ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

PATIENT INFORMATION AND REHABILITATION MANAGEMENT GUIDELINES

Patient Name: _______________________________ Age___ M/F. Hospital No: ___________

Date of Admission: _________ Date of Surgery: _________ Date of Reviews: _____,____,____
ProcedureDone:________________________________________________________________
__________________________________________________________________________
Background: The Anterior Cruciate Ligament
The anterior cruciate ligament (ACL) is one of the main restraining ligaments in the knee. It runs through
the centre of the knee from the back of the femur (thigh bone) to the front of the tibia (shin bone) and it
acts as a link mechanism between the thigh and lower leg. The main function of the ACL is in stabilising the
knee especially in rotation movements and sidestepping, cutting or pivoting manoeuvres. This means that
when the ACL is ruptured or torn the tibia moves abnormally on the femur and almost jumps out of joint
such that the knee buckles or gives way. The main feeling is a sense of the knee giving way on twisting or
pivoting movements and a feeling of not trusting the knee.
Mechanism of Injury
The ACL is typically injured in a non-contact twisting movement involving rapid deceleration on the leg or
sudden changing of direction such as side stepping, pivoting or landing from a jump. Injuries are often associated
with a popping sensation followed by the development of swelling in the knee over the subsequent few hours due
to bleeding from the torn ligament.
Indications for Reconstruction of the ACL
The main consequence of tearing the ACL is that the knee no longer feels stable in pivoting and twisting
movements. The result is a tendency for repeated episodes of giving way or buckling of the knee. It is these
episodes that carry the risk of damaging the other structures in the knee – in particular the articular
cartilage and the meniscus. Surgical reconstruction is therefore indicated in individuals who wish to return
to pivoting type sports and in individuals who have problems with giving way in daily activities.
The Operation
The operation to reconstruct the ACL involves replacing it with other ligament type graft tissue taken from
around the knee. There are two main grafts in common use: the patella tendon (Fig 12) or the hamstrings
graft. Both are considered to be equally good and the choice usually depends on the surgeon’s preference.
The two tendons are taken through a small incision on the front of the tibia and are folded in half to make a
four strand construct. The inside of the knee is prepared using an arthroscopic technique. Tunnels are made
in the tibia and femur through the sites of the attachment points of the old ligament. The old ACL is
removed to allow space for the new graft. The new ligament is then held in place within the tunnels using
absorbable screws or staple fixation type devices. These usually do not need to be removed. If there is a
tear of the meniscus or damage to the articular cartilage then this can be tidied up or repaired during the
procedure. Suture Removal is probably done on 12th day after surgery (or during first review). For a
successful outcome of surgery after reconstruction of the Anterior Cruciate Ligament, rehabilitation
exercises are of utmost importance. These have to be started from the day following your surgery and are
gradually modified as your recovery progresses.
Final view of the new ligament from front of the knee
 ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
PATIENT INFORMATION AND REHABILITATION MANAGEMENT GUIDELINES
Rehabilitation
1. Exercises should be performed without any jerky or abrupt motion and done within limits of pain.
2. Mild discomfort during exercise is to be expected but not sharp pain. Stop exercises that cause pain or
knee swelling.
3. For total return of function and pre injury sports fitness some of the exercises have to be done for up
to a year post surgery.
4. Serious Athletes and Dancers need to do specific knee conditioning exercises throughout their career.

An attempt has been made here to give general guidelines for the exercises. Take time to go thro’ this protocol.
Most exercises are self-explanatory. If you have trouble understanding, consult a physiotherapist or your local
orthopedic surgeon at________________________________________________________________________.

Stair climbing / descending:

Stair climbing / descending after 4 to 6 weeks. Initially, with the help of crutches and later using one leg
(good leg) at a time. Normal as tolerated.
Returning to work:
Sedentary, office work can be resumed in 4 to 6 weeks. However, if you have to use public transportation to
reach your place of work can be resumed after 8 weeks. If you are in a sales job or one that involves
touring, you may take 8 to 12 weeks to return to the job. Use a hinged knee brace until 3 Months.
Car / 2 wheeler driving:
Car driving may be started approximately by 6 weeks.
2-wheeler driving is best avoided for 8 to 12 weeks. Use the hinged knee brace while using a 2 wheeler.
Gym use & Sports:
• Stationary cycling after 6 weeks
• Can use gym machines - Upper body as usual and lower body as prescribed. Lower limb after 8 weeks but
under supervision of physiotherapist or Instructor.
• Swimming after 6 to 8 weeks.
• Jogging and other strenuous activities not before 4 months.
• Contact sports etc after 9 months to 1 year.
Signs NOT to be ignored:
· Fever, Excruciating pain, Swelling, redness or warmth over the knee joint, Pain and swelling over the
cut taken for procuring the graft for ligament reconstruction, if your knee does not bend as expected,
please consult your doctor or physiotherapist.
Minor problems after reconstructive surgery:
(May pass off or remain, not to be concerned about)
· Swelling: swelling or “effusion” in the knee is usual until three months after surgery, Clicking during
movement, Stiffness after prolonged sitting / standing, Numbness over a small patch on the upper &
outer part of the leg.
Position of the leg:
• Keep the operated leg elevated on pillows. Pillows should be placed longitudinally so that the foot
/ ankle / leg & knee are well supported.
• Leg elevation is recommended for the first 2 to 3 weeks.
• A rigid knee brace has been applied to keep your knee straight & protect the operated area. This
brace is to be used for the first 4 weeks.
• Use crutch for walking until 6 weeks.

