Anterior Cruciate Ligament (ACL) Surgical Reconstruction

You may be on crutches for up to 3 weeks.  This will depend on your pain, swelling and muscle power.

Your Consultant will arrange to review you several weeks after your ACL operation.

General principles of rehabilitation

The main principles when gradually rehabilitating your knee following ACL surgery are:

• Control pain and swelling.
• Gradually restore full range of motion.
• Improve lower limb strength and joint stability.
• Improve your standing balance and co-ordination.
• Improve your general cardiovascular fitness.

There are five phases to rehabilitating your knee after ACL surgery.

Phases in ACL knee rehabilitation

Immediately post-operation

In hospital and discharge home 

Phase 1

0 to 3 weeks 

Phase 2

 4 to 6 weeks 

Phase 3

7 to 13 weeks 

Phase 4 

13 weeks to 9 months 

Phase 5

+9 months 

Average time frames for return to normal activities of daily living 

Driving 

Up to 4 to 6 weeks depending on advice with your insurance company. 

Return to Work 

• Sedentary/Desk based activities usually within 4 to 6 weeks. May be earlier if working from home.
• Heavy duty work e.g. construction, usually 3 months. 

Sports 

• Cycling/swimming usually after 8 weeks post operation.
• Jogging/running usually after 4 months post operation.
• Golf usually after 4 months post operation.
• Jumping/hopping/cutting activities/changing direction usually after 6 months post operation.
• Contact/competitive sports e.g. skiing/football/rugby post operation usually after 9 to 12 months post operation.

Early Phase: Immediately post-operation. While in hospital and on discharge home.

Aims:

• Reduce pain and swelling.
• Protect the wound.
• To be able to manage and walk with crutches.
• Improve muscle recruitment.

Advice

Put your leg up regularly throughout the day. Use ice packs for 10 minutes every couple of hours to help reduce the pain and bruising.

Applying ice packs to the operated area in the early stages helps reduce pain, swelling and bruising. Application of ice can be repeated regularly, every 2 hours (while awake) in the first 24 hours. It must be done carefully. It is possible to get an ice burn.

Technique for ice treatment at home

1. Use either a bag of frozen peas or a plastic bag with ice cubes.
2. Cover the area to be treated with a damp tea towel or damp cloth.
3. Place the ice pack over the area and hold in position with a towel or bandage.
4. Leave for 10 to 15 minutes on bony areas. 20 to 25 minutes over more fleshy or muscular areas.
5. Check the skin every 5 minutes and if painful or damaging the skin, remove the ice pack.

Wound Care

Keep the wound covered with a light dressing until the staples are removed. These are usually removed at 10 to 14 days after the operation. If there is any yellow discharge or abnormal redness seek advice from your physiotherapist or General Practitioner (GP).

Moving around

Move around with the help of your crutches. Keep your walking to short distances.

Exercise the knee gently at first. Do the exercises you were given by the physiotherapist on the ward.

Phase 1 - Exercises

Phase 1: Rehabilitation: Up to 3 weeks Post Operatio

Aims

• Reduce pain and swelling.
• Begin movement exercises, bending and straightening the knee.
• Begin muscle strengthening exercises.

Advice

Use ice as outlined in the previous section and elevate the leg regularly.

Guidance for Return to normal activities of daily living

The aim of phase 1 is to get the best start to the

rehabilitation process. Many of your normal day to day activities will gradually increase as you continue to recover after your operation. Your physiotherapist will be able to answer any questions you may have about your progress. You need to rest more in this case.

Things to avoid

• Do not sit and straighten the knee against resistance.
• Do not cross your legs.
• Do not run or jump.
• No twisting and swivelling movements.

*N.B. Achieving full range of motion in the first few weeks after the operation is crucial.  This speeds progress and

return to sports.  There is evidence that it could prevent   arthritis in the knee later in life.

Phase 2 Rehabilitation: Weeks 4 to 6

Criteria for Progression onto Phase 2:

• Minimal or no pain/swelling
• Able to fully weight bear
• No giving-way
• Good range of movement.

Aims

• Reduce pain and swelling
• Restore full range of motion
• Mobilise independently

Guidance for return to normal activities of daily living

• Sedentary/desk based activities usually within 4 to 6 weeks, earlier if working from home.
• Heavy duty work e.g. construction not usually until 3 months.
• Driving can be commenced at 6 weeks under consultation with your insurance company.

