NHSGGC Paediatrics for Health Professionals
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Overview of the programme

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ACL Reconstruction Surgery

The ACL graft takes in excess of 12 months for full biological integration into the knee. The combination of the ACL injury and subsequent ACL reconstruction surgery will inhibit muscle strength, control, balance and joint proprioception. Progression through the various stages of rehabilitation exercises is specifically designed to address these issues. As the individual achieves these measurable goals the focus of the rehabilitation program becomes more advanced.

This program needs to be guided by a physiotherapist and you will prescribe specific exercises which will work on your patients goals but remain within these guidelines.

NB: If your patient is not achieving their set goals within the time frame then they should not be progressed onto the next set of exercises until the goals set have been met and achieved to a high standard.

Prior to Surgery
  • Focus on achieving full ROM
  • Pre-conditioning of hamstrings (single leg deadlifts; leg curls; reverse planking)
  • Pre-conditioning of quadriceps (stationary cycle; air squats to 90 degrees; single leg squats)
  • Avoid all pivoting sports (these may cause further intra-articular chondral & meniscal damage)
Phase 1: Day 0 – 14 Compression & Cold Therapy

Your patient will be placed into a ROM brace for 6 weeks post op, the patient will be shown how to adjust this once bandages have been de-bulked and effusion dissipates the brace may become loose.

Patients are advised to NOT TOUCH the side dials, the brace will be unlocked and movement within it will not be restricted.

NB: If your patient has also undergone a meniscal repair along with their ACL reconstruction it is important that their ROM brace is locked 0-90 for 6 weeks and that they also use ECs for 6 weeks post surgery, after this time frame and once consultant is happy with healing of the meniscus then the patient can continue with ACL rehab as normal.

  • Progress weight bearing as tolerated, keeping crutches when mobilizing (to use ECs for 6/52 PO if meniscus was repaired)
  • Full weight bearing is beneficial during this phase
  • Day 1 post surgery, de-bulk bandages/padding and apply full length tubi-grip elastic to leg
  • Ice packs for 15 min x 6 times daily until effusion has resolved.
  • Focus on achieving full extension at knee and continue use of ECs until this is gained freely along with quadriceps control and reciprocal gait. Once this is achieved the ECs can be discarded.

You should start this protocol at ward level with your patient.

Wound review with Mr Smith between 7-10days post op, your patient will be given a return appointment for this prior to discharge from the ward.

Phase 2: Week 2 - 6 Range of Motion & Muscle Activation
  • Commence full ROM exercises with patient
  • Closed chain muscle activation exercises only
  • Massage patellofemoral joint to prevent adhesions
  • Regular desensitisation of surgical wounds with gentle rubbing

ROM brace can be removed at week 6 and patient can be weaned from elbow crutches if there was meniscal involvement.

Review with Mr Smith at 6 weeks post op.

Phase 3: Week 6 – 12 Muscle Endurance
  • Regular wound massage with Oil or Vitamin E cream & patellofemoral massage
  • Commence running in pool & swimming. No kicking in pool! (use a float between knees)
  • Gradually introduce open chain exercises with supervision of physiotherapist.
  • Introduce regular single leg balance exercises, wobble board
  • Hip extension (Glut Max), abduction & flexion endurance training
  • Abdominal core strength training
  • Mini trampoline

Review with Mr Smith (orthopaedic consultant) at 3 months post- operatively.

Phase 4: Month 3 – 6 Muscle Power & Running Progression
  • Continue quadriceps, hamstrings, calf, gluteals & core strengthening.
  • Commence straight line running, initially alternate jogging and walking on flat grass or track
  • Increase distance and intensity in a straight-line interval running
  • Work up to straight line sprints by 16 week mark.
  • After sprinting commenced, begin box jumps to level of knee height
  • Commence unrestricted endurance pool swimming.
Phase 5: Month 6 – 12 Dynamic Movement, Jumping & Running Speed
  • Straight line sprints, bounding running & skipping (interval training for anaerobic fitness)
  • Running on bends with decreasing radius of curvature
  • Progress to practicing transition from left bend to right bend and back again
  • Increase height of box jumps. Focus on safe landing
  • Single leg hopping (forwards, backwards, side to side) maintaining stable head, core and in-line limb posture
  • Progress to participation in desired sports training environment.
  • Can return to non-competitive and non-contact sport once clearance is given by Physiotherapist.

Review with Mr Smith at 6 months post-surgery.

Return to Sport
  • All patients should undergo biomechanical Return To Sport (RTS) assessment performed at their local physiotherapist department 12 months post-surgery.
  • General principles of RTS are that the injured leg should be able to achieve >90% of the healthy leg in a series of strength, balance and proprioceptive tests. The goal is to return to symmetry.

Patients aged <21 yrs: No return to competition until 12 months post op.

X-rays performed at 6/12/18 months to check for growth arrest and angular deformity)

Consultant review 7-10 days Post-operation/ 6 weeks/ 3 months/ 6 months/ 12 months/ 18 months