A recently published article from the British Journal of Sports Medicine discusses
rehabilitation after ACL reconstruction. A systematic review of the 140 studies was
conducted and then clinical guidelines are made via expert consensus with a panel of 9
practioners. The review is aimed to be utilised by physiotherapists during the rehabilitation
of clients after ACL reconstruction.
The review is broken into 5 categories summarised by the infographic below:
Timing and Structure
– Preoperative rehabilitation may improve post-op outcomes such as quads strength
and knee range of motion. A visit to your physiotherapist is recommended prior to
– Both supervised and unsupervised exercise programs can be suitable provided the
patient has access to appropriate equipment and is motivated. All programs should
– Functional criteria should be used to progress rehabilitation whilst being mindful of
graft healing timeframes.
– Cryotherapy is inexpensive, low risk and demonstrates high levels of patient
satisfaction in early stage post-op.
– Neuromuscular electrical stimulation can be used in the very early phase post-op to
increase muscle activation and reduce disuse atrophy.
– Blood flow restriction training may be used in the early phases to improve hamstring
and quadriceps strength in patient are struggling with knee pain or high loads.
– Active range of motion, weight bearing and static quadriceps activation should
begin as early as possible in recovery. This should be done within patient tolerance
levels and whilst being mindful of surgical indications.
– Leg press between 0-45 degrees knee flexion and eccentric quadriceps (on a stepper
or eccentric cycle) between 20-60 degrees can be started from week 3, with open
chain exercises between 45-90 degrees knee flexion clear to start from week 4
without compromising graft integrity.
Strength and Motor Control training
A combination of closed and open kinetic chain exercise is more effective than either in
isolation. Monitor for anterior knee pain during open kinetic chain exercises and adjust
Using eccentric strengthening as part of a program can elicit improved strength and
functional outcomes after anterior cruciate ligament (ACL) surgery.
Motor control, strength training, plyometric training, agility training and core stability
exercises are all integral parts of the rehabilitation and should be combined in the
rehabilitation protocol to improve outcomes.
Aquatic therapy may be used in the early phase of rehabilitation to improve subjective knee
function. It is recommended to commence around 3-4 weeks post op once wounds are
Return to Activity
Returning to driving is recommended once the patient can safely apply the brake as
required in an emergency this will be at approximately 4–6 weeks after right-sided ACLR and
approximately 2–3 weeks after left-sided ACLR.
Returning to running is criteria driven with the consensus stating the following:
– 95% knee flexion range of motion (ROM).
– Full extension ROM.
– No effusion/trace of effusion.
– Limb symmetry index (LSI)>80% for quadriceps strength.
– LSI>80% eccentric impulse during countermovement jump.
– Pain-free aqua jogging and Alter-G running.
– Pain-free repeated single-leg hopping (‘pogos’).
Returning to sport minimum criteria for a professional athlete returning to full training is
listed below. This should then be followed by a gradual return into full match play. It is
important to note that not all clinicians will have access to isokinetic testing.
– No pain or swelling.
– Knee full ROM.
– Stable knee (pivot shift, Lachman, instrumented laxity evaluation).
– Normalised subjective knee function and psychological readiness using patient-
reported outcomes (most commonly the International Knee Documentation
Committee subjective knee form (IKDC), the ACL-Return to Sport after Injury scale
(ACL-RSI) and Tampa Scale of Kinesiophobia).
– Isokinetic quadriceps and hamstring peak torque at 60°/s should display 100%
symmetry for return to high demand pivoting sports. Restore (as a minimum)
preoperative absolute values (if available) and normative values according to the
sport and level of activity.
– Countermovement jump and drop jump>90% symmetry of jump height and
concentric and eccentric impulse. Reactive strength index (height/time)>1.3 for
double leg and 0.5 for single leg for field sport athletes (higher for track and field).
– Jumping biomechanics—normalise absolute and symmetry values for moments,
angles and work in vertical and horizontal jumps especially in sagittal and frontal
plane at hip, knee and ankle.
– Running mechanics—restoration of>90% symmetry of vertical ground reaction
forces and knee biomechanics during stance during high-speed running and change
– Complete a sports-specific training programme.
If you are looking for advice regarding your sporting injury please make an appointment
with us today.
Reference: Kotsifaki R, Korakakis V, King E, et al Aspetar clinical practice guideline on
rehabilitation after anterior cruciate ligament reconstruction British Journal of Sports