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ACL Rehabilitation: One Size Doesn’t Fit All by James Vickers

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Simply having ACL reconstructive surgery does not guarantee you a return to full activity.  The rehabilitation after surgery is a critical part of the process.

There are many considerations that may influence your ACL rehab. The list below highlights some:

  • Type of surgery you have

  • Time and rehab-history since your initial ACL rupture

  • Mechanism of your injury

  • Your previous injuries (not only previous ACL)

  • Your end goal, i.e. what type of activities you want to return to

  • Your level of sport

  • Your time and commitments

  • Your strengths and weaknesses

It is therefore apparent that a standardised ACL rehab protocol has some limitations. For the best results your rehab should be specific to you but follow key stages.

Progression through the Key Stages

Time is often used to direct the stages however it should not be used in isolation. The time after surgery is important as it indicates tissue healing, but many of the neuromuscular deficits that are associated with ACL injury do not change with time. You require targeted rehab to generate the muscle recruitment and tissue adaptions. Also you may have certain risk factors that make you more prone to ACL injury. Therefore significant proportions of the rehab should target these.

To guide your progression through the stages your performance should be assessed with some appropriate tests. These tests should reflect the stage of the rehab respecting the tissue healing. The tests should also reflect your goals. For example a semi-professional rugby player who suffered a contact ACL injury will have different tests compared to a beginner skier who suffered a non-contact ACL injury.

Therefore both time and performance are important to guide the progression through the stages.

The stages of recovery are:

  1. Initial stage-Return of basic knee function

  2. Strength and muscle hypertrophy stage

  3. Return to run

  4. Sport specific and end stage rehabilitation

  5. Return to sport


Initial Stage – Basic Knee Function

The aim of the initial stage is that you regain basic knee function. This stage it the exception, as the markers are similar no matter what type of patient you are. It is important that you achieve these markers before you progress to the more progressive strength training.

The initial markers ideally should be achieved by 6 weeks after surgery, and they are:

  • No swelling

  • No night pain with limited morning stiffness

  • A fully straight knee

  • Near full knee bend

  • The front thigh muscle (quadricep) is able to contract both on clinical testing and in weight bearing/walking

  • The back of the thigh muscle (hamstring – often where the graft is harvested from) demonstrates endurance against gravity

  • A normal walking pattern with no walking aids

Perhaps the most important factor in this initial stage is that you reduce your swelling. When the knee is swollen it is very difficult to achieve the remaining markers. Swelling is a natural consequence of the surgery but it is important to reduce it as quickly as possible.

You should apply ice, elevation and compression to the knee regularly. Wimbledon Clinics can advise on the best cooling devices. Some of them do work better than a trusty bag of frozen peas.

You also need to find the correct level of activity for the knee. Too much time in weight bearing, even standing around, will make the knee swell. However too much static activity will make the knee stiff and the swelling can pool in side the knee and fail to shift. To assist this you should take the first 2 weeks fairly easy, with the main focus on basic range of movement and quadricep recruitment. You can improve the latter with a muscle stimulator that can be rented via Wimbledon Clinics.

Strength / Muscle Hypertrophy Stage

Unfortunately muscle loss is associated with ACL injury and the surgery. This strength stage aims to reverse these changes whilst allowing time for the graft and harvest site to heal, and for the graft to stiffen.

Your quadricep is particularly susceptible muscle wasting and therefore needs early attention. This is highlighted in the initial stage markers. It is however important that you don’t forget the following muscle groups: the calf-peronei, hamstring, adductors-abductors and obliques. These muscle groups should be targeted on both legs and considered with reference to your strengths and weaknesses.

The strength focus is the backbone for 3-5 months after the initial phase. The best way for you to progress a strength program is with firstly bilateral loading (both legs working at the same time), then single leg isometrics (one leg working but with no movement), and then finally with single leg loading with movement. Ideally your strength program should be progressed every 4 weeks or so, but that depends on the work done…

Progress should only be done if you maintain the initial stage markers.

Return to Run

During the strength phase a decision on when you should run is likely. This normally occurs 3-4 months after surgery. It maybe later if you have a low priority to run or you’re not meeting the required markers.

Returning to run is a key decision point in the ACL rehab process and it often causes concern and it is crucial that you don’t run too early. We have recognised this at Wimbledon Clinics and have a designed an assessment process to help guide your readiness to run. It complements your physiotherapy program and provides clarity on whether you are ready to run. This involves an hour assessment at around 4 to 5 months after surgery. It can be booked to take place at your follow up appointment.

Key questions that are evaluated during this assessment are:

Are you demonstrating sufficient single leg strength for running compared to your body weight?

Are you demonstrating sufficient single leg control at the foot-ankle, knee and hip-pelvis-trunk?

Do you have eccentric quadricep and soleus endurance?

Can you tolerate open chain quadricep and hamstring torque?

