Milestones Following ACL Reconstruction

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If you have been unlucky enough to have suffered a total Anterior Cruciate Ligament (ACL) rupture and subsequent surgical reconstruction then this information should be very relevant to you.

The following protocol has been designed using research based on accelerated ACL rehabilitation and from clinical experience. It was originally compiled by Grant when he was working at the Musculoskeletal Centre of Excellence, BUPA Wellness, Barbican, London, UK, so thank you to the staff there for their valuable input at that time. It has been updated now to apply to our Willis Street Clinic. This protocol is primarily designed to be used with patella tendon grafts, but can also be applied to hamstring graft reconstruction. However, any pure hamstring exercises need to be started very gradually and will also be delayed with tendon grafts. Although this protocol has been carefully designed it MUST be stated that these guidelines are dependent on:

Bracing may be used by the surgeon to maintain joint integrity and control functional range of motion.

A good outcome from ACL reconstructive surgery is dependent on: 

Pre-operative Management

Controlled Milestone Rehabilitation

The frequency of physiotherapy input can be dependent on the surgeon’s protocol but also depends on each individual.   More intensive monitoring is recommended in the early weeks to ensure good range of movement and to prevent complications. Then the general recommendation is every 2 to 4 weeks until 6 months post-op. After this it is determined by the patients’ specific activity and/or strength deficits. The seven stages involve critical milestones that should be achieved before progressing the patient’s function. In documenting the date of achievement this enables another physiotherapist to easily establish where a patient lies on the rehabilitation ladder.

Stages of Rehabilitation 

STAGE I: 0-2 weeks
STAGE II: 2-4 weeks
STAGE III: 4-6 weeks
STAGE IV: 6-10 weeks
STAGE V: 10-12 weeks
STAGE VI: 3-4 months
STAGE VII: 4-9 months

STAGE I: 0-2 weeks

OBJECTIVES

METHOD

GOAL: To achieve isolated muscle control and initiate a co-contraction of the quadriceps and hamstrings.

MILESTONES

STAGE II: 2-4 weeks

OBJECTIVES

METHOD

GOAL:

1. Independent gait +/- altered pattern (concentrating on heel-toe gait) 
2. Complete all activities of daily living independently.

NB: Driver / Vehicle Licensing Association (New Zealand) mandatory requirement; no driving until 4 weeks as driving reflexes are diminished by 0.2 secs per 5m before this – (Tietjens).

MILESTONES

STAGE III: 4-6 weeks

Patient should now be able to drive safely – may be prudent to inform their car insurance company to ensure they are covered.

OBJECTIVES

METHOD 

GOAL:

1. Independent gait pattern with no compensation. 
2. Knee flexion of >90º+ (note: return of knee flexion tends not to be a problem in isolated ligament injuries).

MILESTONES 

STAGE IV: 6-10 weeks

The transplanted graft dies then revascularises – this should occur between 8-12 weeks.

OBJECTIVES 

METHOD

GOAL: To decrease base of support when exercising therefore increase proprioception.

MILESTONES 

STAGE V: 10-12 weeks

The transplanted graft dies then revascularises –this should occur between 8-12 weeks.

OBJECTIVE
Preparation for running

METHOD

GOAL:

1. To start light jogging on a mini tramp. 
2. Progress loaded activities adding in lateral stability work, i.e. slide board.

MILESTONES

Able to achieve 10 slides maintaining knee alignment with no tibial torsion

1. Forward

2. Laterally in and out of abduction

STAGE VI:  3-4 months

OBJECTIVES

METHOD
Progress proprioception 
Agility skills, advance plyometrics, cutting, hopping figure 8s 
Increase speed / height of step / height of jump gradually as confidence improves.

GOAL:

1. Safe to introduce open kinetic chain exercises if sport indicated 
2. Patient should have good hip and knee control, proprioception and be free of effusion to initiate running.

MILESTONES    

STAGE VII: 4-9 months

Shelbourne and Nitz found that the patellar tendon graft remains consistently viable and attains its maximum fibroblastic size and number at 6 months. The ACL graft at 6 months is 50% of normal breaking strength, at 8 months 80% of normal breaking strength. Typically return to full sport specific activity drills at 4-6 months but dependent on: 

OBJECTIVES 

METHOD

GOAL:

1. To have control and strength to complete multi-directional activities / running drills. 
2. Ability to control speed with alignment while completing complex skills relevant to individual sport / goals.

MILESTONES 

Important treatment factors which are often ignored: