ROLE OF PHYSIOTHERAPY IN ACL INJURY

Phase

Goals

Interventions

Phase 1

Maximum Protection Day1-Week2

– Control of pain, swelling and inflammation

– Obtain ROM 0-90 week 1, 0-110 week 2, with emphasis on full extension*

– Maintain patellar mobility

– Regain muscle control

– Independent ambulation with crutches WBAT*

– Walking retraining without crutches can be started day 4-10**

– Early weaning of brace/immobilizer is preferred***

– RICE

– Ambulation with knee immobilizer in full ext

– CPM/PROM/A-AROM 0-110

– Patellar mobilization in all directions (Grade 1-2)

– Leg elevation with pillow below heel at rest

– Isometric/muscle sets (quad with emphasis on VMO retraining, hamst, glutei, adductors & calf)

– Isotonic open chain (OC) (knee ext 90-40) without resistance (seated), hamstring prone exercises (0-90)

– Isotonic closed chain (CC) (knee flex 0-60) (mini squats, wall slides and sit-stand from high chair with VMO control)

– Electric stimulation of quadriceps muscle (if desired)

– SLR (4 planes) in full extension

– Gait/stair training with crutches WBAT

– Heel/toe raises, marching, step ups/downs

Criteria to progress to phase 2

– Less pain level (VAS)

– Minimal swelling

– ROM 0-110

– Good patellar mobility

– Good muscle control to perform a mini squat 0–30 and SLR (4 planes)

– Independent ambulation with crutches WBAT

Phase 2

Moderate Protection Week 3-9

– Continue control of pain, swelling and inflammation

– Good patellar mobility

– Full ROM (lack of extension can be treated aggressively to prevent arthrofibrosis)

– Improve muscle flexibility

– 4/5 muscle strength

– Normal gait pattern and ADL functions

– Improve proprioception and neuromuscular stability

– Improve cardiopulmonary endurance

Continue as in phase 1, in addition to:

– Patellar mobilization in all directions (Grade 3-4)

– CPM/PROM/A-AROM to full flex

– LE stretching program (hamst, ITB, calf & adductors)

– Increase intensity of isometric exercise

– Isotonic OC (knee ext 90-30) with progress in the resistance (quad bench, sand weights & therapand)

– Isotonic CC (knee flex 0-60) with progress in the resistance (step ups/downs/sides, wall squats, leg press machine & sit-stand)

– Gait retraining (heel/toe raise, forward, backward, side to side, marching & on treadmill)

– Progressive proprioceptive training (double-one leg stand on floor, trampoline & balance board/pad)

– Cardiopulmonary endurance training (stationary cycling, swimming & ergometer)

– Hydrotherapy LE exercises

Criteria to progress to phase 3

– No or minimal pain/swelling

– Full pain-free ROM and normal patellar mobility

– 4/5 Muscle strength

– Dynamic control of knee

– Normal gait pattern.

– Unrestricted ADL functions

– Exercises of previous phase are carried out properly

Phase 3

Minimum Protection

Week 9-16

– Maintain full ROM

– Maintain muscle flexibility

– Optimize muscle strength, power & endurance (75% compared to the contralateral side)

– Improve neuromuscular control, dynamic stability & balance

– Improve running/jumping

– Improve cardiopulmonary endurance/fitness

– Continue LE stretching program

– Advance OC with gradual increase in resistance/repetitions (quad bench, sand weights & theraband)

– Advance CC with gradual increase in resistance/repetitions/double-one leg (step ups/ downs/ sides, wall squats, leg press machine & sit-stand)

– Initiate isokinetic training (if desired)

– Hydrotherapy LE exercises

– Advance proprioception training (one leg stand on trampoline & balance board/pad with alternate arm  movements)

– Jogging training in a straight line, if not strong/painful/fear, try jogging in water first

– Progressive jogging/running on treadmill

– Outdoor jogging (week 13)

– Cardiopulmonary training (cycling, swimming, jogging & stepping)

Criteria to progress to phase 4

 – No pain or swelling

 – Full ROM and normal muscles flexibility

 – Quadriceps and hamstring strength 75% compared to the contralateral side

 – No pain or difficulty with running & jumping

 – Hop, jump and squat tests 75% compared to the contralateral side

 – Exercises of previous phase are carried out properly

Phase 4

Return to Activity

Week 16-24

– Maximize muscle strength, power & endurance

 – Maximize neuromuscular control

 – Maximize cardiopulmonary endurance/fitness

 – Improve agility skills, skill-specific pattern & work/sport-specific skills

– Continue advanced strengthening & flexibility exercises

– Advanced proprioception training

– Advanced cardiopulmonary/fitness endurance (cycling, swimming, running & stepping)

– Plyometric exercises (bouncing, jumping rope, box jump) with slowly progress in duration/speed/double legs to single leg

– Progressive agility drills training (running, turning, cutting & sprints with increase in duration and speed)

– Progressive sport-specific tasks training (e.g.: training tasks of football, basketball, karate…etc)

Criteria for returning to sports

– No pain, no swelling,

– Any-active ROM

– The strength of the quadriceps and hamstring muscles was 85%, compared to the contra lateral side

– No functional instability of compliance

– Squat-test, which increased by 85% compared with the contra lateral side

– High cardio respiratory stamina

– The exercises in the previous step were performed correctly

– The patient tolerated the sporting activity and physical agility exercises, with a maximum duration and the frequency of

– Pre-competition testing