ACL Reconstruction

Warning. You may not want to read this page if you are of a squeamish disposition. It
contains explicit descriptions and pictures of a surgical procedure.

The Injury
In December 1996, I moved to San Francisco. That Christmas and New Year, my friend Nick
came to visit, and we decided that to fit in with the locals, I'd have to do all of the things the
locals do. So we went out mountain biking, tasted the local wine, visited the microbreweries,
went to the beach, and hired roller blades on a quiet afternoon.

I had ice skated a little bit, but never used roller blades before. I quickly found it to be harder
than I expected, there was a lot less resistance from the blades. Very soon after we started, I
found myself on a shallow slope, got out of control, and fell over while desperately trying to
keep my balance. As I fell my right lower leg twisted outwards, I heard a loud popping sound,
and I ended up on the ground. There wasn't much pain and I was able to stand up shortly, so I
didn't think I had done anything serious. In fact I continued to skate for a short while afterwards.

Over the next day my knee swelled up a little bit and was painful. I wasn't able to go cycling
again during that vacation. I used a support bandage for a couple of weeks, but when it became
obvious that I wasn't getting any better, I consulted my medical insurance and then went to see
the Orthopaedics clinic at Stanford University, close to where I work in Menlo Park.

Diagnosis
The initial diagnosis took some time, probably because I was being very protective of the knee
and unconsciously tensing the muscles around the joint when the doctor manipulated my knee;
the muscles had not been damaged, so tensing them masked the looseness of the joint. An MRI
scan settled the matter, it was clear that the anterior cruciate ligament (ACL) had been
completely separated. This ligament is internal to the knee joint, and prevents excess motion of
the joint surfaces forwards and backwards.

This was also bad news because I had been intending to learn to ski properly that winter, and the
ACL is very important in stabilising the knee joint for the sort of turning motions experienced
during skiing.

The Decision
I didn't want to rush into anything immediately, so after the diagnosis I gathered as much
information as I could about ACL injuries. The doctor told me that there would not be much
damage caused by the lack of an ACL for a while (in fact some people elect not to have any
operation, and get by fine for the rest of their lives without an ACL). This allowed me to delay
the decision on whether to get an operation, and see how much functionality I could restore.
I attended the Stanford Sports Injuries and Rehabilitation clinic for several weeks, working on
exercises to strengthen the muscles around the joint and increase its flexibility. By the summer, I
was mountain biking and swimming again, but I had a constant low-level pain in my knee during
hard exertion.

I also found out as much as I could about the surgery available. The doctors explained the types
of operation available, the operation procedures, success rates, and what the operations were
expected to achieve. The ACL reconstruction operation is a functional restoration operation, if
successful it allows a complete or near-complete return to pre-injury functionality of the joint.
There was some speculation amongst the doctors that it may help prevent premature arthritis in
the joint, but there had been no long-term studies to prove or disprove this.

During this period I also found out that ACL injuries were very much more common than I'd
thought; when I mentioned it, I found that many people I met had had knee surgery.

Preparation for the Operation

During the summer I made the decision that I wanted to have the ACL restoration by an allograft
(tissue taken from a cadaver). The alternative operation would be to take a part of one of my
other ligaments and use it, but I decided against that because I did not want to potentially impair
my functionality in other ways. I felt that if the allograft did not take, I would not be in any
worse condition than before, and if it did work I would potentially be much better. I must admit
that I gave the speculation about premature arthritis too much weight, even though it is
unproven.

Once I had decided that I would have the operation, I started preparing myself for it. I knew that
there would be a lot of rehabilitation exercises, and that a lot of them would hurt. I wanted to be
highly motivated to do my exercises; I decided that it would be easier if I was fitter and in a
regular exercise schedule. At that time, I was also a little bit overweight, at over 77kg (170 lbs).

I kept a normal calorie intake, but changed my diet to cut out a lot of fat (I don't have a sweet
tooth, so I didn't need to do much on reducing sugars). I started weight training (concentrating on
exercises which would also be beneficial to my archery, and I increased the regularity with
which I commuted by bicycle and Caltrain, even until I was enjoying cycling in the rain. I started
swimming regularily. By the time of my operation, I had lost about 9kg (20lbs), and was much
fitter and motivated to exercise than before.

The Operation
I finally had the ACL reconstruction on 22nd January 1998. The operation was delayed a couple
of times because of scheduling problems with the surgeon and the Christmas/New Year holiday
periods. During the delay I was beginning to reconsider whether I really needed the operation; I
was fit, exercising, and worried about could go wrong. Talking to the doctors did not help, they
reiterated all of the information they had provided earlier, but provided no help in making a
judgement. I finally decided to go through with it after a late-night phone conversation with Nick
the night before the operation.

I had the first operation of the morning; I was in the hospital at 7am, into the operating theatre at
9am, out by about 11am, and a friend drove me home by lunchtime.

The operation was done arthroscopically. Several small incisions were used to insert a video
camera lens into the joint, and other small incisions were used to insert tools and the replacement
ligament. The operation was video taped, some stills from the video are shown here. In general,
the video is rather boring. It is not easy to follow without knowledge of exactly what is going on
during the operation. The operation was done under general anaesthetic; I had the option of
general or epidural, I decided that I didn't want to be aware of anything, since the surgeons
would be sawing and drilling into bone.

The first part of the arthroscope video shows a lot of examination and
probing of the joint. The space where my torn ACL used to be is visible in
these sections. The ACL was completely torn, and in the time between the
injury and the operation the remains of it had all but disappeared.

After all of the probing, the joint capsule was cleaned and some
damaged cartlidge trimmed. Various implements were used for this,
including a rotary cutter. The implements in these pictures look huge, but actually are very
small. The lens on the arthroscope camera enlarges the apparent size significantly.

Attaching a new ligament to replace the ACL is not quite

straightforward. The ligament can't just be sewn into place (stitches
would not hold in the ligament, and since the ligament attaches to bone it
would also be impossible to sew if the previous ligament is completely
gone). The ACL reconstruction operation involves cutting bone out either
end of the ligament site. The replacement ligament is cut with bone each
end, and the bone each end is screwed into the prepared sites. The bone
eventually assimilates to provide the strength of the graft. This stage was cutting away the bone
at the sites where the replacement ligament would be attached.

The site for the ligament is prepared, and the

replacement ligament is drawn into place by a guide-
wire through the joint. The bone is drilled, and a small
hex-head screw is used to attach the graft. The hex-
head screw looks huge in the pictures here, but is
actually only a couple of millimetres diameter.

The other end of the graft was attached with a couple of metal staples. The
replacement ligament was now in place. Finally all the instruments were
removed, including the arthroscope camera (giving an impression of ``Fantastic
Voyage'' as it came out of the guide-tube, with a glimpse of the operating theatre
at the end).
The first few days after the operation I count amongst the worst of my life. The painkillers I had
been prescribed were not sufficient to completely numb the pain, and they had unpleasant side-
effects on my metabolism. I stopped using them after a few days and just suffered the pain. One
of the worst problems was having to keep the knee elevated above head-height for the first few
days; this pretty much meant I had to lie flat on my back, a position from which it is difficult to
read, operate a computer, or do just about anything else.

I was greatly relieved when I could sit up, but the extra pressure in the joint from standing up and
moving about was excruciating. I was very grateful to have a friend come in and make my
dinner, do my laundry and my shopping several times, and even more grateful that one of my
neighbours opened the apartment door for her; I live on the top floor of an apartment block, and
the apartment door does not have a remote release on it.

Rehabilitation
The rehabilitation process was painful at times, tedious at other times. There were some
moments when it seemed like having the operation was a big mistake.

My rehabilitation was at Stanford Rehabilitation Clinic again. The first time I visited was very
difficult. I tried to used public transport to get to the clinic from San Francisco, and found it to be
very awkward moving around. After that, I cajoled and prevailed upon colleagues and friends to
take me to and from the clinic.

Patients having ACL reconstructions used to be put into in a full-length cast for six weeks or so,
and then on crutches and braces for months afterwards. The current experience indicates that
getting the leg moving and active as soon as possible after the operation is beneficial, so at my
first appointment the physiotherapists started manipulating the leg. There was quite a bit of
swelling from the operation, and the muscles around the knee joint were not responding.

I had a post-operative knee brace with a range of motion lock; initially the brace was kept locked
in full extension, with the range of motion slowly increased over several weeks. I found sleeping
very difficult with my leg locked straight out; I normally sleep lying straight anyway, but it's
rather different trying to sleep with a brace preventing the leg from being bent at all and the leg
elevated. Some times during recovery I twitched in my sleep, involuntarily contracting the
muscles around the knee. This would result in me waking up instantly in pain; it was not a
pleasant experience.

The first few physiotherapy sessions concentrated on activating the quadriceps. This muscle is
used to extend the lower leg. Initially I could not even tense that muscle. When the
physiotherapist asked me to try, I felt that every other muscle in my body was tense, but I just
couldn't activate the quads. By using electrical stimulation and bio-feedback devices, we quickly
reached the point where I could activate the muscle and then do exercises to strengthen it. I was
amazed at how quickly muscles will atrophy if not used. The preparation I had put in before the
operation helped, I was diligent in doing all of my exercise sets, and keen to get back fit and
riding my bicycle.
Even with several daily exercise sets, it was a couple of weeks before I could lift my leg on its
own without assistance from my hands. I remember that moment as a major achievement; it may
sound patronising, but the experience of not being able to move my leg at will gave me a lot of
respect for what disabled people endure.

Another good moment early in the recovery was when I managed to rotate my feet all the way
round in my bike pedals. I had bought a bike trainer to help with my recovery, and was using it
for range of motion exercises on it, rocking the pedals backwards and forwards. Later in my
recovery I used it for hamstring and quad strengthening, doing both single-leg cycling,
endurance exercises and interval training until I felt confident enough to take the bike back on
the road.

I was able to dispose of my crutches a few weeks after the operation, and walk with great care
using only my knee-brace. My parents visited me from the middle to end of February, and by the
end of that time I was just able to drive again. While my parents were visiting I also found
another use for a knee-brace; we got seated early in a restaurant we visited because the staff did
not want me standing around in pain. I've resisted the temptation to put the knee-brace on just to
get priority seating since I stopped needing it. I had arranged to work from home during this
period, which I was very glad of, since it was also the period when the worst of the El Niño
storms were starting to hit California.

The knee-brace came off after another few weeks, when I was able to walk without risk of re-
injuring myself through weakness in the knee. There then followed one of the more tedious parts
of the rehabilitation, doing more and more of the same exercises to build strength, and extend the
range of motion. I spent a lot of time working on quad strength, without realising how much my
hamstring strength had also been affected. It was a bit dispiriting to find out how much work I
had to do on that too.

The exercises in the first weeks ranged through quad tightening, terminal knee extensions, calf
stretches to leg lifts, wall squats, leg shuttles and stationary bike work. I found that getting the
physiotherapist to show me a range of exercises which I could choose some different ones from
helped prevent me from getting too bored with the same sets.

Once I was able to ride my bicycle on the road again, the quad strength became less of a
problem. Initially I experienced some pain in the knee and had to be very careful about high-
stress cycling, such as riding out of the saddle, and avoided stationary holds or other tricks.
Cycling is a good low-impact activity for rehabilitation.

The final phase of the recovery was the closed-chain exercises, which are designed to provide
feedback through the leg to the knee. These exercises were the turning and cutting motions that
are stressful to the knee. I didn't think I had any problems with them until I tried to go running
one day. I've never been much of a runner, so this was also an experiment to see whether I could
avoid getting bored (which was always the problem I had with running before). In the first few
steps, I found out how little impact my knee could really tolerate. When I got back from my run,
I was surprised to find that while my right quad was fine, my left one ached! Fortunately, my
tolerance for impact has increased a lot, and I now sometimes run as part of my exercise
programme.

I also took my bike off-road again around this time, to make sure that I could manage some more
technical riding, and reinstated my medical certificate for my pilot's license.

In July 1998, I proved to myself that my knee was sound again by backpacking into the
wilderness with Nick and Jeff and climbing Glacier Peak, a 10,500 foot volcano in Washington
State's Cascade range. I did get some swelling after our final day, which involved 30 miles of
walking and about 3 miles of elevation change, including a good bit of ice climbing on the
glaciers.

Aftermath
On 10th August 1998, I had my final doctor's appointment, and was signed off to go and do
whatever exercise I want, with a knee brace recommended for high impact activity. My plans
now are to learn to rollerblade and ski! This time, I'm going to learn to rollerblade properly. I'll
use a knee brace, stay off slopes until I can skate and stop on the flat, and learn to breakfall
properly.

The irony is that I had full protective gear on when I fell. If I'd accepted that I was going to fall
and had controlled the fall instead of trying to stay upright, I probably wouldn't have hurt myself
at all.

I can't finish without thanking Bob, Laura, Danni, and the others at Stanford Rehabilitation
Clinic. My recovery is now almost complete; there are some motions that cause me pain (breast
stroke kick, for example), but overall I now have less trouble than before the operation, and am
optimistic about a total restoration of functionality. I'm planning on getting back into karate,
which I haven't been able to practice properly since the injury.

Anterior Cruciate Ligament Reconstruction

(ACL) - Recovery and Rehabilitation
 Medication
Analgesics or pain killers are prescribed for several days following discharge from hospital.

Anti-inflammatory tablets may also be taken if the analgesics alone do not control the pain.
However anti-inflammatory tables should be stopped as soon as the knee is comfortable and
analgesics then continued if necessary.

Physiotherapy

The physiotherapist will see you immediately after surgery. Continuous passive
motion may be used to assist in knee flexion. The physiotherapist will see you again on your
return to the ward and explain static quadriceps exercises, exercises to encourage full knee
extension and to begin knee flexion. Patients are usually able to stand and walk gently with
crutches within 24 hours of surgery. Crutches may be discarded as soon as possible and usually
in 2-4 days following surgery. A supporting knee brace is usually used for the first f4-6 weeks.
This is useful if it is locked in the straight position at night. This encourages full knee extension.
Patients are usually discharged from hospital 48 - 72 hours after surgery.

After discharge it is important to continue with the rehabilitation protocol. The physiotherapist
should give a program to you at the time patients leave hospital. The physiotherapist should also
arrange for follow up physiotherapy. This should be undertaken two or three times a week for six
weeks and then perhaps once a week for another six weeks. Physiotherapy will be directed
initially at controlling any pain or swelling of the knee and regaining a full range of knee motion
by 6 weeks. Subsequently physiotherapy will be directed towards balance, muscle reaction and
reflexes and proprioception. This is an essential stage in the rehabilitation protocol. The
supporting knee brace can usually be removed after 4 weeks. Driving, static cycling and pool
exercises can be undertaken after 4 weeks and gentle crawl swimming and gently low weight
gym exercises after 6 weeks. Normal cycling, swimming, jogging and golf can usually be
restarted after 12 weeks. Squash, tennis and field sports can usually be undertaken after 6
months.

+ find out more about Physiotherapy

Results and Complications

You will find that the leg may be painful for the first few hours after
surgery. This is quite normal and the pain usually eases by the following day. Generally by the
first day after your operation you will be able to get around walking with crutches without too
much difficulty. Repair of the ACL usually involves a total of 1 to 2 days in hospital. After you
go home, you should keep bending and lifting your knee in order to strengthen the muscles and
regain movement. The dressings should be removed after 5 days and the wound inspected. If
there is any excessive redness or infection patients should return to the GP or the clinic. Ten to
14 days following the operation you should return to the GPs clinic to have the stitches removed
and the wound inspected. Crutches will be used for only 2 - 4 days. A brace is often used to
protect the knee for the first 4 weeks when walking outdoors. This has the effect of avoiding
excessive activity in this period. The brace is usually worn at night for 4 weeks locked in full
knee extension to reduce the degree of morning stiffness.

ACL reconstruction by the use of a Patellar Tendon graft is a very safe and successful procedure.
Mr. Johnson expects that almost all of his patients should be able to return to twisting, pivoting
or contact sports without restriction. A brace is not usually required for these activities.
Complications (anaesthetic, medical and surgical) can occur after any surgical procedure. Every
care is taken to minimise such problems. The occurrence of such problems should in total be less
than in 1% of cases. Possible problems include infection (antibiotics are given at the time of
surgery to prevent this), bleeding, swelling, stiffness and venous thrombosis (blood clots). A
fever or redness and swelling around the wound, or an unexplained increase in the pain may
suggest infection. Increasing calf pain or intermittent chest pain may suggest a venous
thrombosis. As with all surgery if at any stage anything seems amiss it is better to telephone or
see your local doctor rather than wait and worry.
In the first 6 weeks the graft is held in position by only 2 small screws. Any excessive force on
the knee produced by tripping, stumbling or doing incorrect or unsuitable exercises may disrupt
the integrity of the ligament and it will fail. So take care and listen carefully to the advice given
by the physiotherapist. One particular problem is the formation of excessive scar tissue inside the
knee. Early movement and physiotherapy minimises the problem. Very occasionally further
arthroscopy after 3 months is sometimes necessary.

