What is the rehabilitation protocol for an Anterior Cruciate Ligament (ACL) reconstruction using a semitendinosus graft?

ACL Rehabilitation Protocol for Semitendinosus Graft

The rehabilitation protocol for ACL reconstruction using a semitendinosus graft should follow a criteria-based approach with specific timeframes for graft protection, beginning with early mobilization and progressive strengthening while avoiding continuous passive motion devices. 1

Early Phase (Weeks 0-4)

Immediate Post-Operative (Days 1-7)

• Pain and Swelling Management

  • Apply cryotherapy in the early phase to reduce pain, swelling, and medication use 1
  • Compressive cryotherapy is more effective than cryotherapy alone if available 1

• Range of Motion

  • Begin immediate knee mobilization within the first week to prevent extension deficit 1
  • Focus on achieving full extension and progressive flexion 1
  • Avoid continuous passive motion devices as they show no benefit over active motion exercises 1

• Early Strengthening

  • Start isometric quadriceps exercises including static contractions and straight leg raises during the first 2 postoperative weeks 1
  • These exercises help faster recovery of knee ROM without compromising stability 1

• Weight Bearing

  • Implement weight bearing as tolerated if correct gait pattern can be maintained 1
  • Use crutches initially if needed 1

Weeks 2-4

• Closed Kinetic Chain Exercises

  • Begin partial weight-bearing squats and step-ups from week 2 1
  • Progress from isometric to concentric and eccentric exercises when quadriceps is reactivated 1
  • Monitor for pain, effusion, or increased temperature as signs to modify progression 1

• Neuromuscular Training

  • Add balance and proprioception exercises to improve neuromuscular control 1
  • Low load blood flow restriction training may be beneficial to improve quadriceps/hamstring strength and prevent disuse atrophy in early phase 1

Intermediate Phase (Weeks 4-12)

Weeks 4-8

• Open Kinetic Chain Exercises

  • Start open kinetic chain exercises at week 4 with restricted ROM (90°-45°) 1
  • Progress ROM gradually: 90°-30° in week 5,90°-20° in week 6,90°-10° in week 7, full ROM in week 8 1
  • Note: Semitendinosus grafts may be more vulnerable to early open kinetic chain exercises compared to BTB grafts 1

• Advanced Strengthening

  • Begin leg press at 3 weeks to improve subjective knee function and functional outcomes 1
  • Implement eccentric training for greater strength gains and muscle hypertrophy 1
  • Add core stability exercises to improve gait and knee function 1

Weeks 8-12

• Progressive Loading

  • Increase resistance in both open and closed kinetic chain exercises 1
  • Use both open and closed kinetic chain exercises for optimal quadriceps strength recovery 1
  • Monitor for anterior knee pain, which may be more common with open kinetic chain exercises 1

• Neuromuscular Control

  • Progress balance and proprioception exercises 1
  • Add eccentric and plyometric training combinations for improved balance outcomes 1

Advanced Phase (Weeks 12+)

Weeks 12-16

• Return to Running Assessment

  • Evaluate readiness for running at approximately 12 weeks using a combination of time-based, clinical, and functional criteria 1
  • Note that there are no conclusive results whether return to running at or before 12 weeks is safe 1

• Advanced Strengthening

  • Implement plyometric and agility training to improve subjective function and functional activities 1
  • Continue eccentric training for strength gains 1

Weeks 16-24

• Sport-Specific Training
  • Begin sport-specific drills before full competitive activities 1
  • Monitor quality of movement during all exercises 1
  • Progress only if exercises do not provoke pain, effusion, or increase in temperature 1

Return to Sport Criteria

• Comprehensive Testing

  • No pain or swelling
  • Full knee range of motion
  • Limb Symmetry Index (LSI) >90% for strength and hop tests
  • Stable knee on clinical examination
  • Normalized patient-reported outcomes 1

• Psychological Readiness

  • Assess fear of reinjury and its impact on rehabilitation outcomes 1
  • Address psychological barriers to return to sport 1

Special Considerations for Semitendinosus Grafts

• Monitor hamstring strength carefully as the harvest site may cause specific deficits 2
• The semitendinosus graft with preserved tibial insertion (if applicable) may improve tendon-bone healing and biomechanical strength 3
• Consider that rehabilitation duration should be individualized based on criteria rather than fixed timelines, with a minimum of 19 weeks showing similar outcomes to longer protocols 1

Common Pitfalls to Avoid

1. Delayed Mobilization

   • Delaying knee mobilization can lead to extension deficit and osteoarthritis development 1

2. Neglecting Quadriceps Strengthening

   • Quadriceps strength deficits >20% have major negative impacts on long-term outcomes 1

3. Focusing Only on Strength

   • Both strength and neuromuscular control are essential to prevent reinjury 1

4. Accelerating Return to Sport Based on Time Alone

   • Use objective criteria rather than time alone to determine readiness for sport return 1

5. Overreliance on Bracing

   • Functional bracing is not recommended for routine use after primary ACL reconstruction 1