The anterior cruciate ligament (ACL) is a key structure in knee kinematics because it resists tibial anterior translation and rotational loading. The ACL provides approximately 85% of the total binding force of anterior translation. It also prevents excessive medial and lateral tibia Rotation and varus and valgus stress . Nevertheless, due to the presence of mechanoreceptors in the ligament, its main role is proprioceptive function . Therefore, ACL injury may be considered a neurophysiological dysfunction rather than a simple peripheral nerve injury. Musculoskeletal injuries.  Due to its complex role in knee kinematics in the event of an ACL injury, clinical symptoms and subjective instability are present, thus requiring a comprehensive rehabilitation program . ACL injury is a relatively common knee joint Athletes and women are two to eight times more likely to be injured than men.
Injuries range from mild (eg, small tears/sprains) to severe (when the ligament is completely torn) . Surgical reconstruction is indicated when the ACL is completely ruptured and there are clinical and subjective signs of instability. However, ACLs are not self-evident Reconstruction will automatically result in a return to pre-injury activity levels.
ACL rehabilitation has both conservative and surgical treatments.
See these pages for related ACL injuries
Clinically Relevant Anatomy
The anterior cruciate ligament (ACL) is a band of dense connective tissue that runs from the femur to the tibia. The ACL originates from the posteromedial corner of the medial side of the lateral femoral condyle, is located in the intercondylar notch, and inserts in front of the intercondylar eminence of the femur. The tibia fuses with the anterior horn of the medial meniscus. As the ACL travels from the femur to the tibia, the ACL travels anteromedially and distally across the joint. As it does so, it opens itself in a slight outward (lateral) spiral.
The density of blood vessels within the ligament is uneven. In the ACL, the avascular zone is located within the anterior fibrocartilage of the ligament facing the anterior border of the intercondylar fossa . Vascular malformation and coincidence of presence Fibrocartilage is also found in sliding tendons in areas bearing compressive loads, which plays a role in the ACL’s poor healing potential. 
See the following pages for relevant anatomy: Anterior Cruciate Ligament (ACL) and Anterior Cruciate Ligament (ACL) – Structure and Biomechanical Properties
ACL rehabilitation has changed considerably over the past decade. Intensive studies of the biomechanics of injured and operated knees led to studies in the early 1980s of delaying weight bearing and Range of motion (ROM) limitations of current early rehabilitation programs, namely immediate ROM training and weight bearing exercises .
ACL rehabilitation is suitable for both conservative and surgical treatment. Conservative treatment of ACL injuries may be the best option for sedentary patients. Indeed, the most important symptoms of subjective instability in physical activity and activities of daily living should be considered when the patient is older Deciding for or against ACL reconstruction . In these cases, a physical therapy program to fully regain ROM, a comprehensive program to strengthen and restore proprioception, and normal gait pattern training may be the best rehabilitation option. However, if symptoms are unstable The knee was not reduced after physical therapy, and ACL reconstruction was not recommended after adjusting activities. This may prevent multiple interventions due to further meniscus and cartilage damage .
It is useful to remember that ACL injuries rarely occur alone. The presence and extent of other injuries may affect how an ACL injury is managed. In fact, the mechanism of injury can also damage the medial collateral ligament (MCL) or meniscus. other related injuries May be microfracture or bone contusion with or without cartilage damage.  In these cases, ACL rehabilitation programs must not be standardized and take into account comorbidities.
The main goals of general rehabilitation for an ACL injured knee are:
- Gain full ROM of the knee
- Restoring muscle strength and proprioception
- Gaan in good functional stability
- Reach optimal functional level (walking run jumping…)
- Decrease the risk for re-injury
- (Return to sport)
Phases of ACL rehabilitation
Physiotherapy interventions can be broken down into several phases:
- Acute Stage
- Preoperative stage or conservative treatment
- Post-surgical Stage
- Return to sport
After an ACL injury, with or without surgery, physical therapy focuses on restoring motor strength, proprioception, and stability. PRICE or PEACE AND LOVE should be used in the acute phase to reduce swelling and pain to try a full range of Exercise and reduce joint effusion. Use appropriate anti-inflammatory medications to help manage pain and swelling .
Indications for the use of crutches and eventually a knee immobilizer may be appropriate for some patients. However, prolonged use of the knee immobilizer should be limited to avoid quadriceps atrophy .