If all goes well you may expect a knee that is stable, does not give way, has a full range of
motion, is pain free and you will be able to play sport at the same level as prior to injury. If
skiing I always advise the use of a brace to protect the new ligament. Despite all the efforts of the
patients, the surgeon and physiotherapists and usually as a result of a further significant injury, in
very a small proportion of patients the ligament will fail. In this situation further measures may
be considered.

Mr. Johnson normally expects the vast majority of ACL reconstruction patients (in the region of
95%) to be able to return to their chosen sport without any significnat knee problems.

Return to Work / Sport

If your job is sedentary and mostly sitting you may wish to return
to work after only 1 or 2 weeks. If your job is physically demanding and requires standing or
walking for most of the day, your return to work may take 6 to 8 weeks. Driving can usually be
performed after 4 weeks providing that the knee is pain free and you are able to make an
emergency stop.

Exercises in a pool can usually be started after two weeks when the wounds have healed. Gentle
swimming and cycling on an exercise bicycle should be undertaken after 4 weeks and light
weight training may be undertaken after 6 weeks. This will speed up the rehabilitation.
Breaststroke swimming should be avoided during this time. The knee should be protected from
impact and excessive strain during this time.

After 3 months normal outdoor cycling, normal swimming, weight training and golf may be
undertaken. Gentle jogging on a straight line on a running machine or grass should be performed.
After 6 months normal running including rough ground and twisting can be performed. Tennis,
badminton and non competitive squash is allowed. Training for soccer, rugby, hockey and
basketball may be started with gentle kicking of a ball but tackling should be avoided in
recreational athletes at this time. Professional atheletes may wish to return at a slightly earlier
time in the rehabiltation process.

After 9 months competitive, soccer, rugby, hockey and basketball may be undertaken but the
ligament will not reach its full strength for 12 months, so take care. At 12 months full return to
sporting activity and skiing is allowed.

Follow-up Appointments
The first follow up appointment is usually arranged for 3 weeks after
surgery and subsequently 3 and 9 weeks later. Progress is again
assessed after 6 and 12 months. About the
Author:
Mark De Carlo, PT, MHA,
SCS, ATC, Chief Operating
Officer Methodist Sports
Medicine Center, Indianapolis,
Indiana, USA

Mark De Carlo is the Chief

Accelerated ACL Reconstruction Operating Officer at Methodist

Sports Medicine Center in
Indianapolis, Indiana. He is

Rehabilitation Program
responsible for overall clinic
administration and direction all
aspects of the Center including
the physical therapy department,
scholastic healthcare
coordination, clinical research
and patient care. He has
presented many lectures
nationally and internationally
including over 70 lectures over
the past 4 years alone on topics
related to orthopaedic and sports
physical therapy.

 
This update on ACL rehabilitation was kindly written and put Mark has over 35 published
together by Mark De Carlo and his team, exclusively for Chester articles and book chapters in the
area of sports physical therapy.
Knee Clinic website, for which we are very grateful. The text, De Carlo received his Bachelor
of Science degree in Secondary
images and videoclips should not be used without author’s permission. Education/Athletic Training
from West Virginia University.
He then received a Master of
Science degree from the
Rehabilitation following anterior cruciate ligament (ACL) University of Indianapolis
Krannert School of Physical
reconstruction has changed dramatically over the past few decades. Therapy. He is certified as a
The staff of Methodist Sports Medicine Center in Indianapolis has over Sports Clinical Specialist by the
American Board of Physical
15 years experience with patients sustaining injury to the anterior Therapy Specialties and has
completed a Master of Science
cruciate ligament. Over this time we have developed a progressive degree in Health Administration
at Indiana University.
philosophical approach to rehabilitation following ACL reconstruction.
Mark is currently serving as
president of the Sports Physical
Our present philosophy on rehabilitation following ACL reconstruction Therapy Section of the
American Physical Therapy
has evolved through observation of our patients and documented Association, treasurer of the
clinical results. We have continually attempted to modify and update Journal of Orthopaedic and
Sports Physical Therapy, Inc.
our protocol as a means of improving patients’ final outcome following Board of Directors and member-
at-large of the International
surgical reconstruction. The ideal situation is one in which the patient Federation of Sports
Physiotherapy.
with ACL deficiency undergoing surgical reconstruction will
   
ultimately have a result of excellent stability, full range of motion and strength, and normal
function.

Conventional rehabilitation emphasized early protection of the ACL reconstructed knee by

restricting knee motion, weight bearing, and rate of return to functional activities. In 1982, the
surgical leg was placed in a cast at 30 degrees of flexion to avoid excessive graft stress. Weight
bearing without a brace was not allowed for 6-8 weeks following surgery and most patients were
restricted from full participation in sports activities for the first year. The high rate of
postoperative complications, including permanent knee stiffness, knee pain and low
predictability with return to high level sports, has brought about a number of changes in ACL
postoperative rehabilitation.

In 1985, we conducted a study comparing compliant patients with those who progressed more
rapidly than we recommended (noncompliant patients). To our surprise, the noncompliant
patients demonstrated fewer long-term knee motion problems and fewer subjective complaints
than their compliant counterparts, without difference in long-term stability. Through this process,
we learned that:

 an early loss of knee extension often led to long-term loss of extension accompanied by
subjective symptoms,
 patients who failed to regain early leg control often struggled with regaining full quadriceps
muscle strength later on, and
 patients who returned to sporting activities before recommended had similar knee stability to
patients who were compliant with our restrictions.

This helped us to place emphasis on factors felt to be of primary importance. These include:

 restoration of full hyperextension equal to the uninvolved knee,

 regaining of good quadriceps muscle leg control, and
 allowing for early wound healing.

Phase I (Preoperative)
Rehabilitation for the injured knee begins immediately following ACL injury. The clinical goals
for Phase I include restoring full range of motion (ROM) and normal strength and control
swelling prior to surgery. Patients are also to completely understand the basic principles of
accelerated rehabilitation including full terminal knee extension, early weight bearing, and
closed and open chain strengthening. The time needed to accomplish these goals can be as little
as 1 week or as long as 2 months, depending on how the knee responds to the initial injury.

To reduce swelling, a cold compression cuff (Cryo/Cuff) (Fig. 1) is applied to the knee and filled
with ice-cold water. The patient can wear the cuff continually except when walking. Swelling
reduction eases the return of normal range of motion.
 Returning full knee range of motion equal to the uninvolved
knee prior to surgery decreases complications such as post-
operative knee stiffness. To restore full range of motion, the
patient is instructed in several exercises including heel props
(Fig. 2), prone hangs (Fig. 3), and towel extensions (Video 1)
for extension and wall slides (Video 2) and heel slides (Video
3) for flexion. If the patient has problems attaining full
terminal extension with the exercises, he or she may be giving
a hyperextension device (extension board) (Fig. 4) to assist in
gaining full hyperextension.

Figure 2 Figure 3 Figure 4

Video 1 (1.3mb / mpeg) Video 2 (2.5mb / mpeg) Video 3 (970k / mpeg)

Encouraging the patient to move from partial to full weight bearing as tolerated stresses the
importance of restoring a normal gait. Full passive extension and quadriceps control is necessary
before normal gait con be accomplished. Therefore, the emphasis of gait instruction is on
achieving full knee extension at heel strike with full weight bearing on the involved side. The
patient is expected to be walking normally prior to surgery.

To encourage early strengthening, the patient is instructed in several closed kinetic chain
exercises including leg press (Fig. 5), squats (Fig. 6), step-downs (Fig. 7), bike (Fig. 8), and
Stairmaster (Fig. 9). These exercises are introduced after swelling from the injury has decreased
and ROM has been restored.

Figure 5 Figure 6 Figure 7

Figure 8 Figure 9

During the initial evaluation, the functional demands of the patient are assessed including
activities of daily living and athletic and recreational activities. School, work, and family
schedules are also examined to determine the most appropriate time to schedule surgery.

Phase I also includes patient counseling on the concepts of our approach to rehabilitation, the
timing of surgery with details of the reconstructive procedure, and specific postoperative
rehabilitation goals and expectations. Because mental preparation is a very important aspect of
success of the surgical reconstruction and rehabilitation, it is essential that the patient understand
the goals of rehabilitation process and how these goals will be achieved.

Phase II (Immediate Postoperative)

The clinical goals of Phase II include decreasing swelling, obtaining full passive knee extension,
and obtaining 110 degrees of flexion. Additional variables include performing an independent
straight leg raise and restoring normal walk.

Phase IIa: (1 to 6 days)

To minimize pain and swelling, a Cryo/Cuff is placed on the patient’s knee immediately
following the operation. The Cryo/Cuff remains on the knee at all times, except when performing
motion exercises. Continuous passive motion is initiated following discharge from the recovery
room and the machine is set to 0-30 degrees. The CPM machine is to remain on, with the
patient’s leg in it at all times, except when doing motion exercises and going to the bathroom.

Exercises for regaining full ROM are begun the day of surgery. Hyperextension is maintained
with 10 minutes of heel prop exercises every waking hour. Flexion exercises are performed six
times daily. This can easily done by slowly increasing flexion of the CPM machine to the 110
degrees and holding the position for 10 minutes four times a day. Once maximal flexion has been
attained in the CPM machine, patients can continue to increase bend
beyond 110 degrees by pulling leg further to buttocks with their
hands.

Leg-control exercise is started on the day of surgery and consists of

quadriceps contraction exercises and independent straight leg raises.  
Active heel height exercises (Figure 10) are performed to promote
leg control and to minimize the potential for a patellar contracture.
During the first week patients are to remain lying down as much as
possible. However, when getting up to go to the bathroom patients is
encouraged to be weight bearing as tolerated. Crutches may be used Figure 10
for the first few days to facilitate a normal walking pattern

The patient will report to physical therapy one week after surgery and should have full terminal
extension and flexion to 110 degrees, minimal swelling and soft tissue healing, and normal
walking.

Phase IIb: (7 to 14 Days)

The patient is evaluated at the one-week visit by both the surgeon and the physical therapist. The
patient’s rehabilitation program is advanced concentrating on swelling control, ROM, quadriceps
leg control, and walking.

Regaining full extension range of motion is the most critical factor in this phase. Full
hyperextension is maintained with heel prop and prone hang exercises. As in the preoperative
phase, if the patient has problems maintaining full hyperextension, an extension board may be
used. The CPM is discontinued at one week. Flexion range of motion is progressed with wall
slides and heel slides. The Cryo/Cuff is stilled used on a regular basis to control swelling when
the patient is not performing exercises.
  
The patient is encouraged to progress from partial to full weight
bearing without crutches (Video 4). Walking activities involve heel to
toe walking, retro-walking, and high-knee activities. The focus on
retro-walking is to fully extend the knee when going from toe to heel. Video 4 (770k / mpeg)
Practicing walking in front of a mirror greatly aids in the return of a
normal walking pattern. The mirror gives patients an immediate
visual cue as to how they are walking. It is very important to
emphasize leg control early in the rehabilitation program. Through
early extension and normal gait the patient is able to regain good  
quadriceps tone and leg control. This combination of clinical
variables will set the pace for the entire rehabilitation program and a
successful outcome.
Video 5 (800k / mpeg)
The patient is encouraged to lock out the knee by standing with the
weight shifted to the ACL reconstructed leg so that extension is full and the knee is fully locked
(Video 5). This exercise is referred to as single leg stance and is preferred whenever the patient is
standing. Single leg stance on the involved leg is an effective method of working on full ROM
and leg control, while giving the patient confidence in standing on the injured leg to begin to do
functional activities.

Once the patient has regained full knee extension and is ambulating normally it is possible to
implement strengthening exercises. Leg strengthening exercises include bilateral one-quarter
knee bends and calf raises. It is felt that this type of exercise facilitates return of lower extremity
strength with minimal stress to the joint.

Patients will return 2 weeks following surgery for a physician and therapy visit. At that time, the
patient should have full extension, flexion to 130 degrees, controlled swelling, normal walking,
and able to return to school or sedentary work.

Phase III: (2 to 4 weeks)

Phase III begins at the second postoperative visit two weeks after surgery. Clinical goals for
Phase III include full terminal extension and full flexion to 130 degrees, consistent weight room
and moderate speed strengthening, and early return to agility and sports specific drills.

Maintaining full knee extension is continued with exercises including prone hangs, passive and
active heel lift, and, if needed, a hyperextension device. Increasing flexion is achieved by
exercises such as heel slides and by using a stationary bike to facilitate flexion ROM.

Functional strengthening is initiated once the patient has sufficient leg control to perform a
unilateral knee bend without difficulty. Exercises include one-quarter squats, unilateral leg press,
unilateral calf raises, unilateral step-downs, Stairmaster, and riding the stationary bike.
Swimming and other hydrotherapy exercises can be started once the incisions have healed. Our
preferred exercise progression includes short arc quadriceps from 90 to 30 degrees, knee bends,
step-ups and leg press. These exercises are started with lower weight and then gradually
progressed to higher weight with lower repetitions.
If full ROM and other goals have been met sport specific and agility drills may be initiated
including jump rope, single leg hop, and easy position drills.

After Phase III, the patient will return to physical therapy every 4 to 6 weeks until 6 months, then
again at 9, 12, and 24 months following surgery.

Phase IV: (4 weeks on)

The emphasis in Phase IV is on advanced strengthening and return to sports. To advance into the
final phase of the rehabilitation program, the patient needs to have nearly full ROM. Our goal is
to reach this phase by four to five weeks after surgery. However, if the patient has not achieved
the goals of the previous phase, advanced agility and sport specific activities are not yet initiated.
The clinical goals for Phase IV include full ROM including terminal extension, improved
quadriceps tone, at least 70% strength, agility specific program, complete a sport specific
functional progression and return to full activity.

Exercise instruction includes an increase in weight room and home strengthening activities.
Exercises include unilateral leg press, unilateral leg extensions, unilateral step-downs, unilateral
calf raises, full squat to no more than 90 degrees, and lunges. Patients are encouraged to progress
from high repetition/low weights to low repetition/high weights. Also, some type of moderate
speed strength and cardiovascular activity should be continued such as bicycling, swimming, or
using a Stairmaster.

The patient’s first visit during Phase IV is four weeks after surgery. This visit will include the
first isokinetic strength test (Fig. 11), a isometric leg press test (Fig. 12) and a KT-1000
ligamentous stability test (Fig. 13).

Figure 11 Figure 12 Figure 13

 
Factors influencing the patient’s return to controlled agility training and sport specific activity
includes the patient subjective rating, as well as isokinetic and isometric test scores. If the
patient’s strength ratio is at least 65%, agility activities are started. These activities include
lateral shuffles, cariocas, cross over drills, and backward running. Patients may also begin solo
sports such as shooting a basketball or hitting a racquetball. These early agility activities promote
patient confidence, facilitate moderate-speed strength, and re-develop quickness, agility, and
sport specific skills. As the patient progresses, agility workouts become more vigorous to include
activities such as figure of eights and half to full speed running. The speed of progression is
based on the specific athletic and recreational desires of the patient. Sports specific activities are
incorporated into the progression with specific focus on athletic goals.

Although many patients ask “when can I start running again” at the beginning of Phase IV,
running for conditioning or rehabilitation actually is the final step in the rehabilitation process.
We prefer that the patient work on agility drills and sport specific skills instead of running two to
three miles. Running long distances at this time leads to swelling and, therefore, can cause a
delay in the rehabilitation process.

The athlete must participate in sport specific activities. Although we allow them to and they can
successfully return to practice and playing early after surgery, it can take two to three months of
sport specific activities (both practicing and playing) before the athlete will feel completely
comfortable with their knee and recover 100% of their quickness.

The patient is followed every four to six weeks for up to six months, but is allowed to return to
practice and playing as they feel comfortable and as our evaluation allows. Specific testing
strategies at each visit consist of isokinetic and isometric strength testing, single leg hop, and
KT-1000 measurements.

A knee injury involving the anterior cruciate ligament (ACL). The ACL runs diagonally across
the front of the knee from the underside of the femur (the thigh bone) to the top of the tibia (the
bigger bone in the lower leg).

