PHYSICAL THERAPY FOR KNEE PAIN (ACL INJURY)

Have you sustained a knee injury from pivoting movements?
Do rapid changes of directions or kicking cause knee pain?
The anterior cruciate ligament (ACL) is located in the knee joint and plays a big role in joint stability. The ACL’s main purpose is to prevent excessive forward translation and rotation of the tibia (the shin bone) under the femur (the thigh bone).
Sports that involve pivoting, rapid changes of direction and kicking can cause the ACL to be injured. In the event of a torn or ruptured (think of a rope that snaps), the affected knee becomes unstable. This instability can cause the knee to give way and cause further damage to surrounding structures.
This blog will outline the phases and pathway involved post ACL injury that will allow you to return back to normal function. This is by no means an exhaustive list, each program is individualisedto suit your needs. If you require further assistance with post-operative rehabilitation, please book into our Jindalee or Darra clinics where our friendly physiotherapists will get you the rehab result you’re after.
Not all ACL tears require operations. The decision is ultimately made between the surgeon and the patient and is influenced by a range of factors such as age, functional capacity, occupation and type of tear.
ACL Post-OP Blog

Normal Ligament: No tear, no deficit Grade 1: Small, partial tear Grade 2: Bigger tear but still partial. Ligament still intact Grade 3: Full thickness tear. Completely torn and ligament not intact

ACUTE STAGE: INITIAL INJURY PHASE
Once the ACL is injured, regardless of whether surgery is being considered, the focus of physiotherapy is to maintain or regain strength, range of movement and stability. Outlined below are a range of exercises that can be utilised in order to prevent deterioration of the knee pre-operatively.
ACL Post-OP Blog
Straight leg raises
ACL Post-OP Blog
Inner range quadricep contraction
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Active knee extension
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Passive knee extension
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Ankle active range of motion
All directions: (from top left to bottom right) Dorsiflexion, plantarflexion, inversion and eversion
ACL Post-OP Blog
Knee flexion in prone
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Knee active range of motion in sitting
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Gluteus maximus (hip extension) strengthening
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Gluteus medius (hip stabiliser) strengthening
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Weight transfers in standing

PRE-OPERATIVE STAGE: PREPARING FOR SURGERY
After the initial injury, proper implementation of rest, ice, compression and elevation (RICE) will help to reduce pain, swelling and restoration of full range of motion in the knee. This allows the knee to be in good condition before the surgery. A list of guidelines has been provided to achieve an optimum pre-operative state for the knee.
ACL Post-OP Blog
An example of a knee immobiliser brace worn pre-operation

  1. An immobiliser brace helps to protect the site of injury. During this time, exercises can be done outside of the immobiliser to maintain muscular strength and stability of the knee.
  2. Anti-inflammatories and icing can be used to effectively control pain and swelling.
  3. Normal range of motion restoration is vital. As shown in the ACUTE STAGE, isometric quadriceps activation, straight leg raises and range of motion exercises should be commenced post-injury to achieve full range of motion pre-operation.
  4. Low impact exercises to maintain muscle strength after full range of motion is achieved
  5. Knowledge of the procedure to be undergone: to understand what the surgery entails and the phases of rehabilitation that will follow. This is important to make sure the patient’s expectations are the same as the specialist’s expectations.
POST-OPERATIVE PHASE: REHABILITATION
This phase of the process is split into sections and outlines the functional milestones.
  • 1 week post-op: Rest, ice, compression and elevation (RICE) during this phase is vital.
    1. Goals: Full knee extension (straightening) + continued use of crutches and brace
  • 2-3 weeks post-op: RICE can still be used during this phase
    1. Goals: Increase weight-bearing + weaning off both crutches to walking with one crutch
    2. Painkillers can be useful during this phase due to the gradual activity increase
  • 5-6 weeks post-op: Continued improvement with weight bearing and the commencement of strengthening
    1. Goals: Wean off the knee brace and crutches
    2. Further improvement in quadriceps and hamstring strength with bilateral and single leg exercises
    3. Exercises such as stationary bike work, leg press and steps can be commenced if pain is minimal and muscle control is good
    4. Balance can also be commenced during this phase if muscle control is good
    ACL Post-OP Blog

    An example of single leg balance progressions

  • 10-12 weeks post-op: Strength improvements to this point provide the foundation for explosive exercises.
    1. Goals are to start forward, backward and sideways movements
    2. Further progression of resistance exercises
    3. At 12 weeks post-op, running and jumping can be commenced
    4. Implementation of balance, coordination, power and agility is gradual during this phase.
  • 4-6 months post-op: Maximal knee stability and control and the addition of sport-specific exercises.
    1. Goals are the ability to rapidly accelerate and decelerate, change direction and explosive generation of power through the knee.
HOW CAN PHYSIOPHI HELP?
  • Joint mobilisations are important in the acute phase and post-operatively to assist with range restoration.
  • ACL Post-OP Blog

