Anterior Cruciate Ligament (ACL) injuries can be an excruciating ordeal to overcome. There are so many questions such as graft options, physicians, rehab protocols, etc. We can help guide you at Rock and Armor, if you have suffered this injury. Below are some key points nicely put together by one of our current students, Chris Edwards, SPT, from Eastern Washington University.
ACL Graft Options1
1. Bone-Patellar Tendon-Bone (BTB) autograft- Is considered the gold standard in ACL reconstruction. Requires the harvest of the central third of the patellar tendon with attached bone blocks from the patella and tibial tubercle. BTB is the graft of choice for active individuals especially under the age of 25.
Advantages- Bone to bone healing, ease of harvesting, good clinical outcomes, lower graft failure rates.
Disadvantages- Anterior knee pain, low risk of patella fracture and patellar tendon rupture.
2. Quadrupled Hamstring graft- Semitendinosus and Gracilis tendons are harvested from their pes anserine attachment and then folded to form a quadrupled construct.
Advantages- Decreased donor site morbidity and greater initial biomechanical strength.
Disadvantage- less reliable healing because it relies on bone growth into tendinous soft tissue opposed to bone to bone healing, also unable to stretch hamstrings for up to 6 weeks post-surgery.
3. Allografts- Include cadaveric patellar, quadriceps, hamstring, and achilles tendons.
Advantages- eliminates harvest site morbidity
Disadvantages- infection risk, increased failure rates in more active individuals (due to graft weakening from sterilization processes).
Attachments: Tibial attachment- medial to the anterior horn of lateral meniscus, Femoral attachment- posterior lateral aspect of the intercondylar notch on lateral femoral condyle. Graft fixated with interference screws, Graft strongest and fixation weakest initially.
Incisions- Two 1 cm incisions around the patella tendon for the arthroscopy equipment. Small 2cm incision below the joint along the inside of you knee where the tunnels are drilled and the graft is obtained, small incision above and outside the knee where the fixation for the graft on the femur was placed.
Pre-Operative: increase range of motion (ROM), decrease swelling, decrease pain, restore normal strength for ADL’s and gait, prepare for surgery.
Post OP days 1-10: RICE medicine, early ROM exercises (passive extension exercises, seated AAROM for knee extension and flexion), quadriceps strengthening (quad sets, SLR in immobilizer), hamstring strengthening (heel slides, avoid until 4-6 weeks if hamstring graft used), 50% weight bearing use two crutches, suture removal, maintain passive extension, and return to desk job.
Days 10-14: Maintain full passive knee extension, achieve 100-120 degrees of knee flexion, develop muscle control to wean off knee immobilizer (able to perform SLR with no sag), early closed chain exercises (partial squats, calf raises), 50-75% weightbearing use 1 crutch (progress to no crutches if they can walk with no limp with a reciprocal gait pattern), and stationary bike (if 100 degrees of knee flexion).
Weeks 3-4: Full extension ROM, continue strengthening exercises, expected ROM 100-120 degrees of knee flexion (add wall slides), and start elliptical training.
Weeks 4-6: Push ROM exercises want 125 degrees of knee flexion (closing in on full flexion), strength building (Goal at week 6 is affected leg quad strength to be 60% of non-affected), add double leg balance activities (airex pad, tilt board).
Week 6-12: Week 6 want to maintain full extension and receive 135 degrees of knee flexion, can start hamstring curls if hamstring graft used, start flat treadmill, begin outdoor bike on flat road, strengthening exercises (week 8 goals are quadriceps and hamstrings of affected leg to be 80% of non-affected leg), add single leg balance activities if good knee control.
Week 12-20: Continue strengthening, introduce light jogging and running if can perform all ADLs and exercises without an increase in swelling, introduce agility.
24 weeks: Earliest you should plan to return to sport. Return to sport goals include quadricep and hamstring strength at least 80% of unaffected limb, full motion, no swelling, good stability and can complete a running program.
Return to Sport Tests4,5
Return to Sport tests include: Y balance, triple hop test, single hop distance test and isometric knee extension strength. Experts recommend not to return to sport until the Y Balance ANT has < 4 cm difference between affected and non-affected leg, be able to jump at least 90% the distance on the affected leg as the non-affected leg and to have at least 85% strength in the hamstrings and quadriceps on the affected side compared to the non-affected side.
If you need some guidance following ACL injury, please feel free to reach out to us at firstname.lastname@example.org, call 208-917-2660, or DM us on instagram or FB @rockandarmor
1. Klinge SA, Sawyer GA, Hulstyn MJ. Essentials of Anterior Cruciate Ligament rupture management. Rhode Island Medical Journal. 2013;96(5):28-32.
2 Hosea, T. ACL reconstruction: techniques and avoiding pitfalls. University Orthopaedic Associates. 2015;1-38..
3. Evans, IK. ACL reconstruction rehabilitation protocol. Sports Medicine North Orthopedic Specialty Center. 2018; 1-23.
4. Teyhen DS, Robertson J. Return to sport: when should an athlete return to sport after an ACL surgery?. J Orthop Sports Phys Ther. (2011);41(6):388.
5. Garrison JC, Bothwell JM, Wolf G, Aryal S, Thigpen CA. Y balance test™ anterior reach symmetry at three months is related to single leg functional performance at time of return to sports following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2015;10(5):602-11.