Things to Avoid 

• Do not cross your legs 

• Do not run or jump 

• No twisting and swivelling movements

Phase 2 – Exercises

1. Phase 2 – Exercises
2. 1) Continue with the following exercises from Phase 1:

1. Bending and Straightening (Range of motion)
2. Kneecap mobilization
3. Prone hamstring strengthening
4. Bridging
5. Calf Raises
6. Calf, Hamstring and Thigh (Quadriceps) stretching

6. Cardiovascular fitness

a) Walking

Technique:  You should normally be managing without your crutches at this point. You can gradually start to build up your walking distance.  Be careful not to overdo it.  Your knee can still swell up easily and this can slow down your progress.

Phase 3 Rehabilitation: Weeks 7 to 13

Criteria for progression to Phase 3:

Must be able to:

• Fully straighten (extend) the operated knee.

Preferably be able to:

• Fully bend (flex) the operated knee.
• Have minimal pain/swelling

Your graft is at its most vulnerable at the start of this phase.

Aims of the phase

• To regain full range of movement, if not already achieved.
• To build up leg strength.
• To improve balance and coordination.

Guidance for return to normal activities of daily living

• Return to moderate manual work as agreed with consultant.
• Cycling/Swimming usually after 8 weeks post operation.
• Return to swimming (avoid breaststroke leg kick)

Continue to avoid twisting and high impact activities.

• No kicking.
• No running.
• No jumping.
• No twisting/swiveling.
• No open chain thigh (quadriceps) exercises.
• Do not cross your legs.

Phase 3 - Exercises

1. Continue with the following exercises from Phase 1 and Phase 2:  

a. Bending and Straightening (Range of motion) 

b. Calf, Hamstring and Thigh (Quadriceps) stretching 

c. Hip strengthening bridging 

d. Calf Raises 

e. Single leg balance

11) Cardiovascular Fitness 

If you have access to a gym then using a treadmill, stationary bike, rowing machine, cross trainer and step machine are all appropriate.  Avoid any equipment that involves a twisting motion of the knee.

This program is a rough guide on how you can gradually build up your cardiovascular fitness without using gym equipment.  You can speed up or slow down your progress through the program as you feel appropriate.

a) Walking

5 times weekly for 20 to 30 minutes

Try to find places to walk.  These should be over even ground, but with hills to vary the challenge to the legs.

Exercise progression: add a backpack with weights/books in to your back.

b) Steps

Climb and descend a set of 10 to 15 steps (stairs).

Repetitions: 10 to 20 times.

Sets: 3 sets at a time.

Weekly:  3 times a week.

Exercise progression: add a backpack with weights/books in to your back.

c) Light Jogging

Can be commenced from week 10-12 only after discussion with your physiotherapist however do not start jumping or twisting during this phase of your rehabilitation.

In a Swimming Pool:

d) Swimming

Duration: 10 to 30 minutes.

Weekly:  2 to 3 times a week.

Front or back crawl only - No Breaststroke.

Exercise progression: use a float to increase leg workout.

e) Aqua Jogging

Use either an ‘aqua jogger belt’ or other floatation device in the deep end of the pool. Your feet should not hit the bottom. Mimic the jogging motion with your legs (and arms, if not needed for floatation).

Duration: 10 to 20 minutes.

Weekly:  2 to 3 times a week.

Phase 4 Rehabilitation: Weeks 13 to 9 months 

Criteria to progress onto phase 4:

• Full knee range of motion and no pain and swelling.
• Walking without any aids and able to stand on one leg without difficulty.
• No feelings of knee giving way.

Aims

• Continue to build up strength with emphasis on functional retraining.
• Progress aerobic fitness to a level appropriate to your normal function.

Guidance for return to normal activities of daily living

• If you perform a heavy manual job, consider returning to this post after 12 weeks, if agreed with your Consultant.
• You can return to light sporting activities e.g. light aerobics during this phase.   However you must have good range of motion, good strength and have minimal swelling or pain to do this.
• Jogging/running is usually after 3 months post operation.
• Golf is usually after 4 months post operation.
• Jumping/hopping/cutting activities/changing direction is usually after 6 months post operation.
• Contact/Competitive sports e.g. skiing/football/rugby post operation is usually after 9 to 12 months post operation (See Phase 5)

You should get confirmation from your Consultant or Physiotherapist before returning to such activities.

