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U W H E A LT H S P O R T S R E H A B I L I T A T I O NRehabilitation Guidelines for ACL Reconstructionin the Adult Athlete (Skeletally Mature)Anterior cruciate ligament (ACL)injuries affect men and womenacross a wide age range and at alllevels of athletics.About the Anterior CruciateLigament (ACL)There are four main ligamentsthat stabilize the knee. The ACLis located in the center of theknee along with the posteriorcruciate ligament (PCL). The ACLis responsible for stabilizing kneerotation that occurs during cuttingand pivoting activities. The ACL isalso a secondary restraint to kneehyperextension.The ACL stabilizes the knee jointin two ways. First, the ligamentacts as a passive restraint toexcessive movement throughits connection to the shin bone(tibia) and thigh bone (femur).Second, the ACL has mechanicallysensitive nerve receptors, calledproprioceptors, which sense theposition of a joint. When a jointstarts to exceed its normal rangeor speed of movement theseproprioceptors will send a signalto the brain and spinal cord, whichin turn stimulates the appropriatemusculature to assist with stabilizingthe joint.Mechanism of InjuryAn ACL injury usually occurswithout contact from anotherplayer. The most common form ofnon-contact injury is a decelerationinjury. An athlete often plantstheir foot on the ground to cutor change directions and the ACLcannot withstand the force placedon it, so it tears. This causes theknee to buckle or give out. TheACL also can be torn if the kneeis forcefully hyperextended whilelanding from a jump. An ACL injurycauses pain and a lot of swellingin the knee. Sometimes people saythey felt or heard a “pop” in theknee. It is often hard to walk afteran ACL tear. It is also usually hardto bend and straighten the knee allthe way after the injury. Even onceswelling goes down, people mayfeel like the knee “gives out” orfeels unstable.Although less common, contact ACLinjuries occur. A common contactinjury occurs when an athlete is hitfrom the side at the knee with thefoot planted on the ground. Theseinjuries often involve more thanone ligament.Research studies have attempted todetermine what factors contributeto an increased injury risk, butACL injuries are multi-factorial andcannot be isolated to a single cause.Diagnosis of an ACL InjuryThere are several ways to diagnosean ACL injury. A thorough historyof how the injury occurred isimportant to know, but the physicalexamination is often the mostreliable and least expensive methodof diagnosis. A sports medicinephysician, physical therapist orNormal ACLTorn ACLFigure 1: MRI images of the ACL of the kneeathletic trainer will assess the knee’slaxity, compared to the uninjuredknee, using a Lachman’s test andan anterior drawer test. They willalso test the rotational stabilitycomponent with a test called thepivot shift test. This test attempts toreproduce the athlete’s sensation ofbuckling or giving out.A magnetic resonance imaging(MRI) scan (see Figure 1) canvisualize soft tissue and is arelatively accurate test in predictingan ACL tear. A KT-1000 is a deviceThe world class health care teamfor the UW Badgers and proudsponsor of UW AthleticsUWSPORTSMEDICINE.ORG621 SCIENCE DRIVE MADISON, WI 53711 4 6 0 2 E A S T PA R K B LV D . M A D I S O N , W I 5 3 7 1 8

Rehabilitation Guidelines for ACL Reconstruction in the Adult Athlete (Skeletally Mature)Patellar Tendon GraftHamstringTendonGraftFigure 2: Donor sites for patellar tendon and hamstringtendon graftsthat measures the laxity or loosenessin the uninjured knee compared tothe injured knee. In a diagnosticarthroscopy, a surgeon looks insidethe knee with a camera to determinean injury. This is the most definitivetest but also the most expensive andinvasive.Consequences of an ACL InjuryWhen treating an ACL injury, thekey is controlling the instability ofthe knee. Repeated instability notonly hinders athletic performance,but more importantly increases therisk of further injury to the cartilageand other ligaments of the knee.Cutting and pivoting activities(common in sports like football,soccer, basketball and volleyball)are the most stressful for the ACLand are the activities most likelyto reproduce the instability in anathlete with a torn ACL.Treatment Options foran ACL InjuryThe choices for treatment shouldbe individualized and should take2Figure 3: Example of a bone-patellar tendon- Figure 4: Example of a hamstring tendonbone graft using two interference screwsgraft using an endobutton on the femoral sideand a interfix screw on the tibial side screwsinto account the age, activity leveland the desire to return to sportswhich require significant amounts ofcutting and pivoting or other highspeed movements. One form ofconservative treatment is to modifythe athlete’s sports participation.This involves discontinuing sportsinvolving cutting and pivoting,such as soccer and basketball.These sports could be replacedby sports that do not involvecutting and pivoting, such asswimming or running. Anotherform of conservative treatment isrehabilitation. Rehabilitation for anACL injury focuses on improvingan athlete’s proprioception andreactive muscular stabilization. Forsports such as basketball, soccer andfootball, rehabilitation alone may notbe enough to prevent instability. Ifinstability persists, the athlete mustundergo surgical reconstructionof the ligament to return to thesesports.Surgical reconstruction involvesreplacing the torn ACL with a graft.For the athlete that is done, ornearly done growing, the surgicalreconstruction involves placing agraft within drill holes (tunnels) inthe thigh (femur) bone and shin(tibia) bone. There are severalacceptable graft choices: hamstringtendon, patellar tendon andquadriceps tendons. Factors suchas; other current injuries to the knee(ie. meniscus or MCL), pre-existinginjuries, work or sport returningto, and age may determine whichof these three is best for you (SeeFigures 2-4).All athletes will undergo six totwelve months of physical therapy.The post-operative physicaltherapy can be divided into fivephases. During the first phase, therehabilitative goals include protectingthe healing graft, improving rangeof motion, decreasing swelling andregaining leg muscle control. It isespecially important to regain fullextension very early post-operatively.When the knee is fully extended(straight) the ACL sits against theUWSPORTSMEDICINE.ORG621 SCIENCE DRIVE MADISON, WI 53711 4 6 0 2 E A S T PA R K B LV D . M A D I S O N , W I 5 3 7 1 8

