, including knee immobilization, rehabilitation bracing, and functional bracing. No brace or duration of bracing has shown an advantage over another type or no bracing at all. Bracing does not provide any benefit and is not necessary.
Accelerated rehabilitation has shown no harmful effects and is likely safe for patients to begin immediate postoperative weight-bearing, move the knee from 0 to 90 degrees of flexion, and perform closed-chain strengthening exercises.
Eccentric quadriceps muscle strengthening and isokinetic hamstring muscle strengthening can be safely incorporated three weeks after surgery. They may be safe sooner, but further research is needed.
Home-based rehabilitation can be effective. Neuromuscular exercises are not likely to be harmful but have a small impact, making them unlikely to yield large improvements in outcomes or help patients return to sports faster. Neuromuscular exercises should not be performed to the exclusion of strengthening and range-of-motion exercises.
Neither supplemental vitamin C nor vitamin E appears to be beneficial. Postoperative hyaluronic acid injections may improve some measurable parameters, but their cost must be considered.
Single-leg cycling to maintain cardiac fitness may be beneficial. Continuous passive motion (CPM) is still not recommended. The studies focused on improving rehabilitation following ACL reconstruction aim to safely allow the expeditious return of mobility, strength, and ultimately sport participation.
However, few studies have measured the ability to return to sports and the timing following interventions. Availability of such data could strengthen study conclusions and should be considered in future research. Despite numerous randomized trials, further investigations into the timing of rehabilitation and supplemental exercises are needed to continue improving the care and function of patients following ACL reconstruction.
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