From the Guidelines
The post-operative standard of care for ACL repair focuses on a progressive rehabilitation protocol over 6-12 months, prioritizing immediate knee mobilization and strength/neuromuscular training, as recommended by the most recent and highest quality study 1.
Key Components of Rehabilitation
- Immediate knee mobilization and strength/neuromuscular training should be used during ACL postoperative rehabilitation, as supported by high-quality clinical practice guidelines 1.
- Cryotherapy can be applied in the early phase of postoperative management to reduce pain and swelling, with a high level of patient satisfaction and minimal adverse events 1.
- Weight-bearing should progress from partial to full within 1-2 weeks, with crutches and a hinged knee brace locked in extension when walking, to minimize the risk of complications and promote proper healing 1.
- Physical therapy should begin immediately with gentle range of motion exercises, progressing to strengthening exercises and sport-specific training, to optimize functional outcomes and reduce the risk of re-injury 1.
Rehabilitation Phases
- The rehabilitation protocol should consist of three phases:
- Impairment-based phase, focusing on pain management, range of motion, and strength training
- Sport-specific training phase, progressing to functional exercises and activities
- Return to play phase, emphasizing psychological readiness and functional assessment to minimize the risk of re-injury 1
Return to Sports
- Return to sports typically occurs at 9-12 months, when the patient demonstrates symmetrical strength, proper movement patterns, and psychological readiness, as assessed by a comprehensive test battery including strength tests, hop tests, and measurement of quality of movement 1. This gradual approach allows proper graft incorporation and ligamentization, reducing the risk of re-injury and optimizing functional outcomes.
From the Research
Post-Operative Standard of Care for ACL Repair
The post-operative standard of care for ACL repair involves a comprehensive rehabilitation program that aims to restore full, unrestricted function and assist the patient to return to their pre-injury level. The key components of this program include:
- Early weight bearing and range of motion exercises to prevent stiffness and promote healing 2, 3
- Strengthening exercises and proprioceptive and neuromuscular control drills to provide a neurologic stimulus and improve knee function 2, 4
- Addressing preexisting factors that may predispose to future injury, such as hip and hamstring weakness 4
- Use of alternative modalities such as neuromuscular electrical stimulation and blood flow restriction to accelerate patient recovery 3
- Clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program 3
Rehabilitation Protocols
Rehabilitation protocols for ACL repair have evolved to become more individualized and criterion-based, rather than relying on a standardized length protocol 5, 6. The protocols are designed to address the specific needs and preferences of each patient, and may include:
- Early-stage rehabilitation focusing on pain and swelling management, knee joint range of motion, arthrogenic muscle inhibition and muscle strength, movement quality/neuromuscular control, psycho-social-cultural and environmental factors, and physical fitness preservation 6
- Mid-stage rehabilitation emphasizing strengthening exercises, proprioception training, and open chain exercises 6, 2
- Late-stage rehabilitation focusing on return to sport and high-level activities, with an emphasis on psychological preparation and addressing anxiety around return to sport 3
Complications and Considerations
The post-operative standard of care for ACL repair also involves monitoring for potential complications, such as:
- Infection and deficits to knee motion and strength in the short-term 5
- Secondary ACL injury to either the involved or contralateral knee and lack of ability to return to high-level sports in the long-term 5, 3
- Psychosocial impacts of ACL injury, recovery, and anxiety around return to sport, which can be addressed through novel methods and modalities 3