ACL reconstruction surgery rehab

What to Expect After ACL Reconstruction

ACL sprains or tears are serious injuries. Not everyone who injures their ACL (anterior cruciate ligament) will opt for surgery but the majority of individuals with ACL injuries undergo ACL reconstruction or repair. If you are an athlete participating in a sport where ACL tears can happen unexpectedly, you may wonder how common this injury is. According to the National Institute of Health, approximately 1 in 3500 people will experience an ACL injury each year. 

The ACL is the most commonly injured ligament of the knee, accounting for half of all knee injuries, whereas the posterior cruciate ligament (PCL) accounts for around 5-20% of injuries. Surgical and nonsurgical approaches to ACL tear management exist. Those who opt to forgo surgery in favor of conservative treatment like physical therapy are often called “copers.” The remainder, somewhere around 400,000 people yearly in the U.S., will opt to undergo some type of ACL surgery. ACL reconstruction involves replacing the injured ACL tissue with the patient’s own or donated tissue and is the focus of this article. 

UNDERSTANDING ACL INJURIES

The ACL, which stands for anterior cruciate ligament, is one of four major stabilizing ligaments in the knee. The medial and lateral collateral ligaments lie on the inside and outside borders of the knee. The ACL and PCL are positioned within the knee joint. Each of these ligaments plays an important role in limiting motion and providing stability to the knee joint. Disrupt one of these ligaments and the stability of the joint is compromised. 

The ACL is a strong band of connective tissue and collagen fibers that extends from the front portion of the tibial plateau (flat aspect of the top of the tibia bone) posterolaterally to the inside of the lateral femoral condyle (end of the thigh bone). The main role of the ACL is to limit anterior translation or shifting of the lower leg bone forward but it also limits some medial and lateral movement and provides some rotational stability. 

While ACL injuries can occur during a serious trauma like a car accident, most ACL injuries occur during athletics and under non-contact circumstances. This means that most ACL injuries occur during movements that do not involve contact with another player (though this certainly can lead to an ACL injury). Pivoting on a fixed foot with a bent knee can cause the tibia (lower leg bone) to shift forward and stress the ACL to the point of tearing. A direct hit to the side of the knee can also lead to ACL injury. As you might imagine with these mechanisms of injury, athletes in certain sports are at higher risk for ACL tear than others. Skiers, soccer players, football players and basketball players have the highest incidence of ACL tears. 

While other types of injuries can be harder to detect, a tear or sprain to the ACL usually announces itself immediately. Many people remark hearing and feeling a pop in their knee when the injury occurs. It is typically very painful and athletes often need assistance to walk afterwards. Swelling in the knee can develop quickly and individuals may feel like their knee is giving way and have difficulty bending and straightening it fully. 

ACL RECONSTRUCTION AND RECOVERY

Most people will undergo ACL surgery to re-establish good stability and control of the knee joint. Without this many people will continue to experience feelings of instability in the knee and they may be unable to resume activities like sports. There are two surgical approaches to ACL injury management– ACL repair and ACL reconstruction. ACL repair is appropriate for partial tears and involves sewing and repairing the patient’s native ligament. ACL reconstruction involves using either the patient’s own tissue or donated tissue to create a new ACL. When the patient’s own tissue is harvested it is called an autograft and surgeons often use part of the patient’s patellar tendon, hamstring tendon, or quadriceps tendon.

Recovery from ACL reconstruction can take as little as 6 weeks to return to daily activities and up to a year or more for athletes to return to their prior level of sport and competition. The risk of reinjuring the ACL is always the biggest concern so working with a PT knowledgeable in ACL reconstruction and return to sport is imperative.

PHYSICAL THERAPY POST-ACL RECONSTRUCTION

Physical therapy for ACL Reconstruction will be individualized to your specific needs but here are some things you can expect during your course of care:

Up and At ‘Em: While you will be given crutches, a walker or maybe even a wheelchair, you will be encouraged to start walking as soon as possible with a goal of returning to full weight-bearing as soon as you can tolerate it. 

Ice, Ice Baby: Early use of ice or cryotherapy to minimize swelling and pain is very important after ACL reconstruction. Swelling can limit the return of range of motion and inhibit muscle contractions around the knee.

Range of Motion Rescue: Regaining full passive knee extension and eventually flexion are important early-phase rehabilitation goals but should be managed by your therapist.

Start exercising: Because the risk of tearing the graft is higher in the early phases of rehab you want to follow the guidance and instructions of your physical therapist. Avoiding exercises and positions that stress the graft too early is essential. Isometric exercises which involve activating a muscle without moving the knee joint itself are usually prescribed early on for the hamstrings and quadriceps. Eventually, eccentric training of the quadriceps is added. Active knee range of motion where you move the knee yourself through a limited range can be helpful early on as can closed chain exercises like squats or leg presses where your feet are in contact with the support surface. 

Open chain quadriceps exercises where the foot is free to move through space, isokinetic quadriceps strengthening and certain leg extension maneuvers should be avoided in early phases. If this sounds a bit confusing, don’t worry, this is why you work with an experienced physical therapist. Follow their guidance and they will help you keep your graft safe. 

NMES: NMES or neuromuscular electrical stimulation is a modality in which electrodes are placed on a weak or inhibited muscle and an electrical current is used to stimulate a contraction. NMES or a Russian Protocol is often used early in ACL reconstruction rehab to stimulate muscle contractions and improve the strength of the quadriceps muscle.

Returning to sport: As you progress through the stages of ACL reconstruction recovery, you will begin to add more exercises that help rebuild strength, stability, neuromuscular control, power, coordination and endurance around the injured leg. Researchers have worked hard to establish better guidelines for when it is safe to return to sport and how to minimize the risk of re-rupture of the ACL graft. 

Most athletes take eight or more months to return to sport and should be able to demonstrate good technique and control in a series of sport-specific activities and functional tests like single and double leg hopping and jumping as well as control of dynamic valgus or the tendency for the knee to buckle inward which increases the risk of ACL re-injury and injury to the opposite knee. 

SET UP YOUR PHYSICAL THERAPY APPOINTMENTS TODAY

If you’ve sustained an injury to your ACL, it’s time to set up your physical therapy appointments. Physical therapy can start immediately after an ACL injury and resume again after ACL surgery. Schedule an evaluation with a physical therapist at Evolve to help you get on the road to recovery after ACL injury.

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