Regaining Mobility and Strength
Phase One (ACL Knee)
The ACL-reconstructed knee, Day of Surgery through Postoperative Day 14
Movement is one of the most important elements in a rapid recovery and return to full mobility.
A number of different devices and exercises are introduced to patients through an
Accelerated (ACL) Rehabilitation program in the advancement towards recovery.
Established in three phases, the first device used in this rapid recovery process is the CPM, which
takes the ACL knee through the range of motion from hyperextension to 30 degrees. This is begun the
same day the surgery takes place to help to maintain Range of Motion (ROM) and keep the knee higher
than the heart to diminish swelling.
During the first week, and after thirty minutes of motion from hyperextension to 30 degrees of flexion,
the CPM machine is set at 110 degrees of flexion and stopped for ten minutes during each waking hour in
order to stretch the quadriceps mechanism and gain flexion.
In addition to this device, patients must also perform Active Range of Motion exercises in order to put
their knee through a range of motion from hyperextension to a complete bend such that the heel touches
the buttock. In order to accomplish this, the knee is fully extended by placing several folded towels
under the heel, and a single towel held by both hands under the forefoot. As toes are pulled toward
the head, assisted by the towel held in both hands, the patient pushes the back of their knee down
toward the bed. This enables physiologic hyperextension, which is important for a return to sports
to occur. For knee flexion, the towel is then put over the toes and held with both hands. As it is
pulled, the knee bends to a point where the heel touches the buttock. Following completion of this
exercise, the CPM is set to operate from hyperextension through 30 degrees flexion - and the cycle is repeated.
Phase One (Graft Knee)
(Ignore in cases of allograft or autograft from same leg)
The Graft Harvest Knee, Day of Surgery through Postoperative Day 14
Harvest of the bone-patella-bone graft does not cause much knee stiffness. But active Range of Motion
exercises must also be performed on the graft leg. These exercises are done in the final ten minutes of
each waking hour and are performed exactly the same way as on the ACL knee.
Exercises must be directed to the graft leg to strengthen and restore the size of the extensor mechanism
after harvest of the bone-tendon-bone graft. The Shuttle is another device provided from the first
postoperative day through the end of the second week to help exercise and strengthen the graft leg. The
series of knee extension exercises provided by the Shuttle is done in bed. Patients perform four sets
of 25 reps each day for one week on the graft leg. As the leg strengthens, the level of resistance is
increased.
Mealtime Exercises-both knees in the first week while in bed.
During mealtimes, the CPM is removed and the patient sits on the bed allowing legs to dangle off the
side at a bend of 90 degrees. Following meals, an active exercise is done by actively extending the
ACL limb for ten reps. The same ten reps are then performed by the Graft limb.
The second half of Phase One
Postoperative day 8 through 14
On the eighth day following surgery, patients are generally able to resume regular sedentary activities
and have a normal gait without crutches. Patients should continue their active exercises four times per
day. A follow-up appointment is made at this time. The Shuttle is used for an additional week for 1
0-minutes four times per day, though the CPM machine may be returned if flexion of the knee is at least
110 degrees.
Phase Two
Postoperative Day 15 through 28
At two weeks, patients continue their exercise program by adding the Step Box for both legs. This simple
device is used for the performance of closed chain knee extension exercises on both legs, beginning with
four sets of 25 reps of two-inch excursions until fatigue each day then increasing until 50 reps can be
performed. The same routine is then continued with a four-inch excursion. After the same goal is reached,
the excursion is increased to six, then eight inches. Remember to do at least four sets per day on each leg.
The patient may start to work in the stationary bike and/or the Stairmaster, as well as continuing with the
Step Box at increasingly longer excursions through the end of the fourth week. In addition, in the fourth
week, programs of jogging, swimming, and specific sports-related activities are begun.
The team of certified trainers at the Sanders Clinic then develop an ongoing exercise plan and assist in the
Accelerated (ACL) Rehabilitation, to continue strengthening the injured area and surrounding muscle groups.
This ensures the best postoperative results.
Phase Three
Postoperative Day 29 until return to sports
At the beginning of this phase, patients undergo Range of Motion and strength and stability assessment by
the doctor and certified trainer. They then gradually begin sports-specific exercises and agility training
to continue building strength and endurance. For example, an avid biker may incorporate short bike rides into
an established exercise program. Through this phase, the patient begins gaining confidence in the capability
of the reconstructed knee. Often times there is soreness at the graft site following a hard practice. This is
self-limiting and only seems to occur in the first year. Two-a-day practices should be avoided. Many athletes
are on the field in uniform four months following surgery, but will begin playing well after six months.
Certified trainers work one-on-one with the patients to continue a Reconditioning Program and establish an
exercise routine that can be done both at home independently, as well as at a gym or clinic under supervision.
During months three and four, patients may begin returning to sports at a restricted level. And through the
remaining year, patients are periodically evaluated with strength and measurement tests.
