M ON ACL Rehabilitati n Guidelin s M ULTIC
NTERO RTHOPAEDIC HOP AEDIC
O UTC OM ESNETW
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General Information: The f llowing ACL rehabilitation guidelin s are b sed on a r view of the randomize controlled trials related to ACL ehabilitatio . For man aspects of ACL rehabilitation there are either no studies that qualify as “best-evidence” or the number o studi s is too few for conclusions to be drawn with c nfidence. In these circumstances, the recommendati ns are bas d upon the guidance of the OON panel of content experts. The guidelines h ve been developed to ervice the spectrum of ACL injured people (n n-athlete elite athlete). For this reason, exam ple exercis es are es are provided instea of a highly structured rehabilitation pro ram. At te ding reha ilitation sp ecialists ecialists sh ould tailor the program to each atient’s atient’s s ecific n eed eed s . The ulticenter nature of the MOON group necessit tes that the MOON ACL Reh bilitation P ogram only include treatment methods that can be empl yed at all sites without purchasing expensive equipment. Con equently, s me treatm nt methods with supporting evidence (e.g. using a high-i tensity electric stimulation training progr am for strength, aquatic therapy) ar e not includ d in the progr am becaus the expert panel belie es that it is unreasonable to expe t all sites to carry out s ch treatments. Progr ession from one phase to the next is based on the patient demonstrating readiness by chieving fu nctional cri teria rathe than the tim e el el psed sinc surgery. surgery . he timefra es identified in parentheses afte each Phase are appro imate time imate time for the average patie t, NOT gui elines for progression. Some patients will be r eady to progress soon r than the timeframe identified, wh reas other will take longer. The r ecommend d number of visits to the rehabilitation specialist (including visits erely for evaluation an /or exercis progression) is 16 to 24 visits 24 visits wi h the major ity of the visits occurrin early (Bi w ekly x 6 w eks ). However, it is recognized th t some patient’s healt plans are everely restrictive. For this reason, the minim m number of post-ACL reconstr uction visits to a rehabilitation speciialist has been set at 6 visits for visits for t e MOON g oup patients.
Sports Medici e UNIVERSITY OF CO LORADO
If the e are any questions re arding the OON ACL Rehabilitati on Guid lines, then please cont ct Dr.____ ________ _________ ___ or the Sports Me icine Cent r’s Rehabili ation Liaison: ____ ________ _________ _________ ________ _____.
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ACL Reha bilitation
PHASE 0: Pre-oper ative Reco
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mendatio ns
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Nor al gait
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AROM 0 to 120 egrees of f lexion
Stre gth: 20 SL with no la
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Mini al effusion
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Pati nt educatio on post-o erative exercises and need for co pliance
• •
Edu ated in am ulation with crutches
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Wound care instructions
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Edu ated in MO N follow-u expectatio ns
PHASE 1: Immediate Post-op rative Pha e (Approximate time fr ame: Surgery to 2 wee s) GOALS Full nee extension ROM
• •
Goo quadricep control (> 0 no lag S R)
Mini ize pain
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Mini ize swelling
• •
Nor al gait patt rn
Crutch
se: WBA with crutches (beginni g the day of surgery)
Crutch
/C Criteria:
Nor al gait patt rn • Ability to safely scend/descend stairs (reci rocal stair limbing) •
ithout note orthy pain r instability
Knee Im mobilizer: None (Exception: First 4 hours aft r a femoral nerve bloc ) Cryotherapy: Cold ith compression/eleva ion (e.g. Cr oCuff ®, ice with com ressive stocking) First 24 hours or until acute inflammatio is controll d: every hour for 15 mi utes
•
After acute infla mation is controlled: 3 times a day for 30 minutes
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Crushed ice in the clinic (po t-acute sta e until D/C)
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2
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EXERCISE SUGGESTIONS ROM •
Extension: Low load, long d ration (~5 inutes) str tching (e.g., heel prop, prone hang mini izing co-c ntraction a d nocicept r response)
•
Flexion: Wall sli es, heel sli es, seated assisted kn e flexion, bike: rocking-forrange
Patellar mobilization (medial/lateral mo ilization initially followed by superior/inferior direction while monitori g reaction to effusion and ROM)
•
Muscle Ac ti vat io n/ trength •
Qua riceps sets emphasizin g vastus lateralis and v stus medialis activatio
SLR emphasizin g no lag
• •
Elec tric Stimul tion: Optio al if unable to perfor no lag SL Disc ontinue us when able to perform 0 no lag S R
•
Dou le-leg quarter squats
Standing Thera- and® resis ed terminal knee exten ion (TKE)
• •
Hamstring sets
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Hamstring curls
Side lying hip adduction/abd uction (Avoid adduction moment in this phase concomitant gra e II – III M L injury)
•
•
ith
Qua /ham co-contraction supine
Prone hip exten ion
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Ankl pumps with Thera-Ba d®
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Heel raises (calf press)
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Cardiop ulmonary UBE or similar e ercise is recommende
•
Scar Massage (wh n incision is fully heale ) CRITERIA FOR PR GRESSION TO PHA E 2 •
20 n lag SLR
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Nor al gait
Crut h/Immobiliz er D/C
• •
RO : no greater than 5º active extensi n lag, 110º active flexi n
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PHASE 2: Early Rehabilitation Phase (Approximate time fr ame: week 2 to 6) GOALS Full
•
OM
Impr ove muscle strength
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Progress neuro uscular ret aining
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EXERCISE SUGGESTIONS ROM Low load, long duration (assisted p.r.n.)