Symptoms of an ACL injury include:

  Feeling or hearing a pop in the knee at the time of injury.
 Pain on the outside and back of the knee.
 The knee swelling within the first few hours of the injury. This may be a sign of bleeding inside
the knee joint. Swelling that occurs suddenly is usually a sign of a serious knee injury.
 Limited knee movement because of pain or swelling or both.
 The knee wobbling, buckling, or giving out.

There are 3 Types of Grades associated with ACL injuries :

Grade I sprain

 The fibers of the ligament are stretched, but there is no tear.

 There is a little tenderness and swelling.
 The knee does not feel unstable or give out during activity.

Grade II sprain

 The fibers of the ligament are partially torn.

 There is a little tenderness and moderate swelling.
 The joint may feel unstable or give out during activity.

Grade III sprain

 The fibers of the ligament are completely torn (ruptured); the ligament itself has torn
completely into two parts.
 There is tenderness (but not a lot of pain, especially when compared to the seriousness of the
injury). There may be a little swelling or a lot of swelling.
 The ligament cannot control knee movements. The knee feels unstable or gives out at certain
times.

The focus of this write up is not to discuss exactly what happens when an ACL injury occurs, this write up
will focus on the rehabilitation process to go through before and after an ACL reconstruction operation.

It is usually a patient who suffers from a Grade III Sprain that undergoes the reconstruction surgery,
however the exercises and rehabilitation process in these article can be useful for  everyone who suffers
an ACL injury.

Preoperative period
It is very important for people who have decided to undergo the reconstruction surgery to try and regain
full Range of Motion (ROM) on the injured leg. This means that you should be able to flex and extend
your injured knee as far as the uninjured side.
During this period of time, you should concentrate on maintaining as much strength as possible in the
quadriceps muscle. The quadriceps muscle brings your knee into full extension. This is one of the
strongest muscles in your body, but unfortunately, it can loose a significant amount of strength after any
type of knee surgery.

Regaining the strength in your quadriceps muscles can be difficult, because your knee may hurt quite a
bit in the first few weeks after your injury. The following exercises are recommended to help regain
ROM and increase strength in the muscle : These exercises ideally should take place at least 6 weeks
before your operation. The completion of a preoperative program has been shown to significantly speed
up postoperative recovery.

Exercises:

1. Knee extensions and quad sets: To perform these two exercises, place the heel of your injured
leg on an object that is a few inches thick (like a phone book). Gradually relax and let your leg
come to full extension. This first part of the exercise helps you to maintain a normal range of
motion.
2. Quad sets: After your knee has stretched out for a while, perform a set of ten quadriceps
contractions with your leg in the same position as in the Knee extensions. Without lifting your
heel up in the air, tighten your quadriceps muscle as hard as you can for ten seconds. Then relax
for ten seconds before tightening your muscle again. Repeat this ten times. This exercise helps
you to maintain quadriceps strength.
3. Heel Slides: For this next exercise, start with you injured leg stretched out. Then, while keeping
your heel on the floor, gradually bend your knee and slide your heel towards your buttock. Bend
your knee until it becomes just slightly uncomfortable and you can feel a bit of pressure inside
your knee. Hold it in this position for ten seconds. Then straighten your knee out again and relax
for ten seconds. Repeat this exercise ten times as well. This exercise will help you to maintain
range of motion.
4. Straight leg raise: This exercise helps you maintain your quadriceps strength. Start with your leg
flat on the bed. Begin by tightening your quadriceps, as in the quad sets exercise. Then lift your
leg off the bed until your heel is approximately eighteen inches off of the bed and build up to
holding for ten seconds. Lower your leg back down and repeat. Repeat this exercise five times.
5. Prone leg raise: This exercise helps to maintain the hamstring strength. This is done in a similarly
to the straight leg raise but with you lying on your stomach. Begin by lying face down. Then lift
your leg off the floor until your foot is at least 6 inches from the ground. Keep the elevated leg
as straight as possible - hold this position for ten seconds. Repeat this exercise five times.

As soon as the knee feels capable, begin to use a stationary bike. This will help with the ROM and help
maintain the quadriceps strength.  Begin by doing five minutes with low resistance and gradually build
up the time and resistance. This is a very beneficial exercise for pre and post operation as it helps regain
ROM and work the quadriceps.

Preoperative Tips:

 Put plastic chair into shower to sit on when washing

  Have plenty of ice packs to keep rotation of cold packs (4+)
 If one lives alone, make copies of keys to give to trusted friends + family to bring food and help
 Have easy ready to eat stuff floating around or go hungry
  Make a home on the couch with everything, connect power boards near couch-home, plug all
gadgets (chargers, phones, laptops etc) in so everything is reachable when lying down.
 Have torch nearby just in case, and plug in a desk lamp on above power board - you wont want
to be switching off lights you forgot about
 If you have a dvd collection to watch - and a laptop - watch em on the laptop - you wont want to
get up to put the dvds in the player by the tv
 Keep an ACL journal - To help keep you motivated and show progress
 Keep a plastic bottle by couch bed. You will wake up and need to go to the toilet
 Keep a water bottle by couch too. IMPORTANT: Don't get bottles confused in the night.
 Keep towels around the shower area, especially 1-2 to use on the floor - crutches can slip and
cause re-tear
 Always travel with backpack - even to Kitchen or bedroom, will be invaluable for bringing items
back with you.

Postoperative period

Physical therapy will help your regain knee flexion (bending). However, being able to fully extend
(straighten) your knee soon after surgery is vital! If full extension is not achieved within the first eight
weeks, a second surgery may be necessary.

With this in mind, you must NEVER put anything under your knee when you are resting, sleeping, or
propping your leg up. The pillow must go under the heel.

IMPORTANT : NEVER put anything under your knee (see above)

Concerns:

1. Numbness around the incision site on the outside part of the knee is a result of a disruption of a
superficial nerve during the operative procedure. Most of this will resolve over time but a small
area the size of a quarter usually remains numb. This is unavoidable because of the proximity of
the nerve to the incision.
2. A sudden rush or feeling of fullness with pain when going from a sitting to a standing position in
the knee is common after surgery.
Reduce Swelling

You will meet with a physiotherapist after surgery, if possible try and locate a Cryo Cruff to use for the
first week after surgery. This will help reduce swelling at a much quicker rate.

The use of one of these will help speed up the rate at which you can begin your rehabilitation program.

Week 0 - 2:

 The goals of the first two weeks of post-operational rehabilitation are to reduce swelling,
restore full range of motion in extension and flexion, ambulate without the use of crutches, and
sit down and stand from a seated position.

 Proprioception is diminished following injury to the ACL, and it is therefore very important
that this is regained following reconstructive surgery.After surgery, pain and swelling can
inhibit the activity of your muscles. This can quickly result in muscle wasting which
ultimately can lead to abnormal joint movement and can therefore create further
problems.

 During the first week after surgery, rehabilitation is mostly passive. Regular icing and elevation
are used to reduce swelling. Your goal is full extension (or 10 degrees short of that) and 70
degrees of flexion by the end of the first week.You should ice the knee as often as possible
(especially after exercising) to reduce swelling and discomfort. Do not ice the knee more than 20
minutes at a time. Let the knee warm up before reapplication. Avoid getting your wound wet.

Some exercises that you may be able to perform near the end of Week 1 :

1. Gentle knee cap (patella) mobilizations : Sitting with you leg out straight and well
supported, remove or undo your brace. Feel for the edges of your kneecap and using
gentle pressure, slowly push your kneecap from side to side 5-10 times, and also glide it
top to bottom 5-10 times.
2. Passive knee stretch / Knee hang: It is important to regain full extension of your knee as
well as flexion. Place your heel on a block or rolled up towel so there is no support
beneath it, let the knee “hang” for 3-5 mins or as tolerated.
 3. Ankle Pumps : With each foot separately or at the same time, point and flex the toes as if
pumping the gas pedal of a car repeatedly, 25-50 times every five to 10 minutes.
4. Ankle Circles : With each ankle separately or at the same time, rotate the ankles in a large circle
about 10 times each direction, 25-50 times every five to 10 minutes.

Repeat 4-5 times a day or as necessary to get your knee straight

Week 2 - 6:

SECTION 1: RANGE OF MOTION EXERCISES

Days per week: 7

Times per day: 2 - 3

1. Knee extensions : To perform these two exercises, place the heel of your injured leg on an
object that is a few inches thick (like a phone book). Gradually relax and let your leg come to full
extension. This first part of the exercise helps you to maintain a normal range of motion.
2. Quad sets: After your knee has stretched out for a while, perform a set of ten quadriceps
contractions with your leg in the same position as in the Knee extensions. Without lifting your
heel up in the air, tighten your quadriceps muscle as hard as you can for ten seconds. Then relax
for ten seconds before tightening your muscle again. Repeat this ten times. This exercise helps
you to maintain quadriceps strength.
3. Heel Slides: For this next exercise, start with you injured leg stretched out. Then, while keeping
your heel on the floor, gradually bend your knee and slide your heel towards your buttock. Bend
your knee until it becomes just slightly uncomfortable and you can feel a bit of pressure inside
your knee. Hold it in this position for ten seconds. Then straighten your knee out again and relax
for ten seconds. Repeat this exercise ten times as well. This exercise will help you to maintain
range of motion.
4. Straight leg raise: This exercise helps you maintain your quadriceps strength. Start with your leg
flat on the bed. Begin by tightening your quadriceps, as in the quad sets exercise. Then lift your
leg off the bed until your heel is approximately eighteen inches off of the bed and build up to
holding for ten seconds. Lower your leg back down and repeat. Repeat this exercise five times.

SECTION 2: STATIONARY CYCLING

Days per week: 5

Times per day: 1

At this time, you can begin stationary cycling with both legs, using a spin or light resistance
mode. Initially it is suggested that you set the seat height higher than normal so that it is easier to
complete the cycling motion. As the cycling becomes easier, you can adjust the seat height to
your normal level. Begin very slowly; as the knee feels stronger and more comfortable, increase
the rpms with a spin or light resistance mode. Start with approximately 10 - 15 minutes; your
goal will be to achieve 30-45 minutes of cycling. 

SECTION 3: WATER WORKOUT

Days per week: 3

Times per day: 1 

Another excellent way of being able to perform some type of activity, and at the same time keep
range of motion and work the cardiovascular system, is to use the aquajogger exercise program.
It is essential to find a pool that is deep enough so that the feet do not touch the bottom. This
exercise is totally non-weight bearing and will allow for a very low impact type of movement
sequence. We suggest between 20 and 30 minutes of actual jogging in the water per session.

SECTION 4: BALANCE TRAINING ( PROPRIOCEPTION )

Days per week: 5

Times per day: 1

After ACL surgery you need to retrain your leg by also completing balancing exercises. These involve
standing on one leg (your injured leg)  and maintaining balance for 120 seconds. When you are
comfotable doing this, then you try and repeat but this time closing your eyes. This increases the
difficulty.

Two extra items that can be handy for proprioception are a wobble board and a mini trampoline. These
will greatly help in the balance training.

If you purchase a wobble board and/ or mini trampoline then exercise guides come with them. You can
also continue to do the exercise mentioned above. Always try and build up to 120seconds and beyond.
Step 1 is with eyes open, Step 2 with eyes closed and Step 3 is looking at feet and then looking to the
side.
Week 6 - 11:
From six to twelve weeks, emphasis is placed on improved muscular control, proprioception and general
muscular strengthening. Proprioceptive work progresses from static to dynamic techniques including
balance exercises on the wobble board and eventually jogging on a mini-tramp. The injured party should
have a full range of motion during this stage and gentle resistance work should be added. By the end of
this period the patient should be able to cycle normally, swim with a straight leg kick and be able to jog
freely on the mini-tramp.

Continue exercises from the previous section while adding the following :

Lunges:

 Stand with injured foot forward, other foot back about 3 feet apart. Bend the knees to lower the
body towards the floor. Keep the front knee behind the toes and be sure to lower straight down
rather than forward.
 Keep the torso straight and abs in as you push through the front heel and back to starting
position.
 Don't lock the knees at the top of the movement.
 Hold for five seconds and repeat five times.

Lunges should be done for both legs, make sure the knee never goes out in front of the toe.

Squats:

 Place your back against a wall or swiss ball resting on a wall. Position your feet slightly wider
then hip-width apart with your toes slightly turned out.
 Slowly and under control bend your knees and lower yourself to a 90 degree angle without
lifting your heels off the floor and then after a brief pause at the bottom push your weight back
up until you are back at the starting position
 Do 10 to 15 repetitions to finish one set before resting. You can repeat the set, but use your own
discretion as to how much you can manage. Try to go for 5 sets.

Step ups:
Stand behind a 15-inch platform or step. Place the injured foot on the step, transfer the weight to the
heel and push into the heel to come onto the step. Concentrate on only using the injured leg, keeping
the other leg active only for balance.Slowly step back down and repeat all reps on the injured leg before
switching to the other leg. Perform 1-3 sets of 10-16 reps.

Leg Press: Single Leg

Note: Only perform on the uninjured leg, do not use injured leg for this. You want to build up the
strength in the healthy leg.
Hamstring Exercise:
Placing your back against a wall or door, bend the knees to 90 degree angle . Have your feet 12 inches
out in front. Push back against wall/door and hold for ten second. Repeat five times.

Swimming:
Swimming can commence at this stage, but ensure that you only use the flutter kick, avoid breaststroke
until 4 months after surgery as this puts pressure on the ligament. Build up resistance and don't over do
it.

Increasing Load:
During this time period you should look to increase your work in the water and on the stationary bike.
Swelling around the knee should be reduced and you should be pain free. Increase time and resistance
on the bike and begin to swim in order to build back up cardiovascular fitness.

Continue Proprioception drills, e.g. wobble board exercises balancing on two legs, balancing on one leg,
ball tosses while balancing, done with the eyes closed for advanced drills. Repeat for mini- trampoline.

Months 3 - 6
From 3 Months to 6 Months continue with your exercises.You can often begin light jogging(figure of
eight rotations), cycling outdoors, and pool workouts. Side-to-side, pivoting sports -- such as basketball,
soccer and football -- must be avoided.

Toward the end of this phase, some people can begin shuttle runs, lateral shuttles and jumping
rope. I recommend running in a pool throughout this phase while building confidence in the
knee.

Month 6 & Beyond

Increase cardiovascular work and build overall leg strength. If your knee is feeling strong you can begin
to do more dynamic moves like hopping along with vertical and multiple jumps, both legs; hops, one leg
at a time;

continue to concentrate on building hamstring strength to help prevent future injury. Single leg squats
(have a bench behind you when practicing - so if you lose balance you can sit back on the bench) should
be emphasized to help build on the strength you have returned to your knee.

Conclusion
The road back from ACL surgery is a long one, after the initial gains you will find that progress is slow,
your knee feels different and you begin to wonder if it ever will be the same. If you follow a healthy
rehab program and monitor your knee you should beable to return to competitive sports.

Note: Don't worry too much about the 'crunching' sound you will hear/feel when you begin to run again,
this is built up scar tissue that will eventually break down. My main tip is to try and get confidence in the
knee as your muscle - mind connection will have been severly damaged after surgery. It takes a while to
build this back up - and remember warm up & warm down before exercise. I find a stationary bike is
good for loosing my knee before any exercise where i need to use my knee and gives me extra
confidence it wont break down.

If you've recently suffered an anterior cruciate ligament injury (ACL) the following exercises can
get you on the road to recovery.

Exercises you can do as tolerated, include the following.

 Heel slide: Sit on the floor with legs outstretched. Slowly bend the knee of you injured leg
while sliding your heel/foot across the floor toward you. Slide back into the starting position and
repeat 10 times.
 Isometric Contraction of the Quadriceps: Sit on the floor with your injured leg straight
and your other leg bent. Contract the quadricep of the injured knee without moving the leg.
(Press down against the floor). Hold for 10 seconds. Relax. Repeat 10 times.
 Prone knee flexion: Lie on your stomach with your legs straight. Bend your knee and bring
your heel toward your buttocks. Hold 5 seconds. Relax. Repeat 10 times.

Add the following exercises once knee swelling decreases and you can stand evenly on both legs
without favoring the injured knee.

 Passive knee extension: Sit in a chair and place your heel on another chair of equal height.
Relax your leg and allow your knee to straighten. Rest in this position 1-2 minutes several times
a day to stretch out the hamstrings.
 Heel raise: While standing, place your hand on a chair/counter for balance. Raise up onto
your toes and hold it for 5 seconds. Slowly lower your heel to the floor and repeat 10 times.
 Half squat: Stand holding a sturdy table with both hands. With feet shoulder’s width apart,
slowly bend your knees and squat, lowering your hips into a half squat. Hold 10 seconds and
then slowly return to a standing postion. Repeat 10 times.
 Knee extension: Loop one end of Theraband around a table leg and the other around the
ankle of your injured leg and face the table. Bend your knee about 45 degrees agaist the
resistance of the tubing and return.
 One Legged Standing: As tolerated, try to stand unassisted on the injured leg for 10
seconds. Work up to this exercise over several weeks.

