ACL Prevention Rehabilitation Protocol (Sports Med)

This protocol outlines a comprehensive rehabilitation program designed to reduce the risk of Anterior Cruciate Ligament (ACL) injuries, particularly in athletes. It emphasizes neuromuscular control, strength, agility, and plyometrics. This is a general guideline and should be tailored to individual patient needs and progress under the supervision of a qualified physical therapist.

Pathophysiology of ACL Injuries

ACL injuries commonly occur due to non-contact mechanisms involving a combination of valgus stress, tibial external rotation, and knee hyperextension. These movements often happen during cutting, pivoting, landing, or deceleration activities. Risk factors include:

• Quadriceps dominance over hamstring strength
• Poor neuromuscular control and proprioception
• Decreased core stability
• Excessive knee valgus during dynamic movements
• Anatomical factors (e.g., narrow intercondylar notch)
• Hormonal influences (e.g., higher incidence in female athletes)
• Fatigue

This protocol focuses on addressing these risk factors through targeted exercises and training techniques.

Phase I: Protection (Weeks 1-3)

Goals:

• Reduce pain and inflammation
• Restore full range of motion (ROM)
• Activate quadriceps and hamstring muscles
• Improve weight bearing tolerance

Exercises:

• Pain and Edema Management: Ice, compression, elevation (PRICE principle). May include modalities like electrical stimulation or ultrasound for pain relief.
• Range of Motion (ROM):
  • Ankle pumps: 3 sets of 15-20 repetitions.
  • Heel slides: 3 sets of 15-20 repetitions, focusing on regaining full knee extension.
  • Patellar mobilization: Gentle superior, inferior, medial, and lateral glides to maintain patellar mobility.
  • Standing hamstring stretches: Hold for 30 seconds, repeat 3 times.
• Muscle Activation:
  • Quadriceps sets: Isometric contractions, holding for 5 seconds, 3 sets of 10-15 repetitions. Focus on maximal voluntary contraction without pain.
  • Hamstring sets: Isometric contractions, holding for 5 seconds, 3 sets of 10-15 repetitions.
  • Gluteal sets: Isometric contractions, holding for 5 seconds, 3 sets of 10-15 repetitions.
  • Hip adductor squeezes: Using a ball or towel between the knees, squeeze and hold for 5 seconds, 3 sets of 10-15 repetitions.
  • Hip abductor isometrics: Push the lateral aspect of the knee against resistance, hold for 5 seconds, 3 sets of 10-15 repetitions.
• Weight Bearing:
  • Partial weight bearing (PWB) with crutches, progressing to full weight bearing (FWB) as tolerated.
  • Gait training with crutches, emphasizing proper mechanics and minimizing compensatory patterns.

Progression Criteria:

• Minimal pain and edema
• Full knee extension and near full knee flexion
• Independent ambulation with or without assistive device.

Phase II: Loading (Weeks 4-8)

Goals:

• Improve strength and endurance of lower extremity muscles
• Enhance neuromuscular control and proprioception
• Progress weight bearing activities
• Begin sport-specific drills with controlled movements

Exercises:

• Strengthening:
  • Mini squats: 3 sets of 10-15 repetitions, focusing on proper form and avoiding knee valgus. Progress to deeper squats as tolerated.
  • Leg press: Start with low weight and gradually increase resistance, 3 sets of 10-15 repetitions.
  • Hamstring curls (machine or with resistance band): 3 sets of 10-15 repetitions.
  • Hip abduction and adduction with resistance band: 3 sets of 10-15 repetitions.
  • Calf raises: 3 sets of 15-20 repetitions (progress to single leg).
  • Step-ups: 3 sets of 10-15 repetitions, focusing on controlled descent and proper form.
  • Lunges (forward, lateral, and reverse): 3 sets of 10-12 repetitions per leg, maintaining proper alignment.
• Neuromuscular Control:
  • Single leg stance with eyes open/closed: Progress duration and add perturbations (e.g., reaching, throwing a ball).
  • Balance board or wobble board exercises: Gradually increase difficulty and duration.
  • BAPS board exercises: Progress through various planes of motion.
• Proprioception:
  • Joint position sense exercises: Focus on replicating specific knee angles with eyes closed.
  • Dynamic stabilization exercises: Using unstable surfaces or resistance bands to challenge balance and control.
• Agility Drills (Controlled):
  • Forward/backward jogging
  • Lateral shuffling
  • Carioca drills
  • Figure-of-eight running

Progression Criteria:

• Good strength and endurance in lower extremity muscles
• Adequate neuromuscular control and proprioception
• Pain-free performance of agility drills

Phase III: Return to Function (Weeks 9+)

Goals:

• Restore sport-specific skills and agility
• Improve power and plyometric capabilities
• Gradually increase training intensity
• Return to sport with confidence and reduced risk of re-injury

Exercises:

• Plyometrics:
  • Double leg jumps (forward, lateral, vertical): Progress height and distance.
  • Single leg hops (forward, lateral, vertical): Focus on controlled landing and stability.
  • Box jumps: Progress height of box and focus on soft landing.
  • Bounding: Progress distance and speed.
• Agility Drills (Sport-Specific):
  • Cutting and pivoting drills
  • Shuttle runs
  • Ladder drills
  • Sport-specific movement patterns (e.g., basketball lay-ups, soccer dribbling)
• Strength and Power:
  • Progressive overload with weight training exercises
  • Power cleans
  • Jump squats
  • Medicine ball throws
• Running Progression:
  • Increase running distance and intensity gradually
  • Interval training
  • Sprints

Return to Sport Criteria:

• Symmetrical lower extremity strength and power (assessed with hop tests and isokinetic testing)
• Successful completion of agility and plyometric testing
• Pain-free performance of sport-specific activities
• Psychological readiness to return to sport

Common Special Tests

• Anterior Drawer Test: Assesses anterior tibial translation on the femur.
• Lachman Test: Considered the most reliable clinical test for ACL integrity.
• Pivot Shift Test: Assesses rotatory instability of the knee.
• Single Leg Hop Test: Assess overall lower extremity function and symmetry. Includes hop for distance, timed hop, and triple hop for distance.

Important Considerations:

• Adherence to proper form and technique is crucial throughout the rehabilitation process.
• Patient education regarding ACL injury prevention strategies is essential.
• Psychological support and encouragement are important for patient motivation and adherence.
• This protocol should be individualized based on patient-specific factors and progress.