Wellness & Lifestyles Australia

ACL REHABILITATION E-BOOK

prepared by
Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents

Page No.

IMPORTANT NOTICE ..............................................................................................1

INTRODUCTION ...................................................................................................2
ACL ANATOMY, INJURY AND INDICATIONS FOR SURGERY ..................................................3
Anatomy .................................................................................................3
Injury .....................................................................................................3
Indications for surgery.................................................................................3
PRE-OPERATIVE ADVICE AND PLANNING ......................................................................4
To prepare yourself ....................................................................................4
To prepare your knee ..................................................................................4
OPERATION PROCEDURE.........................................................................................5
Patella tendon grafting ................................................................................5
Hamstring tendon grafting ............................................................................6
Artificial LARS (Ligament Augmentation & Reconstruction System) graft.....................6
ACUTE INPATIENT PHASE (WEEK 1) ............................................................................7
Goals......................................................................................................7
Exercises .................................................................................................7
What to do...............................................................................................9
What youll notice......................................................................................9
EARLY OUTPATIENT PHASE (WEEKS 2-4) .................................................................... 10
Hydrotherapy.......................................................................................... 10
Exercises for the water .................................................................................. 10
Stationary bike riding ................................................................................ 11
Exercises on land ..................................................................................... 11
Laying down ............................................................................................... 11
In standing ................................................................................................. 12
EARLY REHABILITATION (4 WEEKS to 3 MONTHS).......................................................... 14
In the gym ............................................................................................. 14
Balance exercises..................................................................................... 16
MID STAGE REHABILITATION (3-5 MONTHS) ................................................................ 18
Jogging and running.................................................................................. 18
END STAGE REHABILITATION (5+ MONTHS) ................................................................. 21
Hopping ................................................................................................ 21
Sport specific skills................................................................................... 22
RETURN TO SPORT ............................................................................................. 23
SUMMARY ........................................................................................................ 24
CONTACT US .................................................................................................... 25

MANUAL LAST MODIFIED 4/8/2010

IMPORTANT NOTICE
The information provided in this document can only assist you in the most general way. This document
does not replace any statutory requirements under relevant State and Territory legislation.
Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the
material contained in this document, which is provided on the basis that the Office of W&L is not thereby
engaged in rendering professional advice. Before relying on the material, users should carefully make
their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and
should obtain any appropriate professional advice relevant to their particular circumstances.
To the extent that the material in this document includes views or recommendations of third parties, such
views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its
commitment to a particular course of action.
Copyright Australia 2009
This work is copyright. You may download, display, print and reproduce this material in unaltered form
only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart
from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION
Welcome to the W&L series of eBooks. You have chosen the edition on anterior cruciate ligament (ACL)
reconstruction and rehabilitation.
This resource will be beneficial to anyone who:
is interested in the anatomy and biomechanics of the knee joint;
has had an ACL injury and is wondering what surgery involves;
is participating in an ACL rehabilitation program and wants a comprehensive guide to their exercises;
is running a rehabilitation program and wants up-to-date information with all the important details.
This eBook will cover information about the anatomy of the knee, what happens when the ACL is injured
and an explanation of the reconstruction surgery. It will also accompany you from the days leading up to
surgery until your first day back at sport with advice, answers and exercises.
The information provided is up-to-date and follows industry standard. W&L recommends that you
continue to consult your doctor and physiotherapist so that your progress can be monitored and program
tailored to your specific requirements.

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ACL ANATOMY, INJURY AND INDICATIONS FOR SURGERY

Diagram taken from:

Ogiela, D. (2009). Normal Knee Anatomy, Medline Plus, accessed 1st August 2010
http://www.nlm.nih.gov/medlineplus/ency/imagepages/8716.htm

Anatomy
The anterior cruciate ligament is one of four main ligaments in the knee. It extends from the back of the
femur bone to the front of the tibia bone, deep inside the knee joint. It helps to hold the knee joint in
place by stopping the tibia from sliding forward on the femur.

Injury
The ACL can be injured by having the tibia forced forward, the femur forced backward or some twisting
movements. Common scenarios include:
Having a planted foot and being tackled front on.
Landing with a hyper extended knee.
Quickly changing directions and twisting the body with the foot remaining planted.
Being slide tackled from behind and forcing the lower leg forwards.
There are three grades of ACL injury:
1. Micro tear where <5% of fibres are torn.
2. Partial rupture where 5-95% of the fibres are torn.
3. Complete rupture where >95% of the fibres are torn.

