Top 10 Essential Strategies for ACL Rehabilitation Success

Successfully navigating the rehabilitation journey after anterior cruciate ligament (ACL) reconstruction is more than just physical recovery—it’s a comprehensive process that addresses physical, psychological, and lifestyle factors. As both patients and rehab professionals, we have had the unique opportunity to experience ACL rehabilitation from both sides. These experiences have fueled our passion for “upping our game” and elevating the standard of care in managing these patients through effective strategies for ACL rehabilitation.

Key Components of a Successful ACL Rehabilitation Plan

Throughout our careers, we’ve gathered invaluable insights that can significantly improve outcomes for your patients. Now, we want to share these insights with you.

By focusing on these areas, you can optimize the recovery process, minimize complications, and help your athletes return to their pre-injury level of activity and performance.

1. Provide a Discharge Checklist

An effective strategy for ACL rehabilitation includes providing a discharge checklist at the beginning of the rehabilitation process. This offers significant advantages for the patient and the rehab professional by setting clear expectations and helping patients understand the specific milestones and goals necessary before discharge.

During a long rehabilitation plan, it can seem like the “goalposts” for the patient’s return-to-sport timeline are constantly moving. Using a discharge checklist helps minimize this confusion by clearly defining the intent of the rehabilitation process and helping patients stay focused and committed by giving them specific targets to work toward.

A discharge checklist also empowers patients by offering a roadmap, fostering a sense of control over their recovery, reducing anxiety, boosting confidence, and enhancing engagement. It allows for the early identification of issues or delays, enabling timely adjustments to the rehabilitation plan. Additionally, the checklist is a vital communication tool, providing a tangible reference point for discussions between the patient and rehab professional regarding progress, setbacks, and necessary modifications.

Overall, the discharge checklist is essential for structuring the rehabilitation process, enhancing patient engagement, and ensuring a thorough and effective recovery. If discussing discharge planning feels challenging, our ACL Rehab Live Patient Case Series: Setting up Success offers a detailed demonstration of how to effectively introduce this tool to your patients.

2. Achieve Full Knee Hyperextension Within the First Week Post-Op

Everyone agrees that restoring knee extension range of motion (ROM) following surgery is crucial, but merely achieving 0 degrees of extension is not enough. The goal should be full knee hyperextension that matches the contralateral side, ideally within the first week post-operatively. Let’s dispel the misconception that restoring knee hyperextension will destabilize the joint or stretch the graft—there is no data to support these concerns.

Full knee hyperextension is essential for a normal walking pattern. Without it, patients often develop compensatory gait mechanics that can lead to additional issues and inefficiencies in movement. Failure to achieve full hyperextension can result in knee stiffness, pain, and a loss of overall knee ROM, which can impede functional activities and negatively impact the rehabilitation outcome. Additionally, inadequate knee extension can place excessive stress on other parts of the knee, such as the patellofemoral joint and surrounding musculature, potentially leading to pain and further injury.

Achieving full knee extension early in the post-operative period—ideally within the first week—is also critical for the optimal function of the quadriceps. Better mobility allows proprioceptors to function properly, resulting in better activation and strength of the quadriceps, which is vital for knee stability and function, especially following ACL reconstruction. While traditional approaches vary, solid evidence supports the importance of specific treatments with detailed parameters to optimize outcomes.

3. Use Soft Tissue Mobilization Techniques to Improve Range of Motion (ROM)

Addressing the soft tissue around the knee joint is a critical strategy for ACL rehabilitation to improve mobility and decrease protective muscle tone. Soft tissue mobilization targets the muscles, fascia, and other connective tissues, helping to break down adhesions and scar tissue that can restrict movement. However, immediately following ACL reconstruction, scar tissue and adhesions have not yet formed, so limited soft tissue mobility is primarily due to protective tone and tension.

Therefore, soft tissue techniques should be gentle and inhibitory to maximize early knee ROM and reduce inflammation. Loosening the surrounding soft tissues allows for a greater range of motion and flexibility in the knee joint, which is essential for regaining full function. Don’t just focus on addressing the quadriceps and hamstring muscle groups, but also remember the gastrocnemius and popliteus muscles, which are critical for improving motion.

While performing joint mobilization techniques is not wrong, your primary goal in the early postoperative phase should be protecting the healing graft. Low-grade mobilizations can effectively inhibit pain and reduce protective muscle guarding, which is often more beneficial than stretching the capsule at this stage.

4. Use Blood Flow Restriction with Electrical Stimulation Earlier and Longer Than You Might Think

Incorporating blood flow restriction (BFR) with electrical stimulation (estim) early in the rehabilitation process and for longer durations than traditionally recommended has proven to be a game changer. Research in this area is rapidly emerging, and the evidence is compelling:

• Improved Muscle Strength: Effects of Electrostimulation with Blood Flow Restriction on Muscle Size and Strength — This study by Natsume, et al., (2015) demonstrated that electrical stimulation significantly improves long-term quadriceps muscle strength, strongly correlating with long-term functional outcomes.
• Enhanced Muscle Size: Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction — This research by Jack, et al., (2023) found that BFR significantly enhances the cross-sectional area and strength of the quadriceps.
• Combined Techniques for Better Results: Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients — This study by Hughes, et al., (2019) suggests that combining BFR with traditional resistance training techniques might yield even better results.

