It is intensive physiotherapy undertaken for approximately 3-6 months before the decision to have surgery. However, the rehabilitation program is similar to that undertaken after surgery and is not a waste of time! Like with any rehab process however, If you are not committed your outcomes won’t be as favourable.
The science shows little difference in pain, function and return to sport in the long term between those who do or do not have surgery, even if surgery is delayed by ‘prehab’ 2,3,4,5,6,7,8,9. A successful ACL rehab is not “time” based i.e. 6-9-2 months. The Rehab is based on “Have i ticked all the boxes”. By doing a prehab you start ticking boxes before surgery. Makes sense to me especially when there is evidence that undertaking a bout of ‘prehab’ prior to surgery results in better overall outcomes then if you do not partake in prehab 2,3.
What Does Prehab Look Like?
A good ACL prehab program, much like any rehab program, should be tailored to you. Your program should be made to work around your schedule, your injury, and your goals.
However, in saying that there are some core fundamentals of ACL prehab that should be adhered to! These are:
- Early Recovery
- Knee Range of Motion and Mobility
- Local Knee Strength & Function
- Global Strength of The Entire Body
- Motor Control: The Ability to Co-Ordinate Your Body Safely & Efficiently
- Cross Training: Staying Fit
1. Early Recovery
After an ACL tear the knee often becomes hot and swollen due to the Hemarthrosis (or ‘blood in the joint’) that occurs due to the tearing of the ACL which has a blood supply. Combined with any added injuries like a meniscus tear this can make the knee quite painful and stiff.
Which Knee Is Injured?
However, the body is damn cool and will flush the knee out slowly and knee range of motion will improve. For pure ACL tears (meaning there is no added meniscus tear) this process will be faster. If there is meniscus involvement that is physically ‘blocking’ the knee, then surgery is often required.
Make sure you follow you are Dr’s / Physio’s advice when it comes to determining if your knee is Blocked. Provided there is no physical block many meniscus injuries improve on their own however this once again depends on the ‘type’ of meniscus tear e.g. bucket handle meniscus tear.
Types of Meniscus Tears
So, what do we want to focus on immediately post injury?
Early Recover Goals = a ‘Quiet Knee’
The goal in early recovery is to get a ‘quiet knee’ which is a knee that is not too swollen, too sore and has improving range of motion:
- Settle the swelling:
This is done with appropriate rest meaning; avoiding prolonged time on feet and using crutches if required to achieve as much of a normal gait as possible. Also, elevating the leg above your heart when lying down and using compression sleeves will assist in the drainage of your knee. If you have been instructed to use a brace this is very important, especially if you have a lateral or medial collateral ligament tear (acronyms are MCL/LCL). These often are fixed without surgery through bracing so keep it on! Most swelling settles in 7-21 days from injury.
- Settle the Pain:
Use your medication as prescribed by the doctor. Avoid long, sustained periods of walking and being on your feet. Try to reduce knee swelling as often as possible. Begin light exercise as able to improve range of motion and quads strength.
- Restoration of Gross Movement:
Full knee movement will take time but achieving consistent improvement in knee range of motion is possible. You may find achieving the last 10 degrees of straightening or bending the leg to be challenging. However, the majority of your range of motion should improve steadily. If the knee feels like its physically jammed mid-way through your range of motion, I suggest getting it assessed by a physiotherapist or doctor who work in sport.
Your Knee Anatomy!
2. Knee Range of Motion and Mobility
Knee Mobility Is Important! These mobility exercises that are easily performed by patients at home with minimal to no equipment. After you suffer an ACL injury it is important that you take some time to let the knee rest. Most knee effusion (swelling) will settle within 7-21 days depending on the severity of the injury. During this time, it is important that the knee is checked for any fracture and the presence of any meniscus or ACL injury.
The meniscus is the major concern and NOT the ACL as the meniscus cartilage’s health is very important for long term knee function. Once the knee has settled however and no immediate surgery is needed to preserve the meniscus we can get into some mobility and range of motion work! Now I will go into what strength exercises can be done at the same time AS these exercises in other videos. This video is purely on Mobility progressions only. Mobility and strength SHOULD be done simultaneously.