Indications for surgery

The main reason for surgery is if the knee gives way or feels unstable. The risk of knee degeneration is
also considered because the knee joint can wear quicker if it is unstable, especially if there is a family
history of osteoarthritis.
Surgery is highly recommended for active individuals and those wanting to return to sports.

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PRE-OPERATIVE ADVICE AND PLANNING

To prepare yourself
Ask your surgeon to explain about any other knee damage you may have had from the injury and if you will
have other procedures besides the ACL reconstruction.

To prepare your knee

Before the operation it is best to:
Minimise swelling by avoiding excessive use.
Maximise the range of motion in your knee by stretching it out and bending it.

It is also good to master muscle co-contractions of quadriceps and hamstrings as you will be able to better
control your knee after surgery.

Instruction: with your leg resting on a bed try to push the back of your knee and the heel of your foot into
the bed so that you feel both the front and back of your thigh tightening.

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OPERATION PROCEDURE
There are three procedures used for ACL reconstruction and each surgeon has their own preference.

Patella tendon grafting

The patella (or knee cap) sits at the front of the knee and is joined to the tibia by the patella tendon.
The middle 2/5 of the patella tendon is removed along with a plug of bone at the top (from the patella)
and bottom (from the tibia). This graft is put in place of the damaged ACL and the bony ends are
connected to the femur and tibia.

Diagram taken from:

Medical Internet Solutions, Anatomy of the Knee, accessed 1st August 2010
http://www.aclsolutions.com/surgery_4.php

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Hamstring tendon grafting

The hamstring muscle is at the back of the thigh and attaches just below the knee joint with tendons
either side of you knee. If you bend your knee and feel the back of your knee you will notice two tight
bands which loosen when you relax your knee again. These are hamstring tendons. Some of the tendon
from the inner aspect of your thigh is stripped and folded to form the graft which is then attached inside
your knee.

Diagram taken from:

Medical Internet Solutions, Anatomy of the Knee, accessed 1st August 2010
http://www.aclsolutions.com/surgery_4.php

Artificial LARS (Ligament Augmentation & Reconstruction System) graft

If early after injury the ends of the ACL are still healthy a synthetic porous fibre ligament, which mimics
the original structure, can be used to form a join. Later a patella tendon/hamstring graft is put in place
and the synthetic ligament is left in place to reinforce it. This is particularly useful when an early return
to activity is required as it strengthens the newly formed ligament as well as helps to protect it.

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ACUTE INPATIENT PHASE (WEEK 1)

Goals
The main goals for this first week are to be able to:
Fully straighten knee and bend it past 90.
Walk normally without using crutches or walking aids.

Exercises

Ankle pumping do this 10 times every hour.

Flexion do this 10 times, twice a day.

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Calf stretch hold for 30 seconds and repeat 2 times, twice daily.

Knee straightening hold for 30 seconds and repeat 2 times, twice daily.

Walking try to walk normally and with control. Focus on co-contractions when youre walking around
and controlling your knee movement.

Note: it is not advised to use your knee actively without having your foot planted on a surface in the first
week.

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What to do

Elevate leg as high as tolerated for 30mins, 2-3 times a day.

Ice the knee and paddle your foot to help swelling to resolve (especially important after knee use) and
continue this until your leg looks normal.
Your leg may be put on a continuous passive movement (CPM) machine which will bend and straighten
your leg for you but try and contribute to the movement yourself.

What youll notice

The swelling and pain settling considerably in this first week.

Bruising (depending on the surgical technique and area of incision).
Stiffness when you first wake up (but this will resolve with movement).
Youll be given tubigrip (like a bandage), keep this on (except for showers) for the week.

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EARLY OUTPATIENT PHASE (WEEKS 2-4)

Hydrotherapy
Doing exercises in the water is a great way to strengthen the knee muscles without putting too much
pressure through the joint. As well as strengthening the muscles around the knee, it is important to focus
on technique and control when doing all your exercises so that your brain has practice in controlling your
knee during movements. To start off with, it is best to limit sessions to 20 minutes and gradually build up.

Exercises for the water

Walking - practice walking through the water in different directions (forwards, sideways and
backwards) trying to keep steps symmetrical and controlled.

Running - move through the water with a fast walk and focus on kicking your heels towards your
bottom.

Kicking - using a kickboard and laying on your front or back, kick your legs making sure that your feet
stay below the water surface.

Swinging:

Standing on your good leg and holding onto the wall, raise your leg straight in front of you and
have your foot turned outward.
Swing your leg back while bending your knee and then swing the leg forward again, straightening
your knee again.