If you’re interested in a deeper dive into this combined approach of BFR with estim, Johnny Owens provides an in-depth discussion in his MedBridge course, A Comprehensive Approach to the Use of Blood Flow Restriction in ACL Rehab.

5. Use Open Kinetic Chain Exercises

Historically, open kinetic chain (OKC) exercises have been avoided in ACL reconstruction rehabilitation due to concerns about anterior shear forces. While some early studies from the 1990s suggested potential risks, more recent and robust evidence—such as the comprehensive review by Brinlee, et al., (2022) on ACL reconstruction rehabilitation—shows that the stress of resisted OKC exercises places no greater strain on the ACL than walking. If your patient is cleared for walking, they can safely engage in resisted OKC strengthening.

Additionally, OKC strengthening has been shown to result in better strength gains, decreased pain, and reduced laxity compared to closed kinetic chain exercises (Pamboris, 2024).

During our ACL Hot Topics course on Knee Extension ROM and Open-Chain Strengthening, we delve into the research and practical applications of OKC exercises, providing you with the confidence and techniques needed to incorporate them effectively into your ACL rehabilitation program.

 6. Assess Movement Early and Often in Rehab

A fundamental strategy for ACL rehabilitation is to assess movement quality early and frequently throughout the rehabilitation process. Following ACL reconstruction, the primary goal is to return the athlete to sport healthier and better than before. A key metric in achieving this is evaluating movement quality. However, objective measures for assessing movement are often either not performed or are collected too late in the plan of care to effectively address all relevant findings.

To enhance movement assessment early in the rehabilitation process, you should consider incorporating the following tools:

• Functional Movement Screen (FMS): Identifies limitations and asymmetries in seven fundamental movement patterns, aiding in creating a tailored rehabilitation plan.
• Selective Functional Movement Assessment (SFMA): Provides a systematic approach to categorizing movement dysfunctions and helps pinpoint the underlying causes of pain and limitations.
• Y Balance Test: Assesses balance and stability in three directions, helpful in identifying asymmetries and functional deficits in lower extremity control.

By using the FMS, SFMA, and Y Balance Test early in the ACL reconstruction rehabilitation process, you can establish a baseline, target specific movement deficiencies, and ensure a thorough, personalized recovery journey. These tools help identify musculoskeletal risk factors and pain that could impede progress, allowing for effective early intervention.

To learn more about implementing and interpreting these movement tests in your ACL rehabilitation plan, you can explore our ACL Rehab Live Patient Case Series on Strengthening and Complex Movement. This course will help you identify and address movement dysfunctions, improve overall movement quality, enhance balance and stability, and reduce the risk of future injuries right from the start.

7. Use Hop Testing and Vertical Jump Testing 

When determining whether an athlete is ready to return to sports, a hop testing battery is often completed, usually involving three different tests to assess horizontal hop distance. Additionally, the single-leg vertical jump—more accurately termed a “hop” since it is performed off one leg—evaluates the athlete’s vertical displacement. According to Kotsifaki, et al., (2021), these two jump types assess different aspects of a jump’s initiation and landing phases across all joints of the lower extremity. Single-leg hop performance measures total extremity function rather than isolating a specific joint.

While some current discussions suggest that the single-leg vertical jump should replace traditional horizontal hop testing, this view misinterprets the research. Although many participants who achieved a 90 percent limb symmetry index (LSI) on horizontal hopping did fail to meet symmetry measures in the vertical jump, this does not diminish the value of horizontal hopping; it simply measures a different aspect of power. Also, remember that a 90 percent LSI is likely not stringent enough as a passing standard. Therefore, it’s recommended to include both horizontal and vertical hop tests in your return-to-sport battery.

8. Tibial ER Mobilization Can Improve Knee Extension Range of Motion

Tibial external rotation mobilizations are particularly effective for improving knee extension range of motion (ROM) following ACL reconstruction. During knee extension, the tibia must externally rotate relative to the femur to achieve full extension, a movement often referred to as the “screw-home mechanism.” 

Following ACL reconstruction, this natural rotation can be restricted due to post-surgical stiffness or altered joint mechanics. Tibial external rotation mobilizations help restore this normal rotational movement, facilitating proper knee extension. Early and appropriate mobilizations can prevent complications such as arthrofibrosis (excessive scar tissue formation) and chronic knee stiffness, which can severely limit knee function if not addressed promptly. 