But What If I NEED Surgery: Can I Still Do Prehab?
If you have been given your surgery marching order and you are stuck in a brace and told not to walk, do not fear. You do not have to wait to have surgery before you can start the process of recovery.
Follow the mobility exercises from step 1 (just above in this article) as able and use this ‘brace protocol’ for strength. This video is appropriate for many knee injuries before or after surgery when stuck in a brace.
3. Local Strength & Function of the Knee
So, if I can walk and exercise what are the best ACL prehab exercises for my knee?
The first goal is getting the quads working (activating) and then developing quads strength and size. In the video below is my list of the best exercises to perform for ‘quad’ strengthening when undergoing an ACL prehab. In this video I go over early, mid, and later stage quad exercises to do as part of prehab for an ACL injury.
The goal of this video is to demonstrate the need to progress exercise difficulty, making them harder and more challenging. By working hard and making your exercises more difficult you will in turn improve your leg strength. So when you decide to have surgery or not 3-6 months after your knee operation you will be able to make a better ‘informed’ decision as to whether you feel the need to have your surgery or not.
Details of the video:
The Early stage exercises are non-weight bearing (closed kinetic chain) exercises i.e. straight leg rise, knee extensions and ways to make these harder.
The mid stage exercises are weight bearing knee exercises (closed kinetic chain) based on simple squats goblet squats, front squats, back squats.
The Late stage exercises include heavy back squats or front squats into single leg squats weighted single leg squats.
Early stage Exercises: 3 sets of 20 to 30 repetitions to be done three to four times a week. The mid stage Exercises: 3 sets of 12 to 15 repetitions to be done three to four times a week Late Stage Exercises: 3-4 sets of 8 to 12 repetitions two to three times a week.
4. Global Strength of The Entire Body
These two videos cover Hamstring, Calves, Glutes & Trunk Strength which are all necessary when undergoing ACL prehab!
Hamstring strength is important as often surgeons will opt for a hamstring graft. Meaning they take one of the hamstrings (semitendinousus) and use it as a replacement ACL. Thus, making the hamstring complex weaker. We also need our hamstrings when running at high speeds. So, whether you have a reconstruction or not it is still important to have strong hamstrings!
Hip/glutes and trunk strength is of the utmost importance in ACL prehab and rehab. Hip strength is important in preventing the knee from buckling inwards (as per the picture below) into the ACL tearing Position! Having a strong trunk is important in sport. If we cannot control our torso when changing direction, the knee must deal with these additional forces. So, performing exercises that develop trunk strength along with hip/glute strength will assist you preventing yourself from going into the ACL tearing position (as per photo below).
ACL Tearing Position/Mechanism
5. Motor Control: The Ability to Co-Ordinate Your Body Safely & Efficiently
In this episode I cover some progressions from static balancing to different hip, ankle and knee motor patterning skills that are important to master. Motor skills is a fancy way to talk about our ability to execute body movements well e.g. cutting, changing directions.
It may seem strange but often ACL injury occurs due to movement deficiencies combined with other factors around strength, level of play etc. By developing good body movements and skills in basic patterns like. Hip hinge, squat, jumping, landing, and skipping we can start to tick some boxes in the prehab phase as these also have to be covered in post op rehab.
Please keep in my mind that in this video the progressions get harder as the video goes on and my patients have to have master the skills at the beginning of the video before they move on to the next.
6. Cross Training: Staying Fit
Quite often when undergoing prehab, we may feel like we can’t get a sweat on and that we will become very unfit! Being unable to walk, swim or run can make you feel this way! However, with some clever modification we can get you working hard through cross training!
If you have access to cardio machines: Rower, Ski erg, Assault Bike, are all great tools to maintain your fitness. Other ways of staying fit are upper body strength sessions. The video progresses from easiest (minimal to no knee involvement) to exercise where the knee is heavily involved.
Other ways of staying fit are training your upper body. However, I suggest that if you are training alone its best to use the ‘pin loaded’ machines over regular free weights. As having to twist and load bars is not ideal on a knee that has just suffered a major injury
So yes, you need it!
