Early ACL Rehab 101: Top 10 Interventions

by Mitch Hauschildt, MA, ATC, CSCS

An Anterior Cruciate Ligament (ACL) tear can be a HUGE injury.  They are all-too-common among athletes, especially in speed and power sports.  They usually sideline an athlete for at least 6 months, but my greater concern for the young people that I work with is the long term health of their knee.  The research is pretty conclusive in that there is an almost 100% likelihood that individuals who tears their ACL will eventually develop some level of Osteoarthritis.  That statistic is frightening!

That risk factor, combined with others, really reinforces the fact that we must do everything that we can to rehab someone well after such a large injury.  It is also imperative that the patient seek out the best possible surgeon to reconstruct their knee.  The vast majority of ACL reconstructions that are performed in this country are performed by surgeons who repair less than 10 per year.  That alone may account for some of the long term risk factors.  I don’t know about you, but I would personally prefer to have mine reconstructed by a surgeon that performs 10 per week.  But, that’s an issue that I can’t control on the rehab side of things.

My point is, an ACL patient isn’t “just another patient”.  They demand focus, long term planning and lots of individual attention if we are going to treat them the right way to both return them to play and minimize their long term issues.

In an effort to advance the conversation on what can and should be performed as a part of an ACL rehab program, I am putting out a series of Instagram videos, along with this blog post, to discuss the first 1-2 weeks of a high quality ACL rehab program.

What I have found over the past 16+ years of rehabbing ACL patients is that if they work really hard and have great care for the first few weeks following surgery, the rest of their rehab will be easy. For many, it can even become boring when things are done well early on.  But, if we aren’t aggressive enough up front and/or the patient resists or is afraid of what might happen, the long term program suffers, drags out and isn’t very fun for everyone involved.

When we look at the first 1-2 weeks for post op ACL patients, I have 5 major goals to accomplish:

1. Reduce Pain:  Get them out of pain quickly and efficiently so they can perform everything else that I want them to while getting off of pain medications.
2. Manage Post Op Effusion:  We have to get rid of their swelling.  You can decide if compression, decompression or some combination of the two is the best.  Just get rid of it ASAP.
3. Reduce Hypertonic Tissue:  The body’s natural reaction to injury is to spasm and lock up.  Poor management of hypertonic tissue will only feed the pain-spasm cycle.
4. Improve Proximal Stability:  Proximal Stability leads to distal mobility.  Providing the body with a stable platform will do wonders for everything else on this list.
5. Improve Range of Motion:  If you have done the previous 4 items well, this one will come easily.  Too many people push for range of motion right away without addressing the rest of this list.  Unfortunately, that leads to headaches (and knee-aches) and can lead to the feeling of banging your head against the wall.

With our overall goals in mind, what are the best interventions to achieve these goals?  Here are my top 10 interventions that I believe everyone should be performing within the first 1-2 weeks after an ACL reconstruction;

1. Diaphragmatic Breathing:  It is just too important to ignore.  It can be done anywhere and anytime.  If you gain control over this area of the body quickly, you will easily develop trunk stability.  Breathing is also the best way to turn off the sympathetic nervous system without pain meds.  Teaching patients how to breath will empower them to control their pain.
2. Soft Tissue Mobilization:  This includes massaging incision sites immediately to prevent scar tissue from developing, as well as patellar mobilizations and Instrument Assisted Soft Tissue Mobilization (IASTM) to up or down regulate tissue as needed.
3. Extension Mobilization:  Extension is always my first priority with regards to range of motion.  Flexion is easier to get later if needed, but if they develop an extension lag, it is hard to get rid of.  I perform a combination of manual joint mobilizations as well as patient directed extension stretches.
4. Flexion Mobilization:  I’m not a big fan of towel or wall slides, but however you work on it, just remember that without at least some flexion, a normal gait isn’t possible.  I prefer to see at least 90 degrees of active flexion by the end of week 1.
5. Hip Hinge Progression:  The hip hinge is extremely important for establishing control of the lower extremity and can be done very early on in the rehab program.  There are a lot of ways to modify a basic hip hinge to fit the post op patient, including seated and/or with different kinds of load.
6. Core Engaged March:  Always one of my favorite exercises.  It preloads the stabilizers of the trunk and promotes proper timing and sequencing of our stabilizers.  It also allows you to introduce single leg stance in a safe environment and promotes active knee flexion.
7. Core Engaged Leg Lowering:  A typical favorite post op exercise for the knee patient is the straight leg raise.  I personally don’t love it, but don’t hate it.  The biggest problem with it is that people can’t perform it well, which is why I prefer to reverse engineer it.  By performing the leg raise from the top down, you put your patient at a mechanical advantage and take advantage of the body’s natural motor learning processes.
8. Core Engaged Bridge:  I love bridging because of the control that the glutes provides the knee.  It can be a bit challenging for the post op patient, but if you are creative, modifications can be made to improve the stability and motor control that is needed.
9. Gait Training:  We have to improve how our patients move with their activities of daily living and walking is a big part of their ADLs.  Proper gait training allows independence for the patient and reinforces a lot of the work you are performing in their rehab sessions.
10. Turkish Get Up:  A full get up won’t be possible in the first couple of weeks, but working on a get up progression is a great way to begin integrating all of these interventions together.

If you are unfamiliar with any of these interventions or have questions, I’ll be posting a series of videos on this topic on my Instagram account so you can learn more there.

As I said earlier, if you do the work up front, the rest of the rehab is a lot easier.  If things slip through the cracks in the first few weeks or are allowed to lag, the rest of the rehab process can drag on.  Get after it early and save yourself some headaches.