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ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
• Open kinetic chain exercises should begin in a limited range (90-45 degrees) and gradually progress to the full range as healing allows "ACL-friendly" position : This is approximately 20-30 degrees of knee flexion. This position minimizes stress on the ACL graft and can be used as a starting point for many exercises. Clinicians should address hip and core strength in ACL rehabilitation, as these muscle groups play a crucial role in lower extremity control and injury prevention. Neuromuscular Training and Injury Prevention Neuromuscular training can be beneficial as part of the rehabilitation process and as a strategy for preventing future injuries. There is significant evidence supporting the use of neuromuscular training programs to reduce the risk of ACL injuries, particularly non-contact injuries. Key components of effective neuromuscular training programs include: 1. Plyometric exercises 2. Balance training 3. Strengthening exercises 4. Agility drills 5. Sport-specific movement patterns These programs should be performed at least 2-3 times per week and should be continued as a maintenance program, even after return to sport. Consistent implementation of such programs can reduce ACL injury risk by up to 50%. Clinicians should be aware of the importance of proper landing mechanics. The tuck jump assessment can be used as a tool for evaluating neuromuscular control and identifying athletes who may be at higher risk for ACL injury. Return to Running Progression The course provides a detailed overview of a return to running progression, typically implemented around 3-4 months post-surgery. It outlines the following stages: 1. Straight-line running on a consistent surface (e.g., turf or track) 2. Curved running (e.g., around a track or field) 3. Acceleration/deceleration drills ("buildups") 4. Figure-8 running 5. Cutting drills 6. Sport-specific agility patterns It is crucial to monitor the athlete's response to each stage, including pain, swelling, and movement quality. It is not recommended to progress to the next stage until the athlete can complete the current stage without adverse effects. Endurance running (e.g., distance running) can typically be introduced around the figure-8 stage, assuming the athlete has progressed through the earlier stages without issues.
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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