The Rehabilitation Road Map

The accelerated rehabilitation program after ACL reconstruction surgery ensures a safe and rapid return to daily activities. Controlling postoperative swelling that leads to stiffness and regaining strength and range of motion is key at the start. Approached in three primary phases and carefully monitored by Dr. Sanders and his certified trainers each step of the way, the program can have patients riding the stationery bike by day four, running and swimming by week four – and athletes back in the game even the end of month three.

Phase One – Day of surgery to postoperative day 14
• Edema and Swelling Control
• Load Bearing Activities
• Range of Motion Exercises

Phase Two – Postoperative day 15 through 28
• Load Bearing Activities
• Range of Motion Exercises
• Whole-body Strengthening

Phase Three – Postoperative day 29 until return to sports
• Strength and stability assessment
• Advanced exercise program
• Return to some athletic activity
• Individualized Reconditioning Program

Phase One – Day of Surgery to Postoperative Day 14

During this phase, the emphasis is on minimizing postoperative swelling, attaining full knee passive hyperextension and knee flexion of the ACL limb.It also focuses on avoiding infection, strengthening the graft limb, and walking in a normal fashion without crutches or braces. Although patients will visit the Clinic for therapy on the first and fourth postoperative day, they are urged to restrict activities and rest with their legs elevated during the first postoperative week.

The Focus
The primary focus at this stage is avoiding stiffness that would make a return to sports impossible. This is why certain steps are taken to control swelling and prevent stiffness.

Compression stockings are placed on both legs, along with a Cryo/Cuff®, to further reduce swelling by applying both cold therapy and compression. Both knees rest straight with two pillows under the heels and nothing under the crease of the knees. Four times every hour patients must actively put their knees through a range of motion, beginning straight to bending completly – heel touching buttock. These Active Range of Motion exercises are critical for a successful return to sports and optimal recovery.

The exercise is done by fully extending the knee and placing several towels or firm pillows under the heel. A single towel is held by both hands under the forefoot. As toes are pulled towards the head, assisted by the towel held in both hands, the patient pushes the back of their knee down towards the bed. This enables the knee to hyperextend. Another way to accomplish this is to lie on the floor and elevate the legs by putting both heels on a coffee table. Patients then actively extend their knees as much as possible. A trainer or coach can see if both legs extend equally. If not the trainer or coach can exert some manual pressure on the knee that doesn’t want to extend as much, in order for both to be equal.

To flex the knees, the cannonball position is preferable. The patient grasps the back of both thighs and pulls them up to the chest. As this occurs, the quadriceps muscle relaxes and gravity causes the knees to bend. Patients are asked to breath and exhale deeply. The trainer or coach can determine if both knees are flexing equally. If not, then some gentle pressure can be placed on the foot of the deficient knee to cause it to flex as much as the opposite one. During this time it is important to concentrate on breathing – and in particular the exhalation.

The flexion and the extension exercises should be done four times per hour while awake.

From the first postoperative day through week two, another device known as the Shuttle is provided to exercise and strengthen the Graft leg. This series of knee extension exercises is done while in bed and should be performed each day during this time – four sets of 25 reps. The Shuttle resistance is increased as strength increases. A stationary bike one hour a day is introduced into the exercise routine as early as day four.

On the night of the surgery, patients are able to walk 300 feet in a normal fashion without crutches or braces. Knee Range of Motion is from full extension through greater than 110 degrees of flexion. By the seventh day following surgery, patients are allowed to resume regular sedentary activities and have a normal gait without crutches. Patients should continue their active exercises four times per day. A follow-up appointment is made at this time. The Shuttle is used for an additional week for 10 minutes four times per day on the graft leg. Patients must still take it easy and limit their activities.

After the second week, when the Shuttle is discontinued, the Step Box is added. This is a simple device used to improve performance of closed chain knee extension exercises on both legs (graft and ACL).

Phase Two – Postoperative Day 15 through 28

In this phase, patients continue to work to minimize swelling and maintain physiologic hyperextension and full flexion. Strength work is increased and advanced flexion exercises begun. These include use of the stationary bicycle with the seat set lower than normal. Patients return completely to daily activities in this phase.

The Focus
Continuing to build strength and flexibility is the primary focus during this phase. Following the two-week follow-up visit and assessment by Dr. Sanders and a certified trainer, patients continue their exercise program by adding the Step Box for both legs. This simple device is used for the performance of closed chain knee extension exercises on both legs, beginning with four sets of 25 reps of two-inch excursions until fatigue each day, then increasing until 50 reps can be performed. The same routine is then continued with a four-inch excursion. After the same goal is reached, the excursion is increased to six, then eight inches. Remember to do at least four sets per day on each leg. The patient may start to work in the stationary bike and/or the Stairmaster, as well as continuing with the Step Box at increasingly longer excursions through the end of the fourth week. In addition, in the fourth week, programs of jogging, swimming, and specific sport related activities are begun.

Patients can begin running and swimming at four weeks – advancing in athletic activities as tolerated and as comfort level allows. Though, resumption of athletic activities in close cooperation with the doctor and trainer is required. At one month, neuromuscular retaining begins, particularly on the female athlete, in order to avoid a rupture of the reconstructed, or the opposite ACL. Patients return to sports by the end of the third month.

Phase Three – Postoperative Day 29 until Return to Sports

Before beginning this phase, patient progress in ROM and strength is assessed and the knee is manually checked for stability. They then begin a progressive strengthening program that also includes some agility training. The patient learns to become confident with the capability of the reconstructed knee.

The Focus
The certified trainers work one-on-one with patients in this phase to develop the optimal strength training and sport specific exercise program for their needs. Exercise routines that can be done at home as well as in a gym, or clinic, are established in order to restore the patient’s independence and allow routines to become a part of their daily activity. Runners, bikers and swimmers can begin incorporating their sport into their exercise routine – continuing to build back to their initial strength endurance.

While closely monitored, patients may return to sports at a less aggressive level in the third month. Using strength and measurement tests, as well as subjective results, Dr. Sanders evaluates patients at five weeks, three months, six months and one year. Patients should then be able to resume all previous activities with a strengthened capacity by three months post surgery.