Quadriceps neuromuscular inhibition from intra-articular effusions may negatively impact strengthening. In any case, the exercise should encourage initial strengthening of the quadriceps and hamstrings in the range of motion and ultimately enhance proprioception . In fact the power and Altered proprioception occurs in both injured and uninjured limbs . To assist in preoperative optimization, the following guidelines are recommended for the acute and early subacute phase following injury:
- Full extension is obtained by doing:
- Passive knee extension: A physical therapist can provide passive knee extension through manual therapy and teaching exercises that add leverage to stretch gently and forcefully
- Patellar self-mobilisations,
- Heel Props,
- Prone hang exercise,
- Static quads/SLR;
- Bending (Flexion) is obtained by doing:
- Passive knee flexion: A physical therapist can provide passive knee flexion through manual therapy and teaching exercises, adding leverage to flex with gentle force
- Prone Knee Bend (Gentle Kicking Exercise)
- Wall slides,
- Heel slides;
- Knee flexion/extension in sitting;
- Ankle DF/PF/circumduction;
- Glutes medius work in side lying;
- Gluteal exercises in prone;
- Weight transfer (forward/backward/sideways) while standing.
Research has also shown that combining neuromuscular electrical stimulation (NMES) with exercise is more effective at improving quadriceps strength than exercise alone .
It may also be useful to consider taping to provide stability and promote swelling reduction .
There is no clear transition from the acute phase to the preoperative phase, and each phase may last days or months before surgery. Instructionally, the acute phase ends when the patient regains full range of motion in knee extension and at least 110 degrees of knee ROM. Curved or near normal gait pattern.
Before Surgical Stage
Knee stiffness is most likely to occur when ACL surgery is performed when the knee is swollen and painful with limited range of motion.
The risk of knee stiffness after surgery can be significantly reduced if surgery is delayed until the acute inflammatory period has passed, swelling has subsided, normal or near-normal range of motion (especially extension) has been achieved, and a normal gait pattern has been achieved. reconstruction . However, practical guidelines   agree that the indication for reconstruction is persistent instability of the knee joint with complaints of concession. This diagnosis is difficult to make in an emergency. Guidelines recommend that ACLR should not be in The first week after trauma to minimize the risk of surgery in asymptomatic patients.
Once the acute phase is over, it is important to prepare the knee for surgery and optimize the outcome as much as possible. The focus needs to be on strength and proprioception. Still, physical therapists must keep the injured knee stationary to improve range of motion Minimal swelling.
RICE and electrotherapy may be applied a few weeks before surgery to achieve a full range of motion and reduce joint effusion. The patient should also have a normal gait pattern: it is therefore useful to analyze leg movements during the swing phase of walking And in the stage of standing on one leg. This will help patients regain faster movement and strength after surgery .
The length of this preoperative phase can last days or weeks. Therefore, the role of the physical therapist also includes maintaining patient compliance. For this reason, rehabilitation programs must have measurable weekly goals to improve muscle strength and Adjusts for range of motion and improves proprioception. This will provide new goals to be reached each week: patients who achieve these goals will maintain adherence to treatment .
In the preoperative phase, it is important to provide different methods to enhance muscle strength and proprioception. Therefore, offering patients two different exercise programs at the gym and at home could be a good solution. However, given Submaximal loading on the injured knee to avoid knee swelling or re-injury due to lack of proprioception.
- Achieve and maintain full range of motion in extension and continually improve range of motion in flexion with minimal swelling;
- Develop Muscle Strength: Once you reach 110 degrees of flexion, you can start building muscle strength. Examples of exercises are:
- Swimming (avoid breaststroke),
- Low-impact exercise equipment, such as ellipticals, cross trainers, stationary bikes and treadmills
- Leg press machine,
- Leg curl machine or leg extension machine (see Open Kinetic Chain below)
- Weight-bearing exercises, such as squat lunges (see closed kinetic chain exercises below);
- Improve proprioception:
- One-leg- standing exercise
- Standing exercises on one leg, adding balance pads or cues to the arms (throwing or catching a ball that reaches the target…)
- Single-leg standing exercise in different planes (frontosagittal plane)
- Preparation for controlled jumps;
- maintain a high degree of adherence to the rehabilitation program ;
- Mental preparation: It is important for the patient to know what to expect from the surgery and understand the stages of recovery after surgery. 
