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ANTERIOR CRUCIATE LIGAMENT INJURY 

 

INTRODUCTION

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An ACL injury is a tear or sprain of the anterior cruciate ligament (ACL) — one of the major ligaments in your knee. ACL injuries most commonly occur during sports that involve sudden stops or changes in direction. Anterior cruciate ligament injuries occur from both contact and non-contact mechanisms.

 

MANAGEMENT

 

NON OPERATIVE MANAGEMENT

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Maximum Protection Phase

WEEKS 1-3

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Patient education to modify activities until appropriate stability is obtained.

 

To decrease pain, joint effusion, reflex muscle guarding and to protect healing tissues.

  • PRICE – protective bracing, rest, ice, compression and elevation.

 

To maintain ROM and joint play.

  • PROM/ A-AROM exercises to be done.

  • Grade 1 and grade 2 patellar mobilizations to be given.

  • SLRs

  • Aerobic conditioning.

 

To establish home exercise programme.

  • Teach protected weight bearing with use of crutches and partial weight bearing as tolerated.

  • Teach safe transfer activities

  • To begin muscle setting exercises of quadriceps, hamstrings, and adductors.

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Moderate Protection Phase

WEEKS 3-6

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To achieve full, pain-free ROM and improve joint mobility.

  • PROM/ A-AROM exercises to be done.

  • LE flexibility exercises.

  • Use of supine wall slides, patellar mobilization, stationary cycling.

  • Protective bracing

To restore muscular strength.

  • Continue multiple angle isometrics.

  • Initiate PRE.

  • Closed chain strengthening exercises

To restore endurance and normalize ADLs

 

To restore balance

  • Perturbation and balance training.

  • Stabilization exercises

 

Minimum Protection Phase

WEEKS 5-8

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To maintain ROM gained.

  • LE flexibility exercises.

To increase strength, power, and neuromuscular control

  • Advance PRE strengthening.

  • Advance closed chain exercises.

  • Reinforce quadriceps contractions with high intensity electrical stimulation if there is an extensor lag.

  • Advance endurance training.

  • Progress running program, full-speed jog, sprints, figure-eight running and cutting.

To improve dynamic stability.

  • Advance perturbation training.

 

Return to Activity Phase

WEEKS 8-12

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To improve strength, power, endurance.

  • Advance flexibility, strengthening and endurance training.

  • Advance agility drills.

  • Implement drills specific to sport or occupation.

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To improve cardiopulmonary conditioning

  • Biking- stationary biking, jogging, walking on a treadmill, swimming.

 

POST OPERATIVE MANAGEMENT

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Pre Operative Care

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  • Provide patient education to prepare patient for surgery.

  • Diminish inflammation, swelling, and pain by giving ATMs,Brace elastic wraps,Icing, Elevation.

  • Restore normal ROM (especially knee extension) and voluntary muscle activation.

  • To initiate weight bearing as tolerated by the patient.

 

Immediate Pre Operative

Days 1-7

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Exercises begin the day of or the day after the surgery

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Patient education regarding the protective brace which should be locked in extension for ambulation and sleeping (drop lock brace).

  • Brace removed during ROM exercises.

  • No strenuous activities

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To prevent vascular complications, reduce joint swelling and pain.

  • Ice

  • Ankle pumping exercises

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To prevent reflex inhibition of knee musculature, improve strength,re-establish quadriceps control.

  • Muscle setting exercises of quadriceps, hamstrings and hip abductors, adductors and extensors

  • Use of electrical stimulation or biofeedback to augment quadriceps activation.

  • Perform 4 position SLRs, first with assistance, progress to active hip motions with knee bent in extension. Add external resistance (when hip control)

  • Multiple angle isometrics of the knee musculature (emphasize on quads)

  • Hamstring stretches.

  • Consider low-intensity eccentric quadriceps training

  • Hamstrings activation: supine heel-slides,hamstringscurls,scooting forwards while seated on rolling stool.

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To improve ROM and patellar mobility.

  • controlled PROM and AAROM.

  • Overpressure into full passive knee extension.

  • Patellar mobilizations

  • Increase passive knee extension by propping the heel on a rolled towel or bolster with the knee unsupported.

