Anterior Cruciate Ligament – Reconstruction (ACL – R)
Tears of the Anterior Cruciate Ligament (ACL) are relatively common especially among sports people. The aim of this information page is to ensure safe and speedy progress is made to aid your recovery, with or without surgery. By following these exercises we will guide you through each step on your return to normal living and specific sporting goals.
Any exercise has an inherent risk. Always consult with your physiotherapist for any queries or issues.
The Knee
The knee is formed of the tibia (shin bone), femur (thigh bone) and the patella. To provide stability at the knee there are various ligaments. The collateral ligaments provide stability to each side of the knee and the Cruciate ligaments prevent the tibia sliding forwards and back in relation to the femur.
The ACL is a broad thick band which stops the tibia sliding forwards in relation to the femur. It starts from the bottom of the femur, and passes down and forwards to attach to the top of the tibia. As the ACL is situated inside of the joint capsule, when you rupture your ACL it causes bleeding. This is why your knee quickly swells after the rupture.
The surrounding quad, hamstring and calf muscles also play a vital role for additional stability and providing strength and movement at the knee.
How has your injury happened?
Non Contact: believe it or not, the most common cause of ACL injury is through a non contact mechanism when the knee is subjected to sudden deceleration forces combined with rotation eg twisting on a fixed foot, especially on pivoting and landing. Another common mechanism is through Extreme hyper-extension and hyper-flexion.
Contact injuries occur when there has been a direct blow to the outside of the knee or lower leg.
Following your injury, you may experience symptoms of giving way and instability at your knee. This may in turn affect your normal activities and participation in sport.
What Next!
To treat an ACL injury a decision will be required as to whether you follow the surgical or conservative pathway. Not everyone needs surgery! Current research has shown there to be little or no difference, in return to activity, between surgical patients and those who choose the conservative route. It depends on various factors, including; your age, degree of your knee stability, any associated injuries such as meniscal tears and the level of activity/sport that you wish to return to. An in depth discussion with your physiotherapist and consultant will help you with your decision.
Despite your decision initial management of ACL sprains remains the same.
Pain Management
After an injury you may have heard from someone before about RICE (rest, ice, compression and elevation) when managing an injury. However, rest can be harmful and inhibits recovery. Recent research has now advised we use the acronym POLICE.
- Protection
- Optimal-Load
- Ice
- Compression
- Elevation
The key term is Optimal-load, this replaces Rest. You may need to speak to your physiotherapist to discuss what your optimal load might be as it is specific to you but will help speed up your recovery process.
If you are not getting surgery, you can skip the next section, however it may be of interest to read, in case you are still considering this option.
Surgery
The two most common forms of ACL reconstruction are by using a hamstring or patella tendon graft. The hamstring graft is a much more common procedure which comprises of removing part of the semitendinosis and/or the gracilis muscles from the hamstrings, which are then stitched together to make the graft. Small tunnels are then drilled in the femur and tibia so the graft can then be pulled through and secured in place. The graft is placed as close to the original ACL position as possible and acts as a substitute for the damaged ACL. 
Another method to fix the ACL is with a patellar tendon graft also known as a “bone-patellar tendon-bone” graft or BPTB graft, as it consists of tendon and bony attachments.
ACL reconstruction with a BPTB graft has can be stronger than the hamstring graft, although there is a risk of anterior knee pain (Patellofemoral joint pain), due to where the graft is taken from. It is usually surgeon preference for which surgical procedure is used, however you can discuss this further with them.
Post Operative Care
Following surgery you will experience a certain amount of pain, this can be controlled by taking regular pain medication as prescribed by your doctor.
At this point the POLICE principal will take place. Ice not only helps to reduce swelling but can also help manage acute post-operative pain. Following the surgery you will be allowed to fully weight bear, unless instructed otherwise by your consultant. It is important to continue mobilising your knee and maintaining as normal a walking pattern as possible. Your physiotherapist will teach you how to use crutches to ensure you are optimally loading the knee is the safest possible manner. They will also give you exercises to do, which are available below.
You are likely to be discharged home on the same day as your surgery, as long as you are safe to do so.
It is important to note should you experience any severe redness and increased temperature around the knee to contact your GP as soon as possible. Another post op complication can be the risk of Deep Vein Thrombosis, therefore if you are experiencing any intense severe calf of groin pain, you will need to contact your GP or attend accident and Emergency urgently.
What can physiotherapy do for me?
On your first outpatient physiotherapy appointment your therapist will conduct a needs analysis so your rehabilitation is tailor made to you. Regular physiotherapy and exercise will be extremely important to achieve your specific goals.
The main aim of physiotherapy immediately after injury/surgery is to:
Evaluate/test dysfunction: using a specific needs analysis for your specified goals
Reduce swelling: ICE
Reduce pain: pain medication provided following your injury or surgery from the doctor
Protect the graft
Regain full range of mobility/movement (especially full extension of the knee)
Re- educate muscles and begin muscle activation
The Exercises
Participating in an exercise program carries a certain element of risk for some people. You should consult with your physiotherapist before initiating this program to ensure your safety.
If you have any issues please do not hesitate to contact the physiotherapy department. If you feel light headed, dizzy or have issues with your breathing please contact your general practitioner (GP) immediately.
When carrying out this exercise program you may feel some discomfort in your knee. It is important that the pain does not exceed 3-4/10, where 10/10 is the maximum and 0/10 is no pain.