See these pages for ACL Rehab: Emergency Management After Surgery
ACL reconstruction has undergone considerable change over the past decade. Various tissues/grafts have been used for anatomical reconstruction of torn ACLs. Most commonly used are autografts (patella and hamstrings) and sometimes allografts (taken from a cadaver). ligamentization process Grafts require precautions regarding loading and physical requirements.  However, it seems to indicate that remodeling of new ACLs is a process lasting 9 years or more. Also, it appears to be an adaptation rather than a full recovery.  Nevertheless, there are During the postoperative phase of the graft, physical therapy approaches did not differ substantially.
Consider pain, swelling, muscle contractures, restricted range of motion, and abnormal gait patterns as indicators of a good outcome. In the postoperative phase, three factors are important:
- Early knee extension equal to opposite side
- Early weight bearing,
- Closed and open kinetic chain strengthening exercises.
Early knee extension provides the foundation for the entire rehabilitation program.
The incidence of knee flexion contracture with quadriceps weakness and extensor mechanism dysfunction after ACL reconstruction was significantly reduced with accelerated knee extension immediately after surgery.
According to ACL Rehab Guidelines, a good physical therapy program depends on achieving weekly goals.
- Periodic icing and elevation are used to reduce swelling . Ultimately use medication or pain relievers according to MD to try and recover goals.
- Aim for full extension and 70 degrees of flexion by the end of the first week.
- Agree with your surgeon and use knee braces and crutches only when needed. In fact, wearing a knee brace after ACL reconstruction has no additional therapeutic value . The author gradually reduced the use of knee pads.  Postoperative rehabilitation brace  Expanding or opening the hinges for the ROM did not provide a significant advantage.  The necessity of postoperative functional bracing and the consensus regarding the duration of the bracing have been questioned in many rehabilitation protocols. Harilainen et al. compared Effect of functional bracing versus postoperative unbracing after ACL reconstruction with patellar grafts. There were no significant differences in functional outcome stability or isokinetic muscle torque between the two groups at 1 and 2 years postoperatively . in similar The study by Risberg et al found no significant differences in knee laxity, range of motion, muscle strength, functional knee tests, or pain. 
- At least 8 weeks of multidirectional movement of the patella should be included. Additional mobilization exercises for the first 4 weeks are passive extension of the knee (without hyperextension) and passive and active mobilization of flexion.
- The strengthening exercises for the calf muscles, the hamstrings and the quadriceps (vastus medialis), can be done lying on the back or on the stomach.
- Isometric quadriceps exercises are safe from the first postoperative week 
Early weight bearing appears to be beneficial and reduces patellofemoral pain. Early exercise is safe and may help avoid later problems with joint fibrosis. Continuous passive movement does not improve patient outcomes. Supervised physical therapy at a selected minimum Motivated patients appear to be safe with no significant risk of complications .
ACL Reconstruction: Rehab Planning Workshop  Heel Lift for ACL Reconstruction 
- There is no evidence that ice and elevation are useful after the first week.
- The first goal is to maintain full extension and increase flexion each week.
- Try really adding to the standing phase, try walking with one crutch. Cane use can be reduced earlier with good hamstring/quad control.
- Strengthening exercises for the calf muscles, the hamstrings and the quadriceps (vastus medialis), can be done seated on a stationary bike or with light weights. Progression of movement depends on painful swelling and quadriceps control.
- Eccentric quadriceps training (in CKC) was initiated 3 weeks after ACLR safety and contributed more to improvements in quadriceps strength than concentric training 
- In some patients with good hamstring/quad control, one can really try to do some exercises in closed kinetic chains (half squat hip hinge calf strengthening…). Often these exercises are performed by patients who have been training for a long time in a good preoperative phase program.
Stretching and bearing weights early on builds quadriceps strength. The combination of early knee extension, early weight bearing and closed dynamic quadriceps strengthening allows patients to complete the postoperative recovery period fairly quickly without requiring Damage to ligament stability. 
- Passive mobilization should normalize movement, but flexion should not be complete.
- Hamstring and quadriceps strengthening can begin at higher intensities with both open-chain and closed-chain exercises. Exercises should start at a light intensity (50% of maximum strength) and now gradually increase to 60-70%. Closed chain exercises should start with irresponsible people position (leg press step) to a more crowded starting position (ex.squad). Progression of movement depends on painful swelling and quadriceps control.
