ACL Injuries

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Knee & ACL Injury Therapy

What is the ACL?
The anterior cruciate ligament (ACL) is one of the four primary stabilizing ligaments in the knee joint. The ACL prevents the shin bone (tibia) from sliding too far forward, allowing for cutting, pivoting and jumping activities.

How can you injure the ACL?
The most common ACL injury can occur from a combination of sudden stopping and pivoting or twisting on the leg. The ACL can also injure in contact sports where the player is clipped forcing the knee into an abnormal position.

Who is at risk?
There are a multitude of scientific studies indicating that females are at a 4-6 times higher risk of ligamentous knee injuries compared to their male counterparts. A high percentage of these injuries occur in non-contact sports, but also with sports involving pivoting, cutting and landing from a jump.

Signs and symptoms that you may have an ACL injury:
The player will most likely experience a “pop” following a feeling of instability, pain and increased swelling of the knee joint(called an effusion). Over the next several hours, pain will increase and it may even be difficult to walk. Later, a feeling of giving way or buckling in the knee joint may be reported.

Treatment Options for the ACL:

  • Conservative Treatment: Some patients, particularly those over the age of 30 who are not highly active, may not require surgery. These patients can function very well as long as they avoid high risk sports such as skiing, basketball, soccer and football. Wearing a knee brace may help stabilize the knee, improve function and can help prevent re-injury but this is individualistic. These patients should participate in physical therapy to restore strength, power and endurance in the knee joint.
  • Limited Arthroscopic Surgery: ACL injuries may also be accompanied by injuries to additional structures of the knee joint including torn meniscus or fragments of the articular cartilage creating a loose body in the joint. Symptoms include the knee joint locking, pain and swelling. Arthroscopic surgery can remove the torn meniscus or loose body improving the patient’s pain and eliminating locking; however will not resolve the instability of the knee associated with the torn ACL.
  • ACL reconstruction: ACL reconstruction involves replacing the ACL with a tendon (or a graft) with another structure within the knee. There are generally three different grafts that orthopedic surgeons use. The surgeon chooses the type of graft depending on the patient’s age, activity level and personal preference. The rehabilitation is similar for all three grafts.

ACL Reconstruction (3 general types):

  • Middle third patellar tendon: the tendon that connects the knee cap to the shin bone (tibia). The oldest and repeatedly proven successful in the literature.
  • Hamstring tendon: the tendon of the back of the thigh muscle take from the inner thigh to the back of the knee is used.
  • Allograft: tendon grafts taken from a cadaver.

A fourth type that is under investigation is a procedure called a “bridge” graft where the surgeon attempts to connect a sponge to the two ruptured ends and allow the human body to “re-connect” across the sponge. This procedure is touted locally by Dr. Martha Murray at Boston Children’s Hospital

Rehabilitation after surgery (2 protocols):

There are several different protocols that orthopedic surgeons recommend following surgery. Listed below are examples of activitie on a timeline (accelerated for athletes vs. non-accelerated for patellar third reconstruction) that your doctor may prescribe. Please be advised that this is only a sample protocol and your doctor will recommend what is best for you. It should also be noted that an accelerated protocol will most likely not allow for a quicker return to competitive sport any sooner than non-accelerated protocol.

 

Non-Accelerated ProtocolWeek
1
Week
2
Week
3
Week
4

Week
5

Week
6
Week
7
Week
12-16
Week
16-24
Phase 1 (Week 0-2)
Quadriceps Setting      
Patellar Mobilization      
Heel Slides      
Sitting Heel Slides      
Heel Prop      
Prone Hang      
Straight Leg Raise   
Hip Abduction   
Ankle Pumps      
          
Phase 2 (Week 2-6)
Stationary Bicycle    
Water Workout (Optional)         
Aqua Jogger Exercise    
Flutter-kick swimming    
Standing Hamstring Curl    
Standing Toe Raises    
1/3 Knee Bends    
Wall Slides    
Phase 3 (Week 6-12)
Balance Training     
Hamstring Stretch
Quadriceps Stretch
Calf Stretch
Phase 4 (Week 12-16)
Aerobic Conditioning:         
Stairmaster       
Elliptical/Nordic Track       
Swimming       
Seated Leg Press      
Resisted Hamstring Curls      
Hip Abduction/Adduction      
Roman Chair      
Calf Raise Machine      
Single Leg Step Up/Down      
Single Leg Wall Slide       
Single Leg Squat to Chair        

 

Phase 5 (Week 16-24)Weeks Post-Surgery 
Running Slowly12-16 
Golf16-20 
Rollerblading18 
Sprinting20-24 
Tennis20-24 
Backwards running20-24 
Zig-zag running20-24 
Figure 8 running20-24 
Circle running20-24 
Carioca running20-24 
Running quickly with slow starts and stops24 
Running with sprinting with fast starts and stops24 
Hopping and jump training24 
Quickly pivoting and cutting24 
Return to sports practice24-32 
Full return to sports32-36 

 

Accelerated ProtocolWeek
1
Week
2
Week
3
Week
4

Week
6

Week
8
Week
10
Week
10-16
Week
16-24
Phase 1 (Week 0-2)
Ankle Pumps       
Straight Leg Raises (3-way)     
Quadriceps Setting       
Hamstring Stretch     
Mini-squats       
Weight Shifts       
Patellar Mobilization       
Prone Hang     
Multi-angle Isometrics       
Standing Hamstring Curl       
Phase 2 (Week 2-4)
Leg Press      
Front and Side Lunge      
Half Squat      
Stationary Bicycle 
Pool Program (Optional)    
Lateral Lunge    
Lateral Step-ups    
Front Step-ups    
Phase 3 (Week 4-10)
Hamstring Curls     
Hip Abduction/Adduction     
Hip Flexion/Extension     
Wall Squats     
Calf Raises     
Balance Training     
Backward Running     
Forward Running      
Balance with Throwing      
Plyometric leg press       
Pertubation Training       
Walking Program       
Aerobic Conditioning       
Plyometric Training        
Phase 4 (Week 10-16)
Continue with Strength and Balance Training as above         
Phase 5 (Week 16-22)
Return to Sport