The anterior cruciate ligament (ACL) is a vital ligament for proper movement. The ACL receives
more injuries than the other ligaments.[which?] Injuries of the ACL range from mild such as small
tears to severe when the ligament is completely torn. There are many ways the ACL can be torn;
the most prevalent is when the knee is bent too much toward the back and when it goes too far to
the side. Tears in the anterior cruciate ligament usually take place when the knee receives direct
impact[clarification needed] while the leg is in a stable position. Torn ACL’s are most often related to
high impact sports or when the knee is forced to make sharp changes in movement and during
abrupt stops from high speed. These types of injuries are prevalent in soccer, high jump,
basketball, and American football. Research has shown that women involved in sports are more
likely to have ACL injuries than males. ACL tears can also happen among older individuals by
slips and falls and they are seen mostly in people over forty due to wear and tear of the
ligaments. An ACL tear can be determined by an individual if a popping sound is heard after
impact, swelling after a couple of hours, severe pain when bending the knee, and when the knee
buckles or locks during movement.

[edit] Epidemiology
Mountcastle et. al performed a study on gender difference in ACL tears in relationship wih
physical activities.[1] The researchers performed an epidemiology study on young athletic
populations. Preceding studies have signified that women that participate in the same physical
activities as men are more at risk for ACL injuries. The authors hypothesize that the frequency
rate for males and females in the athletic and college aged population is the same. The
procedures for the study was college graduation classes from 1994-2003 at a major institutions.
The players who received a whole tear were examined for apparatus of injury and the type of
sport they played when the injury occurred. The authors calculated the accident rate, opinion of
danger, gender incidents, class year, and the accident rate differentiating men and women. There
was 353 ACL injuries in 10 classes during the span of the study. The researchers calculated a 4
year accident proportion of 3.24 per 100 students for men, and 3.51 for women. Overall, the
ACL injury rate not including male only sports was substantial greater in women with an
incidence ratio of 1.51 (pg 5). Women are more likely to get injured at gymnastics course with
an incidence ratio of 5.67, with an indoor obstacle course test is 3.72, and 2.42 incidence ratio on
basketball. The authors concluded that there is slim gender difference in gender ACL tear. On
the other hand, there were significant gender differences ACL injury rates when particular
specific sports and physical activites were compared. Also, when male only sports were detached
from the whole rate evaluation.

A notable finding is that women are three times more likely to have an ACL injury than men.
The reason is because of the variation of hormone levels. Also, ligament strength of the ACL
handles more force in men than in women. Most importantly, there is substantial difference
neuromuscular coordination and control in landing, women have less hip and knee flexion.
Athletic trainers and team physicians advise female athletes to adapt an ACL conditioning
program.

[edit] Symptoms
Symptoms of an ACL injury include hearing a sudden popping sound, swelling, and instability of
the knee (i.e., a "wobbly" feeling). Pain is also a major symptom in an ACL injury and can range
from moderate to severe.[2] Continued athletic activity on a knee with an ACL injury can have
devastating consequences, resulting in massive cartilage damage, leading to an increased risk of
developing osteoarthritis later in life.

[edit] Causes
ACL injuries occur when an athlete rapidly decelerates, followed by a sharp or sudden change in
direction (cutting). ACL failure has been linked to heavy or stiff-legged landing; as well as
twisting or turning the knee while landing, especially when the knee is in the valgus (knock-knee)
position.

Women in sports such as football (soccer), basketball, tennis and volleyball are significantly
more prone to ACL injuries than men. The discrepancy has been attributed to differences
between the sexes in anatomy, general muscular strength, reaction time of muscle contraction
and coordination, and training techniques. A recent study suggests hormone-induced changes in
muscle tension associated with menstrual cycles may also be an important factor [3]. Women have
a relatively wider pelvis, requiring the femur to angle toward the knees[4]. Recent research also
suggests that there may be a gene variant that increases the risk of injury [5]

The majority of ACL injuries occur in athletes landing flat on their heels. The latter directs the
forces directly up the tibia into the knee, while the straight-knee position places the lateral
femoral condyle on the back-slanted portion of the tibia. The resultant forward slide of the tibia
relative to the femur is restrained primarily by the now-vulnerable ACL.

[edit] Diagnosis
The pivot-shift test, anterior drawer test and the Lachman test are used during the clinical
examination of suspected ACL injury. The ACL can also be visualized using a magnetic
resonance imaging scan (MRI scan).

An ACL tear can be determined by the an individual if a popping sound is heard after impact,
swelling after a couple of hours, severe pain when bending the knee, and when the knee buckles
or locks during movement.

Though clinical examination in experienced hands is highly accurate, the diagnosis is usually
confirmed by MRI, which has greatly lessened the need for diagnostic arthroscopy. MRI has a
higher accuracy than clinical examination in detecting ACL tears when multiple ligaments are
torn. This is of particular benefit if there is a coexisting posterolateral corner injury. Addressing
the posterolateral corner injury at the time of ACL reconstruction will prevent premature graft
failure.

[edit] Anterior drawer test

The anterior drawer test for anterior cruciate ligament laxity is one of many medical tests used to
determine the integrity of the anterior cruciate ligament.[6] It can be used to help diagnose sprain
and tears.

The test is performed as follows: the patient is positioned lying supine with the hip flexed to 45°
and the knee to 90°. The examiner positions themselves by sitting on the examination table in
front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs
are placed along the joint line on either side of the patellar tendon. The index fingers are used to
palpate the hamstring tendons to ensure that they are relaxed; the hamstring muscle group must
be relaxed to ensure a proper test. The tibia is then drawn forward anteriorly. An increased
amount of anterior tibial translation compared with the opposite limb or lack of a firm end-point
indicates either a sprain of the anteromedial bundle of the ACL or a complete tear of the ACL.
This test should be performed along with other ACL-specific tests to help obtain a proper
diagnosis.

[edit] Lachman test

Lachman test

 The knee is flexed at 30 degrees

 Doctor pull on the tibia to identify frontward motion of the lower leg in comparison to the upper
leg.
 A knee that has an ACL tear will have a lot of forward motion at the conclusion of the movement

The Lachman test is a medical test used for examining the anterior cruciate ligament (ACL) in
the knee for patients where there is a suspicion of a torn ACL.[7] The Lachman test is recognized
by most authorities as the most reliable and sensitive clinical test for the determination of
anterior cruciate ligament integrity, superior to the anterior drawer test commonly used in the
past. To do this, lay the patient supine on an examination table. Put the patient's knee in about
20-30 degrees flexion, also according to Bates' Guide to Physical Examination the leg should be
externally rotated. The examiner should place one hand behind the tibia and the other on the
patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity. On pulling
anteriorly on the tibia, an intact ACL should prevent forward translational movement of the tibia
on the femur ("firm endpoint").

Anterior translation of the tibia associated with a soft or a mushy endpoint indicates a positive
test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a
torn ACL ("soft endpoint"), as does 10 mm of total anterior translation. An instrument called a
"KT-1000" can be used to determine the magnitude of movement in mm.

This test can be done in an on-the-field evaluation in an acute injury setting, or in a clinical
setting when a patient presents with knee pain. In either situation, ruling out fracture is important
in the evaluation process. Also when evaluating the integrity of the ACL, it is important to test
the integrity of the MCL, because this is a common ligament torn in an ACL injury as well.[8]
This test is named after orthopaedic surgeon, John Lachman.

[edit] Pivot Shift Test

 Person lies on one side of the body

 Knee is extended and internally rotated
 Doctor applies stress to lateral side of the knee, while the knee is being flexed
 A positive test indicates a crash felt at 30 degrees flexion.

[edit] Prevention
Research has shown that the incidence of non-contact ACL injury can be reduced anywhere from
20% to 80% by engaging in regular neuromuscular training that is designed to enhance
proprioception, balance, proper movement patterns and muscle strength.[9]

A National Institutes of Health funded study is underway with the objective of identifying unique
movement patterns that predispose female athletes to ACL injuries and evaluate and improve
injury prevention programs. The study is overseen by Dr. Christopher Powers at the University
of Southern California's Division of Biokinesiology. An initial phase of the project evaluated the
Prevent Injury and Enhance Performance (PEP) program developed by the Santa Monica
Orthopaedic and Sport Medicine Research Foundation. During the final stage of the study, the
Competitive Athlete Training Zone ("CATZ") in Pasadena, CA the ACL injury prevention
training program is being enhanced and continually improved by CATZ founders Jim Liston and
Kevin Wentz. Information on the PEP program, and the latest developments at CATZ can be
monitored at the project website.[10][11]

[edit] Treatment
The ACL primarily serves to stabilize the knee in an extended position and when surrounding
muscles are relaxed; so if the muscles are strong, many people can function without it. Fluids
will also build the muscle.
The term for non-surgical treatment for ACL rupture is "conservative management", and it often
includes physical therapy and using a knee brace. Lack of an ACL increases the risk of other
knee injuries such as a torn meniscus, so sports with cutting and twisting motions are strongly
discouraged. For patients who frequently participate in such sports, surgery is often indicated.

[edit] Conservative

A torn ACL is less likely to control the movements of the knee. When tears to the ACL is not
repaired it can sometimes cause damage to the cartilage inside the knee because with the torn
ACL the tibia and femur bone are more likely to rub against each other. Immediately after the
tear of the ACL, the person should rest it, ice it ever fifteen to twenty minutes, produce
compression on the knee, and then elevate above the heart; this process helps decrease the
swelling and reduce the pain. The form of treatment is determined based on the severity of the
tear on the ligament. Small tears in the ACL may just require several months of rehab in order to
strengthen the surrounding muscles, the hamstring and the quadriceps, so that these muscles can
compensate for the torn ligament.

[edit] Surgery
Main article: ACL reconstruction

If the tear is severe, surgery may be necessary because the ACL can not heal independently
because there is a lack of blood supply going to this ligament. Surgery is usually required among
athletes because the ACL is needed in order to perform sharp movements safely and with
stability. The surgery of the ACL is usually done several weeks after the injury in order to allow
the swelling and inflammation to go down. During surgery the ACL is not repaired instead, it is
reconstructed using other ligaments in the body. There are three different types of ACL surgery.
Patella tendon-bone auto graft and hamstring auto graft are the most common and preferred
because it produce the best results. After the surgery, rehabilitation is required in order to
strengthen the surrounding muscles and stabilize the joint.

There are two main options for ACL graft selection, allograft and autograft. Autografts are the
patients' own tissues, and options include the hamstring tendons or middle third of the patella
tendon. Allograft is cadaveric tissue sourced from a tissue bank. Each method has its own
advantages and disadvantages; hamstring and middle third of patella tendon having similar
outcomes. Patellar grafts are often incorrectly cited as being stronger, but the site of the harvest
is often extremely painful for weeks after surgery and some patients develop chronic patellar
tendinitis. Replacement via a posthumous donor involves a slightly higher risk of infection.
Additionally, donor grafts eliminate tendon harvesting which, due to improved arthroscopic
methods, is responsible for most post-operative pain.

The surgery is typically undertaken arthroscopically, with tunnels drilled into the femur and tibia
at approximately the original ACL attachments. The graft is then placed into position and held in
place. There are a variety of fixation devices available, particularly for hamstring tendon
fixation. These include screws, buttons and post fixation devices. The graft typically attaches to
the bone within six to eight weeks[citation needed]. The original collagen tissue in the graft acts as a
scaffold and new collagen tissue is laid down in the graft with time. Hence the graft takes over
six months to reach maximal strength.[citation needed]

After surgery, the knee joint loses flexibility, and the muscles around the knee and in the thigh
tend to atrophy. All treatment options require extensive physical therapy to regain muscle
strength around the knee and restore range of motion (ROM). For some patients, the lengthy
rehabilitation period may be more difficult to deal with than the actual surgery. In general, a
rehabilitation period of six months to a year is required to regain pre-surgery strength and use.
[citation needed]
This is very dependent on the rehabilitation assignment provided by the surgeon as
well as the person who is receiving the surgery. External bracing is recommended for athletes in
contact and collision sports for a period of time after reconstruction. It is important however to
realize that this type of prevention is given by a 'surgeon to surgeon' basis; all surgeons will
prescribe a brace and crutches for post surgery recovery total usage time is one month. After
surgery no sports for 6 to 7 months. Whether the ACL deficient knee is reconstructed or not, the
patient is susceptible to early onset of chronic degenerative joint disease.

[edit] Rehabilitation

The rehabilitation process is the most important part of the surgery. There is a long and rigorous
process involved in getting back to one hundred percent. The doctor will start the patient on the
rehabilitation program, which is broken down into phases:

Phase 1: This step is called the early rehabilitation phase. This is basically the things that were
covered in short term, things to reduce pain and swelling while gaining movement.

Phase 2: This phase covers weeks 3 and 4. At this point the pain should be subsiding and the
patient will be ready to try more things that their knee isn’t willing perform. That is why there is
a lot of emphasis put on joint protection during this step. The patient will be able to start doing
exercises such as mini wall sits and riding stationary bikes. The aim of this is to be able to bend
the knee 100 degrees.

Phase 3: This phase is known as the controlled ambulation phase and it covers weeks 4 to 6. At
this point the patient will be doing the same exercises from phase 2 plus some more challenging
ones. The patient will try to get their knee to bend 130 degrees during this stage. The aim during
this period is to focus heavily on improving balance.

Phase 4: This is the moderate protection phase and it covers weeks 6 to 8. In this period the
patient will try to obtain full range of motion as well as increase resistance for the workouts.

Phase 5: This is the light activity phase and it covers weeks 8 to 10. This period will place
particular emphasis on strengthening exercises with increased concentration on balance and
mobility.

Phase 6: This is the return to activity phase and it lasts from week 10 until the target activity
level is reached. At this point the patient will be able to start jogging and performing moderately
intense agility drills. Somewhere between month 3 and month 6 the surgeon will probably
request that the patient perform physical tests so s/he can monitor the activity level. When the
doctor feels comfortable with the progress of the patient, s/he will clear that person to resume a
fully active lifestyle.[12]

[edit] Prevention
ACL injury prevention should be taken sincerely. The best way to prevent an ACL injury is to
implement and add warm up drills like jumping and balancing. These drills will induce increase
neuromuscular control and conditioning. In turn, muscular reactions will improve thus
decreasing the risk of an ACL injury. A warm up program of at least 15 minutes 2-3 times per
week is essential in order to prevent an ACL injury. Identifying the causes of the ACL and how
painful they are the best way to avoid or escaped a painful experience it is to stretch the ligament
before a physical activity. The leg muscles like the quadriceps and hamstrings have to be made
stronger.

 Backward running to warm up the hip extensors and hamstrings

 One of the fundamental ways to avoid an ACL injury is to not wear shoes that have cleats in
contact sports.
 When a person has already suffered an ACL injury, but wants to return to competitive sports,
the best way to prevent another injury is to strengthen the quadriceps and hamstrings.
 Another way is to change mechanics like pivoting, cutting excessively because it puts extra stress
on the knee.
 Overall, sports like football, soccer, basketball, and other contact sports the risk is always high.
 The best way is to wear a knee brace.

Stretching

Stretching the quadriceps and hamstrings before an event will also prevent ACL injury because it
promotes flexibility, decrease firmness, and increase performance. The muscle stretching has to
be done in reps.

File:Quad stretches.jpg

Quaricep Stretching

 Calf Stretch 1-2 minute of stretching the lower leg muscles. Ankle circles will stretch the
gastrocnemius.
 Quadriceps- 2–3 minutes of seated butterfly 3 reps of 20 seconds
 Hamstrings-1 minute of wall sits 2 reps of 30 seconds
 Inner thigh stretch- 1 minute of knee to chest
 Hip flexors-2 reps of at least 20 seconds of lunges
Accelerated Rehabilitation Following Anterior
Cruciate Ligament Replacement Surgery
Bertram Zarins, MD, William B. Workman, MD, Alex Petruska, PT

INTRODUCTION

Operative procedures to stabilize knees that have suffered ligamentous injuries have recently undergone
dramatic changes. Knees that have sustained multiple ligament tears are often initially treated non-
operatively to allow the collateral ligaments to heal. The torn cruciate ligaments are replaced at a later
time using arthroscopic techniques.