- If overall strength is good, proprioception and coordination exercises can develop. This includes balance exercises on skateboards and tollbooths.
Postoperative phase 1 ( 1-5 weeks)
Possible examples of exercises for knee self-mobilization and quadriceps and hamstring strength:
Week 1: Self-mobilization  Week 3: Strength training and gait training  Week 5: Strength training 
Week 10: Forward-to-Back Lateral Dynamic Week 12: Forward-Back Lateral Dynamic Week 15: Sprint Jump Cuts 
- The loaded process is the basis from now on.
- Proprioception and coordination exercises can be more specifically tailored to a patient’s individual motor needs. If the patient does not want to return to sports, these exercises can meet his ADL needs (climbing stairs, walking uphill or downhill skating, swimming…)
- Can include forward-backward and lateral dynamic motion as well as isokinetic motion .
- After 3 months, patients can perform functional exercises such as running and jumping.
- Faster changes in direction are possible as proprioceptive and coordination exercises become more intense. To stimulate coordination and control through afferent and efferent information processing exercises, should be enhanced by changes in velocity of visible input surface stability (trampoline) Motor performance complexity Task resistance Single or bipedal performance etc. .
- The ultimate goal is to maximize the endurance and strength of the knee stabilizer, optimize neuromuscular control with plyometrics, and add sport-specific training.
- Variations in acceleration and deceleration during running, turning and cutting maneuvers improve articulation reflexes to prevent new trauma during competition. 
Return to Sport
ACL injury can lead to static and functional instability, which can lead to changes in movement patterns and increase the risk of osteoarthritis. In many cases, an ACL injury can end an athlete’s career prematurely. 
ACL Return to Sport: Hop Test|
Inadequate strength and power after surgery can be a risk factor for future injury and can set athletes back from trying to return to previous levels of performance. Researchers suggest that a surgically repaired leg should function at least 90% as well as your previously uninjured leg Return to sport . The three jump test can be used as part of a comprehensive physical and functional exam to help ensure not only a quick but safe return to sport after an ACL reconstruction. These 3 tests are sensitive enough to measure left-right differences and can be used during A more advanced recovery phase after surgery to help ensure that the athlete’s exercise program successfully restores the injured leg to at least the level of the uninjured leg .
Athletes undergoing ACL reconstruction should be informed that participation in Class I sports postoperatively increases the 2-year knee re-injury rate more than fourfold. A later return to class I motion and the more symmetrical quadriceps strength prior to recovery significantly decreased this ratio .
Mechanisms of previous injuries can guide the final stages of rehabilitation as strength and conditioning grow: ACLR due to indirect injury mechanisms can focus on ankle-knee-hip coordination exercises or core stability or sport-specific posture .
Please refer to these pages for relevant return to sport
Open and closed kinetic chain exercises
Closed kinetic chain exercises (CKC) and open kinetic chain exercises (OKC) play an important role in restoring muscle (quadriceps hamstring) strength and functional knee stability.
- CKC exercises are more popular than OKC exercises in ACL rehabilitation. Some clinicians consider CKC exercises to be safer than OKC exercises because they place less stress on the ACL graft. In addition, they also felt that CKC exercises were more practical and equally effective than OKC practise. Bynum et al. (1995) concluded that CKC exercises were safe and effective and sacrificed some important advantages over OKC exercises. 
- A study comparing the amount of anterior tibial displacement in ACL-deficient knees with (1) resisted knee extension OKC exercise and (2) parallel squat CKC exercise concluded that ACL-deficient knees had significantly greater tibial anterior displacement during extension. displacement The knee extension motion is 64° to 10° compared to the parallel squat motion .
- However, in one study, no difference was found in the strain of the intact ACL between OKC and CKC exercises .
- Currently, ACL grafts may respond more like an intact ACL. Therefore, they considered both sports to be performed safely .
- However, a study examining the effect of OKC and CKC exercises on functional activity concluded that both OKC and CKC programs resulted in the same good long-term functional outcomes .