Cautions

• No pivoting or twisting activities during the first

6 months after your operation. 

• No contact sports during this time period.

Phase 4 – Exercises

1) Stretches

Continue stretching exercises for the calf, hamstrings and thigh (quadriceps) as in the previous Phases outlined.

See diagrams in Phases 1, 2 & 3

2) Strengthening

Continue the strengthening exercises already described in the previous Phases: See diagrams in phases 1, 2 & 3

a) Deep Squats: See pervious Phases 3

b) Single Leg Squat: See pervious Phases 3

c) Step up: See pervious Phases 3

d) Step down: See pervious Phases 3

8. General Cardiovascular exercise program

Your Physiotherapist or Consultant will establish if you have adequate strength and knee control to start jogging.  You can then start to slowly build up a jogging program, if your lifestyle requires it.  The table below demonstrates how you can gradually build up to 30 minutes of continuous jogging.

This program is a rough guide on how you can gradually build up your cardiovascular fitness. You can speed up or slow down your progress through the program as you feel appropriate.  If running is not something you need to return to then you do not need to carry out this part of Phase 4.

Remember: Do not start a jogging program until you have been advised it is safe to do so by your Physiotherapist or Consultant.

If you are able to perform 30 minutes of running without pain, you can speak to your Physiotherapist about trying the following speed drills. Once again, if your lifestyle doesn’t require sprinting then you do not need to perform these drills.

• Sprint 20 meters, rest for a minute then repeat 5 times, (slow acceleration and slow stop).
• Sprint 20 meters, rest for a minute then repeat 5 times, (slow acceleration and fast stop).
• Sprint 20 meters, rest for a minute then repeat 5 times, (fast acceleration and fast stop).

Phase 5 - from 9 months onwards 

Phase 5 Rehabilitation – from 9 months onwards

Criteria for the phase

• No pain/swelling
• Good exercise technique
• Good bilateral leg strength (your physio will carry-out tests to help determine this before you start)

Aims of this Phase

Return to Sport

Knee ligament operations help people return to their sport.  Practicing jumping, hopping and turning exercises before returning can help. However these exercises have risks and benefits. Returning to sport is a common aim after knee ligament operations.  About 65% of people return to their sport.  This can take between one to two years following their operation.  You may need more specific exercises to help you return to your sport safely.  Only you can decide if you want to get back to your sport.  The more demanding your sport, the more specific training you will need to do.  Building up the level of exercise will help you return to your sport. 

If your knee recovery is progressing well and your sport or hobby demands more dynamic activities then progress to plyometric work may be appropriate.  Plyometrics are exercises in which the muscles are repeatedly and rapidly stretched ("loaded") and then contracted (e.g. as in jumping high off the ground or skipping).  The aim of plyometrics is to improve muscle power, speed and agility. Please discuss the use of plyometric training with your Physiotherapist before commencing on a programme as not all individuals will require them.

When Can You Return to Sport?

The decision to return to sport can be difficult.  Many people lack confidence in their operated knee at first.  This takes time to come back.  The physiotherapist can test the knee in the department to determine if you are ready.  These tests may involve a slight increased injury risk.  Injuries include damage to the new knee ligament or cartilage.  The risks of injury are small.  We do need to warn you about these.

The risks can be reduced by:

• Warming up properly.
• Strengthening the leg muscles.
• Improving your balance.
• Gradually doing jumping, hopping or turning exercises.
• Training for your sport before returning to competition.

Exercises in the hospital gym cannot replace sports training.  You will still need to train for your sport.  A coach who knows your sport can help.

Physiotherapy exercises can reduce the risk of injury.  All exercise however has a degree of risk. Your physiotherapist can discuss this with you.

Guidance for return to normal activities of daily living

• Jumping/hopping/cutting activities/changing direction usually after 6 months post operation.
• Contact/Competitive sports e.g. skiing/football/rugby post operation usually after 9 to 12 months post operation

Plyometric Training

a) Programme Information

Length of time: approximately 12 weeks before progressing onto contact/competitive sport

Frequency: 48 to 72 hours (2 to 3 days) should be left between plyometric sessions, so between 2 and 4 sessions per week.