    Manual therapy of the knee cap helps to reduce stiffness

  • Advice and educationis the guiding pathway to full function. Our expertise helps to set you back on track and achieve a full recovery.
  • Exercise monitoring and progressions ensure that progress does not stagnate. It also covers aspects that are harder to monitor such as balance and plyometrics (power).
ACL Post-OP Blog

Retraining power in the legs with squat jumps during end-stage rehabilitation

DISCLAIMER
An ACL reconstruction is not a small event and neither is the rehabilitation process post-operation. Having the correct team behind you to facilitate return to sport or daily life is crucial. It is our strong recommendation to book an appointment at Physiophi so that we can guide you through to the finish line.
PLEASE CONTACT US ON: (07) 3172 4332 TO HAVE A CHAT WITH OUR FRIENDLY STAFF OR SIMPLY BOOK ONLINE ON: WWW.PHYSIOPHI.COM.AU
REFERENCES
Andreisek, G. (2021). New Evidence for the Old Question If ACL Reconstruction Is Beneficial over Nonsurgical Therapy. Radiology, 299(2), 394-395. https://doi.org/10.1148/radiol.2021210146
Biz, C., Cigolotti, A., Zonta, F., Belluzzi, E., & Ruggieri, P. (2019). ACL reconstruction using a bone patellar tendon bone (BPTB) allograft or a hamstring tendon autograft (GST): a single-center comparative study. Acta Biomed, 90(12-S), 109-117. https://doi.org/10.23750/abm.v90i12-S.8973
Buckthorpe, M. (2019). Optimising the Late-Stage Rehabilitation and Return-to-Sport Training and Testing Process After ACL Reconstruction. Sports Med, 49(7), 1043-1058. https://doi.org/10.1007/s40279-019-01102-z
Buckthorpe, M., Danelon, F., La Rosa, G., Nanni, G., Stride, M., & Della Villa, F. (2021). Recommendations for Hamstring Function Recovery After ACL Reconstruction. Sports Med, 51(4), 607-624. https://doi.org/10.1007/s40279-020-01400-x
Buckthorpe, M., & Della Villa, F. (2020). Optimising the 'Mid-Stage' Training and Testing Process After ACL Reconstruction. Sports Med, 50(4), 657-678. https://doi.org/10.1007/s40279-019-01222-6
Gokeler, A., Bisschop, M., Benjaminse, A., Myer, G. D., Eppinga, P., & Otten, E. (2014). Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices. Knee Surg Sports TraumatolArthrosc, 22(5), 1163-1174. https://doi.org/10.1007/s00167-013-2577-x
Horstmann, H., Petri, M., Tegtbur, U., Felmet, G., Krettek, C., & Jagodzinski, M. (2021). Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-021-03862-8
Janssen, R. P. A., van Melick, N., van Mourik, J. B. A., Reijman, M., & van Rhijn, L. W. (2018). ACL reconstruction with hamstring tendon autograft and accelerated brace-free rehabilitation: a systematic review of clinical outcomes. BMJ Open Sport Exerc Med, 4(1), e000301. https://doi.org/10.1136/bmjsem-2017-000301
Joreitz, R., Lynch, A., Popchak, A., & Irrgang, J. (2020). CRITERION-BASED REHABILITATION PROGRAM WITH RETURN TO SPORT TESTING FOLLOWING ACL RECONSTRUCTION: A CASE SERIES. Int J Sports Phys Ther, 15(6), 1151-1173.https://doi.org/10.26603/ijspt20201151
Krupa, S., & Reichert, P. (2020). Factors influencing the choice of graft type in ACL reconstruction: Allograft vs autograft. Adv Clin Exp Med, 29(10), 1145-1151. https://doi.org/10.17219/acem/124884
Lee, J. C., Kim, J. Y., & Park, G. D. (2013). Effect of 12 Weeks of Accelerated Rehabilitation Exercise on Muscle Function of Patients with ACL Reconstruction of the Knee Joint. J Phys Ther Sci, 25(12), 1595-1599. https://doi.org/10.1589/jpts.25.1595
Tapasvi, S., & Shekhar, A. (2021). Revision ACL Reconstruction: Principles and Practice. Indian J Orthop, 55(2), 263-275. https://doi.org/10.1007/s43465-020-00328-8
Walker, A., Hing, W., Lorimer, A., & Rathbone, E. (2021). Rehabilitation characteristics and patient barriers to and facilitators of ACL reconstruction rehabilitation: A cross-sectional survey. Phys Ther Sport, 48, 169-176. https://doi.org/10.1016/j.ptsp.2021.01.001
Wilk, K. E., Arrigo, C. A., Bagwell, M. S., &Finck, A. N. (2021). Considerations with Open Kinetic Chain Knee Extension Exercise Following ACL Reconstruction. Int J Sports Phys Ther, 16(1), 282-284. https://doi.org/10.26603/001c.18983 Wright, R. (2013). Rehabilitation plus early ACL reconstruction and rehabilitation plus delayed reconstruction were similar at 5 years. J Bone Joint Surg Am, 95(16), 1516. https://doi.org/10.2106/JBJS.9516.ebo781

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