- In another study, group 1 underwent quadriceps strengthening with CKC only, while group 2 received CKC training and OKC training from postoperative week 6  which appeared to increase OKC quadriceps after ACL reconstruction. Muscle training resulted in significantly stronger quadriceps, whereas no Knee stability decreased at 6 months and also resulted in more athletes returning to previous activities earlier and at the same level as before the injury. The authors concluded that the combination of OKC and CKC exercises was more effective than CKC exercises alone .
- The use of bone-patella-tendon-bone autografts was more likely to cause anterior knee pain than the use of hamstring autografts. Therefore, the type of autograft can guide the physical therapist in selecting the correct period to insert the OKC sitting leg extension. will be earlier than In the case of hamstring muscle transplantation, the status of patellar tendon transplantation one week later. Guidelines agree to insert OKC exercises within 4 weeks after surgery .
- In any case, it is important to follow the progression of loading on the knee so as not to cause pain or laxity. A recent systematic review of randomized controlled trials comparing OKC versus CKC exercise in post-ACLR patients  found that:
- No or insufficient evidence of differences between OKC and CKC in terms of pain scores or joint laxity
- The former can be explained by: (1) lack of sensitivity of the questionnaire used (2) insufficient statistical power of the analysis or (3) virtually no difference in pain between patients undergoing OKC vs CKC
- There is weak evidence for better knee extensor strength with open-chain exercises, and weak evidence for better active knee flexion with closed-chain exercises.
- No or insufficient evidence of differences between OKC and CKC in terms of pain scores or joint laxity
- Non-weight bearing
- Motion occurring at a single joint: isolated motion that promotes more shear forces 
- Distal segment free to move
- Resistance is usually applied to the distal segment
Open Kinetic Chain Knee Extension Exercises
These exercises appear to have a controversial role in ACL rehabilitation programs, as several studies have shown that OKC extension exercises from 60° to 0° flexion significantly increase tibial anterior translation in ACL-deficient knees as well as reconstructed ACL graft strain Knee  Despite these findings, the OKC extension was not excluded from ACL rehabilitation programs because the same study showed that the OKC extension from 90° to 60° of flexion can be done safely without increasing tibial Anterior displacement or ACL graft Strain
In short, the OKC extension exercise in an ACL rehabilitation program can be done safely in 90° to 60° flexion ROM and is also useful for training isolated quadriceps.
Open kinematic chain knee flexion exercise
OKC flexion exercises play an important role in the rehabilitation process as studies have shown no tibial anterior displacement or ACL graft strain during these exercises. Additionally, they cause isolated hamstring muscles to contract. 
Closed-Kinetic-Chain Knee exercises
- Weight bearing
- Multi-joint movement: Compound movement that typically produces compressive forces 
- Distal portion fixed to a surface: The limb maintains constant contact with the fixed surface (usually the ground) 
- Resistance can be applied proximally and distally: the entire limb bears the load .
Closed-Kinetic-Chain Knee exercises
CKC exercises play an important role in ACL rehabilitation because they cause co-contraction of the hamstring-quadriceps, which reduces tibiofemoral shear forces. Additionally studies have shown that body weight provides tibiofemoral joint compression while reducing tibiofemoral shear during CKC exercise Troops.
CKC exercises have several advantages over OKC exercises
- Increased knee stability (more joint compression)
- Functional load
- Strong coordinative training
- Minimal shear force
- Less stress on the ACL
- Training for the entire extended chain 
- No selective muscle training
- The weakest link in the chain is feeling the heaviest load and corresponding maximum training effect
- Fewer complications, such as patellofemoral symptoms
- CKC practice applies earlier than OKC practice
In a retrospective cross-sectional analysis by Culvenor et al. . Patellofemoral pain (PFP) develops in 30% of patients 12-15 months after ACLR with hamstring grafts. Those 27 and older were 2.6 times more likely to report PFP. Patellofemoral cartilage injury menstrual tear (both Assessed by arthroscopy), pre-injury activity level, time from injury to surgery, and sex were not predictors of postoperative PFP.
Those with PFP did not have a reduced range of motion, but performed worse on jumping distance and single-leg tasks. The patient also reported a significant decrease in quality of life, a poor attitude towards returning to sport, and an increase in kinesiphobia.
PFP is important because maladaptive fear-avoidance motor patterns perpetuate pain and dysfunction by lowering the pain experience threshold. Appropriate language is recommended during rehabilitation and psychosocial interventions.
Loss of hamstring strength after ACL surgery 
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