Recovery: During exercises you should wait about 5 and 10 seconds between each jump, and 2 to 3 minutes between sets of jumps. This applies to all plyometric exercises. It's important to balance volume with intensity of exercises to avoid overtraining and injury, particularly because plyometric exercises put a higher level of stress on the muscles and joints.

b) Volume

Plyometric training volume refers to the total amount of work performed during a plyometric training session or over a period of time, typically measured in terms of the number of repetitions, sets, or ground contacts (GC)* (e.g., jumps or bounds).

Beginner - no experience 80 repetitions/GC.

Intermediate - some experience 100 repetitions/GC.

Advanced - considerable experience 120 repetitions/GC.

*Ground contact (GC): Each time the foot (or feet) makes contact with the ground during a plyometric exercise, it is counted as one ground contact

c) Criteria for Plyometrics

Safety: you should be able to squat at least 1RM (section d).

Speed: you should be able to perform 5 repetitions of a squat, with 60% of your body weight in under 5 seconds.

d) 1RM

A 1RM, or one-repetition maximum, is the maximum amount of weight that a person can lift for one repetition of a given exercise. It is commonly used in strength training and conditioning to assess an individual's maximum strength for a specific lift, such as a squat, bench press, or deadlift.

The 1RM is a critical measure for several reasons:

• Strength: It provides a baseline for tracking progress and setting strength goals.
• Program Design: Helps to personalised a training program. Many training protocols use a percentage of the 1RM to determine the appropriate load for different training phases (e.g., hypertrophy, endurance, strength, plyometrics).
• Safety and Efficiency: Ensures that the weight used in training is both safe and effective for the individual.

Estimating 1RM

• Warm up with lighter weights.
• Gradually increase the weight while performing single repetitions until you reach the maximum weight you can lift once with proper form.

Strength Ratio before starting plyometrics

• The  operated side should be at least 90% strength of the non-operated side
• Overall strength should be x1.5-2 x your body weight

Plyometric warm up drills

1) Marching

Mimics running movements: emphasises posture and movement technique; enhances correct lower body movements for running.

2) Jogging

Prepares for high impact and high intensity plyometric drills; include jogging on the toes only – emphasises quick reaction.

3) Skipping

Exaggerated form of upper and lower limb movements with the emphasis on quick take off and landing.

4) Footwork

Drills that target change of direction, like shuttles, figure 8 movements and striding drills.

5) Walking lunge drills

Lunging along the length of your hall or in a straight line outside, alternating between left and right side lunges.

Lower Body Plyometric Drills

Equipment: you may benefit from access to an agility ladder and/or plyometric box for some of these exercises.

1) Jumps in place

Jumps in place emphasise the vertical component of jumping and are performed repeatedly without rest between jumps.

2) Standing jumps

These emphasise either horizontal or vertical components.  These are maximal efforts with recovery between jumps.

3) Multiple hops/jumps

Involve repeated movement and may be viewed as a combination of jumps in place and standing jumps. An example of this is a zigzag hop.

4) Bounds

Bounding drills involve exaggerated movements with greater horizontal speed than other drills. Volume for bounds is usually measured by distance but can be measured in the number of hops performed.

5) Box drills

These drills increase the intensity of multiple hops or jumps by using a box. The box may be jumped on or off.  The height of the box depends on the person jumping.

6) Depth drills

The athlete jumps from one box and immediately upon landing, jumps onto another box.

For long term benefit from your surgery you need to continue to maintain the mobility, strength, balance, coordination and general fitness at your knee.

Worries or concerns

For non-urgent issues or concerns

For non-urgent issues or concerns please contact your Physiotherapist or Consultant’s Secretary through the NHS Fife Hospital Switchboard 01592 643355.

For urgent issues or concerns

If you have any urgent concerns regarding your condition, please contact the Physiotherapy Service on 01592 647199.

Urgent advice for patients between 8am to 8pm Monday to Sunday, contact the National Treatment Centre - Fife Orthopaedics on 01592 643355 Extension 22685.

Urgent out of the hours advice

For an urgent problem out of hours, please contact NHS 24 on 111 or attend Accident and Emergency.

Emergency advice

For emergency advice, attend Accident and Emergency or call 999.