9. Get the Person in the Gym Once off Crutches

Most people who undergo anterior cruciate ligament reconstruction (ACLR) are athletes accustomed to a competitive team environment. When this environment is taken away, it can present significant physical and mental challenges. Additionally, most insurance companies limit the number of post-operative visits, which can delay reintroducing the athlete to the gym until near discharge or when insurance visits are nearly exhausted.

Getting the athlete back into the gym as soon as they are off crutches—ideally five days per week in addition to one day in rehab—can offer psychological benefits and significantly improve rehabilitation outcomes. Rather than focusing on what the athlete can’t do, we need to shift the mindset to what they can do at the gym, which is often a pretty extensive list. 

10. Retest Biomarkers Frequently

Re-testing strength, range of motion (ROM), and movement frequently is a critical strategy for ACL rehabilitation for several key reasons:

• Tailored Rehabilitation: Regular evaluations provide data that can be used to modify and tailor rehabilitation exercises to the patient’s current needs.
• Prompt Adjustments: If progress stalls or regressions occur, the program can be promptly adjusted to address these issues.
• Addressing Functional Deficits: Strength and movement assessments ensure that functional deficits are identified and corrected. This is particularly important for tasks involving complex movements, such as returning to sports or physically demanding activities.
• Restoring Movement Patterns: Ensuring that strength and movement patterns are restored is essential for full functional recovery.
• Reducing Re-injury Risk: Re-testing helps correct strength and movement asymmetries before the patient returns to high-risk activities. Balanced strength and proper movement mechanics are critical in reducing the risk of re-injury to the reconstructed ACL or other knee structures.

Before returning to sports or demanding activities, it is essential to confirm that the knee has regained adequate strength, ROM, and movement quality. These frequent assessments provide the necessary data to make informed decisions about when it is safe to return to play. For a detailed approach on how to conduct these assessments, you can refer to Dr. Plisky’s Discharge and Return to Sport series.

Bringing It All Together: Elevate Your ACL Rehabilitation Approach

Successfully guiding your patients through ACL rehabilitation is about more than just ticking boxes—it’s about integrating comprehensive strategies that address every facet of recovery. By implementing these top ten strategies, you can elevate your approach, ensuring that your patients not only return to their pre-injury levels but come back stronger and more resilient. Stay committed to these best practices, and you’ll help your athletes achieve the best possible outcomes, setting them up for long-term success in their sport and daily life.

References

1. Perriman, A., Leahy, E., & Semciw, A. I. (2018). The effect of open- versus closed-kineticchain exercises on anterior tibial laxity, strength, and function following anterior cruciate ligament reconstruction: A systematic review and meta-analysis. The Journal of Orthopaedic and Sports Physical Therapy, 48(7), 552–566. https://doi.org/10.2519/jospt.2018.7656 
2. da Silva Marques, F., Borges Barbosa, P. H., Rodrigues Alves, P., Zelada, S., da Silva Nunes, R. P., de Souza, M. R., Pedro, M. D. A. C., Nunes, J. F., Alves, W. M., Jr, & de Campos, G. C. (2020). Anterior knee pain after anterior cruciate ligament reconstruction. Orthopaedic Journal of Sports Medicine, 8(10), 2325967120961082. https://doi.org/10.1177/2325967120961082 
3. Grapar Žargi, T., Drobnič, M., Stražar, K., & Kacin, A. (2018). Short-term preconditioning with blood flow restricted exercise preserves quadriceps muscle endurance in patients after ACL reconstruction. Frontiers in Physiology, 9, 1150. https://doi.org/10.3389/fphys.2018.01150 
4. Jack, R. A., 2nd, Lambert, B. S., Hedt, C. A., Delgado, D., Goble, H., & McCulloch, P. C. (2023). Blood flow restriction therapy preserves lower extremity bone and muscle mass after ACL reconstruction. Sports Health, 15(3), 361–371. https://doi.org/10.1177/19417381221101006
5. Kacin, A., Drobnič, M., Marš, T., Miš, K., Petrič, M., Weber, D., Tomc Žargi, T., Martinčič, D., & Pirkmajer, S. (2021). Functional and molecular adaptations of quadriceps and hamstring muscles to blood flow restricted training in patients with ACL rupture. Scandinavian Journal of Medicine & Science in Sports, 31(8), 1636–1646. https://doi.org/10.1111/sms.13968 
6. Kotsifaki, A., Korakakis, V., Graham-Smith, P., Sideris, V., & Whiteley, R. (2021). Vertical and horizontal hop performance: Contributions of the hip, knee, and ankle. Sports Health, 13(2), 128-135. doi: 10.1177/1941738120976363
7. Pamboris, G. M., Pavlou, K., Paraskevopoulos, E., & Mohagheghi, A. A. (2024). Effect of open vs. closed kinetic chain exercises in ACL rehabilitation on knee joint pain, laxity, extensor muscles strength, and function: a systematic review with meta-analysis. Frontiers in Sports and Active Living, 6,1416690. doi: 10.3389/fspor.2024.1416690