Can you tolerate single leg plyometric load?

The specific markers for each of these questions will vary. However inadequate assessment will leave your knee and graft vulnerable to stress. This is likely to be reflected in a loss of the initial stage markers especially a recurrence swelling within the knee. If these conditions continue then stiffness or articular cartilage damage occurring will compromise the longevity of your knee.


Sports Specific / End-Stage Rehab

At this stage your rehab should become more and more specific to your sport or activities. Therefore the focus of your rehab should shift from muscle hypertrophy (strength) to power (rate of force production).

This stage should only be commenced when you have made acceptable progress with the strength stage. This progress can be illustrated by the catalogue of your rehab over the previous months and by performance markers.

To make significant strength gains it is likely to take at least 3 months of work. Therefore from a muscle function perspective it usually takes a minimum of 5-6 months from surgery to be in a position to start sport specific rehab.

At around 4 months your ACL graft starts to stiffen and by 6 months there is usually significant stiffness in your graft. This fits nicely with the muscle function progression if your rehab has gone well. Therefore your sport specific rehab can start around the 5-6 month mark if the muscle function is there. The reality is that it often takes slightly longer to get the strength.

Assessing this strength progression and readiness to start sport specific training is another common sticking point of the ACL rehab process. It is at this point that traditional physiotherapy and recovery start to give way to coaching and sport specific training. A clinical assessment that considers the following key questions is beneficial at this point. They form the basis of a sport specific assessment designed to tell you exactly what is required to get you fit to return to your favourite sport. As with the running assessment this one hour session at Wimbledon Clinics compliments your existing physiotherapy program. Following this session you may then start to work with a coach to start to reintroduce training to get back to play.

The basic points covered are:

 Are you powerful enough relative to their bodyweight in all three planes of movement?

Can you coordinate complex movement patterns that replicate your sport?

Can you tolerate sufficient running for your sport?

Do you have any significant asymmetries or weaknesses in any of the key muscle groups?


During the sport specific stage you should start to practice your sport but in a broken down, less intense way. Take skiing for example. Wimbledon Clinics offers a Return to Ski Program that includes a day of tuition at Hemel Hampstead Snowdome with The Warren Smith Ski Academy. This provides the opportunity for a graded return to skiing and adds some expert ski instruction. This will increase your confidence and provide specific teaching points for you to take into your rehab and own ski trips.


Return to Sport

The return to sport part is the most important part of the rehab process as it is the reason why most patients opt for surgery. Unfortunately the clinical evidence suggests that if the rehab is not comprehensive then a safe return to sport is not achieved. Either you don’t return or you reinjure in alarmingly high numbers (40-70%!).

It is expected that your sport specific rehab will take 2-3 months before you’re ready to return to sport. This gives a return to sport at around 8-9 months but with the demands of life it is often around the year mark.

Using skiing as an example again, it is common that an ACL injury occurs in February. Surgery is completed by late March, early April. The initial stage markers are achieved by June. The strength focus runs over the summer and into the autumn. The sports specific stage extends from late autumn to early winter. Attending the Return to Ski Program highlights some weaknesses to work on but builds your confidence. Then you can work on the final aspects and be ready to ski at Christmas, in January or at February half-term. This program can be tailored to whatever sport you play.

This process provides confidence that you’re returning to your sport in better shape than you left it. Getting a clear opinion on this is valuable and this is the final assessment point offered at Wimbledon Clinics. Key considerations for a return to sport are:

Can you tolerate high intensity multi-planar movement?

Are you powerful relative to the loads seen in your sport?

Have you sufficiently targeted the neuromuscular deficits that are associated with ACL injury?

Do you have a management plan for your knee going forward?

I hope this gives you an insight into the rehab pathway. It might appear daunting but it is well worth getting right. It is long and requires commitment. The way we work at Wimbledon Clinics is that you will be seen regularly after surgery by the follow up team that includes a very experienced physiotherapist and the surgeon. At each appointment you are assessed by myself in addition to the surgeon so don’t worry we will guide you all the way back to sport. Therefore the most important factor for adherence is that it is enjoyable. This supports the need for the rehab to be specific to you and not a time-driven standardised protocol. In my opinion it is these time-driven standardised protocols that are largely the reason for the poor surgical outcomes seen in the clinical research.

James Vickers MSc Sports Physiotherapist

Former physiotherapist to British Ski and Snowboard, New Zealand Triathlon

James Vickers works alongside Mr Jonathan Bell to provide an enhanced surgical follow up appointment. In addition James offers specific assessment appointments including:

Ready to run assessment?

*Ready to return to sports assessment?

* This is included in the Return to ski package. 

Comprehensive self pay packages are available for ACL reconstruction that are designed to get you back to sport. The Ready to run and Ready to return to sport appointments are usually one hour long .

Enquiries, prices and bookings can be made by calling us on 0208 944 0665 or emailing [email protected].