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Heel slides/wall lides
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Heel prop/prone hang (mini ize co-contraction / no iceptor res onse)
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Bike (rocking-for -range
•
ri ing with lo seat height)
→
Flexibility stretching all major groups
•
Strengt ening Quadric ps: •
Qua sets
Mini-squats/wall- squats
•
Step-ups
• •
Kne extension
Leg ress
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Shuttle press without jumping action
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Hamstri gs: •
Hamstring curls
Resistive SLR with sports c rd
•
4
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Other M sculature: Hip dduction/a duction: SLR or with e uipment
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Standing heel ra ises: progress from double to singl leg suppor
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Seated calf press against re istance
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Multi-hip machine in all direc tions with proximal pad placement
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Neurom uscular training •
Wobble board
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Roc er board
Singlle-leg stanc with or wit out equip ent (e.g. in trumented alance sys em)
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Slid board
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Fitte
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Cardiop ulmonary Bike
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Elliptical trainer
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Stair master ®
•
CRITERIA FOR PR GRESSION TO PHA E 3 Full
•
OM
Mini al effusion pain
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Functional stren th and control in daily ctivities
• •
IKD Question 10 (Global Rating of F nction) score of > 7
10. How would you rate the fu nction of y ur kn ee o a scale of 0 to 10 wit 10 bein g norm al, excellent fu ction and 0 being the inability to perform a y of your usual dail activities
0
1
2
3
4
5
6
7
8
9
10
5
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PHASE 3: Strength ening & Co ntrol Phas (Approximate time fr ame: week 7 through 2) GOALS Maintain full RO
• •
Demonstrate ability to descend an 8” st p without p in or deviation
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Run ing without pain or swelling
•
Hop ing without pain, swelli g or giving-way
EXERCISE SUGGESTIONS Strengt ening •
Squ ts
Leg ress
• •
Hamstring curl
•
Kne extension 0o to 0o
Step-ups/down
• •
Lun es
Shuttle
•
Spor ts cord
•
Wall squats
• •
Hop ing without pain progression (Bila eral hop/ju p progressing to singl leg ending in ¼ squat. Hop and hold wi h alignment AP, medial-lateral, cro s)
Neurom uscular Tr ining •
Wobble board / r ocker boar / roller board
Pert rbation trai ing
•
Instr mented testing systems
•
Vari d surfaces
•
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Cardiop ulmonary Straight line run ing on trea mill or in a protected e vironment (NO cutting or pivoting)
•
•
All o her cardiopulmonary e uipment
CRITERIA FOR PR GRESSION TO PHA E 4 •
Run ing without pain or swelling
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Hop ing without pain or swelling (Bilateral and Unilateral)
Neur omuscular nd strength training ex rcises with ut difficulty
•
PHASE 4: Advanced Training Phase (Approximate time fr ame: week 13 to 16) GOALS •
Run ing pattern (Figure-8, pivot drills, tc.) at 75% speed with ut difficulty
•
Jum ing without difficulty
Hop tests at 75
•
contralate al values
(Cin innati hop tests: single-leg hop for istance, tri le-hop for istance, cros over hop for distance, -meter tim d hop) EXERCISE SUGGESTIONS Ag gr es ive Streng hening •
Squ ts
•
Lun es
Plyo etrics
•
7
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Ag il it y
rills
ACL Reha bilitation
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Shuf fling
• •
Hop ing
Cari ca
•
Vertical jumps
• •
Run ing pattern at 50 to 75% speed (e.g. Figure-8)
Initial sports specific drill pat erns at 50 –75% effor t
•
Neurom uscular Tr ining •
Wobble board / r ocker boar / roller board
Pert rbation trai ing
•
Instr mented testing systems
•
Vari d surfaces
•
Cardiop ulmonary •
Run ing
Other cardiopul onary exer ises
•
CRITERIA FOR PR GRESSION TO PHA E 5 Maximum vertic l jump with ut pain or i stability
•
75% of contralateral on hop tests
•
Figu e-8 run at 75% speed
• •
IKD Question
ithout difficulty
10 (Global Rating of Knee Function) score of
8
10. How would you rate the fu nction of y ur kn ee o a scale of 0 to 10 wit 10 bein g norm al, excellent fu ction and 0 being the inability to perform a y of your usual dail activities
0
1
2
3
4
5
6
7
8
9
10
8
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PHASE 5: Return-t -Sport Ph se (Approximate time fr ame: week 17 to 20) GOALS 85% contralater l strength
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85% contralater l on hop te ts
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Spor t specific training witho t pain, swelling or difficulty
•
EXERCISE SUGGESTIONS
Ag gr es ive Streng hening •
Squ ts
•
Lun es
Plyo etrics
•
Sport S ecific Acti ities Inter al training rograms
• •
Run ing pattern in football
Spri ting
• •
Cha ge of direction
Pivo and drive i basketball
•
Kicking in socce
•
Spiking in volley all
•
Skill / biomecha ical analysis with coac es and sports medicine team
•
RETUR -TO-SPORT EVALUA ION REC MMENDA IONS: Hop tests (single-leg hop, triple hop, cross-over hop, 6-meter ti ed-hop)
•
Isokinetic streng h test (60°/ econd)
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Vertical jump
• •
Dec leration shuttle test
9
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RETUR -TO-SPORT CRITERI : •
No f nctional co plaints
Conf idence whe running, c tting, jumping at full speed
•
85% contralater l values on hop tests
• •
IKD Question
10 (Global Rating of Knee Function) of > 9
10. How would you rate the fu nction of y ur kn ee o a scale of 0 to 10 wit 10 bein g norm al, excellent fu ction and 0 being the inability to perform a y of your usual dail activities
0
1
2
3
4
5
6
7
8
9
10
10
