Understanding an ACL Rehab Protocol
It is with continuing frequency we see stories of many athletes being reported to be “ahead of schedule” after an ACL reconstruction. I have been closely following the case of Carson Wentz who tore his ACL in December. There werem countless reports of how good he looks and how he is ahead of schedule”. Needless to say, the decision to return an athlete back to play after an ACL is certainly not based on watching them run. Although it makes for good headlines, it is circumstantial evidence at best. It is like watching a car drive down the road and being able to tell what condition it is under the hood. ACL return to play is based on two key factors: time and evidence based functional assessments. Although protocols typically end around 6 months it is believed the healing process of the surgically repaired ligament requires around 9 months to significantly reduce the risk of a re-tear. In other words, even if the athlete looks phenomenal, the research shows the longer the ligament is allowed to heal, the lower the likelihood of a re-tear.
This post is going to take you step by step through the highlights of an ACL return to play protocol. Keep in mind the protocols vary based on surgeon, particular surgery and surgical technique. The protocol below is for an autograft procedure, which is the use of the patients own tendon, either hamstring or patella tendon. If you are recovering from your own ACL tear please follow your surgeons instructions as this is an abbreviated general approach for educational purposes.
Weeks 1 - 4
Weight-bearing as tolerated immediately post-op with crutches
Wean from crutches for ambulation by 2 weeks if tolerated
Calf Stretching
Hip Strengthening with Single Leg Raises
If available, aquatics for normalizing gait, weight bearing and strengthening
If Patella Tendon Graft:
Closed Kinetic Chain Quadriceps strengthening activities as tolerated
(wall sit, step ups, mini squats, leg press 90- 30 degrees)
Hamstring curls – add weight as tolerated
If Hamstring Graft:
Hamstring stretches (very gentle for hamstring tendon autograft procedures)
Delay hamstring strengthening for 12 weeks. (for hamstring tendon autograft procedure only)
Weeks 4 - 10
Range of motion/flexibility exercises as appropriate for the patient
Continue hamstring, gastroc/soleus stretches
Continue to progress hip, hamstring and calf strengthening as tolerated
Elliptical machine for conditioning. Stationary bike - progress time and resistance as tolerated
If available, begin running in the pool (waist deep) or on an unweighted treadmill at 8 weeks.
If Patella Tendon Graft:
Closed Kinetic Chain Quadriceps strengthening activities as tolerated
(wall sit, step ups, mini squats, leg press 90 - 30 degrees)
Continue to progress proprioceptive and balance activities
ball toss, balance beam, mini-tramp balance
If Hamstring Graft:
Initiate quad strengthening and progress as tolerated for hamstring tendon autograft procedures
wall sits, step-ups, mini-squats, Leg Press 90 - 30 degrees, lunges
Initiate proprioceptive and balance activities
ball toss, balance beam, mini-tramp balance
Delay hamstring strengthening for 12 weeks.
Weeks 10 - 16
Progress toward full weight bearing running at 12 weeks for patella tendon autograft and16 weeks for hamstring tendon autograft procedures.
Begin swimming if desired
Progressive hip, quadriceps, hamstring, calf strengthening
Cardiovascular/endurance training via Stairmaster, elliptical, bike
Advance proprioceptive activities
Months 4 - 6
Continue and progress flexibility and strengthening program based on individual needs and deficits.
Initiate plyometric program as appropriate for patient’s athletic goals
Continue progression of running distance based on patient needs.
Initiate sport-specific drills as appropriate for patient
Agility progression including, but not limited to:
Side steps
Crossovers
Figure 8 running
Shuttle running
One leg and two leg jumping
Cutting Acceleration/deceleration/sprints
Agility ladder drills
Goals:
Symmetric performance of basic and sport specific agility drills
If available battery of tests performed in motion analysis lab looking at strength and agility
Quadriceps and hamstring strength at least 85% of uninvolved lower extremity per strength test
After 6 Months
Maintenance of strength, endurance, proprioception and balance
Gradual return to sports participation
Maintenance program for strength, endurance
More information on ACL Tears....