Anterior Cruciate Ligament Rehabilitation

• Rehabilitation of the anterior cruciate ligament after reconstruction surgery is vital in order to recover full knee function as soon as possible.
• The approximate rehabilitation time of the ligament will depend on the characteristics of the patient and whether there is any associated knee injury (meniscus, bone damage, etc).
• In most cases, it is possible to recover full functionality of the knee and return to sporting activity without any problems, although we recommend improving the musculature of the surrounding muscles.

Rupture of the anterior cruciate ligament is one of the most common knee injuries and at the same time one of the most feared by athletes, due to the fact that it requires a long recovery period and the need to undergo surgery for its reconstruction.

In the past, this injury meant the end of any athlete's sporting career, as the torn ligament could not be repaired, but nowadays there are techniques that allow the ACL to be reconstructed and even do so without opening the knee, as is the case with the arthroscopic cruciate ligament reconstruction surgery. 

Today, knee arthroscopy is the method of choice for most meniscus and ligament repairs, which reduces recovery time and speeds up rehabilitation.

You will be able to walk within 24 hours of the operation, with the help of crutches, move your knee within 12-24 hours, bend your knee to a right angle within a week and achieve full mobility between the 2nd and 4th week. 

Full recovery occurs between weeks 6 and 8, so please note that you should not do any heavy physical work until you have recovered.

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Below you will find information on the rehabilitation of the anterior cruciate ligament after surgery.

After anterior cruciate ligament surgery, rehabilitation can be set up according to different phases. It is important to mention that there are different ways of rehabilitation, the most important being that it is supervised by the surgeon or physiotherapy professionals.

To give an example of anterior cruciate ligament rehabilitation, we set out below a series of phases.

Firstly, we will establish a phase consisting of 3 weeks performing a series of exercises and following a series of instructions established by the surgeon, which can be carried out alone or with the help of a physiotherapist.

• Ice: After ACL reconstruction surgery, your knee will feel very swollen, so it is recommended that you place an ice pack on your knee every 3 hours for up to 15 minutes to try to reduce the swelling.
• Taking medication: during the first few days of post-operative and anterior cruciate ligament rehabilitation, your surgeon may instruct you to take anti-inflammatory and analgesic medication to control swelling and pain. This should always be done under a doctor's prescription to avoid taking medications that thin the blood and can be harmful.
• Early exercise: while still in the hospital, a series of exercises will be performed to pump blood to the joint in an attempt to improve the oedema and inflammation. These early rehabilitation exercises will be:
  • Ankle movement by stretching the foot and then retracting it as if you were trying to touch your shin with your fingertips.
  • Placing a towel or pillow under the operated knee, keeping it slightly bent, performs a similar movement to the previous one, bending the ankle towards us, thus exercising the quadriceps.
• Partial support of the operated leg: it is vital to start early mobilisation after cruciate ligament reconstruction surgery (it is important in almost all surgeries), but avoid putting all the weight of the body on the operated leg. To avoid this, crutches should be used.
• Other recommendations: sometimes, the surgeon may recommend the use of an articulated knee brace that prevents the joint from opening wide, thus improving the healing of the anterior cruciate ligament.

The instructions mentioned in the previous section can be extended for up to 6-7 days, at which point exercise can begin, pain permitting.

After the first few days of hospitalisation and once you are discharged from hospital, you will have to work (on your own or with a physiotherapist) on rehabilitation with a series of objectives in mind: improving joint range of motion, increasing the strength and muscle tone of the quadriceps and gradually stopping using crutches to start moving independently. To this end, there are a series of exercises that will allow good results to be obtained. 

All of them should be performed daily with 4 sets of 12 repetitions of each exercise:

• Sitting on a table, we let our legs hang down without holding them at a 90-degree angle. Using the non-operated leg, we perform flexion-extension movements, stretching or flexing the knee as far as possible as far as the pain allows us to do so.
• Another curious but effective exercise consists of performing a flexion-extension movement with a skateboard to improve the opening range of the knee. To do this, you should sit on a chair and place your leg on a skateboard and move your leg forwards and backwards. This allows you to improve joint movement in a gentle way.
• With the aim of strengthening the quadriceps muscles, another rehabilitation exercise for anterior cruciate ligament is to place a cushion under the operated knee and gently flex the joint for 5 seconds, repeating several times.
• Following the line of strengthening the quadriceps, another rehabilitation exercise consists of lying down with your legs facing the wall and leaning your operated leg against it without making a 90-degree angle with it. You then press against the wall with the sole of your foot, thus exercising your quadriceps.

