ACL Rehabilitation in New Jersey

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torn anterior cruciate ligament (ACL) is a scary diagnosis for any person, let alone an athlete, but with advancements in treatment and rehabilitation, ACL tears are now more of a speed bump than a roadblock to further athletic success.

Anyone diagnosed with an ACL tear should start by minimizing swelling and improving range of motion, working with a rehabilitation team that prioritizes recovery. The physical therapy and rehabilitation medicine teams at Centers for Neurosurgery, Spine & Orthopedics (CNSO) work with patients before and after surgery to help them return to full functional mobility. With locations throughout northern New Jersey, CNSO helps people with ACL injuries get back to the sports and activities they enjoy.

What Is The ACL?

The anterior cruciate ligament (ACL) is one of the key ligamentous structures of the knee. It connects the tibia (shin bone) to the femur (thigh bone), and its primary function is to prevent the knee from bending or twisting too much. The ACL is a band of dense connective tissue that originates on the posteromedial (back middle) corner of the medial aspect of the lateral femoral condyle within the intercondylar arch. It inserts anterior to the intercondyloid eminence of the tibia and blends into the anterior horn of the medial meniscus.

The ACL resists 85 percent of the forces of anterior translation of the tibia on the femur. It also plays a minor role in resisting the tibia’s excessive medial and lateral rotation, protecting against valgus deformities (bone angled away from the body’s midline) and varus stresses (pushing the knee inward).

ACL Rehabilitation

When the ACL is injured, it can seriously affect movement and range of motion, and cause pain. Physical therapy can help the patient regain range of motion and proper knee function, as well as help to reduce pain. Physical therapy can help before and after the procedure.

Acute Stage of Rehabilitation

In the acute stage of rehabilitation, regardless of whether surgery is planned, physical therapy is focused on decreasing swelling and pain and increasing range of motion (ROM).

Swelling within the joint can have a negative effect on the strength of the quadriceps and hamstrings. Due to this, exercises in this phase should focus on improving ROM and initial strengthening of hamstrings and quads and eventually working on proprioception (the body’s awareness of movement and location).

There is no clear-cut transition from acute to pre-operative stage, but it tends to be based on the patient regaining full knee extension and at least 110 degrees of knee flexion, or the patient being able to return to a near normal gait pattern. The risk of developing knee stiffness is much higher if the surgery is performed while the knee is swollen or has limited ROM.

Presurgical Stage/Conservative Treatment

This stage can last a few days or up to a few weeks, so compliance with the physical therapy program is key. The physical therapist will provide measurable weekly objectives for the patient to hit involving ROM, strength, or proprioception.

Keys to this stage is to vary the therapeutic exercise (therex) to reinforce strength and proprioception, so giving the patient two different programs can be beneficial. It is important to avoid knee swelling and injury, so all therex will be performed at submaximal loads.

The physical therapist will educate the patient during this time on the post-surgery rehab schedule and goals, so the patient is prepared to get right to work following surgery

Postsurgical Stage of Rehabilitation

Two types of grafts are used to repair the ACL:

• Autografts: The surgeon will take a portion of the tendon of the hamstring, quad, or patellar tendon of the patient’s own body to replace the torn ACL. This method is the most common.
• Allograft: The surgeon will take a portion of the tendon or the ACL from a cadaver to replace the torn ACL.

The physical therapy approach is the same whichever graft is used. The therapist and rehabilitation team will focus on three important factors for good outcomes:

• Early terminal knee extension, equal with the opposite leg
• Early weight-bearing tolerance
• Closed and open kinetic chain strengthening exercises

Rehab Timeline and Goals

Week 1

• Goal: Full extension and 70 degrees flexion by end of week
• Use crutches or knee brace only if instructed by surgeon
• Strengthen calf hamstring and quad in supine or prone positions
• Early weight-bearing is shown to help patellar stiffness

Weeks 2 to 4

• Goal: Maintain full extension and improve active flexion
• Progress quad, calf, and hamstring strengthening in accordance with pain, swelling, and quadriceps control
• Start working on a stationary bike to improve ROM and strength
• Eccentric quad training has been shown to give larger improvements in strength than concentric
• Start to attempt some closed kinetic chain exercises if the patient shows good hamstring/quadriceps control

Weeks 5 to 10

• Goal: Continue to improve strength, control, and proprioception, and look to gain full flexion by week 6
• Patient can perform open and closed chain exercises starting around 50 percent of maximum force and progressing to 60-70 percent
• Start incorporating balance activities and functional exercises based on the patient’s goals regarding a return to sports or prior activity
• Include multidirectional movements to improve stability near week 10

Month 3

• Patient can return to more dynamic activities such as running and jumping
• Focus on stimulating coordination of sensory input and motor output by having the patient perform exercises that challenge their processing, such as changing the patient’s support surface or visual input

Month 4

• Goal: Maximize endurance, strength, and neuromuscular control of knee stabilizers and perform sport-specific exercises pain-free
• Incorporate acceleration, deceleration, cutting, and various speeds of running to improve arthrokinetic reflex and avoid reinjury as the patient returns to his sport

Return to Sport

• ACL injuries can lead to instability in the knee that can change the movement patterns of the knee and increase the risk for osteoarthritis.
• Strength and power deficits compared to the opposite leg are the primary cause of many future injuries, with research suggesting the surgically repaired leg should perform at least 90% as well as the uninjured side before returning to the sport.
• Athletes returning from an ACL reconstruction to level 1 sports increase the 2-year knee reinjury rate more than fourfold, but a later return and more symmetrical quadriceps strength on either side greatly reduces this reinjury rate.