Concepts regarding post-operative rehabilitation following reconstructive knee surgery have also
changed. Instead of immobilization, early motion is encouraged after surgery. An extension of this
approach is to use immediate and continuous controlled motion of the knee following anterior cruciate
ligament (ACL) replacement surgery. Donald Shelbourne developed the concept of accelerated
postoperative rehabilitation. (9,10) This article will describe the postoperative rehabilitation proto-col that
is used by the senior author (BZ) at the Massachusetts General Hospital that balances early return to
sports participa-tion with adequate time for graft healing.

METHODS

We use the accelerated rehabilitation protocol when we replace a torn anterior cruciate ligament with a
mid-third patellar tendon graft (bone-tendon-bone) using the endoscopic method. Bioabsorbable
interference screws are used in the distal femur and proximal tibia, providing graft fixation comparable to
metal screws. (18,19) This technique provides immediate stable fixation and allows the knee to be safely
moved using the continuous passive motion (CPM) machine after surgery.

We believe the autologous mid-third patellar tendon graft is the best graft for ACL replacement surgery,
and we use this graft in all patients in whom we are replacing a torn ACL unless the patient strongly
desires an alternative graft. If the patient has had a prior patellar tendon graft that has failed, we use
hamstring tendon autograft for revision surgery, if available. We do not use the accelerated rehabilitation
program described herein following revision ACL replacement surgery.

Dr. Zarins is Chief, Sports Medicine Service,

Massachusetts General Hospital and Associate
Clinical Professor of Orthopaedic Surgery,
Harvard Medical School

Dr. Workman is a Fellow in Sports Medicine,

Harvard Medical School and Massachusetts
General Hospital

Alex Petruska is a Physiotherapist at the

Massachusetts General Hospital

Please address correspondence to:

Bertram Zarins, MD
Wang Ambulatory Care Center
Suite 514
Massachusetts General Hospital
Boston, MA 02114
bzarins@partners.org

Rehabilitation:

Preoperative protocol

The patient is seen in the office several days before surgery, at which time a preoperative history and
physical examination are performed. After the surgeon explains the procedure, the patient watches a
video tape detailing the preoperative instructions, surgical procedure, risks, benefits, complications,
anesthesia and postoperative course. A physical therapist explains the exercises that will be
accomplished during the first week after surgery.

Phase I

Phase I begins immediately after surgery. The doctor applies a continuous passive motion (CPM)
machine to the patient’s knee in the operating room, before the patient awakes. The patient remains in
the hospital overnight, using the CPM machine continuously. The patient is discharged home the
following morning after receiving final instructions on the operation of the CPM machine from a physical
therapist. A hinged postoperative brace locked in extension is fitted to be used during ambulation. The
patient is allowed to ambulate, full weight bearing, with the postoperative brace in place using crutches.

The patient remains at home for the first Table I

seven days after surgery with the knee
moving 23 hours a day in the CPM machine. Goals of Phase I Phase I Exercise
The remaining one-hour per day is designated
for necessary activities of daily living and to Protect the 1. Heel Prop for
perform prescribed exercises three times a reconstruction—avoid passive knee
day (Table 1). Pain medication is pre-scribed falling extension
as well as elastic stockings and cryotherapy.
By the end of the first week the patient should
have full knee extension, and 90 degrees of Ensure wound healing 2. Prone Hang for
knee flexion. passive knee
extension

The CPM machine is set to hyperextend five Attain and maintain full 3. Quadriceps Setting
degrees in which position it pauses for five knee extension with emphasis on
seconds (extensor pause control on CPM gaining active control
machine). The importance of having the knee of the “screw home”
go into full extension with each cycle of the mechanism
CPM is stressed to the patient, as flexion Promote quadriceps 4. Heel Slides to gain
contracture may develop in the absence of muscle strength flexion range of motion
vigilant attention to regaining full extension.
The speed at which the CPM moves and the
amount of flexion reached are not as Gain knee flexion to 5. Sitting Heel Slides
important near 90 degrees to gain flexion range of
motion
Decrease knee and 6. Ankle pumps
leg swelling Avoid
blood pooling in the
 leg veins

Phase II – one to five weeks after surgery

At the end of the first postoperative week, the patient returns to the office for suture removal and
examination by the surgeon. The postoperative brace is shortened, but the hinges remain locked in
extension. The patient is instructed Phase II exercises which will be followed for the next four weeks. Full
weight bearing is encouraged, and the postoperative brace and crutches may be used as needed for
support and comfort. The patient may progressively discontinue using the crutches and brace as soon as
the knee feels strong enough to be stable. Most patients discontinue the brace and crutches at
approximately two weeks after surgery. Gait is independent (without brace or crutches) between 3 and 5
weeks postoperatively.

Table 2 The patient is instructed to continue all

exercises from Phase I during this time. Phase
Goals of Phase II Phase II Exercise II exercises are added, to be done twice per
day (Table 2). The brace is removed when
Protect the 1. Towel extension exercising. Stationary cycling with no resistance
reconstruction—avoid stretch with quadriceps is recommended on a daily basis for 10 to 15
falling setting minutes. If the patient does not have enough
knee flexion to complete a full revolution, then
he or she pedals back and forth until the knee
Ensure wound healing 2. Straight leg lift will flex enough to allow a full cycle.

Maintain full knee 3. Standing hamstring Phase II exercises include the towel extension
extension (straighten curl stretch with quadriceps setting. The patient,
knee fully) while sitting on the floor or bed, loops a towel
around the foot of the operated knee. The
patient lets the knee extend fully and flatten
Begin quadriceps 4. Standing toe raises against the surface he or she is sitting on. The
muscle strengthening patient is instructed to pull gently on the towel
with both hands until the heel lifts slightly from
Attain knee flexion of 5. Hip abduction the surface while keeping the posterior aspect
90 degrees or more of the knee and calf against the surface. This
action helps passively extend the knee to full
extension. While holding this position, the
Decrease knee and 6. Mini-squat patient should actively tighten the quadriceps
leg swelling muscle and hold the contraction for five to ten
seconds. The next exercise is the straight leg
lift. If the knee has an extensor lag, the patient
Normal gait without 7. Wall slide
should not do this exercise.
crutches

The patient should keep trying to do the quadriceps setting exercise until he or she can lift the limb off the
bed without letting the knee flex. Additional exercises include standing hamstring curls for active knee
flexion and standing toe raises. The wall slide involves supporting the body against a wall and gently
squatting to 30-45. Rounding out the Phase II exercises are side-lying hip abduction, mini-squats from 45
to 60 degrees knee flexion, and the wall slide from 45 to 60 degrees knee flexion.

Phase III – five to nine weeks after surgery

Phase III begins at week five and continues through week nine (Table 3). Swimming may begin at this
time, using only the standard freestyle kick, also called the flutter kick. This kick allows only vertical
scissoring motion of the legs in the sagittal plane, avoiding rotational movements involved in other kicks
(e.g. the breaststroke kick). The strokes that are allowed are the freestyle and backstroke. Swimming with
a kick board is allowed as long as the flutter kick is used.

If full knee extension has been gained and the Table 3

knee can be held fully extended during a
Goals of Phase III Phase III Exercise
quadriceps set, the Phase I exer-cises can be
discontinued. However, quadriceps-setting
exer-cises should continue. Resistance using 1. Protect the 1. Chair squat
ankle weights is added for the hamstring curls reconstruction; avoid
and straight leg lifts, and the exercise frequency falling.
is reduced to 3 times per week. The
development of single-leg strength is 2. Maintain full knee 2. Single limb
emphasized at this time. Quadriceps setting extension concentric eccentric
exercises should continue daily to ensure that closed chain
full active knee extension is being maintained. extensions
An optional regimen of weight room exercises 3. Attain full knee 3.Single limb wall
can be performed during Phase III. For patients flexion slides
who wish to use gym equipment the following
exer-cises are considered optional: leg press,
quadriceps machine, and hamstring curl 4. Walk with a normal 4. Single limb calf
machine. The knee extension machine and heel-to gait with no raises
Stairmaster are to be avoided, as they cause limp.
high patellofemoral contact forces (20,21)
which can cause, or exacerbate, anterior knee 5. Muscle strength and 5. Hamstring stretch
pain following ACL replacement surgery. The conditioning
patient must refrain from running, jumping, improvements
pivoting, and sudden changes in direction.
6. Quadriceps stretch

  7.Calf stretch

Phase IV – from ten weeks following surgery

From the tenth week forward, the patient is in Phase IV of the accelerated ACL rehabilitation protocol.
The goals to be attained in Phase IV are to regain full muscle strength, improve cardiovascular
conditioning, and perform sports-specific train-ing.

Table 4 The patient is instructed to continue muscle-

strengthening exercises from Phases II (Table
Phases of Running Prerequisites for 2) and III (Table 3) three times per week. To
Progression Running Progression build cardiovascular fitness, the patient is
allowed to use any combination of Nordic track,
1. Straight ahead 1. Full range of motion stationary bicycle, rowing machine and
phase swimming. For patients who wish to return to
running sports, the patient does an orderly
sequence of drills designed to retrain the
2. Direction change 2. Strength at least proprioceptive feed-back loops necessary to
phase 80% of the uninjured provide neuromuscular control of the operated
limb knee, but does not usually begin running until
3. Advanced direction 3. Thigh girth within _ four to six month after surgery (Table 4). The
change and impact inch of the uninjured goals of phase IV are to safely recondition the
phase limb knee, provide a logical sequence of pro-
 4. Sports specific 4. Symmetrical gressive drills for presports conditioning and to
phase quadriceps and provide objec-tive criteria for the patients safe
hamstring flexibility return to sports (Table 5). Sport-specific training
and development of functional strength and
proprioceptive timing are enhanced and
  5. Perform and pass improved as the patient advances throughout
functional testing the running progression.

Table 6
Activity Weeks Postoperative

1. Jogging 12

2. Slow start-to-slow 16
stop forward and
backward running

3. Fast start-to –fast 20

stop forward to
backward running

4. Zig-zag running 26

5. Circle running 26

6. Figure-of –eight 26
running

7. Carioca running 28

8. Hop-to-jump 30
progression

9. Run-to-cut 32
progression

10. Sports-specific 34
practice

11. Full return to sports 40

 
Table 5
Functional Test to Prerequisites for
Advance to Running Advancing to
Phases Direction Change
Phase
1. Hop forward on both 1. Hop forward on the
legs at least two feet affected limb for at least
80% of the distance of
the unaffected side
2. Hop to either side on 2. Hop to either side on
both legs at least one the affected limb for
foot 80% of the distance of
the unaffected
3. Hop up and down on 3. Hop up and down on
both feet 10 times the affected limb for 10
symmetrically times without pain
4. Jog with no limp for
100  
feet

A functional brace for sports participation is not

routinely prescribed if the knee is stable after
surgery. The patient is advised to continue all
strength and conditioning drills as part
of a regular fitness and training routine. The
patient typically begins unrestricted running at six
months after surgery, and unrestricted sports at
nine months.

Discussion

The trend to begin immediate mobilization after ACL replacement surgery with continuous passive motion
was first documented in the literature in the early 1980’s (1,7) . Over time, the success with this change in
rehabilitation has convinced many orthopaedic surgeons to add early motion in their rehabilitation
protocols. (8,15) Often the recovery has been so rapid that athletes have been able to return to play
before the graft and/or donor site(s) have healed. In an attempt to push the envelope for return to play,
reports of untoward effects such as patella fracture have reached the media. (4,12,14) Experience at both
ends of the mobility spectrum has led us to an acceptable timetable for rehabilitation and return to play.

Ample evidence suggests that motion and physiologic loading are essential for proper maintenance and
function of articular cartilage. (1) Lengthy immobilization leads to muscle and cartilage atrophy,
osteoporosis, and arthrofibrosis. Biomechanical studies suggest that early motion without load bearing will
not put the graft or the graft fixation in jeopardy. (16,17)

It is of particular importance to remember that the graft and the patella donor site are probably the
weakest at about 3 months. (2,6) This data emphasizes the importance of maintaining motion and
continuing strengthening without stressing the graft. Bennyon noted that the anteromedial bundle of the
ACL is most stressed towards terminal extension. (4) Because of this, there are some physicians who
recommend that patients perform active extension against resistance up to, but not fur-ther than, 40
degrees.

A crucial element of the rehabilitation protocol is regain-ing full extension of the knee. Shelbourne noted
that athletes complained of less extremity pain and fatigue after he began emphasizing extension in
rehab. (10,11)
Many researchers have noted that open chain kinetic exer-cises markedly increase the shear stresses
across the graft, which likely put the graft at risk for stretching or rupture. (3,5,12,13) Closed chain
exercises, on the other hand, decrease forces across the patellofemoral joint and all but eliminate shear
stress to the tibia, particularly when exercises are performed between 30° and 90° of flexion. (1,7,11,12)

There is evidence to suggest that patients with ACL tears, regardless of whether they have surgery or not,
never fully regain quadriceps strength on the affected side. Shelbourne has stated that the best predictor
of regaining quadriceps function was a motivated athlete. The most motivated athletes he observed
gained 85% to 90% of function at 10 weeks. (9)

Our protocol, unlike the regimens of many other surgeons, minimizes loading of the patellofemoral joint.
Patellar tendonitis, anterior knee pain and effusion are common after ACL replacement surgery. We
believe that these complications are secondary to some rehabilitation protocols’ reliance on modalities
such as stair climbing, lunges and squats for muscle strengthening. Our protocol uses other quadriceps
exercises that minimize patellofemoral loading while providing adequate strengthening of the quadriceps
muscles. Patients are allowed to discontinue wearing a hinged postoperative knee brace when they have
demonstrated good quadriceps strength.

In summary, our rehabilitation protocol following ACL replacement surgery combines early motion with
protective strengthening exercises. We have used this protocol for the past five years with all patients
who have undergone primary patellar tendon autograft ACL replacement. Since the patients themselves
control the amount of flexion during use of the CPM machine, we have encountered very few
complications with this accelerated rehabilitation protocol. The goal of this innovative approach is to get
the athlete back to playing sports as early and as safely as possible.

Definition
© Reed Group

Anterior cruciate ligament (ACL) repair is a reconstructive procedure used to restore the integrity
and function of the ACL after it has been stretched or torn from the skeletal structure of the knee.
Unlike other body tissues, the ACL does not heal or repair itself after injury.

The ACL is a powerful ligament extending from the top-front surface of the shinbone (tibia) to
the bottom-rear surface of the thighbone (femur). The ligament prevents instability in the front of
the knee joint (anterior instability). The ACL lies in the middle of the knee, prevents the tibia
from sliding out in front of the femur, and provides rotational stability to the knee. This stability
is particularly important to athletes or individuals whose activities include running or kicking.

ACL injury can occur when an individual comes to a quick stop (sudden deceleration); suddenly
changes direction while running, pivoting, or landing from a jump; or overextends the knee joint
in either direction. The ACL is the most commonly injured major knee ligament. Injury
prevention includes hamstring-strengthening exercises and the use of proper techniques when
playing sports or exercising.

Many cases of ACL injury occur in conjunction with other knee injuries. Approximately 50% of
individuals with ACL injuries also have meniscal tears (Hubbell).

Risk: Risk for ACL injury is higher for athletes in certain sports, such as football, basketball,
soccer, and skiing. Female athletes are 2 to 8 times more likely to tear the ACL than male
athletes. Studies reveal a two-fold increase among female college soccer players and a four-fold
increase among female basketball players compared with their male counterparts. Additional
studies are under way to determine why this occurs, but it may be due to variations in training,
differing strength-to-weight ratios, joint laxity, or muscle recruitment patterns (Hubbell). Recent
studies have discounted the idea that female ACL laxity is due to changes in the menstrual cycle
(Belanger).

Some individuals may be more prone to ACL injury for structural reasons (e.g., those with
femoral notch stenosis).

Incidence and Prevalence: Approximately 100,000 individuals undergo ACL repair in the US
each year (Hubbell).

Source: Medical Disability Advisor

Reason for Procedure

The purpose of ACL reconstruction is to restore the strength and function of the ACL, thus stabilizing the
knee joint. This helps to prevent additional serious damage to the knee and slow the onset of
degenerative arthritis.

Source: Medical Disability Advisor

How Procedure is Performed

ACL reconstruction is usually scheduled at least 3 weeks after the injury to avoid the complication of
arthrofibrosis (the formation of dense fibrous scar tissue within the joint). Surgery may be performed as
an open procedure or may use a special instrument that is inserted through a small incision (arthroscopic
procedure). Most individuals are given general anesthesia, although ACL repair can be performed under
spinal or regional anesthesia.