EXERCISE PROGRAM
Day / Week Exercises

1st day Foot & ankle motion, gentle quadriceps- tightening- press the knee against mattress and hold.
Hamstring tightening – keep the towel under the heel and press it against and hold, both
 exercises should be held for a count of 5 and relax. Repeat 5 times for every 2 hour. Walk with
the use of Crutch on both side without keeping the leg down.
2nd day: Do all the exercise of the day 1, but hold for a count of 10 and relax. Repeat 10 times for every
2 hour. Increase the Distance Your walk.

3rd day Continue the exercises. Repeat all exercises 20 times thrice in a day until 2 week or next review

2nd week Continue the same exercise. Try to do assisted knee bending with hand to attain 0-40o at
the end of the3rd week.

3rd Week Continue Quadriceps tightening - press the knee against rolled towel and hold, Continue
Hamstring tightening. Assisted knee straightening with opposite leg. Straight leg rising to 1
foot above the ground all these exercises have to hold for a count of 10 and relax. Repeat 10
times for every 2 hour. Knee bending with opposite leg or with hand, try to attain 0-90o at the
end of the3rd week. Remove Brace for ROM Activities.
50 %Weight bearing Ambulation with the use of Crutch on both sides at the end of 3rd week.

4th Week Continue Quadriceps tightening. Continue Hamstring tightening.

Assisted knee straightening. Straight leg rising to 1 foot above the ground and hold for 10 sec.
Assisted knee bending 0-120o at the end of 4th week. Remove Brace for ROM Activities.
Weight bearing Ambulation- 100% with only one Elbow Crutch on opposite side.

5th Week Continue Quadriceps tightening.

Continue Hamstring tightening.
Knee bending 0-140o without support at the end of the week, Weight bearing Ambulation-
100% with only one Elbow Crutch on opposite side.
Straight leg rising to 1 foot above the ground and hold for 10 sec.
Active knee straightening without support at the end of the week.
Remove Brace for ROM Activities.

6th Week Active knee bending 0-140o at the end of the week.
Straight leg rising to 1 foot above the ground and hold for 10 sec against ½ kg weight.
Continue Quadriceps tightening. Hamstring tightening.
Knee straightening with 1 kg at end of 6th week.
Knee bending 0-140o without support at the end of the week.
Remove Brace for ROM Activities.
Weight bearing Ambulation- 100% without Crutch by the end of the week.

After 6 weeks

If you are unable to achieve the desired range of knee motion,

• Half squats with
support
• Using a skate board to
improve knee bending
• Prone knee bending
• Assisted knee bending
• Consult Doctor or
Physiotherapist Immediately.
 Additional exercises can be done to
hasten the recovery. These include Side
leg raises, back leg raises & adductor (inner
thigh) raise, Tie a light, 1 to 2 kg. Weight cuff or belt, around the ankle and do
straight leg lifts, back curl in standing, marching like action, Half squats without support, Stationary
cycling

Beginning 8th week, one can start using a gym. A stationary cycle at zero resistance, strengthening
exercises using progressively increasing weights by 2 kg for 10th week and 3 kg for 12th week and increase
the counts from 10 sec at the beginning and 20 sec at the end of consecutive week. At 4 to 6 months,
depending on your recovery and in consultation with a physiotherapist or trainer, one can start advanced
conditioning exercises for balance, agility, speed & progress to sports specific training

Avoided these for 6 Months

Using treadmill or stepper, lunges or full squats, any twisting, jumping or pivoting exercises, sitting leg
movements where you lock or completely straighten the knee, Sitting on the floor and using Indian toilets.

Simson.K.S.
Head of the department
Department of Physiotherapy