The Anterior Cruciate Ligament (ACL) is crucial for stabilising the knee during dynamic movements such as pivoting, jumping, and running. An ACL injury is a common concern, unfortunately, as it can be quite a severe injury. It is especially common among athletes from sports that require sudden changes in direction. In this article, we provide ACL rehab exercises to help you in your recovery, whatever stage of recovery you are currently at.
How ACL Injuries Occur
ACL injuries typically result from a sudden stop, change in direction, or direct impact from the side. These mechanisms can cause the ACL to stretch or tear, ranging from mild (partial tears) to severe (complete tears). Read more about ACL injury causes, symptoms, and treatments here.
Effective ACL Exercises for Recovery
Rehabilitation exercises are essential for recovery from an ACL injury. A structured rehab protocol enhances the healing process and restores function. Here is a breakdown of a rehab protocol that can be used to navigate through the various rehab stages following surgery:
Weeks 0-2
The focus during this phase is on pain and swelling management, establishing a range of motion from 0-90° (with full extension as a priority), and patient education.
Range of Motion (ROM)
- Heel Slides
- Lie on your back with legs extended.
- Slowly slide your heel towards your buttocks, aiming for 0-90° range.
- Return to the starting position.
- Repeat several times, ensuring smooth movement.
- Perform up to 5 sets a day.
- Calf Stretches
- Stand with your hands placed palm down on a wall or chair.
- Step one leg back and try to put your back ankle on the ground until you feel a deep but comfortable stretch in your calf.
- Hold for 20-30 seconds.
- Repeat 2-3 times per leg.
- Hamstring Stretches
- Sit with legs extended.
- Bend forward and try to touch your shins or toes until you feel a deep but comfortable stretch in your hamstrings.
- Hold for 20-30 seconds.
- Repeat 2-3 times per leg.
- Exercise Bike
- Use a bike with low resistance.
- Pedal slowly to maintain mobility.
- Aim for several short sessions a day.
Muscles
- Quadriceps
- Perform static quadriceps exercises (e.g., with a cushion under the thigh).
- Mini wall squats (up to 30°).
- Static lunges and sit-to-stand exercises.
- Hamstrings
- Perform static contractions and co-contractions with quadriceps.
- Gluteals
- Perform isometric and eccentric hip flexion, extension, and abduction (both standing and lying).
- Calves
- Perform standing single and double heel raises (with or without support).
Proprioception
- Single Leg Stance
- Balance on one leg for 30-60 seconds.
Gait
- Crutch Use
- Begin full-weight bearing with two crutches, progressing to one crutch until a normal gait is achieved.
- Perform weight-shifting exercises (side-to-side, forward-and-backward).
Modalities
- Ice Packs
- Apply ice packs for 20-30 minutes, allowing 2-3 hours between applications.
- Analgesics
- Use Paracetamol or NSAIDs as recommended.
Weeks 2-6
The goal here is to progress to full knee flexion and extension, achieve a normal gait, and strengthen the opposite limb.
Range of Motion (ROM)
- Prone Knee Flexion
- Lie face down and gently flex the knee.
- Ensure controlled, smooth movement.
- Perform 5-8 repetitions for up to 3 sets a day.
- Calf Stretch
- Stand with your hands placed palm down on a wall.
- Step one leg back and try to put your back ankle on the ground until you feel a deep but comfortable stretch in your calf.
- Hold for 20-30 seconds.
- Repeat 2-3 times per leg.
- Standing Quad Stretches
- While standing, bend one knee and place that foot into your hand. Feel free to lean on a support structure for balance.
- Hold the stretch for 20-30 seconds.
- Repeat 2-3 times per leg.
- Exercise Bike
- Continue with light exercise on a bike.
Muscles
- Quadriceps
- Perform assisted squats, gradually increasing resistance.
- Wall squats (up to 60°).
- Leg press machine (up to 70% body weight, up to 60°).
- Forward and lateral step-ups, ensuring body weight passes through the heel.
- Hamstrings
- Perform prone-assisted hamstring exercises using the opposite limb. You’ll need a helper for this. Alternatively, perform very light hamstring curls with a machine.
- Lie flat on the ground, face first.
- Attempt to bend your knee, raising your foot into the air.
- Have an assistant provide gentle resistance to your leg as you pull your foot up. Perform 10-15 reps for 3 sets.
Bridging exercises while lying supine with legs on a Swiss ball.
- Perform prone-assisted hamstring exercises using the opposite limb. You’ll need a helper for this. Alternatively, perform very light hamstring curls with a machine.
- Lie flat on your back.
- Place your feet onto a swiss ball
- Press into your heels and lift your hips off of the ground.
- Perform 8-12 reps for 3 sets.
- Gluteals & Calves
- Perform hip strengthening exercises in all directions with ankle weights.
Proprioception
- Double/Single Leg Stance
- Balance with eyes forward and closed.
- Stand on a half foam roller to challenge balance.
Gait
- Progress to Unassisted Full Weight Bearing
- Exaggerate hip and knee flexion during the swing phase of gait.
Cardiovascular
- Exercise Bike
- Continue with increasing resistance and time.
- Elliptical Trainer
- Begin low-resistance elliptical sessions.