Rehabilitation Guidelines for ACL Reconstruction in the Adult Athlete (Skeletally Mature)Figure 5: Photos show the ACL graft, with the first photo shot with the knee in flexion and the secondphoto shot with the knee in full extension.roof of the intracondylar notch.Thus it is important to achieve thisearly on, preventing scar tissue fromforming in that space of the notch.(See Figure 5, ACL in flexion andin full extension). In phase two, thegoal is to focus on restoring properbody alignment and control withbasic movements, such as walking,squats and balance. This phasecontinues to build lower extremityand core (trunk) strength. In phasethree, the focus shifts to developinggood movement control withimpact activities and more complexmovements, such as a lunge with arotational component. Developingmovement control and eliminatingapprehension while cutting andpivoting is the primary goal of phasefour. At this time there is also morefocus on single leg impact and pushoff with change of direction. Thefinal phase transitions the athletefrom performing intense cutting andpivoting activities in a controlledenvironment to an environmentthat more closely replicates theirsport, including return to teampractices with progressive decreasein limitations.3UWSPORTSMEDICINE.ORGWith the return to sports and higherlevel activities, there is the risk ofthe new ACL graft tearing if there isa new injury to the knee. The riskof this happening in young athletes/individuals ( 18 years old) is atleast twice as high as it is in olderadults. It is reported to be as high as15-30% in these younger individuals.Reasons for this are unclear butlikely to do a few different things621 SCIENCE DRIVE MADISON, WI 53711 including the type of surgery,continued physical maturation andreturn to more years of high-levelactivity. Because of this high risk orre-injury, your physical therapist anddoctor will put you through a seriesof progressive tests to determinewhen it is most safe to return toactivity and sports. There is goodevidence to show that the risk ofre-injury goes down significantly bypassing all return to sport testingand not going back too early.4 6 0 2 E A S T PA R K B LV D . M A D I S O N , W I 5 3 7 1 8

Rehabilitation Guidelines for ACL Reconstruction in the Adult Athlete (Skeletally Mature)PHASE I (Surgery to 4 weeks after surgery)4Appointments Rehabilitation appointments begin post-op day 1 and should be 1- 2 times perweek during this phase.Rehabilitation Goals Protection of healing graft fixation Restore quadriceps function and leg control Adherence to home exercise program (HEP) and precautionsPrecautions Weightbearing: Weight bearing as tolerated (WBAT) with crutches Brace: Post-operative extension brace for 2-4 weeks, wean from brace locked tobrace unlocked to no brace as patient establishes leg control, pain control andsafe gait mechanics. Range of Motion (ROM): Goal of 0-90 within 1 week, moving toward full flexionafter the first 4 weeks. The goal in the first phase is to achieve hyperextensionequal to the other side, unless excessive hypermobility exists. Generally 5 of hyperextension should be a maximum. Hamstring grafts: Avoid aggressive hamstring sets, heel slides, prone hangs andother hamstring activities that may aggravate the graft donor site. Slowly andprogressively build in hamstring work. Mensical Repair: For Drs. Baer, Walczak and Spiker- no weightbearing flexion, respect and don’tpush through any compression type pain or discomfort when working on flexionrange of motion Dr. Scerpella- no change in precautions Mensical ROOT Repair: Touch-down weight bearing (TDWB) in locked extension brace for 6 weeks.NWB flexion for 6 weeks ROM 0-90 , always in NWB positionSuggested Therapeutic Exercise Assisted range of motion (AROM) (seated knee flexion or supine wall slides)within above guidelines Knee extension range of motion (avoid hyperextension past 5 ) Ankle pumps progressing to resisted ankle range of motion Patellar mobilizations Quad sets - 10 second sustained and 1 second rapid activation Straight leg raises in multiple directions Supine wall pushes Mini squats Weight shifting drillsCardiovascular Exercise None at this timeUWSPORTSMEDICINE.ORG621 SCIENCE DRIVE MADISON, WI 53711 4 6 0 2 E A S T PA R K B LV D . M A D I S O N , W I 5 3 7 1 8