Sports Knee Rehabilitation

POST-OPERATIVE DAYCASE ACL RECONSTRUCTION PROTOCOL

Patients will have undergone prehabilitation with screening

This protocol is followed with hamstring, allograft and quads tendon reconstructions

IKDC – These will be given to patient at the time of listing, at 3, 6 and 12 months post op

Overall aims
Ensure patient achieves milestone prior to progression
Patient will enter the advanced class at the physiotherapists discretion but will need screening prior to entering the class
No return to contact sports prior to 6 months post-op
Return to gentle non-contact, non-competitive sports at physiotherapist’s discretion but must be over 5 months post-op

Immediate post op management

Patient will have cryotherapy immediately post op in recovery and will be discharged with a cryo cuff and machine to use for as long and as often as
necessary at the physiotherapists discretion
Physio to see post op and discharge on the day of surgery with crutches and FWB as tolerated
Follow up physio to be arranged for circa 1 week post op
Patient will be seen in surgeons clinic at 2-3 weeks post op and will be expected to have full extention

Rehabilitation

PHASE 1 POST-OP – Post ACL reconstructive surgery (day 1-10)

Goal Treatment Milestone to Progress

Minimise swelling and pain  Use of cryotherapy  Minimal or no effusion
 Ensure adequate pain relief  Full or nearing full extension
 Elevate leg  90° knee flexion
 Use of crutches  SLR with no lag (10 reps)
Regain full range of extension/hyperextension  Extension exercises: static quads, heel  Normal, symmetrical gait pattern with or
(compare to non-operative knee) props, prone hanging without crutches

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  Passive stretching
Increase knee flexion as pain allows  Active flexion exercises
 Passive flexion over edge of bed
 Patella mobilisations
Improve quads control and hamstring strength  Static quads, SLRs. Ensure patient can
SLR with no lag
 Co-contraction quads and hams
 Hamstring curls
Ensure flexibility  Hamstring and calf stretches
Restoration of normal gait pattern  Gait re-ed with elbow crutches, WB as
pain allows
 Weight transferring

PHASE 2 – Upon achievement of phase 1 goals: approximately day 10 – 6 weeks

Goal Treatment Milestone to Progress

Minimise swelling and pain (ensure no swelling  Continue as above, as necessary  Minimal/no effusion
before progression) Prevent anterior knee pain  Patella mobilisations  Full range of extension
Regain/maintain full range of  Extension exercises as above  Normal gait pattern without crutches
extension/hyperextension (compare to non-  Passive stretching  Full range of flexion
operative knee)  Single leg stand eyes shut at least 5
seconds
Restoration of normal gait pattern  Ensure FWB, wean off crutches  Bilateral squat, thighs parallel to floor with
Regain full range of flexion  Active flexion exercises even, symmetrical weight bearing
 Progress to quads stretch
Improve quads, hamstring and general lower limb  CKC – wall slide squats with gym ball,
strength squats, lunges, leg press, dips etc.
 Hamstring curls, bridging
 Calf raises, hip extensions, hip abd/add,
VMO, glut med
Increase aerobic capacity  Exs bike
 Treadmill walking
 Step ups

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  Cross trainer
 Rower
Improve proprioception  Single leg stand eyes open/eyes closed
 Wobble board
 Sitfit
 Trampette
Neuromuscular control  Core stability work
 Knee alignment/prevent valgus – squats,
lunges, step ups (ensure good
hip/knee/ankle alignment)

PHASE 3 – Upon achievement of phase 2 goals: approximately week 6-12

Goal Treatment Milestone to progress

Control activity related swelling and pain  Use of cryotherapy post exercise if knee  Minimal/no activity related effusion
swells with increased activity  Full ROM
Regain/maintain full range of movement  Continue stretches  Normal gait and stair pattern – good
Normalise gait and stair pattern  Treadmill walking – alignment and control
forward/backward/incline  10 x single leg squats to 60° with good
Improve quads, hamstring, and general lower limb  Continue CKC – double & single leg biomechanical alignment and control (i.e.
strength press, squats, lunges, increase weight no valgus and good hip/knee/ankle
 Hamstring curls – double & single leg, alignment)
increase weight
 Calf, gluteals, adductors, VMO
strengthening
Increase aerobic capacity  Exs bike
 Treadmill walking
 Step ups
 Cross trainer
 Rower
 Pool walking/running
Improve proprioception  Single leg stand eyes closed

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  Wobble board
 Sitfit
 Trampette
Neuromuscular control  Core stability work
 Knee alignment/prevent valgus as above –
add trunk rotation
Commence bilateral load acceptance/ early  Bilateral drop jumps
plyometrics  Jumps with symmetrical squat landing
 Progress to straight line jogging when
good load acceptance

PHASE 4 – Upon achievement of phase 3 goals

Goal Treatment Milestone to progress

No swelling or pain  Continue as above if necessary  Normal straight line running pattern
Normal straight line running pattern without pain  Progress from jogging to running  Single leg press >75% body weight
and in full control  Increase speed/distance  Single leg stand eyes shut >80%
 Change surface/incline unaffected leg
 Forward running/backward running  Hop tests >80% LSI: single hop, triple hop,
Increase muscle strength and endurance  Increase load on strengthening exs (60- cross over hop, 6m timed hop
80% 1RM)
 Single leg press – push for >75% x body
weight
 Commence open chain quads and
gradually increase resistance
Improve proprioception  Increase dynamic proprioception
Progress bilateral load acceptance/commence  Tuck jumps with stable landing
unilateral load acceptance/plyometrics  Squat jumps, forward/ back/ rotational
 Bilateral plyometric static and multi-plane
exs
 Single leg hop with controlled landing
 Forward, side hops/ drops from step with
controlled single leg landing
 Unilateral plyometric static and multi plane
activities

PHASE 5 SPORTS SPECIFIC – Upon achievement of phase 4 goals

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Goal Treatment Milestone to progress
Increase muscle strength and endurance  Increase load on resistance work  Symptom free sports specific training
Progress unilateral load acceptance and work to  As above – increase speed/intensity to  Hop tests >85% LSI : single hop, triple
fatigue fatigue hop, cross over hop, 6m timed hop
Commence sports specific running agility drills  Sprinting  Single leg stand eyes shut, equal to
 Cutting and pivoting unaffected side
 Acceleration/deceleration
Commence sports specific skills  Ball skills
 Dribbling
 Boxing
 Kicking
 Sports specific activity with controlled
opposition e.g. one on one practice drills

Neuromuscular control following fatigue  Ensure ability to control alignment under

random practice and after fatigue

Return to non-contract sports (only when nearing  Golf/swimming/gentle racquet sports

6months post-op)

PHASE 6 FULL UNRESTRICTED SPORTS TRAINING– Upon achievement of phase 5 goals: USUALLY AT LEAST 6 MONTHS POST-OP

Goal Treatment
Symptom free training  Full, unrestricted training
ROM and muscular flexibility equal to other side  Continue stretching
Good results of all functional testing  Functional tests prior to returning to
contact sports
Return to full unrestricted, confident activity  Progress to uncontrolled practice
situations and competition

References

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Herrington, L, Myer, G, Horsley, I (2013) Task based rehabilitation protocol for elite athletes following Anterior Cruciate Ligament reconstruction: a clinical
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