Chiswick-Physio BLOG

ACL Rehab Excercises
Knee, ACL
acl rehab excercises

Understanding ACL Injury and Rehabilitation

An ACL injury occurs when the anterior cruciate ligament, a vital stabilising ligament in the knee, tears or stretches. This often happens during sports or activities involving sudden stops, changes in direction, or landing from a jump.

At Chiswick-Physio, our ACL rehab protocol has several phases, whether you choose the surgical or non-surgical route. If surgery is considered, we advise pre-op rehab over a 6-12-week period to build strength and mobility. 

Our acl rehab treatment program consists of four phases, which are followed regardless of whether you have had surgery or not. To progress to the next phase, you must achieve specific goals and outcome measures unique to each phase. These goals must be met before you can move on to the next phase. Although ACL injury recovery takes at least 12 months, you will move through the ACL protocol at your own pace. It’s important to note that the criteria of achieving these goals will determine how quickly you progress rather than a pre-determined timeline.

In this blog, we will discuss some typical exercises we use throughout the four stages of ACL rehabilitation, but programs will always be individualised.

What’s important through an ACL rehab?

It is important to note that rehab programs should always be individualised for the person.

At Chiswick-Physio, we monitor our clients to ensure that their response to the exercise is appropriate, that they are progressing optimally, and that they have the appropriate function. We do this with three things in mind. 

  1. Response to exercise > Progression through tasks is allowed only when there is no increase in pain (numeric rating scale) or swelling (stroke test) as a response to the exercise. 
  2. Movement quality > If the task cannot be performed with sufficient quality, then it should be simplified, or the load is reduced.
  3. Strength > This can be done using tools like the isokinetic dynamometer or by noting how much weight your knee can handle during rehab exercises.

Pre-operative rehab exercises 

During this phase, exercises may include range-of-motion, low-impact aerobic exercises such as cycling, and a progressive strengthening regime.

Strength exercises for the knee should be adjusted according to the patient’s clinical condition. The intial goal is to get the leg straight. As the pain and swelling subside and the range of motion improves, the intensity of the strength exercises can be increased. This can include weighted exercises in the gym and activities such as hopping drills that involve jumping and landing. It is important to progress slowly and safely to prevent any further injury.

The clinic uses a portable device called a hand-held dynamometer to evaluate joint stability. During physical assessments it measures muscle strength by applying resistance against specific muscle groups. This device allows us to quickly and objectively assess muscle strength, which is helpful in treatment planning and monitoring progress during rehabilitation.

Read Surgical vs. Non-operative ACL Rehabilitation article >

Early-stage ACL rehab exercises | Recovery stage

Importance, range of motion exercises, strengthening exercises for surrounding muscles

In the early stages of ACL rehabilitation, it is essential to focus on exercising to maintain knee mobility and prevent stiffness. Moving the knee helps reduce swelling, improve blood circulation, and prevent muscle atrophy, which lays the groundwork for a successful recovery. Achieving full knee extension (straightening) is a critical goal. Although you might feel reluctant to move your knee, it is vital to do so.

Here are some exercises we use at Chiswick-Physio during the early rehab phase. In the explanations below, the reference to ‘ACL knee’ or ‘ACL leg’ indicates the knee that has had the ACL injury, whether surgery has occurred or not. 

Isometric Knee Extension

  • Sitting upright with your legs straight and back supported
  • Clench your thigh muscles, pushing the back of your knees into the bed so your leg straightens.
  • Hold the legs straight for 5 seconds.
  • Relax and repeat ten times, three times a day.

The quadriceps muscle at the front of your thigh produces this movement. If you have had surgery, this muscle may be inhibited. To encourage activation, clench both thigh muscles and imagine that you are sliding the knee cap upwards on the thigh.

 

Prone hamstring curls

  • Start by lying on your stomach with your legs extended straight behind you.
  • Gently bend your affected knee towards your buttocks as far as you comfortably can.
  • Control the movement as you slowly lower your leg back to the floor, taking two to three seconds to complete the movement.
  • Repeat this exercise for 12 repetitions three times per day.

The hamstring is an important muscle to strengthen during rehab and can initially be uncomfortable. Doing the exercise a little but often is important, as you may get cramping during contractions.

 

Double-leg heel raises

Please follow the instructions below to perform the heel raises exercise.

  • Stand with your hands on a table or any other stable surface that can provide you support.
  • Place your feet shoulder-width apart.
  • Keep your weight evenly distributed on both legs.
  • Keep your toes on the ground and raise your heels using a two-second count.
  • Hold this position for 3 seconds and then lower your heels slowly for four seconds.
  • Repeat this exercise 12 times and perform it one to three times per day.

Keep your motion vertical and avoid rocking forward or using your arms for support. Performing heel raises can help you improve your calf strength, which will eventually help you walk, jump and run better during your rehabilitation.

 

Double-leg quarter squats

To do a squat, follow these steps.