Tendons cannot be repaired by sewing them back together. The ligament is reconstructed by taking a
piece of tendon from a different part of the body (autograft) or from a donor (allograft) and connecting it
to the shinbone and thighbone. Although there are different methods for ACL reconstruction, they all
involve the same basic procedure. An incision is made in the individual's leg, and small tunnels are drilled
into the bone. Then the new or harvested ACL is brought through the tunnels and secured with a staple-
and-buckle system. Proper tension is crucial, since a lax graft may not restore stability to the knee,
whereas a graft that is too tight may fail or limit knee range of motion.

Patellar tendon autograft uses the individual’s own patellar tendon, which connects the kneecap (patella)
to the shinbone (tibia). The middle third of the tendon and a small portion of the bone on either end are
harvested and used as the new ACL. This method allows a high rate of return to pre-injury levels of
activity. However, 10% to 40% of individuals who undergo this procedure have postoperative anterior
knee pain (Hubbell).

Another autograft method of ACL reconstruction uses the individual's hamstring tendons
(semitendinosus-gracilis), which connect muscles in the back of the thigh to the lower leg. A small
portion of these two tendons is removed through an incision in the individual's leg and looped to form a
strong new ACL. This method is associated with faster recovery from surgery and less anterior knee pain.
Some critics believe this method to be more susceptible to graft stretching (elongation).

A third method of ACL reconstruction, an allograft, uses tendon from an organ and tissue donor
(cadaver). This method does not disrupt other structures within the individual’s knee or leg to obtain
grafts. However, allografts must be properly sterilized. Synthetic grafts are no longer used due to high
rates of complications (Hubbell).

Source: Medical Disability Advisor

Prognosis
In general, conservative treatment of an injured ACL has a variable long-term prognosis. Individuals who
are sedentary, or who engage only in light manual work and sports that do not require abrupt stops or
changes of direction, may benefit from nonoperative treatment of minor instability. The goal of
conservative treatment is to return range of motion and strength comparable to those of the uninjured
knee. Nonoperative treatment may result in a mildly increased risk for recurrent injury, meniscal
damage, and onset and progression of osteoarthritis.

Individuals with major instability or those who do heavy labor or engage in high-demand recreational
activities are candidates for ACL reconstruction. The procedure relieves symptoms, improves function,
and reduces the risk of osteoarthritis. ACL reconstruction restores activity level and stability in 75% to
95% of cases. The ACL repair failure rate is approximately 8% and is largely attributable to recurrent
instability, graft failure, or arthrofibrosis (Hubbell).

Source: Medical Disability Advisor

Rehabilitation
Note on research and authorship
Rehabilitation, requiring months of intense exercise, is recommended for successful recovery
from a surgical repair of the anterior cruciate ligament. Rehabilitation following anterior cruciate
ligament repair follows a structured process beginning immediately after the surgical repair and
ending with the individual returning to work and other activities (Ageberg; Mikkelsen). The
entire process can take up to 9 months.

Phase 1: Initially in Phase 1, the physical therapist uses modalities, such as cold packs, to
decrease postoperative pain. The physician may request very gradual weight-bearing immediately
after the anterior cruciate ligament repair. A rehabilitation brace, also called a postoperative
brace, is used immediately after surgical repair in an effort to put the joint at rest and help protect
it while still allowing appropriate but limited motion. This form of bracing is available in two
particular types: a straight immobilizer and a hinged brace. Straight immobilizers are made of
foam with two metal rods down the side that are secured with Velcro and prevent all motion. The
hinged brace allows range of motion to be set by tightening a screw control.

Once pain and swelling are controlled, range of motion is started in rehabilitation and performed
as tolerated, as guided by the surgeon. This phase continues with isometric exercises, such as the
quadriceps set. Ankle range of motion of the involved lower extremity should be encouraged
intermittently throughout the day to promote blood circulation. By the end of this phase, crutch
walking should be easily tolerated.

Phase 2: This phase usually begins at the end of immobilization, when swelling is controlled and
pain is minimal. Goals of rehabilitation are to achieve full and pain-free motion of the knee joint
along with strengthening of, in particular, the quadriceps and hamstring muscle groups, and all
muscles in the involved leg (Liu-Ambrose).

Phase 3: This phase is considered the intermediate stage of rehabilitation. The criteria for
beginning Phase 3 is no swelling, minimal to no pain and almost full range of motion. The
individual is encouraged to walk, with weight bearing restrictions as indicated by the surgeon,
and may be allowed to return to light work. For some individuals, this phase may not be reached
for several months longer. More intense exercising, with increased resistance, is called for during
this phase. Cycling and proprioceptive exercises may be attempted at this time.

Phase 4: In this phase, resisted exercise is initiated by the therapist. At the completion of Phase 4
of the rehabilitation for anterior cruciate ligament repair, the individual should have full range of
motion, no symptoms, and functional stability with the involved limb demonstrating no more than
10% deficit of strength compared to the uninvolved leg.

Phase 5: This phase focuses on the individual's reinstatement to work as exercise is now directed
toward work requirements. The physician may prescribe a brace to be worn by the individual at
the onset of resuming functional activities, when the individual returns to work, training, or
competition.

Generally speaking, rehabilitation of the anterior cruciate ligament will vary depending on the
type of surgery that was performed, the location from which the graft was harvested, and whether
any associated supporting ligament and cartilage were also injured and/or repaired.

Additional information may provide some insight into the rehabilitation needs of these
individuals (Thomson; Wu).
FREQUENCY OF REHABILITATION VISITS

Surgical

Repair, Anterior Cruciate

Specialist
Ligament

Up to 40 visits within 26
Physical Therapist
weeks

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It
provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor

Complications
Associated conditions include injuries to other structures in the knee, such as tears to the crescent-
shaped discs of fibrocartilage attached to the superior articular surface of the tibia (menisci), fractures of
the patella, and osteoarthritis.

Many ACL reconstructions are successful. Common complications include a decrease in knee range of
motion (which can be minimized by early rehabilitation) and anterior knee pain. Less common
complications include fractures of the patella and patellar tendon rupture (Hubbell). The quadriceps
tendon can also rupture, depending on the site where the graft was harvested.

About 8% of ACL reconstructions fail (Hubbell). These failures are usually due to recurrent instability,
ongoing pain, or arthrofibrosis (scar tissue build-up inside the knee joint). Other surgical complications
include infection, bleeding, stiffness of the joint, vein inflammation (phlebitis), and complex regional pain
syndrome (CRPS). Improper placement of the graft can cause impingement and require additional
surgery. Grafts rupture in approximately 2.5% of cases (Hubbell). If symptoms return after surgery,
hardware removal may be necessary.

Any type of surgery is associated with potential risks and complications that may include, but are not
limited to injury to blood vessels and nerves around the knee (less than 1%); blood clots in the legs (deep
vein thrombosis), which may break off and go to the lungs (embolism) (less than 1%); and infection (less
than 1%) (Hubbell). Small areas of diminished sensation in the front of the knee are common and usually
do not present a problem.

Source: Medical Disability Advisor

Return to Work (Restrictions / Accommodations)

Limited weight-bearing, use of a knee brace, and rest periods for elevation of the leg would be expected
at work during the early stages of recovery. Long-term use of a protective knee brace may be
recommended. Individuals should refrain from activities requiring squatting, jumping, and abrupt turning
or twisting. Postoperative medications may include nonsteroidal anti-inflammatory drugs (NSAIDs) and
prescription painkillers (opioid analgesics). Use of analgesics and other medications can affect dexterity
and alertness. Review of drug policies may be required to accommodate this use.

Post Knee Surgery Exercises

Knee surgery might be the best solution for chronic knee pain or traumatic injury. Knee surgeries
have a high success rate, and the prognosis for return to full function is high. After knee surgery,
your doctor or physical therapist will prescribe exercises to help you recover quickly and
efficiently. By actively participating in your healing by exercising, you can have a positive
impact on your recovery.

Early Post-surgery
1. Range of motion is typically limited immediately after knee surgery. Swelling can negatively
affect your knee flexion and extension range. Early exercises are designed to help regain the
ability to fully flex and extend your knee and to maintain the range of motion in other joints,
such as the hips and ankles. Your surgeon or a physical therapist will provide a list of exercises
for you to perform. Some typical post knee surgery exercises include the following:

Quad sets: Place a rolled towel beneath your knee and contract your quadriceps muscles to
push your knee down against the towel roll. This exercise helps to regain knee extension, or
straightening of the knee.
 Heel slides: While lying on your back, slowly bend your knee and slide your heel up toward your
buttocks. Gently reverse the motion, and slide your heel back so that your knee straightens.

Straight leg raises: Contract your quadriceps muscles to straighten your knee as much as
possible. Lift your leg off the bed while maintaining your knee as straight as you can.

Ankle pumps: Contract the calf muscles to point your toes, and then raise your toes toward your
head. Continue to alternately point then raise your toes.

Continued Recovery
2. As your range of motion improves, you need to begin to strengthen the muscles around your
knee. Strong quadriceps and hamstrings will make your recovery quick. Exercise cycles can help
increase your range of motion, and by increasing the resistance they can help strengthen your
muscles. Begin cycling by keeping the resistance low, and gradually build up the duration and
intensity.

Your physical therapist will tell you when it is appropriate to change your exercise routine to
include more strengthening exercises. Advanced exercises include the following:

Mini squats: Stand and hold onto a walker, railing or other firm surface for support. Slowly bend
your knees and lower your body until your knees bend approximately 90 degrees. Raise your
body back up to a standing position and repeat.

Kick-backs: Wear ankle weights. From a standing position, kick your lower leg back behind you
while maintaining your thigh in a vertical position. This helps strengthen your hamstring muscles
while improving your active knee flexion range of motion.

Long-Term Recovery
3. Full recovery might take several weeks or longer. During that time, continue to be active and use
your knee as much as possible. Walking and climbing stairs are excellent exercise choices that
will help your strength return, and in many cases, improve.

Read more: Best Way - Post Knee Surgery Exercises | eHow.co.uk

http://www.ehow.co.uk/way_5375045_post-knee-surgery-exercises.html#ixzz0rJ1Efxdk

Rehabilitation

Anterior cruciate ligament rehabilitation has undergone considerable changes over the past
decade. Intensive research into the biomechanics of the injured and the operated knee have led to
a movement away from the techniques of the early 1980's characterized by post operative casting
and delayed rehabilitation, to the current early rehabilitation program.
The major goals of rehabilitation following ACL surgery are:

 restoration of joint anatomy;

 provision of static and dynamic stability;
 maintenance of the aerobic conditioning and psychological well being; and
 early return to work and sport.

These have required the development of an intensive rehabilitation program in which the patient
has to take an active involvement.

The graft undergoes physiological changes during its incorporation, as fibroblastic activity
changes the biology of the graft to become more ligamentous. The graft is weakest between six
and twelve weeks post operatively so programs must be designed to protect the graft during this
period. On the other hand investigations into ligamentous healing have shown that progressive
controlled loading provides a stimulus for healing which improves the quality of graft
incorporation. More over, early immobilization has advantages such as maintenance of articular
cartilage nutrition and retention of bone mineralization.

Kinematic research has shown quadriceps contraction causes greatest strain on the anterior
cruciate ligament graft between 10° and 45° of flexion. The anterior cruciate ligament graft lacks
the normal mechanoreceptors that provide biofeedback in the uninjured knee. All these factors
must be taken into account when designing rehabilitation programs.

Our current accelerated rehabilitation program is divided into four phases. In the first one to two
weeks the aims of therapy are to decrease pain and swelling, and increase the range of motion of
the knee. A post-operative brace is ranged from 30 to 90° and is used until there is adequate
quadriceps control. Physiotherapy including CPM is used immediately post operatively. In this
early phase there is an emphasis on static contraction of the hamstrings and co-contractions of
the hamstrings and the quadriceps. Crutch -walking with partial weight bearing is allowed and
the usual modalities are used to reduce pain and swelling.

During the second phase, from two to six weeks, the emphasis is on increasing the range of
motion, increasing weight bearing and gaining hamstring and quadriceps control. The patient is
usually out of the brace by the third to fourth week. During this phase gait re-education and static
proprioception exercises commence. This may include balancing on the affected leg,
biofeedback techniques and pool work to maintain conditioning and range of motion.

During the third stage, from six to twelve weeks, emphasis is placed on improved muscular
control, proprioception and general muscular strengthening. Proprioceptive work progresses
from static to dynamic techniques including balance exercises on the wobble board and
eventually jogging on a mini-tramp. The patient should have a full range of motion during this
stage and gentle resistance work should be added. By the end of this period the patient should be
able to cycle normally, swim with a straight leg kick and be able to jog freely on the mini-tramp.
The fourth phase of rehabilitation from twelve weeks to six months involves the gradual re-
introduction of sports specific exercises aimed at improving agility and reaction times and
increasing total leg strength.

An elite athlete who has had a technically well performed early reconstruction of the anterior
cruciate ligament followed by an adequate and successful rehabilitation program, should be able
to return to the field of his chosen sport between six and nine months. This has been achieved in
many Australian, Olympic and professional athletes.

ACL Exercises After Surgery

An injury to your anterior cruciate ligament, also known as your ACL, can take months, even years to
fully recover from. A serious ACL injury often requires surgery and the surgery requires intense
rehabilitation in order to get your knee back in full working order. Knowing what exercises to do in order
to rehab your knee more efficiently can improve your health and help get you back on your feet.

Ankle Pumps

Every five to 10 minutes, flex and point your toes repeatedly. The motion should be as if you are
continuously pumping the gas pedal in a car. You can do this exercise with both feet simultaneously or
with each foot separately. According to eHealthMD.com, this will help strengthen your leg and increase
the flexibility in your knee.

Heel Slides

Lie on your back, on your bed. Keep your legs straight together and put your arms on your side. Pull your
heel up towards your rear end. Continue bringing it up until you feel a stretch in your knee. Hold the
position for 10 seconds, then slowly move your leg back to its original position. Do two or three sets of
five to ten repetitions each. According to eHealthMD.com, heel slides will help increase the amount of
flexibility in your knee, in addition to increasing the muscle activity in your hamstrings.

Ankle Circles

Rotate your ankles in a large circle in each direction ten times. Do this 25 to 50 times every five to 10
minutes. You can do both ankles simultaneously or each ankle separately. According to eHealthMD.com,
this will help strengthen your leg and increase the flexibility in your knee.
Quadriceps Setting

Lie on your back while on your bed. Put your legs straight and keep your arms at your side. Gently push
your knee down on the bed, until your feel a stretch in your knee. Hold the position for between five
and 10 seconds, then relax your knee. Do two or three sets of five to 10 repetitions each. Performing
this exercise twice daily will help increase the extension in your knee, in addition to initiating the
contraction of your muscles, ‫א‬ccording to eHealthMD.com.

Straight Leg Raising

Standing up raise the leg that was operated on straight in front of you about six to 10 inches. Hold the
position for five to 10 seconds, then slowly lower your leg back to its original position. Do two to three
sets of five to 10 repetitions each. Perform this exercise twice daily. This will help improve your
quadricep and flexor muscles, which will aid your walking ability with the hurt knee, according to
eHealthMD.com.

Read more: http://www.livestrong.com/article/123836-exercises-knee-rehabilitation-after-

acl/#ixzz0rJ28EeHd

Overview

The anterior cruciate ligament (ACL) is one of the four major ligaments of the human knee. It is the knee
ligament most commonly injured in athletics, and severe injury often requires surgery. After ACL
surgery, the primary goal is to regain range of motion (ROM) back to a level comparable to or better
than pre-surgical level. There are dynamic and static stretches that are a part of ACL protocol that your
sports physician, physical therapist or athletic trainer will instruct you to do or prescribe as part of your
home exercise program to improve your range of motion.

Wall Slides

Wall slides are done in the first stage of rehabilitation. Lie on your back and place the sole of the
involved foot up against a wall, as high as you can comfortably place it. Wear a sock or place a towel
between your foot and the wall. Slowly slide your foot down, bending your knee until you feel a stretch
or tightness in the joint. Use the other foot to help push the foot back up to starting position. The
farther away your hips are from the wall, the easier it will be. When you gain more range of motion and
strength, perform the wall slides with your hips closer to the wall. Do 10 slides.
Heel Slides

Heel slides are similar to wall slides, but they are done seated and are more dynamic. Use a stretch cord,
towel, belt or even a dog leash, and place the foot on the ACL injured side in the middle of the cord or in
the loop, if there is one, and hold one end of the cord in each hand. Slowly pull the cord while bending
your knee until you feel a stretch. Hold for 10 seconds and then release. Repeat 10 times.

