Early ACL rehab: Exercise prescription checklist

6 min read. Posted in Knee
Written by Elsie Hibbert info

There can be a lot to think about as a clinician guiding someone through Anterior Cruciate Ligament Reconstruction (ACLR) rehabilitation. Making sure you’re balancing their exercise program to achieve each early-stage goal can be challenging; there is a lot to cover, but you don’t want to overload your patient with an unnecessary amount of exercises! An efficient and effective program to set the person up for a successful, pain-free return to running is the ultimate aim of the clinician in the early stages of ACLR rehab. Below is your checklist to make sure you aren’t missing any of the core principles of exercise prescription in this phase:

Not sure how to progress your clients to enable them to reach their goals?  If you’d like to learn how a top physio manages early stage ACL injuries step-by-step, watch Tim McGrath’s practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.


✅ Quads, quads and more quads

Did I mention quads? There’s no way around it – quad control is a vital part of early-stage rehab. We need those quads firing to have that extension control in activities such as walking, single-leg stance, squatting and running. Initially, the role is to mitigate arthrogenic inhibition ie. when your patient’s quads go MIA after surgery and they can’t straighten their knee. A recent study showed ACLR patients can compensate away from their operated leg for up to five months post-op, and even once they start to load more evenly, they will often compensate by avoiding bending through the operated knee and taking the load through the glutes (1).

In his Practical, Tim McGrath emphasises the usefulness of shallow range exercises to regain quad control in terminal extension, and avoid the hip musculature from commandeering the effort from the knee. Tim utilises familiar exercises such as Spanish squats, wall squats and Bulgarians, however he demonstrates how to integrate shallow ROM with the aim of isolating quads and enhancing extension control. See Tim’s example of a shallow Spanish squat below.

Once you have quad control and extension, you can start focussing more on strength symmetry – more symmetrical quad strength between sides is correlated with a reduction in re-injury risk when returning to sport (2). However, for many ACLR patients, the glutes will generally try to take the brunt of the load when they can. So how do we stop the quads from hiding? Leg extensions have historically been avoided by physios on the basis of graft protection, however a recent systematic review shows that open kinetic chain exercises (when prescribed after six weeks in reduced ROM) did not increase ACL laxity (3), and Tim McGrath argues leg extensions are a safe and effective way to gain quad strength in early stage ACLR rehab – see below the snippet in which Tim uses a shallow range oscillation/hold/oscillation drill which gets the quads working overtime!


✅ Normalising gait

You must walk before you can run! Making sure your patient normalises their gait as quickly as possible, and doesn’t pick up any nasty habits is paramount in early-stage rehab. This, of course, requires adequate knee extension and quad control. Common gait abnormalities seen following ACLR are: walking with bent knee/’fixed flexion’, overusing the calf, avoiding terminal extension, reduced push off, and reduced weight-bearing time on the affected side. Working on gait-specific training from the get-go is important; we want to see controlled extension in mid-to-late stance, allowing adequate push off, and have good quad control throughout the gait cycle.


✅ Hamstring strength

Obviously, if your patient has had a hamstring graft, it is important to regain the strength of the hamstring (while being mindful of the donor site). Regardless of graft type, isokinetic hamstring limb symmetry is one of the most common objective criteria used for return to running (4). Start easy with some isometrics, or heel slides, titrating the force by digging the heels into the ground. As the patient is getting stronger (and the donor site has healed) you can add exercises such as hip thrusters, hamstring curls or band-assisted nordics.


✅ Lateral hip

Research suggests rehab which includes hip strengthening exercises appears to improve sagittal plane dynamic balance at three months after ACLR (5). Additionally, lateral hip strengthening can be an important part of reducing the risk of patellofemoral pain when returning to activities. Try to make lateral hip exercises as functional (and relevant to running) as possible; this could include banded lateral and zig-zag walks; progress by adding external perturbations requiring the patient to maintain pelvic and knee control with external forces. Check out this video from Tim McGrath’s Practical showing a dynamic lateral hip exercise on the cable machine.


✅ Calf

The calf is important to regain strength, spring and stability; particularly gastrocnemius as it crosses the knee and acts as a secondary knee flexor. Early on, aim to maintain ‘active knee extension’ throughout calf exercises, so the knee is not just locked out into extension and the quads are still having to control the position of the knee. Start with double leg raises, shifting to single as quickly as possible to avoid compensation.


✅ Running preparation

While ACLR rehab is criteria-based, we generally start thinking about returning to running around the eight-week mark. The first eight weeks of your patients’ rehab should include principles of the above-mentioned, as well hip extensor and core strengthening in preparation for running. Clinical tests tend to vary, however usually involve some form of repetitive single leg squat test; for example, Tim McGrath uses a repetitive Bulgarian split squat to 90-degrees – before thinking about running, a patient must be able complete this with no anterior pain or knee swelling.

So your patient is doing well, they pass whichever criteria-based test battery you chose, and you’re ready to start thinking about returning to running – now what? You must run before you can run.. in his practical, Tim McGrath advocates for the usefulness of various running drills as a precursor to straight line running. See Tim’s mini-trampoline based pre-running drills below in a snippet from his Practical.


Wrapping up

While ACLR rehab should always address each individual’s needs and goals, the above-mentioned are a general checklist for early-stage rehab to ensure your client is set up for a return to pain-free running without delay. If you want an in-depth understanding of exercise prescription and progressions in this early stage rehab, watch Tim McGrath’s early stage ACL rehab Practical.

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