What is the recommended physical therapy regimen before Anterior Cruciate Ligament (ACL) reconstruction?

Recommended Physical Therapy Regimen Before ACL Reconstruction

Preoperative rehabilitation (prehabilitation) is strongly recommended before ACL reconstruction to improve postoperative quadriceps strength, knee range of motion, and decrease time to return to sport. 1

Assessment Components

Before starting prehabilitation, the following should be assessed:

• Range of motion (ROM) - A preoperative extension deficit is a major risk factor for postoperative extension deficit 1
• Quadriceps strength - A deficit >20% has significant negative consequences for outcomes 2 years after surgery 1
• Hamstring strength - Should be measured although specific recommendations are less clear 1
• Voluntary muscle activation - At least one preoperative visit is needed to ensure adequate activation 1

Prehabilitation Protocol

Duration

• Minimum: At least one preoperative visit 1
• Optimal: 4-6 weeks when facing a delay between diagnosis and surgery 2

Key Components

1. Quadriceps Strengthening

   • Begin with isometric exercises if they provoke no pain 1
   • Progress to concentric and eccentric exercises when tolerated
   • Consider electrostimulation as an adjunct for quadriceps reactivation 1

2. Range of Motion Exercises

   • Focus on achieving full extension - critical to prevent arthrofibrosis 3
   • Address any flexion contractures before surgery 1

3. Balance and Proprioception Training

   • Include neuromuscular training alongside strength training 1
   • Focus on quality of movement to prevent reinjuries

4. Weight-Bearing Activities

   • Immediate weight bearing is safe if using correct gait pattern 1
   • Use crutches if needed to maintain proper mechanics

5. Pain and Swelling Management

   • Consider cryotherapy to decrease pain 1
   • Consider aspiration of painful, tense effusions 1

Progression Criteria

Prehabilitation should continue until:

• Full knee extension is achieved
• Quadriceps activation is adequate
• Minimal joint effusion is present
• Patient understands the postoperative rehabilitation process

Important Considerations

• Timing of Surgery: When surgical treatment is indicated for an acute isolated ACL tear, early reconstruction is preferred as the risk of additional cartilage and meniscal injury increases within 3 months 1

• Arthrofibrosis Risk Factors: Preoperative irritation, limited ROM, and perioperative pain significantly correlate with development of arthrofibrosis 3

• Patient Education: Preoperative information about walking with crutches, early postoperative exercises, and the rehabilitation process improves patient self-efficacy 1

• Communication: Good communication between surgeon and physical therapist is essential for optimal outcomes 1

Common Pitfalls to Avoid

• Delaying Surgery Too Long: Risk of additional cartilage and meniscal injury increases after 3 months 1
• Neglecting Full Extension: Failure to achieve full extension preoperatively increases risk of postoperative arthrofibrosis 3
• Ignoring Quadriceps Strength: Preoperative deficits >20% predict significant strength deficits for up to 2 years after surgery 1
• Starting Muscle Training Too Early: This can increase risk of arthrofibrosis if the knee is not ready 3

By following this preoperative rehabilitation protocol, patients can achieve better postoperative outcomes including improved strength and motion, and increased likelihood of successful return to sport 2.