  • Stand with your feet shoulder-width apart and put your hands on your waist.
  • Bend slightly at your hips and then at your knees.
  • Lower your buttocks down about six inches as if you were going to sit in a chair.
  • Straighten your legs and hips to return to standing position.
  • Make sure your weight is evenly distributed on both legs, and avoid shifting your weight to one side.
  • Keep your trunk straight and avoid leaning forward. Keep the middle part of your knees over your second and third toes without letting your knees go beyond your toes.
  • You can use a mirror to keep your weight evenly on both legs.

Double-leg quarter squats help strengthen the quadriceps, glutes, and hamstrings and improve knee movements underweight.

 

Side-lying hip abduction

To perform the side-lying hip abductions exercise, lie on your good side and follow these instructions:

  • Straighten your top leg and keep it straight during the exercise.
  • Bend your bottom leg and place your knee and hip comfortably.
  • It’s important to bring your top leg slightly behind your trunk with your toes rotated inwards. This will further activate the muscles on the side of your hip.
  • Use your hip to lift your top leg, and avoid using your back or side.
  • Lower your leg.
  • Keep your hips aligned and avoid rotating your trunk back.

Repeat this exercise 12 times, one to three times per day. Side-lying hip abductions are beneficial for improving muscle strength in the side and back of your hip, which can help you walk better.

 

Single leg balance

  • Stand with your legs straight and shoulder-width apart.
  • Initially, you may want to stand with your hands on a table or any other stable surface that can provide you support.
  • Lean slightly to the affected leg while bending the opposite knee and lifting the foot.
  • If you feel unstable, You need to place the foot back down.
  • The aim is to balance on the affected leg for 60 seconds without placing the foot of the unaffected leg down.
  • Repeat 3-5 times a day.
  • You can increase the difficulty level by bending the knee further, but do not exceed your mobility limits.

Balance exercises in early rehab enhance stability, prevent falls, and promote neuromuscular control, restoring knee function and reducing the risk of reinjury.

During this phase, typical exercises and management activities include basic quadriceps-setting exercises and gentle range-of-motion exercises to improve knee extension (straightening) and flexion (bending). Focusing on maintaining the strength of the rest of the body is also important.

Intermediate ACL stage exercises | Strength and neuromuscular control

Progressing exercises to regain mobility and strength, advanced strengthening, plyometrics, and functional exercises.

In this phase, it is recommended to perform exercises and activities such as lunges, step-ups, squats, bridging, calf raises, hip abduction strengthening, core exercises, balance drills, gait re-education drills, and low-impact aerobic exercises, such as cycling, swimming, and walking.

The primary goal is to enhance leg strength, balance reactions, and self-assurance before progressing to more vigorous activities and workouts.

Here are some exercises that we use at the clinic:

Lunges

  • Take a large step forward with your affected leg.
  • Drop your hips down directly between your two feet.
  • Allow both legs and hips to bend so that your knees form a 90-degree angle, your back heel lifts off the floor, and the shin of your front leg is vertical.
  • Push back up to the starting position and repeat.
  • Ensure your knees move directly forward over your toes throughout the exercise.
  • Once comfortable, progress to Bulgarian lunge and loaded variations for added challenge.

Lunges enhance lower body strength, stability, and mobility, which is crucial for ACL rehabilitation and overall knee function improvement.

 

Step-ups

  • Stand facing a step.
  • Place your affected leg on the step.
  • Step up with your other leg onto the step and then step back down to the starting position using the same leg.
  • Ensure that your knee moves forward over your toes during this exercise.

Your affected leg should remain on the step throughout the exercise.

You can progress to loaded and side step-ups.

Step-ups strengthen the quadriceps, hamstrings, glutes, and calf muscles, enhancing lower limb stability, balance, and functional strength essential for ACL rehabilitation..

 

Goblet squats with weight

  • Hold the dumbbell close to your chest.
  • Step your feet wide apart and slightly turn the toes out.
  • Lower your body into a deep squat position, dropping your hips past 90 degrees while keeping your feet on the floor.
  • Control your movement back to the starting position.
  • Progress to a back squat with added weight.

Squats target the quadriceps, hamstrings, glutes, and core muscles, improving lower limb strength, stability, and functional movement patterns crucial for knee stability and injury prevention.

 

Eccentric calf raises

  • Place a step in front of a wall or close to a rail for support
  • Stand up straight on the step
  • Walk your feet backwards so that your heels hang off the back to the step
  • Keeping your knees straight, rise onto the balls of your feet
  • Next, transfer all of your weight onto your affected leg and lift the other behind you
  • Slowly control the movement as you lower your heel back down
  • Place your other leg back on the step and push up through both to return to the top of the movement.
  • Repeat 8-12 repetitions over three sets.
  • Slowly progress to loaded

Eccentric calf raises are essential for strengthening the calf muscles and the Achilles tendon. These muscles and tendons are crucial for shock absorption during dynamic movements such as walking and running.

 

Romanian deadlift (RDL)

Here are the rewritten steps for a proper barbell deadlift:

  • Stand tall with your feet shoulder-width apart.
  • Hold a barbell with both palms facing backwards. Your arms should be straight and slightly wider than your hips.
  • Make sure your shoulders are pinned back and down.
  • Lower the barbell: Move your hips backwards and lower the bar straight down, maintaining the natural curves of your spine. Bend your knees at the last part of the movement to allow the barbell almost to reach the floor.
  • Pull the barbell back to the starting position by driving through your heels and straightening your hips.
  • Note: The barbell should move up and down in a straight line close to your body.