Hamstring Stretch

It's best to perform hamstring stretches while lying on your back because it allows the muscles to relax.
Place your foot through one of the loops of the stretch cord, or use a belt or towel and place your foot in
the center, and while holding the ends pull the involved leg straight up in the air until a stretch is felt
along the back of the thigh. Hold the stretch for 30 seconds. Repeat three times.

Prone Hang

This static stretch improves knee extension. Lie prone (on your stomach) on a flat surface, such as a bed
or weight bench, with the foot on the involved side hanging off. Place a pillow or rolled-up towel under
your knee for comfort. Keep your leg straight---do not roll the hip in or out. Be sure to relax the muscles
of the leg and keep your hips down. Stay in this prone hang for 10 to 15 minutes. Once range of motion
of the knee improves, use an ankle weight to increase knee extension.

Stationary Bike

Adjust the seat of the bike higher than you normally would. Strap your feet into the pedals. Control the
pedaling with the uninvolved leg. Pedal backward to start---it will be easier to make a complete circle
that way. Ride the bike for 10 to 15 minutes. If it's too painful or you can't make a full revolution, raise
the bike seat. As your knee ROM improves, lower the bike seat and begin to use the involved leg while
pedaling.

Read more: http://www.livestrong.com/article/84748-dynamic-static-stretching-improve/#ixzz0rJ2JzRRc

Recovering from ACL Surgery: The Long Road to the

Surgery table
I normally enjoy a wide range of activities. Ball Hockey is my favorite but i also enjoy soccer, mountain
biking and jogging. Since my ACL surgery on my left knee in 1999 i've given up a lot of other activities
such as basketball, squash, tennis and baseball.

Approximately 18 month ago I had hurt my knee playing ball hockey. I was running at top speed and all
of a sudden i went down. Well, after getting two opinions, i was told that i hadnt done any real damage
and that to re-hab it for a few months before going back to sports.

So i rehabbed and waited until April 2007 where i went to a soccer practice which lasted about 20
minutes for me as my knee gave out again.

My doctor immediately set me up to get MRI. Since I'm in Canada and dealing with the Canadian Health
Care System, immediately ment i had to wait 5 months to get the test.

So in September 2007 I had the MRI done at a 2am appointment at my local hospital. The MRI report
came back a week later inconclusive reporting i had a "possible tare". So this means, my family doctor
has to recommend me to a surgeon. It also means i have to wait until December 2007 to see him.

My appointment with the surgeon eventually came and he too could not tell me for sure if my ACL was
torn or not. The MRI was useless. So, the doctor told me he had to first perform arthroscopic surgery to
determine once and for all if my ACL was torn or not.
January 17th 2008, the results of the scope concluded that my ACL on my right knee was torn. I was
actually awake for this surgery which was kind of neat. You could see the torn ligaments. Anyway, the
end result was one month of rehabbing my knee from the arthroscopic surgery i just had plus waiting 4
months until May 22nd for my ACL surgery.

May 22nd, 2008 finally arrives and the surgery was a success according to my surgeon. No
complications. On a side note, i actually chose to have an epidural instead of the standard anesthetic.
This was something i wasnt too sure about but the anistisiologist suggested i could stay awake for the
surgery or he could put me under and i would wake up more alert . The bad thing was, they had to stick
a kneedle in my back. That wasnt too plesant but the surgery was just under 2 hours long and i woke 20
minutes after they were done alert as can be. I just had to wait around longer for the freezing to wear
off. I was in the hospital from about 8am to 2pm and felt pretty good. Better than i remember. But now
comes the hard part. Rehab.
In this blog i plan to journal my rehab schedule and progress and hopefully it will give people an idea
who need this type of surgery, an idea of what they have to go through.

ednesday, June 11, 2008

The first 2 weeks after ACL surgery

4 days after my ACL surgery i took the dressings off to clean up my leg a bit and also to get some nice
pictures. I have had a leg brace on and have been using crutches when to walk but i am putting as much
weight as i can tolorate on my bad leg. Here's the first picture taken May 26th, 2008. The swelling is
mostly in my quad and there is quite a bit of brusing on around my shin and calf. But overall it was not
as bad as i had expected. As you can see they used desolving stitches. I had staples in when i had my first
ACL surgery on my left knee. They were quite painful to take out so I'm thankful i won't have to go
through that again.

May 26th was also my first day at the physiotherapist. I scoped out a few places one month prior to my
surgery and found Kings Cross Physiotherapy in Brampton, Ontario (where i live). I had heard good
things about this place and they have a lot of great rehab equipment for all sorts of sports related
injuries. For those of you in the area and need a place to go for rehab, here is their web site:
http://www.kingscrossphysio.com/
At this point, id like to point out that I'm getting around quite well with the crutches. Ive taken the leg
brace off for good at this point. The evaluation went well, my range of motion was not as bad as i
thought. They measured the angle that i could bend my leg and it was at 105 degrees which was better
than i expected. Once my appointment was over they sent me home with a list of exercises i could do,
some of which i was already doing. Ankle bends, Quad Flexes Patella mobilization and straight leg lifts
and heel slides. Also, when icing the knee after exercises, you need to keep your leg elevated and its
straight. 3 sets of 10 reps, 3 -5 times a day.
Towards the end of the week, the brusing was really starting to show right down my leg all the way into
my ankle. Nasty and a bit sore to the touch but it looks worse than it felt.

By week 2, everything was coming along quite nicely. I am off the crutches already, well ahead of what i
expected and I'm able to drive. The swelling has also come down a bit too. The brusing is still there by
fading. Physio added in a few more exercises for me to do. Mostly to strengthen my Hips and quads and
calves along with some balancing. I will scan them and post them if anyone requests it. After the 2nd
week my knee can bend to 125 degrees, a 20 degree improvement from my first physio appointment.
Not too shabby! This is what happens when you stick with the program.
Here is the final picture for this post. My knee after two weeks.

Here's a good youtube video explaining the surgery: http://www.youtube.com/watch?v=q96M0jRqn7k

Thats it for this post. Thanks for visiting my ACL surgery recovery blog.

Posted by Me at 10:08 PM

75 comments:
Michelle said...

How long were you out of work?

micheraba@yahoo.com

October 17, 2008 4:26 PM

Steve said...

My first ACL surgery in 1999 on my left knee, i took 2 weeks off. For this ACL surgery
on my right knee, i was only off 1 week and 1 day. If you have a physical job then you'll
probably require a lot more time off.

October 17, 2008 6:16 PM

Anonymous said...
 Hey I just found your post randomly. I just had ACL Reconstruction of my right knee in
the middle of September of this year. Just saw the specialist today and everything's good
thankfully. i'm about to start physio next Monday. I was in the hospital for 3 days, had
the epidural, etc. Got up 2 times and almost fainted both times. I had sterry strips and the
scar is looking fantastic. I look forward in being "normal" soon. I can relate to how you
feel in your blog!

Hope all is well!

Lyndsay from New Brunswick

October 30, 2008 12:45 PM

a woman found said...

Nice informative blog. I'm having my surgery in two weeks - full rupture. My question is
this: How long did you wait from your injury until the surgery?

The reason I ask is my injury occurred 9 days ago and the majority of the swelling and
pain has subsided. In fact, I'm walking quite normal and am doing light weight resistance
training.

My doctor told me he normally waits a few weeks out from the injury to have the
swelling subside a bit. Do you know if the recovery is better if your knee is back to
normal minus the ACL rupture?

November 8, 2008 6:11 PM

Anonymous said...

Hi Steve,

Great page, I have been reading this a lot leading up to my surgery. So, I had surgery
yesterday Nov 7, 2008 and they also noticed a torn meniscus. The day of the surgery the
pain was not to bad. Starting last night the pain became excruciating and has been that
way the whole second day. I'll take a vicodin and it relieves the pain for an hour or so,
and then back to real bad. Just curious how your pain was the first few days, I am
assuming it gets better each day, but man this is some serious pain.

Again, thanks for the journal it is great to read how things might be each week, but as you
say everyone heals differently.

Thanks

Brian (31, male)

November 8, 2008 9:23 PM

Steve said...

Hey, Thanks AWF and Brian for reading my blog and also for your comments! To AWF,
since I live in Canada, I didnt have much of a choice but to wait quite a while for my
surgery. There is a huge waiting list to just see a surgeron. To get any kind of surgery
done right away it seems you need to be a professional athlete or have a life or death
situation. So for this surgery it took a good 6 months after my first appt with the surgeon
(Before that it took me 4 months to get an MRI and then 3 months to even get my appt
with a surgeon). There is a benefit to waiting and that is the extra time you have can be
used to get your knee and all the associated muscle groups as strong as possible prior to
the surgery. It may be in your best interest to see a phyiotherapist now and get some
advice on what you should do over the next two weeks before going under the knife.
They may give you some similar exercises as the ones i've been talking about in my blog.

When a professional athlete tears their ACL, they usually have the surgery done within a
week or two of the injury so the fact that your surgeon wants to get it done right away is
not unusual at all. Good luck and I'd be interested in hearing how you progress.

To Brian, It was most painful the first few days. As you can see in the pics, my entire
lower leg was bruised up. Eventually I ended up not even using all my pain killers as i
could tolerate by the 4th or 5th day. Have you ever watched a video of what they do to
your knee during the surgery? Youtube has a couple, you should check it out. Really
explains why you feel so much pain. Be sure to use A LOT of ice and keep it elevated as
Im sure you've been told already. As i explained in this post, my doctor had given me
some exerciese to do at home right after the surgery. I was given quad muscle flexing,
ankle bends, patella mobilization, straight leg lifts and heel slides. Whatever your doctor
said you could do, make sure you do them even if you find it painful and uncomfortable
and get a good physiotherapist as soon as possible if you don't have one already. Good
Luck and keep me updated.

November 9, 2008 12:07 AM

Anonymous said...

Thanks Steve, it is great to hear from someone who went through it. Its feeling a little bit
better today. I'll let you know how things go.

Brian

November 10, 2008 3:32 PM

Anonymous said...

anonymous- I had my ACL reconstructed on October 24th and I experienced similar pain.
Unfortunately it lasted about five or six days before it started to subside. My pain
 medication was written for every six hours but it really only helped for two or three. I
found that on a scale of ten the meds would bring me to a six otherwise I was around 8-9.
Friday will mark three weeks post surgery and I am feeling great. I am almost completely
off crutches and I have nearly full range of motion.

November 11, 2008 10:29 PM

Anonymous said...

Thanks for the input, it helps to hear what others went through. My pain time frame was
very much like the one above, but after 6 days it finally started to subside. I was walking
around a little bit without the crutches after 8 days, and now fully off the crutches after a
week and a half. Doing my excercises and the road of PT starts tomorrow. Again, thanks
for the input.

Brian

November 18, 2008 5:46 PM

anonymousmom said...

Hi, I am a Mom of a 14 yr old girl who had ACL surgery 8-08. They did a nerve block
during surgery.
She has been in so much pain to this day (4 months out) that she can't sleep at night or go
to school. When she started at school, sitting was excruciatingly painful. They have
thrown pain meds, inflammatories, she has done PT 3x week since the beginning--
nothing works. We saw a pain specialist who put her on triccyclics to stop the pain and
creams with a compound pharmacist. Now I'm wondering if they hit a nerve during
surgery is the problem. I saw someone write that the neurologist confirmed that a nerve
was damaged---what tests do they do to confirm that?
Does anyone have a similar story--treatment ideas? Hope for us that she will get better?

November 20, 2008 11:09 AM

Steve said...

very unfortunate. I don't know what to say. I have not heard to many negative stories like
this but I know it does happen. Is there anyone out there that has a similar story as
anonymousmom? I don't recall seeing any comments from anyone about problems with
nevre damage on my blog. If i come by any other information on a similar situation, i'll
try to post it. Best of luck to you Anonymousmom and your daughter.

November 20, 2008 10:56 PM

eek 3 - ACL Surgery Recovery

Week 3 after ACL surgery and my knee is recovering nicely at this point. There is still a lot of bruising
down the side of my shin to my ankle but it is starting to clear up at this point. As you can see, the ends
of my stitches haven't dissolved yet and are still sticking out. I'll be putting the scissors to them before
the end of the week. There is still some noticeable swelling, mostly in my quad above the knee. The
actual incision.

At Physio, im up to 25 minutes on the bike. I then move on to a squating machine where you're basically
doing squats but you're lying down and you have a muscle stimulator machine hooked up to your knee.
After that i move on to balancing on a balance pad. New this week is side steps on an aerobic step and
also stepping over hurdles. Nothing to strenuous but effective. After my 2 hour physio session is over, its
more of the muscle stimulator and ice.
 Week 3 is over and the ends of the
stitches have been cut out....hope that wasn't a mistake.

Anyway, here's a comparason with my good leg on the left. You can faintly see my old scar from ACL
surgery in 1999. When i had that ACL surgery done, it was the same procedure but my progress was a lot
slower. I was on crutches for 6 weeks and them only partially for another 2. It was very frustrating. This
time, the only thing i think i've done differently is that i was on my feet within a few hours after the
surgery. Back in 1999, they made me stay in the hospital overnight and i only got out of bed once. I see a
lot of people now at physio who have had the same surgery and not progress nearly as fast. I guess
everybody's different.

Posted by Me at 7:38 PM

8 comments:
Jason said...

I'm 3 weeks post surgery and yours is the first web site i've found with a similar recovery
rate as my own, definately seems like everyone heals differntly.

August 12, 2008 1:21 PM

Anonymous said...

Definitely! I'm on my 3rd week of recovery (today!) and can only put 40 lb on it so far. I
should actually get cleared tomorrow to come off the crutches. Glad I found this blog!
 March 5, 2009 5:47 PM

Anonymous said...

Me too. I have not yet tried to get on a bike but I am nearly off the crutches. I had the
ends of my stitches cut at the end of week 2 and it all seems to be healing nicely.

May 6, 2009 1:00 PM

Anonymous said...

tomorrow i am also at the 3 week point. i was just told today to come out of the knee
immobolizer, which i was walking with without crutches. i am now supposed to use the
crutches and wean myself off,(weight bearing as tollerated) i have been doing leg raises,
heal sides and quad sets. the pt said next appointment we will add on. my bend is at 115
degrees,the pt said that is good.

May 19, 2009 3:42 PM

Anonymous said...

Has anyone had a low grade fever this late in the game? My son had this surgery on June
2 and he has had a fever the last two days and his knee is burning hot as well. Obviously
I'll call the doctor in the morning, I was just looking for input.

June 23, 2009 11:27 PM

Anonymous said...

Hi,
I have a question for you. I will have reached week 3 in my recovery as of tomorrow, and
what I've found is that I have some hard tissue (not sure if it's muscle, scar tissue, or
swelling) right below the knee cap, close to the surface, that is preventing me from totally
straightening the knee (i'm 4 degrees off from straightening, and am like at 115 for
bending). Is that normal, or has scar tissue built up right there. Am I screwed, or is there
something I can do to get rid of that tissue? I can walk really well with my brace, rode the
exercise bike for 25 minutes today and have good quad strength, but every time I try to
totally straighten the knee, i feel a pinch were the knee cap meets that tissue......If you
have any info or advice, I'm anxious to here...thanks.
Shannon

July 1, 2009 1:23 AM

Anonymous said...

I had acl replacement surgery July 9th. Recovery progress is going better than expected. I
can walk without crutches or my brace. I don't have too much of a limp when I
 concentrate on walking normal. I can handle stairs ok. I can do leg lifts. I rode a bike
yesterday at physical therapy for 3 minutes, and my knee bend is at 120 degrees. All in
all, I feel knee function has been speedy. However, I'm in more pain than expected. My
patella (where they took bone & tendon) hurts as well as where they put the screw in
above my knee. It feels as though those 2 things are limiting my range of motion when I
bend my knee. Any idea when that goes away? Also, I have a horrible time at
night/morning. My calf is so sensitive to the touch & laying down means my leg is
touching the bed or couch. I thought this might be from the bruising, but it occurs mostly
in the morning & hasn't let up. It's sort of a combination between leg
cramping/tingling/bruising. Is all this normal & how long until I get some releif? It's
frustrating that most of my pain is centralized in my calf where I didn't have any surgery
done! Thanks SO much for this blog, it has been very helpful & has answered many
questions.

ednesday, June 18, 2008

Week 4 - ACL Surgery Recovery

Welcome to my ACL surgery recovery blog where i have been keeping tabs on my progress from my
second ACL surgery in the past 10 years. My surgery was on May 22nd, 2008 and I'm now finishing up
week 4 of the recovery stage.

