ACL - A Crucial Cruciate Ligament

“Risk factors for ACL tears include being female, low core strength, and increased joint laxity.”

This week we will be covering ACL reconstructive surgery rehabilitation. The anterior cruciate ligament (ACL) is a key ligament in the knee joint, it resists anterior tibial translation and rotational loads. It is commonly injured in sports that involve pivoting, such as football, basketball, soccer, or skiing, and can be contact and non-contact injuries. Non-contact injuries are more common, and females tend to have a higher incidence rate of ACL injury compared to males. Non-contact injuries often occur with cut-and-plant movements, rapid deceleration movements, landing from a jump, pivoting, and twisting (Physiopedia).

Risk factors for ACL injuries in sports include being female, having low core strength, exercising with cold muscles, and using the non-dominant leg. Other risk factors for sports include having a wider pelvis (greater risk of knees coming together), greater ligament laxity, and neuromuscular factors.

Rehabilitation should always begin with prehabilitation! This involves performing exercises and self-care prior to receiving surgery. Research has shown there is quicker post-operative recovery and reduced muscle wasting when individuals do prehabilitation, as well as improved ROM, strength, stability, and pain post-surgery. When you receive surgery, you and your physiotherapist will receive a rehabilitation protocol to follow from the surgeon. It is important to make progressions based on this protocol and to follow the program given to you by your physician or physiotherapist, but here are some common exercises for ACL reconstruction rehabilitation.

Stage 1 (after surgery): 1-14 days

The main goal is to manage post-operative pain, swelling, and mobility issues. Exercises to perform can include quad contraction with a towel roll, and a hamstring stretch. Quad contractions involve placing a towel behind your knee while laying down, and gentle pressing into the towel to engage your quads. Hamstring stretch involves placing your leg on a hip level surface with your knee straight, and bending slightly forward until you feel a stretch in your hamstring, and hold this for 30 seconds. This will help with knee extension, as getting knee extension after surgery is one of the biggest problems. Knee flexion tends to come more easily after surgery, so focusing on knee extension is important in stage 1.

Stage 2: 2-6 weeks

The goals of this stage are to continue to manage swelling and mobility issues, improve muscle control and to normalize gait patterns. We also want to engage the quadriceps and hamstrings to increase endurance. To keep working on extension in this stage, we can place a towel under the heel while laying down, push down gently for 5-10 seconds and repeat several times. If there is limited flexion, we can work on this by bending the leg while laying down and using the other leg to pull the leg towards your butt to increase flexion, or lay on your stomach and bend your knee to bring your foot towards your butt.

Stage 3: 6-12 weeks

The goals of this stage are to improve neuromuscular control and proprioception. We want to continue to improve total leg strength, improve endurance, and to improve client confidence. Doing half squats during this stage can help improve muscle strength, and these can be performed by placing a band around the knees and squatting slightly to a raised surface. This will help engage the quadriceps and glutes, and you can progress the squats slowly by going lower as the squats get easier. Side stepping with band around knee can also help strengthen and engage the glutes, and shallow walking lunges will also strengthen the quadriceps and hamstrings.

Stage 4: 12 weeks-5 months

The goals of this stage are to incorporate more sport specific activities, introduce agility and reaction time proprioceptive work and to increase overall lower extremity strength. You can begin to progress squats by starting with weighted half squats with a bar, and moving onto full squats when able, being sure to keep good squat form. We also want to focus on building proprioception in this stage, and this can be done by standing on a bosu ball and tossing a ball back and forth. Challenge yourself by having someone toss the ball to different spots to challenge your balance.

Stage 5: 5+ months

The main goal of this stage is to return to sport or activity. For this to happen you have to have full pain-free range of motion, muscle control and strength, and good proprioception. Return to sport can be tricky due to several reasons, but one of the main ones could be confidence. When athletes sustain an ACL injury, they take time off sport and this can lead to decreased confidence and anxiety/nervousness when returning to sport. In order to be safe we need to progress activity in a controlled manner. This would be to perform half practice, followed by full practice, then moving on to scrimmaging + full games/competition. Returning to sport in this stepwise fashion would also help a client improve their confidence while minimizing re-injury.

We hope that this information on ACL reconstruction rehabilitation is helpful! Let us know if you are recovering from surgery and trying some of these exercises, or if you have sustained an ACL injury and want to start your prehabilitation with us. We can help get you back to doing what you love! Give us a shout if you have any questions.

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