The aim of this article is to educate on the need for a robust and comprehensive prehab for people who suffer from an ACL injury. By performing a 3-6 month prehab, ACL tear patients will be able to make positive changes to their knee’s strength and control. If after such time people feel that the knee is strong and stable or if they feel it is strong but unstable, it will allow people to make an informed decision on surgery or no surgery.
If you do need the surgery, the science shows us that you will be better off then if you had not performed the surgery immediately. If perhaps you don’t require the surgery, then you have saved a bunch of money, prevented a second injury (from the surgery being an injury) and you have already got a head start on your ‘rehab’.
Often the ability to make this decision is taken out of the patient’s hands and are rushed off to surgery when many do not need to have immediate surgery. This is seen in Australia where over 90% of all ACL injuries are repaired. ACL surgery is important for many, but it’s not necessary for all. By developing a culture of pushing prehab first and delaying the decision for surgery till 3-6 months post injury will allow many patients to make calm and informed decision about their body.
Alex Holland (M.Phty, B.Phty)
Axe Rugby- Director
- Cavanaugh, J. T., & Powers, M. (2017). ACL Rehabilitation Progression: Where Are We Now? Current reviews in musculoskeletal medicine, 10(3), 289–296.
- Filbay, S. R., & Grindem, H. (2019). Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Practice & Research Clinical Rheumatology.
- van Melick N, van Cingel REH, Brooijmans F, et al. (2016). Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. British Journal of Sports Medicine, 50:1506-1515.
- Grindem, H., Eitzen, I., Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2012). A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament–injured patients after a nonoperative versus an operative treatment course. The American journal of sports medicine, 40(11), 2509-2516.
- Wellsandt, E., Failla, M. J., Axe, M. J., & Snyder-Mackler, L. (2018). Does Anterior Cruciate Ligament Reconstruction Improve Functional and Radiographic Outcomes Over Nonoperative Management 5 Years After Injury?. The American journal of sports medicine, 46(9), 2103-2112.
- Rooney, J. (2018). The Winston Churchill Memorial Trust of Australia investigation of contemporary conservative management programs for anterior cruciate ligament knee injuries.
- Zadro, J. R., & Pappas, E. (2019). Time for a differe(Filbay and Grindem 2019)nt approach to anterior cruciate ligament injuries: educate and create realistic expectations. Sports Medicine, 49(3), 357-363.
- Filbay SR. (2019). Early ACL reconstruction is required to prevent additional knee injury: a misconception not supported by high-quality evidence. British Journal of Sports Medicine, 53:459-461.
- Van Yepren D. T., Reijman M., van Es E.M., Bierma-Zeinstra S. M. A., Meuffels, D. E. (2018). Twenty-year follow-up studying comparing operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-level athletes. The American Journal of Sports Medicine, 1:363546 517751683.
- Nagelli, C. V., & Hewett, T. E. (2017). Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports medicine (Auckland, N.Z.), 47(2), 221–232.
- Wen, C., Lohmander, LS. (2014). Osteoarthritis: does post-injury ACL reconstruction prevent future OA? Nature Reviews Rheumatology, 10(10):577-8.
- Cooper, R., Hughes, M. (2018). Melbourne ACL Rehabilitation Guide 2.0.
- LaTrobe University (2018). Patient Education Anterior Cruciate Ligament Reconstruction: Psychological Impact of Injury. http://semrc.blogs.latrobe.edu.au/wp-content/uploads/2017/04/4.-Psychological-Impact-of-Injury-Copy.pdf
- LaTrobe University (2018). Patient Education Anterior Cruciate Ligament Reconstruction: Things to Look Out For. http://semrc.blogs.latrobe.edu.au/wp-content/uploads/2017/04/Things-to-look-out-for-Copy.pdf
- Spalding, T., Dekkers, M. (2003). Anterior Cruciate Ligament Reconstruction: Patient Information and Rehabilitation Management Guidelines 2ndEdition.
- Andrade R, Pereira R, van Cingel R, et al How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II) British Journal of Sports Medicine Published Online First: 07 June 2019. doi: 10.1136/bjsports-2018-100310