Treading water - in an upright position in the deep end, keep yourself afloat by kicking forwards and
backwards but NOT in circles.

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Stationary bike riding

Bike riding is a safe way to exercise your knee and easily progress the intensity of exercise. Start by doing
a session no longer than 5 minutes per day.

Exercises on land
These should be started once you gain confidence in doing exercises in water and on the bike. You should
consult your therapist so they can assess whether or not you are ready for this stage and also check how
often they should be repeated throughout the day. A general rule would be 10 repetitions twice a day or
stopping when you notice fatigue and soreness.

Laying down

Hamstring stretch laying on your back, pull your leg towards your body with your knee straight until
you feel a slight stretch and hold for 30 seconds.

Single leg raise keeping your knee straight, raise your leg off the bed and lower it again with
control.

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Hip abduction keeping your knee straight, slide your leg out to the side and then bring it back into
your body.

Hamstring curls - lying on your stomach, bend your knee towards your bottom and lower it with
control.

In standing

Calf stretch in lunge:

Stand in a lunge position so that your feet are pointing forwards and are parallel.
You should feel a stretch in your calf; hold the stretch for 30 seconds before changing legs.
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Calf raises - while balancing yourself against a wall, stand on tip-toe and lower yourself back down
slowly.

Quarter squats - do a small squat so that your knee bends about 45 and straighten back up again
with a focus on maintaining a co-contraction of your quadriceps and hamstring muscles.

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EARLY REHABILITATION (4 WEEKS to 3 MONTHS)

In the gym
These exercises should be done with supervision from gym staff the first time you try them so that an
appropriate weight can be selected and technique corrected.

Leg press - do with 2 legs to start with and progress to doing it with one leg.

Hamstring curls - lying on your stomach, bend your knee towards your bottom and lower it with
control.

Step - leading with your operated leg, step up onto the step and then leading with your good leg step
back down onto the ground.

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Pulleys - use pulley resistance to pull you leg forward, back, out to the side and in towards your body.

Trampoline - jump on trampoline, focusing on landing softly by bending your knees and hips.

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Balance exercises

Lunge walking - take large steps and lower down in between steps so that youre in a lunge position
as you walk.

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Standing on operated leg - progress by closing your eyes and maintaining balance, if this is too easy
you can start to do single leg squats.

Balancing on an unstable surface - keep your balance while standing on a wobble board or pillow,
progress by standing on just one leg and then by closing your eyes.

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MID STAGE REHABILITATION (3-5 MONTHS)

Jogging and running
Practice jogging with control and think about symmetry in both legs. Once this becomes easy and you feel
confident, start to increase speed to a light run. You can vary your running to work different muscles
specifically by:

Running with high knees.

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Running with your heels kicking your buttocks.

Practice changing speeds while youre running and when this gets easy you can practice stopping
quickly.

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Run in patterns like zigzags and a figure 8.

Practice running from stationary then progress to doing a crouch start.

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END STAGE REHABILITATION (5+ MONTHS)

To progress to this stage you should be assessed by a physiotherapist first.

Hopping

Hopping on your operated leg while focusing on using you knee muscles to jump up and absorb the
landing force.

Hopscotch or hopping to a pattern so that you have to change direction and make it harder to control.

Hopping off a step and landing on your operated leg (increase difficulty by making the step higher).

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Vertical jump as high as you can manage with a focus on bending your knees when landing.

Sport specific skills

This will depend on what activities you want to return to after rehabilitation. It is important to gradually
build up your ability to perform these skills.
See your therapist for some specific exercises relating to your sport.

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RETURN TO SPORT
Depending on the surgeon, the extent of the injury and the performance in rehabilitation, it can take 6-9
months to return to sport.
It is recommended that you have a follow-up appointment with the surgeon at 6 months.
Before returning to sport your therapist will assess your strength and agility levels to ensure that you are
safe to play.

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SUMMARY
In summary, ACL injuries are fairly common and can range in severity. Surgery is a good option when the
knee is experiencing instability and the individual wants to continue playing sports. There are two main
reconstruction techniques and each surgeon has their own preference.
Early rehabilitation will gently increase knee strength and control but is sensitive to pain and swelling.
Rehabilitation progresses to make the knee have control in more challenging activities and works towards
returning to sport by the end of the program.
Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist.
All the best for a speedy recovery,
The W&L Team

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CONTACT US
Wellness & Lifestyles Australia
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P: +61 8 8331 3000
F: +61 8 8331 3002
E: contact@wellnesslifestyles.com.au
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