From the Guidelines
Post-operative management of an ACL repair should prioritize immediate knee mobilization and strength/neuromuscular training, with a focus on early full weight-bearing exercises, closed kinetic chain exercises, and neuromuscular electrostimulation as needed. The goal of post-operative management is to control pain and swelling while gradually restoring function and strength, with the ultimate goal of returning to sports and activities. Key components of post-operative management include:
- Immediate knee mobilization to increase joint range of motion and reduce knee pain
- Strength/neuromuscular training, starting with isometric quadriceps strengthening exercises in the first postoperative week and progressing to concentric and eccentric exercises
- Early full weight-bearing exercises, as tolerated, to promote graft healing and incorporation
- Closed kinetic chain exercises, prioritized in the first postoperative month, to mitigate the risk of patellofemoral pain
- Neuromuscular electrostimulation, which can be added to isometric strengthening in the initial 6-8 weeks to re-educate voluntary contraction and increase strength of quadriceps muscles, as supported by 1
- Cryotherapy, which can be used immediately after surgery to reduce knee pain without increasing the risk of short-term adverse events, as noted in 1
- Supervised home-based rehabilitation, which can be considered for highly motivated patients, as suggested in 1 The rehabilitation process should be individualized, taking into account the patient's specific needs and goals, and should be guided by a physical therapist or other qualified healthcare professional, with recommendations based on the most recent and highest quality study, 1.
From the Research
Post-Operative Management of ACL Repair
- The goal of post-operative management is to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life 2
- Post-operative rehabilitation protocols have not been standardized yet, but common modalities include post-operative brace use, early restoration of range of motion (ROM), neuromuscular electrical stimulation (NMES), proprioception training, open and closed chain exercises, and early strengthening 3
- Recent studies suggest that vibration training, open-chain and closed-chain exercises, electrical stimulation, and aquatic therapy can be safely incorporated into the post-operative rehabilitation protocol following ACLR 4
- Accelerated rehabilitation may give patients short-term functional benefits, and long-term use of NMES seems to be more beneficial than short-term use 4
- Post-operative bracing does not confer additional benefits, and the use of clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program is becoming more popular 4, 5
Rehabilitation Protocols
- Rehabilitation protocols vary greatly, but there has been a shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences 5
- New protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as NMES and blood flow restriction 5
- The inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport is becoming more important in rehabilitation strategies 5
Return to Sport
- Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings 5
- The use of clinical milestones to determine when a patient is ready for return to sport is becoming more popular, and individualized protocols are being developed to address the specific needs of each patient 4, 5