ACL injuries are in the news more these days. The latest famous victim, Tiger Woods who announced
that his season is over due to a torn ACL which he has been trying to play though. Also, some interesting
stats also come out today from the American Academy of Orthopaedic Surgeons:
  About 200,000 ACL injuries occur annually in the United States, often in conjunction with
damage to other knee ligaments and cartilage. (wow!)
 Doctors perform roughly 100,000 ACL reconstructive surgeries nationwide each year, mostly on
an outpatient basis.
 ACL surgeries have a long-term success rate of 82 percent to 95 percent, depending on
numerous factors.
 Rehabilitation takes about half a year, or longer for certain athletic activities.
Post-surgical limitations can include stiffness, some loss of motion and less stability for the knee
than before the injury.
 Sports commonly associated with ACL tears and ruptures include football, tennis, basketball and
soccer.
 Women have a higher rate of ACL injuries than men, for reasons ranging from estrogen's effects
on ligaments to gender differences in the alignment of the pelvis and legs

Okay on with my progress report. Everybody is different when it comes to recovery time but the main
thing to remember is that you must put your full effort towards your physiotherapy schedule. I'm told
for only being 4 weeks out of surgery that I'm doing very well but despite the positive response to
physio, it's hard mentally not being able to do many things outside when the weather is nice.

As you can see in the pictures below, the bruising from the surgery is all gone and the scar is healing
nicely, however, I've been told that I'm not massaging the incision area enough and the scar tissue is
building up. So they did some ultrasound therapy on it and I've been giving strict order to massage the
area as ofter as possible. The swelling is still there a bit in the quad and knee. Its gone down but still
noticeable.

In addition to all the previous exercises, they added in some balancing on a trampoline. Unfortunately
I'm not allowed to do any jumping. Booooo!!!! Its challenging, especially with your eyes closed. Also
balance on one leg and throwing a ball against a wall. Not much else in the way of new stuff. I can't
stress enough how important your physio program is and should be followed as instructed. This will help
in a quick recovery.

Anyway, that's it for week 4. Thanks for reading my ACL surgery recovery blog. Next week I've been told
I'll be doing some new exercises in the pool.

If you have any questions, leave a comment and I'll answer it.

Here are some more picks of my knee taken today (June 18th, 2008):
Posted by Me at 8:09 PM

24 comments:
Ahmet Emrah said...
 Hi
Were you able to fully strighten your knee (exact 0 degrees) or did the swelling above
your knee prevent it?
I had ACL surgery 18 days ago my progress seems a lot like yours (except that im still in
crutches) but i cannot fully straighten my knee due to swelling. So i wondered if it was
the same with you

Thanks
Very very good job with the block

July 27, 2008 11:32 AM

subs said...

HI My husband is 33 yrs old & had his ACL surgery last Tue(Aug 19). I was wondering
how long the swelling lasts and whwn were u able to fully straighten your leg?

August 23, 2008 1:08 PM

booden86 said...

Hey, i just found your blog and wanted to thank you greatly for posting this detailed
blog! im from richmond hill and just got my acl done at sunnybrook a few days ago! Its
so depressing and frustrating and reading your blog gave me a view of the light at the end
of the tunnel. Was it painful for you to stand up out of bed? how long were you on
painkillers for?

September 7, 2008 2:03 AM

Anonymous said...

Hey everyone. I'm 36 and had ACL surgery on 4/30/2008. 3 months in I was really
worried that my knee wouldn't straighten out but at about 3 1/2 - 4 months it worked
itself out. Now I can get it straight and 'lock' it by flexing my quad muscles. All in all it's
better than I thought it would be at 6 months. I feel ready to start playing ball again. If
anyone wants any advice or has any questions i'll help you out. jgallagher33@msn.com

October 6, 2008 10:22 AM

Steve said...

Hey, Im just noticing that people are posting comments under some of my older posts (i
had the email setting turned off) so my apologies for not responding.

To Ahemet, I was not on crutches very long this time but my first ACL surgery i was on
crutches for a few weeks. Its different for everyone.
 To both Ahmet and Subs, It did not take me long at all to fully straighten my knee. less
than a month. At this point im now 19 weeks in an have my full range of movement.
Swelling comes and goes. If I'm doing heavy weighted exercises, i can feel it swell a little
bit.

and to Booden86, I was not on pain killers very long. I still have most of them in my
medicine cabinet. I guess it depends on your tolerance for pain. I hope your recovery
process is going well.

Take care all.

October 6, 2008 10:44 AM

Dil said...

I'm 15, I had a partially torn ACL and a torn meniscus. I had the surgery four weeks ago,
and I'm still on crutches, but my physical therapist said i can put pressure on it, that's fine,
but my knee is still pretty swollen, some days i can't even feel my knee cap, any
suggestions? I already ice it about 4 times a day.

November 1, 2008 8:01 PM

Steve said...

Hey Dil, other than taking anti-imflamitories, icing and elevating your knee, there's not
much else you can do. When i had my first ACL surgery on my left knee in 1999, the
swelling took quite a while to go down and i was on crutches still at 4 weeks too. This
surgery on my right knee, i was off crutches after a week. Its always different for
everyone. You just need to be patient at this point and keep doing what you're doing and
stick with your physio.

November 1, 2008 10:26 PM

Dil said...

Thanks, do you know if it's okay to do physio twice a day?

November 1, 2008 11:08 PM

Steve said...

going to physio twice a week is good. They should be giving you a routine of exercises
and stretching that you need to do on a daily basis too.
 November 2, 2008 9:42 AM

Dil said...

Thanks for the advice, get well soon.

November 2, 2008 10:44 AM

socrstud said...

Hey guys, I had the double bundle procdure on 11/4/08. This is a pretty cool board by the
way, and could really help people! I was searching for how long it would take me to get
off my crutches! After a week I had full leg extension but still had swelling so I'm not
sure why some people have lags. When I first tore it I did have an 8 degree lag but it went
away after a couple months of PT. I am an avid athlete and cannot wait to get back but
my worry is that my leg just feels really unstable trying to balance on 1 leg... I'm almost
three weeks in now and it does really suck with the swelling and only being able to bring
my knee 70 degrees on my own....back to square one is frustrating. Anyone else have
anything to say about thier results from a duble bundle...

November 23, 2008 6:56 PM

Steve said...

That unstable feeling will go away as long as you rehab it properly.

November 23, 2008 10:27 PM

Jeff said...

I had double tunnel ACL reconstruction using a hamstring graft 14 days ago (12/1/08). I
was able to fully straighten my leg 2 days after surgery. Actually, I've been measured 1
week post-op as being able to hyper-extendi it a couple of degrees. I attribute this mostly
to the fact that my post-op nurses counseled me to keep it as straight as possible
immediately following the surgery to take advantage of the window of time before
everything tightened up. I have been down to a single crutch for a week and off my
stailizer for a few days. Around the house I don't even use the crutch anymore and am
hoping to ditch it completely within the next day or two. I am able to get to about 90
degrees on it's own, a little farther by using my other leg to bend it. All in all, the
swelling is still moderate. Better after icing and elevating, but it swells quickly when I
use it. Compression wrapping it is still a must when I'm up and around. I just hope the
swelling isn't too hard to get rid of.

They say everyone recovers at their own pace. I think a great deal of it has to do with
your level of fitness when you were injured. I have just been trying to follow the PT
instructions and try to get a little more movement in it each day by pushing it to right the
pain threshold but not beyond. Strength has not been a major issue yet, although I am
 only trying to walk normal for now. I intend to get aggressive with the PT once I am able
to walk normally.

Has anyone tried any online products marketed to speed in recovery (like the Goode wrap
or the ultrasound machine from www.aidmymeniscus.com)?

December 16, 2008 3:22 AM

ana said...

Hi,i have Acl and meniscus surgery before 18 days,even iam in 3 week iam still not able
to walk without cruches,i have no pain,iam traying to bend my leg everyday there is
progresion but is very slowely,fisio say i must try to band it 90 d in my 4 week.i dont
belive i will make it in next 5 days beacuse iam bending leg now very littel.Wound is ok i
have no any infection,heamatoms around knee are going out as well slowely but I hope
they will desapear at all.I need liitel to strengt my leg at all.
Iam very worry about my walking and when i can bend my leg more,then i will be able to
walk normal.And ofcorse if somebody can say more about stiffnes in knee?How long
period is normal to feel stifness?Is it possible that something is wrong in knee since iam
still not able to walk?
I operate leg 2 weeks after i get injured,they say that they must do it earlier couse of
meniscus.

Week 5- ACL Surgery Recovery

Recovery week #5 is down after ACL surgery. As you can see in the picture above, the scar is healing
nicely. The leg on the top is my right leg which has had the recent ACL surgery.

This week i got to test my knee out a bit in the pool. My physiotherapy clinic has a "Swimex" pool which
is probably about 12-14 feet long and 5 feet deep. It has jets on both ends to simulate a current and can
get very challenging even for the strongest swimmer. For me however, being 5 weeks out of knee
surgery, the current was kept on the low end. The pool exercises weren't too exciting. Keeping my knee
straight, i had to do side leg lifts into the current. Then, with my back facing the current and keeping my
leg straight, i had to do backward leg lifts, also against the current. After that i had to do some
backwards walking and light running against the current. I tried forwards walking but that seemed a
little more difficult for the stage I'm at right now. After the Swimex session i felt that my knee got a good
work out but the next day, oh boy was my knee sore....a good sore, but sore.

That was the main highlight of my week. I did manage to get 2 days of pool exercises in addition to my
standard balancing and leg strengthening routine. Overall my knee feels good. My Patella sometime
feels weird but i think that may be due to the scar tissue around the incision. I see my surgeon for a
follow up on July 8th and will be asking him about it. There is also some pain in the back of my knee,
especially when im stretching my hamstring but i'm told that is normal for the stage i'm. Other than
that, I am able to lead a normal boring life. By boring, i mean, basically i can go to work which is 80% a
desk job and also do most things around the house, like cutting the grass. Still a long way to go before
sports are in the picture, although, using the pool was a positive sign. Swimming may not be too far into
the future.

If you have any questions or comments please feel free to leave them and i'll response.

Thanks for reading my ACL SURGERY RECOVERY blog.

Posted by Me at 9:29 PM

17 comments:
Michele said...

My ACL surgery was 13 months ago. My knee is doing great. I read that you had ACL in
1999. How is that knee doing? I worry about re-injury and I am concerned about the
strain on my non-operative knee. I can not image going through ACL surgery a second
time. Good luck with your recovery!

June 29, 2008 7:00 PM

Steve said...

Ya, i had my first ACL surgery in 1999 on my left knee. It is doing very well 9 years later
and I've put it through a lot. When i first went back to sports i always had that fear
mentality in the back of my mind that i would reinjure it, probably for 6 months to a year
 but then it goes away as you gain your confidence back. I had a feeling i would
eventually do in my right knee and as you can see, i did. I think for me, sometimes i push
myself too hard. I was playing competitively in ball hockey and soccer 4-5 days a week.
It was a lot of running and my legs were always tired but i still kept playing until
something gave out. I think the best advice i could give is listen to your body. Just
because you did it in your 20's doesnt mean you can keep doing it in the 30's-40's and so
on. Good luck!

June 29, 2008 10:33 PM

Anonymous said...

I will be following this closely because i just had ACL surgery (my third) on June 17th.
So I'm about three weeks behind this guy. I also had micro-fracture of the trochlear notch
so the protocals aren't exactly the same, but close. I just finished 2 weeks out and things
are smooth, I guess. This requires patience !!!

June 29, 2008 11:17 PM

iew said...

Thanks for the support! My family is really traditional, so before I even had my MRI
done, one of my aunts (who's a traditional medicine doctor) decided that she could give
me some herbal paste to keep the swelling down and heal the ligament. Many of my
relatives shared this thinking, too, until I got the verdict from two doctors that I had
indeed torn my ACL. With all these people trying to take a hand in what I'm supposed to
do for my own health, it's been really hard to get something done that I've wanted to do.

Thankfully I've regained some movement in the leg, so I'll be able to get back to some of
my life until surgery. I'll be watching your blog too - thanks for documenting your
experience! It's good to know what to expect. :)

June 30, 2008 6:11 PM

Jack said...

Maybe you mentioned this and I missed it somehow... did you get an autograft or an
allograft? I'm three days into recovery after getting an autograft (ligament taken from my
hamstring to replace the ACL), and I've got a lot of bruising and pain at the back of my
knee and higher up on the leg, near where I imagine the hamstring was harvested.

I was very happy to find this blog, by the way. It's very reassuring to hear the story of
someone else having undergone this process. Thank you for taking the time and energy to
compile all of this!

August 17, 2008 8:25 PM

Irina said...

I just had an ACL reconstruction on my right kneeas well. Mine was July 31st and its
been healing even faster than my already fast rehab schedule requires it too. Im suppose
to resume "light jog" in two months after surgery and i already jog with normal pace! its
been such a tough journey especially because my surgery affected my summer after
graduation to be quite slow. but im happy to see that other people are going through it
too. And i wish you all the best with your knee was well!
God Bless!

September 11, 2008 1:23 PM

Anonymous said...

It has been 5 weeks since my ACL injury (as of tomorrow) and my knee feels great. The
problem I am having is my hamstring. I have an appointment Froday to have it checked
out. I got barrelled into by a rambunctous child right into the back of my leg. Ever since i
have had terrible pain in the back of my thigh.. Just a warning to be very protective of
your leg...

October 29, 2008 4:01 PM

Lcpl. Tim Hoffman said...

I am having ACL surgery in 3 days on my left knee... I am in the Marine Corps, and I am
wondering what I should expect as far as the procedure the day of surgery? And
afterward, what amount of pain were you in, after the pain killers, because, I'm assuming,
there must be some sort of pain involved in the healing process...?

(I am also having my surgery off-base, at a civilian hospital)

March 8, 2009 10:33 PM

Me said...

Well for the first few hours after surgery, it wont feel all tha bad until the freezing totally
wears off. Just take your pain killers before the it does wear off and take them regularly
as prescribed and it will be tolerable. Everyone is different. I didnt need the pain killers a
few days after the surgery. Marines are tough so you should be able to handle it. Good
luck.

March 8, 2009 10:46 PM

Lcpl. Tim Hoffman said...

 I think I'm just nervous because I'm 20 years old, and I've never had surgery before, and I
don't know what to expect. thanks for the help, and for this Blog

March 9, 2009 8:53 PM

Anonymous said...

I'm 47 had 3 previous acl repairs on my rt. knee and now experiencing incredible
swelling and pain. I know that I have very little or no cartilage left there. I take
Glucosamin and Condrotin but nothing seems to help. any suggestions?

March 28, 2009 9:24 AM

Anonymous said...

Had acl and meniscus surgery on 3/5. I am wondering ROM for others? I am at 105 with
help of therapist ad 101 by myself.... had autograph from same injured knee.

March 29, 2009 5:50 PM

Anonymous said...

goodluck too anonymous! im pleased to see you guys are doing better. godbless and i
love you

April 6, 2009 8:19 PM

Me said...

Good luck to everyone thats having these surgeries. Sorry I've missed out on replying to
some of these commentes. To Anonymous who is 47 years old....I feel for you. Has
anyone suggested Knee replacement surgery to you?

Best of luck to everyone!

Steve

April 7, 2009 9:07 AM

Anonymous said...

i just tore my acl two days ago playing in my highschool softball game i have to get
surgery and im scared shitless. will it ever be the same as it was and will i gain speed?
thats a rumor i heard.

April 25, 2009 6:44 PM

Anonymous said...
 Anonymous,
I stopped eating wheat and that took the swelling out of my joints pre-surgery. I'm going
to continue to avoid it. I found that the swelling and pain disappeared totally by avoiding
wheat--but no change if I take MSN, glucosamine, etc... but everyone is different.
As for pain killers, I haven't taken any--anyone else in that boat? Knee is a little stiff
feeling, but the pain is tolerable.

June 26, 2009 10:19 PM

Anonymous said...

Hi i'm 18 and I got my left knee operated on june 18th this summer. It will be 5 weeks on
friday and I'm really getting frustrated with the whole thing. It's been almost rfive weeks
and i walk around with a cane (it has butterflies on it) and a splint that i hateeeeee. It's
falling apart because tthe velcro isnt holding anymore. My quad looks like a toothpick
and my knee is still slightly swollen and it just feels messy inside. I dont have full
extension and i have about 105 degrees of flexion. I want to know if this happened to you
because i really hate how i cant see any results and my summer is going to shit because of
this stupid knee. I just want to be able to get back into doing things a simple as walking
around or playing basketball again. I got mesurements for a scustom knee brace that i
think ill be wearing everyday for a while instead of my splint which i cant wait for. I feel
like walking and using my leg more will make things accelerate a bit. Anyways, yea,
thats my story.