ACL injuries are one of the most common knee injuries and they are increasing in frequency at a rate of 6% per year
ACL injuries can be treated either operatively or non operatively. The best choice for you considers many factors and should be a decision that is well informed from your surgeon, your PT, and consider the severity of your injury, your own goals, and expectations.
Restore Normal Knee Function
ACL injuries can be treated either operatively or non operatively
Whether you choose to have surgery or not, you will require rehabilitation to restore normal knee function. For those who undergo surgery, post-op rehab usually spans over a 9-12 month period, which allows time for the ACL graft to build strength. For those who are candidates for non operative treatment, the amount of time in PT is variable. Again, the choice of how to proceed should be well informed and dependent on the severity of your injury, your goals and expectations.
For those who undergo surgery, we strongly encourage you to complete a short course of preoperative PT to ensure better postoperative outcomes. This pre-op PT helps to restore motion, quad activation, strength and reduce swelling. The pre-operative goals we aim for before surgery include:
- Full passive knee extension
- Passive flexion to at least 125 degrees
- Minimal swelling/effusion (0- 1+ sweep test)
- Quad strength within 10% of the uninvolved side tested with seated hand held dynamometry
- Hamstring strength within 10% of the uninvolved side tested with seated hand held dynamometry
Once you have met these goals you will be given a home program to work on 2x/week leading up to your surgery date with a focus on strength exercises you can do at home or in the gym.
After surgery, PT usually will start within the first 2-5 days. The first phase of PT focuses on attaining a “quiet knee”. This is a knee that has near full range of motion, little swelling, no quad lag, and little pain. They should have named this a “happier knee.” You will get very familiar with exercises including pendulums on the bike, elevated ankle pumps, standing terminal knee extension with a band, and standing marches. In addition, we utilize NMES (neuromuscular electrical stimulation) immediately post-op and Blood Flow Restriction Therapy two weeks post op (refer to the BFR page for more information) to help regain quad activation and rebuild strength.
The second phase of PT focuses on strength and neuromuscular control using more body weight exercises and progressing to a gym based routine. The goal of this phase is to regain single leg balance, muscle strength, completion of single leg squats, and cardiovascular endurance. Examples of exercises within this phase are: goblet squats, forward T, single leg squat matrix, step ups, and leg press.
The third phase focuses on running, agility, and landing. The knee should feel “normal” to enter into this stage. This stage integrates in more sport specific activities and exercises and is much higher in intensity than the previous stages. The goals of this stage are to perfect movement quality with jumping, complete an agility program, and regain full strength and balance. Examples of exercises within this phase include: ladder drills with quick feet, single leg hops (multidirectional), double leg hurdles, unanticipated change of directions drills, plyometrics with perturbations, and sport specific exercises. This is a crucial part of rehab and one that is often skipped. If you plan to return to sport play you need to be challenged in your rehab to adequately prepare you for the specific demands of your sport. If you skip this step in rehab your risk for reinjury or a new injury is increased exponentially.
*To note these phases are criteria and time driven and should always be progressed via PT guidance.
After you have completed phase three, your rehab will focus on return to performance and on successfully passing all return to sport discharge criteria (please see Return to Sport Testing for more information). Once you have passed all Return to Sport tests, you will be able to begin restricted training with guidance from your PT. During this time, we gradually transition you to unrestricted training, starting with low level competition and progressing to high level competition of play.
A couple fun numbers for you pulled from the evidence for real life outcomes with Return to Sport tests:
- Assuming quadricep and hamstring strength is at least 90% of your uninvolved side AND your hop tests are at least 90% of your uninvolved side, your risk of sustaining an ACL or other knee injuries is reduced by 84%
- Of those in this study that did not pass their Return to Sport tests, 38% re-injured their knee
- Overall there was a 4 times greater risk of re-injury if Return to Sport testing criteria was not met.
Once you have been cleared to return to full sport play and discharge from PT, we will provide you with some injury prevention programs to help reduce the risk of a 2nd ACL injury. These programs are well studied and include plyometrics, balance, and strengthening exercises that can be performed before game play and should be done for the remainder of your sporting career. Some examples we utilize are: 11+, netball knee, Santa Monica, and PEP.
We also recommend continuing resistance training to build LE strength, power, and endurance in the gym to further improve your performance and reduce injury risk. We recommend looking for qualified personal trainers or strength and conditioning coaches for further guidance as needed after graduating from PT to keep making those gains.