As you do these exercises, you will continue to use crutches to avoid putting your full weight on your operated knee. This support during rehabilitation from ACL surgery will increase according to your own perception, which should increase as the pain allows.

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The objectives established from the third week of rehabilitation after the operation are basically to improve joint amplitude, reaching an angle of 120º without pain. 

Work will also continue on full knee extension, in the event that it has not been possible to extend the entire joint, the aim will be to improve the musculature and balance of the operated knee and at the same time reduce dependence on crutches for walking, going from using two to progressively only needing one after a month and a half of rehabilitation.

To achieve these goals in the rehabilitation of anterior cruciate ligament reconstruction, you must perform a series of rehabilitation exercises that we discuss below, which should be performed in 4 sets of 12 repetitions each:

• Improvement of mobility: in this phase, the previously described exercises will continue to be performed, seeking in this case to achieve flexion of the joint up to 120º and maximum extension of the leg if it has not yet been reached.
• Improvement of the musculature: in order to continue improving the quadriceps musculature and thus provide stability to the knee, the exercises previously explained should be continued by adding the following exercises:
  • With your back to the wall and your legs slightly forward, lower your buttocks to an angle of about 45°, holding them there for as long as possible. If this is very easy, you can lower even further to an angle of 90° at the knee.
  • Another rehabilitation exercise that can be performed is squats to an angulation of no more than 45°. Again, if the descent of the buttocks to this point is very easy, it can be continued down to 90°. It is important to avoid the knees going over the tips of your toes during the descent. It is important to ask your surgeon or physiotherapist for advice on how to perform the exercise correctly.
  • Roll a ball with your foot against the wall, lying on your back with your leg at 90º, stretch your leg as far as possible until you reach the maximum extension and contract it back to 90º.
• Improving balance: in order to improve the balance of the joint, we recommend the use of a balance board, which is easy to acquire, starting this process with both feet and moving on to balancing with only one if we find it easy after a while. Similarly, it can be done with a trampoline, which we will use both to perform balance exercises on it and to get on it with a small jump when we feel confident, moving from 2 feet to 1 as we can. These exercises should be done for at least 2 minutes.
• Elimination of crutches: as you become more confident, you can gradually wean yourself off crutches, initially moving to one crutch until you can walk on your own.

After each exercise session, it is recommended to put an ice pack on the operated knee for about 15 minutes. Once this month and a half of rehabilitation has been completed, a slightly more intense rehabilitation can be started, provided that you have improved enough to start it.

Once the first month and a half of rehabilitation has passed, the most difficult part is over and relatively more intensive rehabilitation work can now begin.

After the first month and a half of cruciate ligament reconstruction surgery, you can start playing some sports that do not involve excessive stress on the knee, while continuing to perform the exercises mentioned throughout this article in order to regain maximum mobility and strengthen the quadriceps muscles. 

Additional exercises that can be started once the use of crutches has been discontinued include:

• Swimming: Swimming can be started after a month and a half of rehabilitation as long as it is done gently and without excessive strain on the knee. In these cases, it is important to take special care when getting out of the pool to avoid putting excessive strain on the joint.
• Step: elliptical machines will allow you to perform a muscle-building exercise for your legs, avoiding the usual pounding of the leg against the ground when running on a surface. This exercise should be done gently and progressively over time to avoid sudden extensions or flexions that can cause ligament problems.

Despite all this, rehabilitation from cruciate ligament surgery will vary from person to person. As we approach 3 months of rehabilitation, in many cases it may be possible to begin gentle running, progressing gradually in intensity until 4-6 months of rehabilitation, at which point it is possible to return, at least in most cases, to intense sport.

Strengthening the musculature surrounding the knee joint is vital to provide stability to the new ligament, to return to intense sport as soon as possible and to avoid any possible relapse, so it is important to listen to your doctor or physiotherapist throughout your recovery.

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• Valdazo, M. (2013, julio). Ejercicios de rehabilitación de LCA (ligamento cruzado anterior) tras plastia autóloga con semitendinoso. http://www.doctoravaldazo.com/wp-content/uploads/2014/pdfs/rehabilitacionlca.pdf
• Ramos Álvarez, J. J., López-Silvarrey, F. J., Segovia Martínez, J. C., Martínez Melen, H., & Legido Arce, J. C. (2008). Rehabilitación del paciente con lesión del ligamento cruzado anterior de la rodilla (LCA). Revista Internacional de Medicina y Ciencias de la Actividad Física y del Deporte, 8(29), 62-92. https://www.redalyc.org/pdf/542/54222978004.pdf