Anterior Cruciate Ligament (ACL) injury and the road to recovery
Article by Carly Derraven
Matt Roberts
November 2011
What is your ACL?
Your ACL is one of 2 ligaments inside your knee that help with stabilising the joint. Your ACL prevents the femur transcending forward of your tibia. The other ligament inside the knee, your posterior cruciate ligament (PCL), controls the posterior movement of the femur in relation to your tibia.
What causes an ACL injury and what are the symptoms?
Your ACL is the most common ligament to be torn or ruptured in your knee. The cause can be due to sudden acceleration deceleration or sharp sudden changes in direction. These movements can occur in sports such as skiing or football. An impact or force directly to the leg as experienced in contact sports such as rugby and football can also cause a tear or rupture of the ligament If your ACL is damaged you may experience initial significant swelling, pain and a 'giving way' of your knee on weight bearing. If there is additional injury to your cartilage you may experience a locking sensation in your knee. Generally your knee will not feel as stable as normal.
How is it repaired?
You may decide to have an operation to have your ACL repaired. This will mean having a new ligament grafted from either your hamstring tendon or your patella tendon. There are advantages and disadvantages to both and your surgeon will advise you on the most appropriate one for you. Commonly the medial meniscus (cartilage within the knee joint), and/or the medial collateral ligament, is damaged with an ACL injury. This may also need to be addressed in surgery You may also choose not to have it operated on and to treat it conservatively with physiotherapy intervention. This decision will depend on a number of factors including Severity of symptoms, age, and the sporting activities which you wish to continue pursuing.
Rehabilitation and Your Return to Sport
After your injury you will have to follow a rehabilitation programme to get back to full fitness. Below are rehab guidelines which should commence day 1 post reconstruction. Returning to full sporting fitness can take from 9months- 1 year but each case is very individual. The following guidelines are flexible as everybody heals and progresses at different rates.
Weeks 0-3
During the first 3 weeks it is most important to regain full Range of motion (ROM). ROM will be improved when swelling is minimized so it is important to keep the leg up as much as possible and ice regularly. Extension is usually the most difficult to achieve so promptly addressing this immediately post reconstruction will prevent problems later on. You should aim to stay off your feet as much as possible in the first 10 days and manage pain with prescribed painkillers. If you have had a patella tendon graft your patella femoral joint will get stiff with scar tissue and your physio will show you some lateral glides on the knee cap to keep it mobile.
Flexion of the knee should be completed in seated or lying sliding the heel towards your bottom.
Extension can be achieved by propping up the heel with a rolled up towel so that your calf is off the bed. You should also practise squeezing your thigh muscles and pushing the back of your knee down into the bed.
Static quadriceps exercises to maintain the strength of these muscles. These can be completed in lying by pulling your foot back towards shin, pushing your knee down into the bed, squeezing muscles in front of thigh and holding for 5 secs.
Ankle pumps by pointing toes and then pulling toes back towards you. This will help with circulation of blood.
Week 3-6
N.B You need to be aware that if you have had a hamstring graft it will be at its weakest between 4-6 weeks.
In the following weeks you should find your ROM is improving and you should be able to walk without crutches. You should continue with all your exercises to improve flexion and extension. You may need to focus on some gait retraining with your physio to help with your walking. Hydrotherapy or pool work may be incorporated at this stage if your wound is heeled Throughout your rehab you can maintain the strength of the other unaffected muscles around the leg such as your gluteals and your calves. This can be achieved with glute bridges and heel raises. Also strengthening of abductors and adductors with lying side leg raises of the top leg to work the abductors and of the bottom leg to work the adductors. You can also stretch your calf daily on the effected leg but avoid stretching the hamstring if you have a hamstring graft.
Quarter squats concentrating on keeping the torso upright and not letting the knee fall in. N.B do not go any deeper than 90degrees.
Inner range quads - using a rolled up towel under the knee and squeezing the muscles in the front of the thigh to lift the heel off the floor.
Stationary bike can be used with no resistance to help with flexion of the knee.
Static hamstrings - In lying flex the knee and then push the heel down into the bed do not let the heel move. Hold for 5 secs and repeat. You may find that you are able to complete sooner than 3 weeks but if you have had a hamstring graft it may be too sore.
Balance training - Standing on one leg for up to 120 seconds. Start with your eyes open and then progress to them closed.
Week 6- 3months
You should be looking to re-gain full ROM during this stage. You should have full extension and be aiming for 135 degrees of flexion by week 6. Emphasis is placed on improved muscular control, proprioception and general muscular strengthening. Strength Training for the leg should be in a straight line direction. Exercises for the quadriceps should be closed chain and exercises for the hip muscles and the hamstrings can be in open chain.
Partial Swiss ball Squats -Place your back against a wall or Swiss ball resting on a wall. Position your feet slightly wider then hip-width apart. Bend your knees keeping your torso upright and flex to up to 90degrees.
Leg press - Bilateral and keep the weights initially high with more reps Leg curl- Lying on the floor with your feet up on a Swiss ball Dig your heels into the Swiss ball and pull it in towards your bottom. Push the ball back out away from you until your legs are straight.
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.
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.
Proprioception drills - Wobble board exercises balancing on two legs, balancing on one leg, ball tosses while balancing, completed with the eyes closed for advanced drills. These exercises can also be completed on the mini trampoline.
Months 3 – 6
Emphasis during this phase is shifted to strengthening especially balance and proprioceptive work.
From 3 Months to 6 Months you can often begin light jogging Start forwards then backward jogging and start a light running program. You can try Jogging in figure of eight rotations.
Using the pool to practise running can help to build up confidence before running on land.
Cycling outdoors (Minimal gradients on a stable surface, no mountain biking) and pool workouts (use a flutter kick not a breaststroke kick) you should avoid any lateral movements such as in sports like basketball or soccer.
You can increase the resistance and time spent on the spin/recumbent bike.
You may begin to increase resistance on bilateral closed chain leg strengthening exercises such as squats and leg press.
Toward the 6 month phase the emphasis should be on more sports specific training- Agility drills change in direction change in speeds, stopping and starting. Unilateral leg plyometric drills.
Return to Sports - recommended time is 9-12 months
The following pre requisites need to be achieved before you can return to sports
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