Level One
- Static Quad with opposite straight leg raise:
With your operated foot on a large rolled up towel, contract the quads and push your knee into the bed whilst lifting your other leg off the bed, keeping it straight.Hold for 5 seconds and repeat 15 time, completing 3 setshttps://youtu.be/fY6lOwrblyw
- Flexion/extension on bed:
Flex and extend your leg on a flat slippery surface, you can make this more intense by using a towel to hold the knee in the flexed position for 3-5 seconds.Repeat 15-25 times, completing 3 setshttps://youtu.be/zSlOWDfOH8w
- Flexion/extension on wall:
Flex and extend your knee keeping the foot in contact with the wall at all times.Repeat 15-25 times, completing 3 setshttps://youtu.be/oE5rGDP11TM
- Bridges:
Lying on your back with your knees bent, squeeze your bottom muscles and tighten your stomach muscles. Lift your bottom off the bed until there is a straight line between your shoulders and knees.
Hold for 5 seconds and repeat up to 15 times, completing 3 setshttps://youtu.be/gvJPl9PVl5w
- Isometric wall slide:
Stand with your feet shoulder width apart approximately 30-50 centimetres from the wall, with a band around your knees.
Slide down, with equal weight bearing, as far as you feel comfortable.
Hold this position for 10 seconds with the aim to progress to 45, completing 3-5 sets
https://youtu.be/PpAHbaMjWgA
Additional Exercises
At this point your physiotherapist may find that in their assessment you may have other muscular deficits, which may have altered the way you move - also known as your biomechanics. The below links are part of this website and can provide additional exercises, which will help you on your road to recovery. Discuss these with your physiotherapist and remember to use pain as your guide, where is does not exceed 3-4/10.
Gluteal Muscles: Patello-Femoral Joint Pain
Go to level one exercises.
Hamstring Muscles: Hamstring Strain
Go to exercise 4, 5, 6
Calf Muscles: Calf Muscle Strain
Go to level one exercises
Core and stretching (Pilates/yoga): Mechanical Low Back Pain
Go to the level two (core) and stretches (yoga).
Level 2
- Step ups :
Stand facing a step of appropriate height. Put your injured leg on the step and step up by extending through your hip and knee, bringing the other leg through at a right angle. Keep the movement controlled as possible with your knee tracking over your second toe
Repeat 15-25 times, completing 3 sets
https://youtu.be/SIyWLTbdS4M
- Fire Hydrant:
On your hands and knees with the band above both knees. Bring your leg back with your heel towards the sky and turn your knee outwards. Think a dog on a fire hydrant.
Repeat 15-25 times, completing 3 setshttps://youtu.be/mRR022fyqwk
- Double leg, leg press:
Adjust the leg press to a safe suitable range so that you are comfortable. Select the appropriate weight. Keep your feet flat on the plate and your back firmly against the seat. Slowly lower the plate towards you as far as you feel comfortable, then slowly extend the legs pushing against the plate with equal weight bearing on both legs. Do not fully extend your knees!
Repeat 15-25 times, completing 3 sets
https://youtu.be/-xr4AxA97L8
- Single leg bridge
Lying on your back with your knees bent, squeeze your bottom muscles and tighten your stomach muscles. Using the affected leg lift your bottom off the bed until there is a straight line between your shoulders and knees, whilst keeping the other leg straight.
Hold for 5 seconds and repeat 15 – 25 times, completing 3 setshttps://youtu.be/9gXNhRNvH-E
- Parallel goblet squat with band.
With a band around your knees, select an appropriate weight. Perform a squat keeping your knees over your second toes, with your back straight and body weight evenly spread over both feet.
Hold for 5 seconds and repeat 15 – 25 times, completing 3 setshttps://youtu.be/SQxvgqUE3xY
Level 3.
- Dip with support.
Standing on a step use a wall or chair for support and balance on the affected leg. With the good leg extended in front slowly bend the injured knee, ensuring the knee goes over the second toe, then extend back to the starting position. As you feel more confident in the movement you can bend down further.
Hold for 5 seconds and repeat 15 – 25 times, completing 3 setshttps://youtu.be/1ya7-3c9R1Y
- Monster Walk:
With a band around your knees, bend into a mini squat position. Slowly walk forward bringing your foot towards the opposite leg and back out to the side. Repeat this forward and backwards ensuring your knee tracks over your second toe.
Complete 20 steps forward and 20 – 25 steps back, 3 sets.https://youtu.be/QMUjYWm-TXw
- Single Leg, Leg press
Adjust the leg press to a safe suitable range so that you are comfortable. Select the appropriate weight. Keep your foot flat on the plate and your back firmly against the seat. Slowly lower the plate towards you as far as you feel comfortable, then slowly extend the leg pushing against the plate with equal weight through the whole foot. Do not fully extend your knee!
Repeat 15-25 times, completing 3 setshttps://youtu.be/DlEmSpfkP-4
- Lunge
Standing tall, take a large step forwards with your injured leg and bend that knee until the opposite knee is approximately 5cm above the ground, then extend through the hip and knee to return to the starting position. Remember to keep your back straight throughout the movement.Hold for 5 seconds and repeat 15 – 25 times, completing 3 setshttps://youtu.be/OnRcydXHFAY
- Goblet Squat with band on bosu
With a band around your knees, select an appropriate weight. Standing on a Bosu or any unstable surface, perform a squat keeping your knees over your second toes, with your back straight and body weight evenly spread over both feet.Hold for 5 seconds and repeat 15 – 25 times, completing 3 setshttps://youtu.be/11iHF8n9sSU