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ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
Non-Accelerated Programs: 1. Range of Motion : Unrestricted range of motion is typically achieved around week 8 2. Brace Weaning : Usually occurs between 4 and 6 weeks post-surgery 3. Open Chain Exercises : Delay introduction of open chain full extension exercises until around week 12 4. Closed Chain and Functional Tasks : Full range squatting and functional drills are typically introduced around week 12 The majority of current practices lean towards accelerated protocols. The key differences lie in the timing of introducing certain exercises and achieving specific milestones. It is important to understand that these classifications are based on exercise introduction and range of motion goals, not on return-to-play timelines. Regardless of the protocol used, return-to- play decisions should be based on meeting functional criteria rather than solely on time from surgery. Accelerated protocols have shown similar outcomes to non-accelerated programs in terms of knee laxity, functional measures, and patient- reported outcomes. However, there is minimal to no scientific evidence supporting return to sport at less than four months post-surgery, regardless of the rehabilitation protocol used. The debate between accelerated and non- accelerated protocols may be becoming less relevant, as most clinicians now implement some form of accelerated protocol. The focus has shifted towards individualized, criterion-based progression that respects the physiological healing process of the graft while optimizing functional outcomes. The early phase of rehabilitation is critically important in setting the foundation for successful recovery. Early weight-bearing and range of motion within the first week has been supported by research after ACL reconstruction. Key goals of this phase are: 1. Diminish pain and inflammation 2. Restore full knee extension 3. Gradually increase knee flexion 4. Restore volitional quadriceps control
5. Maintain patellar mobility (superior glide of patella and external rotation of tibia) 6. Restore independent ambulation LEARNING TIP! Negative effects can present themselves during the early stages of rehabilitation when pain and
inflammation are not appropriately controlled. These include limited ROM, quad inhibition, and abnormal gait patterns.
Achieving full knee extension is crucial and should be a top priority. Failure to achieve full knee extension can lead to arthrofibrosis and long-term functional deficits. Aggressive measures are recommended to achieve this, including: • Prone hangs • Low-load, long-duration stretching • Heel props Continuous passive motion (CPM) machines : While they were once common, current evidence does not strongly support their routine use. CPM machines may be beneficial in select cases where achieving range of motion is particularly challenging. It is crucial to restore quadriceps control, with a focus on neuromuscular electrical stimulation (NMES) if patients struggle to activate their quadriceps voluntarily within the first few days post-surgery. Progression of Rehabilitation Exercises As the rehabilitation progresses, there is great importance to gradually introducing more challenging exercises. There is a debate surrounding open vs. closed kinetic chain exercises, particularly for the quadriceps. Key points: • Closed kinetic chain exercises can be safely introduced early in the rehabilitation process • Open kinetic chain exercises for the quadriceps should be introduced cautiously, typically starting around 4-6 weeks post- surgery
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