Phase I: preoperative period.
The goal for this phase of the accelerated rehabilitation program is to obtain full range of motion. This means that you should be able to flex and extend your knee as far as the uninjured side by the end of the program. This period is a good time for you to prepare for ACL surgery and to learn as much as possible about the type of surgery and rehabilitation that you are going to have.
During this period of time, you should concentrate on maintaining as much strength as possible in your quadriceps muscle. The quadriceps muscle brings your knee into full extension. This is one of the strongest muscles in your body, but unfortunately, it can loose a significant amount of strength after any type of knee surgery.
The quadriceps contracts, pulling on the patella which is connected to the tibia by the patellar tendon. The force of this contraction brings the knee into extension.
Regaining the strength in your quadriceps muscles can be difficult, because your knee may hurt quite a bit in the first few weeks after your injury. Some common exercises that orthopedic surgeons and physical therapists usually recommend are knee extensions, quad sets, heel slides, and straight leg raises. These exercises are performed in the following manner:
Knee extensions and quad sets --To perform these two exercises, place the heel of your injured leg on an object that is a few inches thick (like a phone book). Gradually relax and let your leg come to full extension. This first part of the exercise helps you to maintain a normal range of motion.
After your knee has stretched out for a while, perform a set of ten quadriceps contractions with your leg in the same position. Without lifting your heel up in the air, tighten your quadriceps muscle as hard as you can for ten seconds. Then relax for ten seconds before tightening your muscle again. Repeat this ten times. This exercise helps you to maintain quadriceps strength.
Heel Slides-- For this next exercise, start with you injured leg stretched out. Then, while keeping your heel on the floor, gradually bend your knee and slide your heel towards your buttock. Bend your knee until it becomes just slightly uncomfortable and you can feel a bit of pressure inside your knee. Hold it in this position for ten seconds. Then straighten your knee out again and relax for ten seconds. Repeat this exercise ten times as well. This exercise will help you to maintain range of motion.
Straight leg raise --This exercise helps you maintain your quadriceps strength. Start with your leg flat on the bed. Begin by tightening your quadriceps, as in the quad sets exercise. Then lift your leg off the bed until your heel is approximately eighteen inches off of the bed. Lower your leg back down and relax for ten seconds.
Phase II: 0 to 2 weeks after surgery
For the first two weeks after your ACL surgery, you will need to concentrate on regaining range of motion and on minimizing the amount of swelling. You should ice and elevate your knee as much as possible, and avoid spending time on your feet. Your doctor may give you a special pair of socks, called TED hose, that will help the swelling to go down. These socks may itch and drive you crazy, but they can significantly speed up the process of removing the swelling. You will require crutches for some period of time after your surgery. The amount of time that you spend on crutches depends on your doctor's rehabilitation plan and how well you are doing.
By the end of this period of time your wound will have healed and you should be able to move your knee from full extension to ninety degrees of flexion. Each doctor and physical therapist has their own schedule and routine for ACL rehabilitation exercises to restore the motion to your knee and the strength to your quadriceps muscle. The following exercises are some of the more common ones. Many rehabilitation programs will have you performing a set of these (or similar) exercises every hour that you are awake. Each of these exercises should be done gently and gradually, and you should not push yourself to the point where you are in a significant amount of pain.
Knee extensions -- This exercise helps you to restore range of motion. Place your heel on object like a telephone book so that your heel and calf are not touching the bed. Remain in this position for five to ten minutes.
Quad sets -- This exercise helps you to maintain your strength and your range of motion. Keep your heel elevated as in the knee extension exercise. Begin by tightening the quadriceps muscle and holding it for ten seconds. Repeat ten times.
Straight leg raise --This exercise helps you maintain your quadriceps strength. Start with your leg flat on the bed. Begin by tightening your quadriceps, as in the quad sets exercise. Then lift your leg off the bed until your heel is approximately eighteen inches off of the bed. Lower your leg back down and relax for five seconds.
Heel slides -- This exercise is for ROM. Begin with your knee flat on the bed and slowly bend your knee until it is just slightly uncomfortable. Hold your knee in this position for ten seconds, and then relax by straightening your leg. Rest for ten seconds. Repeat ten times.
Phase III: 3 to 5 weeks after surgery
During this phase you will work to maintain full extension and gradually increase the amount of flexion your knee is capable of performing. If you conduct your exercises daily you will recover the motion in your knee as well as the strength in your quadriceps muscle quite quickly. You should reach a point where you have a nearly normal range of motion by the end of this time period. During this phase you can start using an exercise bicycle and a stair-stepper, as long as you are comfortable and your knee does not hurt or swell significantly after exercise.
Phase IV: 6 weeks after surgery.
During this phase you will work on building your strength back while allowing the ligament to heal into the bone tunnels in your femur and tibia. Most physical therapists prescribe closed-chain kinetic exercises during this phase. In this type of exercise, your foot is planted on the floor and is not free to move about. Squats are an example of a closed-chain kinetic exercise whereas quadriceps extension exercises on a weight training machine are an open-chain exercise. Most surgeons will wait until at least three months have passed before allowing their patients to return to agility training exercises. When to return to competitive or recreational sports after an ACL reconstruction is a difficult decision.
The timing of your return to normal athletic activities will depend upon how well you have done with your rehabilitation, how solid your knee feels to you, and what you and your surgeon decide is reasonable. Even after you return to your activities, it is important that you pay special attention to keeping your quadriceps and hamstrings in good shape, as this is considered an essential part of protecting the ACL.
POST OPERATIVE ACL PROTOCOL
PHASE 1: DAYS 1 -14
Perform the following excersises frequently: 30 repetitions , 3 – 5 times daily.
QUAD ISOMETRICS HEEL SLIDES
ACTIVE ASSISTED MOTION ICE POSITION 15 MINUTES 2-3 TIMES A DAY
**QUAD excerices have to be done ALL DAY 50 to 60 times.
Wear the immobilizer for 4 weeks when walking
Use ice pack if needed after the excerices with knee in extension
Climbing up sequence
1. Start with Normal Leg then 2. Both crutches one by one then 3. Operated leg
Climbing down sequence
1. Both crutches one by one then 2. Operated leg then 3. Normal leg
PARTIAL WEIGHT BEARING (WITH A PAIR OF CRUTCHES) FOR 3 weeks
Use the crutches and bear weight as tolerated
Active knee bending in lying straight --- Day 3
Active knee bending lying on stomach --- After suture removal
Active knee bending sitting on the besd --- After Suture removal
To get 90 Degree of knee flexion by the end of 3 week from date of surgery
After 2 Weeks
Remove the operated side crutch on 14th day
Remove the brace in the morning only. Must compulsory wear the brace at night.
PHASE 2 after 3 months
Can take the next side crutch after the 21st day
Static cycling half an hour daily
Start half squats (10 repetitions x 3 sets) morning and evening. No knee flexion past 45 degrees
PHASE 3 After 2 months
continue the above
can start slow walking and progress the speed, duration
PHASE 4 After 6 months
Can start swimming
Continue the above exercises
DO's and DONT's
1. To avoid squating on the floor, full squats, cross leg sitting and using an Indian toilet following surgery for 6 months to one year
2. Avoid car driving for a period of one month and 2 wheeler for a period of 3 months from the date of surgery
3. Do not try to get full bending like normal leg for one year
4. Dont do any other excersice which we have not taught you or not in this protocol
5. Apply Ice cube massage in case of swelling or pain for 10 to 15 minutes
6. Continue excercises for as long as possible to keep yourself fit
7. Wear sandles with strap back when you walk