The Romanian deadlift (RDL) targets the hamstrings, glutes, and lower back muscles, essential for knee stability, hip mobility, and posterior chain strength.

Here are the instructions for a star excursion exercise:

 

Star excursion

  • Stand on one leg with your hands on your hips.
  • Slightly bend your knee to assume your starting position.
  • When you are ready, use your other leg to reach as far as possible in each of the following directions, lightly touching the floor to the furthest point before returning to the middle position:
      • Forwards across your standing leg
      • Straight forwards
      • Forwards and away from your midline
      • Sideways
      • Backwards and away from your midline
      • Straight back
      • Back and behind your standing leg

Make sure to maintain your balance and control throughout the exercise.

Balance and star excursion exercises are crucial in ACL rehab. These exercises improve proprioception, neuromuscular control, and lower limb stability. They help restore functional movement patterns, prevent reinjury, and enhance knee function.

Late-stage ACL rehab exercises | Running agility and landing

Transitioning to sports specific exercises sports sports-specific drills to improve agility, speed, and coordination

In the final stage of ACL rehabilitation, you can resume activities such as running, agility drills, jumping, and hopping. At Chiswick-Physio, we have a structured system to gradually increase the difficulty of jumping exercises to prepare you for a return to higher levels of physical activity and sports. This progression enhances competency by gradually exposing you to more complex jump and landing variations.

Jumping and hopping exercises often begin with those that involve absorbing force, such as Tall to Short Landings. Later, you progress to exercises that create force, such as Squat Jumps, and then to stretch-shortening exercises, like Continuous Broad Jumps. During this phase, it is important to have some rest and recovery time since many exercises and activities require eccentric muscle activity, which can be tiring to the leg.

Tall to short landings

  • Standing with your feet hip-width apart
  • Raise onto toes at the same time, raising your arms
  • Drop into a small squat position at the same time, dropping your arms

Progress to Altitude Landings and weighted Tall to Short Landings. This type of exercise builds an adaption to landing forces and sets the foundation for higher-level jumping.

 

Squat jumps

  • Stand up straight with your feet hip-distance apart.
  • Keep your arms bent and hands in front of your shoulders.
  • Lower your body until your hips are below your knees.
  • Propel your body up and off the floor while bringing your arms above your head toward the ceiling.
  • Land softly on the balls of your feet with your arms bent.
  • Repeat as many times as is right for you.

Progress Squat Jumps onto an increasing box height. Such exercises shift the focus from absorbing landing forces above to creating take-off forces.

 

Counter movement jumps

  • Standing with your feet hip-width apart, hands on your hips.
  • Raise onto toes.
  • Drop into a small squat position.
  • Propel your body up and off the floor while bringing your arms above your head toward the ceiling.
  • Land softly on the balls of your feet with your arms bent.

Progress onto single-leg jumps such as Hurdle Jumps. These exercises combine the development and absorption exercises within the same movement, making loading more intense.

 

Continuous broad jumps

  • Stand with feet shoulder-width apart.
  • In one motion, bend your knees, hinge forward at the waist, push into the ground, and jump forward with both feet as far as possible.
  • A two-foot take-off and landing is used
  • Do this in a continuous forward motion for the prescribed amount of reps.

Progress to single-leg and sideways jumping. These exercises challenge the leg to a greater extent and are building blocks to sport-specific movements.

 

Tips for successful ACL rehab

It is important to follow a structured ACL program to ensure successful rehabilitation. You should progress at your own pace, based on individualised outcome measures rather than predetermined timelines. 

It is essential to complete the entire ACL rehabilitation protocol. After successfully resuming running without knee pain, it may be tempting to think the process is complete. However, the final one-third of the protocol is the most crucial. Completing it can significantly reduce the likelihood of re-injury, increase the chances of a successful return to sports, and potentially reduce the risk of developing osteoarthritis.

Conclusion 

Recap on the importance of ACL rehab exercises

The significance of ACL rehab exercises cannot be overstated for individuals undergoing recovery. The exercises above exemplify a progressive loading programme that is crucial to the comprehensive rehabilitation process. They address key aspects such as strengthening, stability, range of motion, and neuromuscular control. Additionally, they help prevent muscle atrophy, enhance proprioception, and restore normal movement patterns. By committing to a well-structured rehab program, you can minimize re-injury risk and support a successful return to daily activities. Furthermore, ACL rehab exercises contribute to long-term joint health. Therefore, following a well-structured rehab program is essential to achieve optimal outcomes in ACL recovery.

Final thoughts on long-term benefits of comprehensive rehab program

 

It’s important to focus not only on the physical condition of the knee but also on your mental preparation for the return to sport and activity during ACL rehabilitation. While ensuring the knee is physically ready is crucial, it’s equally important to consider your overall confidence and psychological readiness. Confidence comes from regular successful training and match play experiences, highlighting the need for a comprehensive approach that addresses not only physical strength and stability but also mental resilience and preparedness for the challenges of sport.

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