ACL Physiotherapy Management

Overview

Key 2025 evidence: A systematic review and meta-analysis (Filbay et al., Sports Med 2025, PMID 40603829) found no significant difference in return-to-sport rate or activity level between ACLR and rehabilitation alone - reinforcing that high-quality physiotherapy is essential regardless of surgical decision.

Goals of Physiotherapy

• Control pain and swelling
• Restore full range of motion (ROM), especially full extension
• Rebuild quadriceps, hamstring, and hip strength
• Restore neuromuscular control and proprioception
• Progress safely through functional milestones to return to sport
• Reduce risk of re-injury

Criterion-Based Rehabilitation Phases

Phase 1 - Maximum Protection / Acute Phase (Weeks 0-2)

• Control pain, swelling, inflammation
• Restore full knee extension (critical - extension lag predicts poor outcomes)
• Initiate quadriceps activation
• Normalize patellar mobility
• Safe weight-bearing and gait

• Cryotherapy, elevation, compression
• Neuromuscular electrical stimulation (NMES) to quad
• Quad sets, straight leg raises (SLR) - only when no extension lag
• Heel props and prone hangs for full extension
• Heel slides for flexion ROM
• Hip strengthening (abductors, extensors)
• Bilateral leg press 0-70 degrees
• Gait training with crutches as needed
• Blood flow restriction (BFR) therapy

• Full knee extension (0 degrees)
• Quad contraction with superior patellar glide
• SLR without extension lag
• Ambulation without limp

Phase 2 - Gait Training and Progressive ROM (Weeks 2-4)

• Progress ROM (target 0-125 degrees flexion)
• Normalize gait pattern
• Good patellar mobility
• Minimal effusion

• Continue Phase 1 as indicated
• Low-resistance stationary bicycle
• Leg press 0-80 degrees
• Mini-squats, forward step-ups
• Open kinetic chain (OKC) quadriceps extension - 90 to 30 degrees arc only (limit to protect graft)
• Heel raises
• Continue NMES and BFR

Phase 3 - Early Strengthening (Weeks 4-12)

• Restore full ROM
• Descend 8-inch step with control
• Improve ADL endurance and flexibility
• Monitor for patellofemoral pain

• Squats to 90 degrees
• Step-downs progressing to single-leg squat
• Gym-based progressive strengthening
• OKC hamstring curls
• Advance proprioceptive training (single-limb stance, perturbation training)
• Stationary bike, elliptical

• Full ROM equal to contralateral side
• 8-inch step descent with control, no pain
• Isokinetic testing: quads and hamstrings within 75% limb symmetry index (LSI)

Phase 4 - Transitional / Return to Running (Weeks 12-16)

• Initiate jogging and normalize running gait
• Begin multi-planar activities
• Introduce plyometric precursors

• Walk-to-jog progression (e.g., 5-min walk/1-min jog intervals, building over 3 weeks)
• Sub-maximal sport-specific training in the sagittal plane
• Bilateral progressing to unilateral plyometrics (double-leg med ball slams, shuttle jumps)
• Agility program initiation

• No pain or swelling with running
• Normal gait mechanics
• Symmetrical joint position sense (< 5-degree error)

Phase 5 - Advanced Strengthening and Plyometrics (Weeks 16-24)

• Maximize strength and flexibility
• Demonstrate pain-free running
• Hop test reaching 75-80% LSI

• Progressive plyometrics: box jumps, tuck jumps, broad jumps
• Multi-directional agility drills: figure-8 runs, ladder drills, circle runs
• Single-leg strength and balance work
• Y-Balance test monitoring

• Symptom-free running
• Noyes Hop Test ≥ 75% LSI
• Y-Balance test ≥ 75% LSI

Phase 6 - Return to Sport (Weeks 24-36+, typically ≥ 9 months)

• Symmetrical sport-specific performance
• Pass full return-to-sport (RTS) battery
• No apprehension with sport-specific movements

• Multi-plane sport-specific plyometrics and agility
• Hard cutting and pivoting (~7-9 months)
• Non-contact practice → full practice → full play (~9-12 months)

• Quadriceps LSI ≥ 90%
• Hamstring/Quad ratio ≥ 66%
• Hop testing ≥ 90-95% LSI with good landing mechanics
• KOOS-Sports questionnaire > 90%
• ACL-RSI (psychological readiness) ≥ 90

Open vs. Closed Kinetic Chain Exercises

Blood Flow Restriction (BFR) Training

Proprioception and Neuromuscular Training

• Single-limb stance progressions (eyes open → eyes closed → unstable surface)
• Perturbation training (tibial translation board)
• Jump landing mechanics training - critical for re-injury prevention
• Nordic hamstring curls for eccentric hamstring strengthening

Psychological Considerations

Conservative vs. Surgical Management

• Filbay et al. 2025 (PMID 40603829) - no difference in RTS rate between ACLR and rehab alone
• "Prehabilitation" (physio before surgery) significantly improves post-operative outcomes - the quad should ideally reach ≥ 90% LSI before surgery

Summary Table