  • Increase knee flexion by doing wall slides in supine or dangle the leg while sitting on the side of a bed.

  • Stretching of hip and ankle musculature for flexibility.

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Restore independent ambulation- weight-bearing as tolerated with two crutches.

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To gain neuromuscular control, proprioception and balance.

  • Stabilization exercises in bilateral stance.

  • Encourage equal weight bearing on BLE.

  • Have the patient maintain a stable, well-aligned position

  • Bilateral mini-squats in the 0-30 degrees range with stepping and marching movements.

  • Gradually decrease upper extremity support. When the knee is pain-free and full weight bearing is possible, progress to unilateral stance.

  • Active/passive joint positioning.

  • Balancing activities.

 

Early Rehabilitation

Weeks 2-4

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To decrease swelling and pain

  • Ice, compression, elevation.

 

Maintain full passive knee extension, gradually increase knee flexion and improve patellar mobility

  • Continue low-intensity, end-range self-stretching

  • Use grade 3 joint mobilization techniques

  • Continue flexibility exercises for hip and ankle musculature, especially the hamstrings, IT band, and plantarflexors.

  • Overpressure into extension.

  • Passive ROM 0-50 degrees.

  • Patellar mobilization.

  • Knee extension 90-40 degrees.

 

Muscle training

  • Closed chain exercises against body weight resistance

  • Muscle stimulation to quadriceps exercises.

  • Isometric quadriceps sets.

  • SLR (four planes).

  • Leg press.

  • Progress from double-leg to single-leg exercises.

  • Progressive resistance program

  • Stair walking- Up/down, forward/backward

  • Initiate open-chain hip extension and abduction and knee extension/flexion against light-grade elastic resistance in appropriate portions of knee ROM.

 

Neuromuscular control/ responses, proprioception, and balance.

  • Static and dynamic balance activities in bilateral stance, progressing to unilateral stance on stable and unstable surfaces.

  • Mini-tramp standing.

  •  Standing ball throwing and catching.

  • Awareness of proper lower extremity alignment and knee control.

 

Gait training:

  • Practice ambulation in a controlled environment with unlocked or without bracing and without crutches.

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Aerobic conditioning

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Integrate simulated functional activities into the exercise program.

 

Controlled Ambulation

Weeks 4-10

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To restore full knee ROM (0-125 degrees) and improve lower extremity strength.

  • Self-ROM

  • Progress isometric strengthening program.

  • Leg press.

  • Knee extension 90-40 degrees.

  • Hamstring curls.

  • Hip abduction and adduction, Hip flexion and extension.

  • Lateral step-overs

  • Lateral lunges.

  • Lateral step-ups.

  • Front step-downs.

  • Wall squats

  • Vertical squats.

  • Toe calf raises

Enhance proprioception, balance, cardiovascular endurance and neuromuscularcontrol and restore limb confidence and function.

  • Balance on tilt board.

  • Progress to balance and board throws.

  • Mini-tramp bouncing.

  • Pogoball balancing.

  • Lateral slide board.

  • Ball throwing and catching on unstable surface.

  • Perturbation training.

  • Bicycling.

  • Pool running (forward), agility drills.

  • Plyometric leg press

  • Figure-of-eight pattern.

  • Large circles, walking or slow jogging.

  • lsokinetic exercises

  • Stair-stepper machine.

  • Pool program (backward running, hip and leg exercises).

 

Advcanced Activity

Weeks 10-16

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Normalize lower extremity strength.

Enhance muscular power and endurance.

Improve neuromuscular control.

Perform selected sport-specific drills.

 

INTERVENTIONS:

  • Continue with exercises

  • shuttle run,

  • lateral slides,

  • carioca cross-overs,

  • figure-of-eight pattern,

  • small circles- running,

  • stair running,

  • box jumps- 1- to 2-ft height.

 

Return to Activity

Months 16-22

 

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Gradual return to full unrestricted sports.

Achieve maximal strength and endurance.

Normalize neuromuscular control.

Progress skill training.

 

EXERCISES

  • Continue strengthening exercises.

  • Continue neuromuscular control drills.

  • Continue plyometrics drills- advance heights

  • Progress running and agility program.

  • Progress sport-specific training.

 

 

​​REFERENCES

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