Weeks 6-9
The goal in this phase is to achieve a full, pain-free range of motion and start isokinetic quadriceps exercises.
Range of Motion (ROM)
- Full Knee Flexion
- Perform exercises that focus on achieving full knee range of motion.
- Maintain hamstring and calf stretches.
Muscles
- Quadriceps
- Full and inner range squats with increasing resistance.
- Dynamic lunges in all directions.
- Step-ups (up to 20 cm) and eccentric lateral step-downs.
- Wall squats (up to 90°).
- Initiate slow and controlled quadriceps strength training.
- Hamstrings
- Continue with the bridging exercise on a Swiss ball, as outlined above.
- Low resistance hamstring curls in prone, standing, and sitting positions.
- Gluteals & Calves
- Advance strengthening with resistance cables and ankle weights.
Proprioception
- Single Leg Stance on Mini-Trampoline
- Balance exercises on a mini-trampoline, incorporating upper body work such as throwing.
Wobble Board
- Perform balance exercises, progressing with complexity.
Cardiovascular
- Exercise Bike
- Increase time and resistance.
- Swimming & Pool Jogging
- Continue pool exercises like walking, hip ROM, and flutter kick swimming.
- Add pool jogging as a low-impact exercise.
- Treadmill Walking
- Begin walking on a treadmill, avoiding jogging.
Weeks 9-12
In this phase, the focus is on progressive quadriceps and hamstring strengthening, proprioception, and cardiovascular fitness.
Muscles
- Quadriceps
- Continue dynamic lunges, backward step-ups, and eccentric step-downs (up to 20 cm).
- Perform single-leg squats and low-resistance jumping.
- Hamstrings
- Progress with hamstring curls in standing, sitting, and prone positions with increased resistance.
- Perform eccentric hamstring exercises.
- Gluteals & Calves
- Continue eccentric strengthening of the glutes and calves.
Proprioception
- Mini-Trampoline & Wobble Board
- Perform catching and throwing drills on a wobble board or mini-trampoline.
- Single Leg Stance on a Floor Disc
- Combine balance exercises with upper-body movements and sport-specific activities.
Cardiovascular
- Pool Running
- Increase the duration and intensity of pool running.
- Exercise Bike & Treadmill
Gradually increase resistance on the bike and speed on the treadmill.
Weeks 12-16
This phase introduces sport-specific strengthening exercises and proprioception, with a focus on improving cardio fitness.
Muscles
- Quadriceps & Hamstrings
- Continue concentric and eccentric exercises with focus on strengthening.
- Perform backward lunge walking, split squat jumps, and single-leg drop landing (from 5 cm).
Proprioception & Agility
- Ladder Drills
- Perform forward, backward, and side-to-side ladder drills to improve agility.
- Mini-Trampoline Drills
- Perform two-leg jumps, jogging, and single-leg jumps on a mini-trampoline.
Cardiovascular
- Pool Hopping & Squat Jumps
- Perform these in shallow water to maintain cardio fitness.
- Jogging
- Jog on flat, even ground, avoiding sudden direction changes.
- Treadmill Jogging
- Progress from jogging to running with increasing intensity.
Weeks 16-26
The focus is now on sport-specific lower chain strengthening and progressing to plyometric exercises.
Muscles
- Quadriceps & Hamstrings
- Focus on addressing specific deficits with concentric and eccentric exercises.
- Progress from jogging to running and perform split squat jumps.
- Increase the height of single-leg drop landings (up to 25 cm).
Proprioception & Agility
- Forward & Side Hops
- Perform hops, maintaining balance for 5 seconds on landing.
- Ladder Drills & Agility Movements
- Practice drills that involve quick stops, lateral movements, and directional changes.
Cardiovascular
- Running & Sprinting
- Progress from jogging to sprinting with proper rhythm and balance.
- Perform drills that include cutting, turns, and running on uneven surfaces.
- Cycling & Swimming
- Increase intensity during outdoor cycling and avoid ‘whip-kick’ while swimming.
6-9 Months
The goal is to achieve adequate strength, power, agility, neuromuscular control, and cardiovascular fitness for returning to sport.
Exercises
- Single Leg Drop Jumps & Triple Jumps
- Perform exercises focusing on control and symmetry between both legs.
- Sport-Specific Drills
- Practise large figure 8s, Carioca running.
Throughout all stages, it’s vital to communicate with your physiotherapist to adjust the program based on your recovery, pain levels, and functional abilities.
Getting Back to Sport
Full recovery from an ACL injury typically spans several months, with the timeline varying based on the injury’s severity and the individual’s response to rehabilitation. It’s crucial not to rush this process. The eagerness to return to sport can be strong once symptoms improve, but fully completing your ACL rehab program and appropriately progressing through all recovery stages is essential for durable success and preventing re-injury.
Remember, your knee must demonstrate strength, stability, and be pain-free before resuming full sports participation. Always listen to your body and adhere to your physiotherapist’s guidance to ensure a safe return to activity.
Disclaimer
Please consult your physiotherapist or surgeon before starting any of the ACL rehab exercises mentioned in this blog. Each injury is unique, and your healthcare provider can offer personalised advice tailored to your recovery needs.
