- History of Injury
- Indications for surgery
- Risks & Complications
- Most injuries are sports related involving a twisting injury to the knee
- It can occur with a sudden change of direction, a direct blow (e.g., a tackle, landing awkwardly)
- Often there is a popping sound when the ligament ruptures
- Swelling usually occurs within hours
- There is often the feeling of the knee popping out of joint
- It is rare to be able to continue playing sports with the initial injury
Long termNot everyone needs surgery. Some people can compensate for the injured ligament with strengthening exercises or a brace. It may be advised that you give up sports involving twisting activities if you have an ACL injury.
- Episodes of instability can cause further damage to important structures within the knee that may result in early arthritis
- Surgery is performed as a same-day procedure or an overnight stay.
- You will have pain medication by tablet or in a drip (intravenous).
- Any drains will be removed from the knee.
- A splint is sometimes used for comfort.
- You will be seen by a physical therapist who will teach you to use crutches and show you some simple exercises to do at home.
- Leave any waterproof dressings on your knee until your post-op visit.
- You can put all your weight on your leg.
- Avoid anti-inflammatories or aspirin for 10 days.
- Put ice on the knee for 20 minutes at a time, as frequently as possible.
- Post-op review will usually be at 7-10 days.
- Physiotherapy can begin after a few days or can be arranged at your first post-op visit.
- If you have any redness around the wound or increasing pain in the knee or you have temperature or feel unwell, you should contact your surgeon as soon as possible.
Acute (0 – 2 Weeks)
- Wound healing
- Reduce swelling
- Regain full extension
- Full weight bearing
- Wean off crutches
- Promote muscle control
- Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise
- Patella mobilization
- Active range of motion knee exercises, calf and hamstring stretching, contraction (non weight bearing progressing to standing), muscle control and full weight bearing. Aim for full extension by 2 weeks. Full flexion will take longer and generally will come with gradual stretching. Care needs to be taken with hamstring co-contraction as this may result in hamstring strains if too vigorous. Light hamstring loading continues into the next stage with progression of general rehabilitation. Resisted hamstring loading should be avoided for approximately 6 weeks
- Gait retraining encouraging extension at heel strike
Stage 2- Quadriceps Control (2-6 Weeks)
- Full active range of motion
- Normal gait with reasonable weight tolerance
- Minimal pain and effusion
- Develop muscular control for controlled pain free single leg lunge
- Avoid hamstring strain
- Develop early proprioceptive awareness
- Use active, passive and hands on techniques to promote full range of motion
- Progress closed chain exercises (quarter squats and single leg lunge) as pain allows. The emphasis is on pain free loading, VMO and gluteal activation
- Introduce gym based exercise equipment including leg press and stationary cycle
- Water based exercises can begin once the wound has healed, including treading water, gentle swimming avoiding breaststroke
- Begin proprioceptive exercises including single standing leg balance on the ground and mini tramp. This can progress by introducing body movement whilst standing on one leg
- Bilateral and single calf raises and stretching
- Avoid isolated loading of the hamstrings due to ease of tear. Hamstrings will be progressively loaded through closed chain and gym based activity
Stage 3- Hamstring/Quadriceps Strengthening (6-12 Weeks)
- Begin specific hamstring loading
- Increase total leg strength
- Promote good quadriceps control in lunge and hopping activity in preparation for running
- Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation
- Active prone knee flexion which can be quickly progressed to include a light weight and gradually increasing weights
- Bilateral bridging off a chair. This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen
- Single straight leg dead lift initially active with increasing difficulty by adding dumbbellsWith respect to hamstring loading, they should never be pushed into pain and should be carefully progressed. Any subtle strain or tightness following exercises should be managed with a reduction in hamstring based exercises
- Gym based activity including leg presses, light squats and stationary bike which can be progressively increased in intensity as pain and control allow. It is important to monitor any effusions following exercise and if it is increasing then exercise should be toned down
- Once single leg lunge control is comparable to the other side hopping can be introduced. Hops can be made more difficult by including variations such as forward/back, side to side off a step and in a quadrant
- Running may begin towards the latter part of this stagePrior to running certain criteria must be met
- No anterior knee pain
- A pain free lunge and hop that is comparable to the other side
- The knee must have no effusion
- Before jogging start having brisk walks, ideally on a treadmill to monitor landing
- Action and any effusion. This should be done for several weeks before jogging properly
- Increased proprioceptive maneuvers with standing leg balance and progressive hopping based activity
- Expand calf routine to include eccentric loading
Stage Four-Sport Specific (3-6 Months)
- Improve leg strength
- Develop running endurance speed, change of direction
- Advanced proprioception
- Prepare for return to sport and recreational lifestyle
- Controlled sport specific activities should be included in the progression of running and gym loads. Increasing effusion post running that isn’t easily managed with ice should result in a reduction in running loads
- Advanced proprioception to include controlled hopping and turning and balance correction
- Monitor potential problems associated with increasing loads
- No open chain resisted leg extension exercises unless authorised by your surgeon
Stage Five-Return to Sport (6 Months Plus)
GoalsA safe return to sporting activities
- Full training for 1 month prior to active return to competitive sport
- Preparation for body contact sports. Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training
- To improve running endurance leading up to a normal training session
- Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity. Circumference measures of thigh and calf to within 1 cm of other side
Medical (Anaesthetic) complicationsMedical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:
Allergic reactions to medicationsBlood loss requiring transfusion with its low risk of disease transmission Heart attacks, strokes, kidney failure, pneumonia, bladder infections. Complications from nerve blocks such as infection or nerve damage. Serious medical problems can lead to ongoing health concerns, prolonged hospitalization. The following is a list of surgical complications. These are all rare but can occur. Most are treatable and do not lead to long term problems.
InfectionApproximately 1 in 200. Treatment involves either oral or antibiotics through the drip, or rarely further surgery to wash the infection out.
Deep vein thrombosisThese are clots in the veins of the leg. If they occur you may need blood thinning medication in the form of injections or tablets. Very rarely they can travel to the lung (Pulmonary Embolus) which can cause breathing difficulties or even death.
Excessive swelling & BruisingThis is due to bleeding in the soft tissues and will settle with time.
Joint stiffnessCan result from scar tissue within the joint, and is minimized by advances in surgical technique and rapid rehabilitation. Full range of movements cannot always be guaranteed.
Graft failureThe graft can fail the same as a normal cruciate ligament does. Failure rate is approximately 5%. If the graft stretches or ruptures it can still be revised if required by using tendons from the other leg.
Damage to nerves or vesselsThese are small nerves under the skin which cannot be avoided and cutting then leads to areas of numbness in the leg. This normally reduces in size over time and does not cause any functional problems with the knee. Very rarely there can be damage to more important nerves or vessels causing weakness in the leg.
Hardware problemsAll grafts need to be fixed to the bone using various devices (hardware) such as screws or staples. These can cause irritation of the wound and may require removal once the graft has grown into the bone.
Donor site problemsDonor site means where the graft is taken from. In general either the hamstrings or patella tendon are used. These can be pain or swelling in these areas which usually resolves over time.
Residual painCan occur especially if there is damage to other structures inside the knee.
Reflex Sympathetic DystrophyAn extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain.