Phase 0/ Pre-operative (≧4 weeks)
2-3 physiotherapy sessions per week
Pre-operative Criteria/ Recommendation
l Normal gait
l 0o to 120o active knee flexion ROM
l Full active and passive knee extension ROM
l Minimal pain & swelling
l Maximize strengthen symmetry
Exercise
ROM Strengthening
Extension Flexion Close Kinetic Chain Open Kinetic Chain
Low load, long duration (~5 minutes) Squat/ wall sit (DL à SL) Quadriceps/ hamstring setting
Heel prop Wall slides Step up Side lying abduction
Prone knee hang Heel slides Bridging (DL à SL)
Assisted knee flexion Good morning (DL à SL)
Bike: rocking-for-range Heel raises (DL à SL)
Neuromuscular Cardiopulmonary
Single leg mid-squat hold (±ball pass) Straight line walking à jogging treadmill = 50% running intensity
Y-balance Bike, rowing machine, elliptical trainer, swimming
Double leg hop
Modalities
Ice for pain Elevation compression for swelling NMES of quads to redued Crutches; D/C ASAP
arthrogenic muscle inhibition
Phase 1 (0-2 weeks)
2-3 physiotherapy sessions per week
Progression Criteria
l < 5o active extension lag
l > 110o active flexion
l Good quadriceps control (> 20 no lag SLR)
l Normal gait pattern
l Crutch/Immobilizer D/C
Exercise
ROM Strengthening
Extension Flexion Patellar mobilization Straight leg raise
Low load, long duration (~5 minutes) Medial/lateral Double leg quarter squat/ wall sit
Heel prop Wall slides Superior/inferior Side lying abduction
Prone knee hang Heel slides Calf raises
Assisted knee flexion
Bike: rocking-for-range
Modalities
Ice for pain Elevation compression for swelling NMES of quads to redued Crutches; D/C ASAP
arthrogenic muscle inhibition
Education/ expectation
l Return to ADLs often takes ≧ 3 months; Sports ≧ 6 months; competition ≧ 9 months
l A minimum of 1 year gym membership will be required
l There will likely be a mix of plateau, regression and progression during rehabilitation
l Barriers to towards successful rehabilitation includes
n Irregular ± inadequate training volume, intensity & duration
n Returning to sports too soon
n Concomitant impairments e.g. PFJ pain, hamstring tendinopathy, iatrogenic hypoesthesia
n Psychological barriers e.g. fear of re-injury, lack of confidence
Phase 2 (2-6 weeks)
2-3 physiotherapy sessions per week
Progression Criteria
l Full ROM
l Minimal effusion/pain
l Functional strength and control in daily activities
Exercise
ROM Strengthening
Extension Flexion Close Kinetic Chain Open Kinetic Chain
Low load, long duration (~5 minutes) Squat/ wall sit (DL à SL) Hip abduction
Heel prop Wall slides Step up
Pone hang Heel slides Bridging (DL à SL)
Assisted knee flexion Good morning (DL à SL)
Bike: rocking-for-range à riding with low seat height Heel raises (DL à SL)
Flexibility stretching all major groups
Neuromuscular Cardiopulmonary
Single leg mid-squat hold (±ball pass) Bike
Y-balance
Phase 3 (7-12 weeks)
1-2 physiotherapy sessions per week
Progression Criteria
Running without pain or swelling
Hopping without pain or swelling (Bilateral and Unilateral)
Neuromuscular and strength training exercises without difficulty
Exercise
Strengthening Neuromuscular
Close Kinetic Chain Open Kinetic Chain Static Dynamic
Squats (barbell, dumbbell) Knee extension Single leg mid-squat hold (±ball pass) Y-balance
Leg press Knee curl Alternating forward hop
Lunges (barbell, dumbbell, high step) Squat jump
Roman chair hip extension Skater jump
Calf raises (soleus & gastro) SL hop on the spot (progress by 45o)
Cardiopulmonary
Straight line jogging treadmill = 50% running intensity
Bike, rowing machine, elliptical trainer, swimming
Phase 4 (≧13 weeks)
1-2 physiotherapy sessions per week
Return to Sports Criteria
Isolated knee flexion strength at mid and outer range (Absence of significant asymmetry)
Isolated knee extension strength at mid and outer range (Absence of significant asymmetry)
Isolated knee abduction strength at inner and mid-range (Absence of significant asymmetry)
Single-leg hop distance (90% Tier 1 sports; 80% Other sports)
Triple hop distance (90% Tier 1 sports; 80% Other sports)
Triple cross-over hop distance (90% Tier 1 sports; 80% Other sports)
Running T-test (Average of 3 tests; ≦11 secs Tier 1 sports; ≦13 secs Other sports)
Psychological readiness
- How certain are you that you can participate on the same activity level as before the injury (out of 10; Aim≧8/10)
- How certain are you that you will not have new knee injuries (out of 10; Aim≧8/10)
Exercise
Strengthening Neuromuscular
Close Kinetic Chain Open Kinetic Chain Dynamic
Squats (barbell, dumbbell) Knee extension Single-leg hop
Leg press Knee curl Triple hop
Lunges (barbell, dumbbell, high step) Triple cross-over hop
Roman chair hip extension Variable hop program
Calf raises (soleus & gastro)
Agility Cardiopulmonary
Running T drill Running, bike, rowing machine, elliptical trainer, swimming
Straight line à multidirectional running (progressive intensity and duration)
Straight line à multidirectional alternative sprint & jog
Sports specific rehab
Rehab Tips
- Observe for rate, distance and method of deceleration
- Promote external focused cues (e.g. touch the cone with your knees) to facilitate motor learning
Return to Sports Criteria Pass/Fail
Inner range Mid-range Outer range -------------
Knee flexion strength -------------------
Knee extension strength -------------------
Hip abduction strength ----------------
Uninjured side 90% Injured side -------------
Single-leg hop distance
Triple hop distance
Triple cross-over hop distance
Running T-test
How certain are you that you can participate on the same activity level as before the injury /10
How certain are you that you will not have new knee injuries /10
Return to Sports Criteria Pass/Fail
Date 1: Inner range Mid-range Outer range -------------
Date 2:
Knee flexion strength -------------------
-------------------
Knee extension strength -------------------
-------------------
Hip abduction strength ----------------
----------------
Uninjured side 90% Injured side -------------
Single-leg hop distance
Triple hop distance
Triple cross-over hop distance
Running T-test
How certain are you that you can participate on the same activity level as before the injury /10
/10
How certain are you that you will not have new knee injuries /10
/10
This protocol are based on the MOON protocol but have been modified to suit the practicality of HPPC.
Pre-operative Protocol: (EITZEN et al. 2010) (Wright et al. 2015)
MOON Protocol: (Wright et al. 2015)
NMES: (Hauger et al. 2018)
Open & Close kinetic chain exercise: (Glass et al. 2010) (Jewiss et al. 2017)
RTS Criteria: (Kyritsis et al. 2016)
Psychological readiness: (Ardern 2015) (Thomeé et al. 2006)
References
Ardern, C.L., 2015. Anterior Cruciate Ligament Reconstruction--Not Exactly a One-Way Ticket Back to the
Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health:
A Multidisciplinary Approach, 7(3), pp.224–230. Available at:
[Link]
EITZEN, I. et al., 2010. A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in
Knee Function Early After Anterior Cruciate Ligament Injury. , 40(11), pp.705–721.
Glass, R., Waddell, J. &Hoogenboom, B., 2010. The Effects of Open versus Closed Kinetic Chain Exercises on
Patients with ACL Deficient or Reconstructed Knees: A Systematic Review. North American journal of
sports physical therapy : NAJSPT, 5(2), pp.74–84. Available at:
[Link]
[Link]?artid=PMC2953392.
Hauger, A.V. et al., 2018. Neuromuscular electrical stimulation is effective in strengthening the quadriceps
muscle after anterior cruciate ligament surgery. Knee Surgery, Sports Traumatology, Arthroscopy,
26(2), pp.399–410.
Jewiss, D., Ostman, C. &Smart, N., 2017. Open versus Closed Kinetic Chain Exercises following an Anterior
Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Journal of Sports
Medicine, 2017, pp.1–10. Available at: [Link]
Kyritsis, P. et al., 2016. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before
return to sport is associated with a four times greater risk of rupture. British Journal of Sports
Medicine, [Link]-2015-095908. Available at: [Link]
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Thomeé, P. et al., 2006. A new instrument for measuring self-efficacy in patients with an anterior cruciate
ligament injury. Scandinavian Journal of Medicine and Science in Sports, 16(3), pp.181–187.
Wright, R.W. et al., 2015. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines.
Sports health, 7(3), pp.239–43. Available at:
[Link]