1. ACL injuries Kerry Jacobs B Physiotherapy (Hons) M Sports and Musculoskeletal Physiotherapy Kerry Jacobs B Physiotherapy (Hons) M Sports and Musculoskeletal Physiotherapy

2. Background ACL prevents anterior translation of tibia on femur, tibial rotation and varus/valgus angulation. Injury commonly occurs in non-contact situation: landing from jump, pivoting or quick deceleration. ACL prevents anterior translation of tibia on femur, tibial rotation and varus/valgus angulation. Injury commonly occurs in non-contact situation: landing from jump, pivoting or quick deceleration.

3. Surgical Treatment  Arthroscopy  Autogenous grafts  Bone-patella-bone  Hamstring (semitendinosus +/- gracilis)  Allografts  Synthetic ligament  LARS (ligament advanced reinforcement system)  Arthroscopy  Autogenous grafts  Bone-patella-bone  Hamstring (semitendinosus +/- gracilis)  Allografts  Synthetic ligament  LARS (ligament advanced reinforcement system)

4. Early Rehabilitation PhaseTime post surgery Goal of phaseExercise programFunctional/sport- related activity PrehabN/A↓ swelling Full ROM > 4+/5 strength Gait, proprioception Patient education ROM exercises VMO/quads Hamstring and hip abd/ext exercises Gait education, proprioceptive training Swelling advice and activity modification Walk Bike-ride Swim – no breastroke Phase 10-2 weeksPWB-FWB ↓ swelling 0-100° ROM > 4+/5 quads strength 5/5 hamstring strength Proprioception Education Gentle flexion ROM Extension ROM 0 ° Quads/VMO setting Bilateral calf raises Hip abd/ext Hamstring pulleys/bands Gait drills Proprioceptive training Nil Phase 22-12 weeksNo swelling Full knee hyperextension Knee flexion 130 ° + Full squat Good balance/control Unrestricted walking ROM drills Quads/VMO Mini squats/lunges Leg press (double to single) Step-ups Bridges (double to single) Hip abd and ext with rubber tubing Single-leg calf raises Gait re-education drills Balance/proprioceptive drills (single leg) Walking Exercise bike

5. Mid-Late Rehabilitation PhaseTime post surgery Goal of phaseExercise programFunctional/sport- related activity Phase 33-6 monthsFull ROM Full strength/power Return to jogging, running, and agility Return to restricted sport- specific drills As above – increased difficulty, repetitions and weights where appropriate Jump and land drills Agility drills Straight line jogging Swimming (light-kick) Road bike Straight line running at 3 months Progressing to sport specific running and agility (progressively sequenced) – running forwards, sideways, backwards, sprinting, jumping, hopping, changing directions, kicking Phase 46-12 monthsReturn to sportHigh-level sport specific strengthening as required Progressive return to sport e.g. restricted training, unrestricted training, match play, competitive match play Adapted from Brukner et Khan 2006

6. Common Problems for Rehabilitation  Combined injuries  Patella problems  Low back pain  Lower limb stiffness  Collagen differences  Combined injuries  Patella problems  Low back pain  Lower limb stiffness  Collagen differences

7. Considerations  Contributors to initial injury  quadriceps dominance  leg dominance  core dysfunction  functional risk position  Train controlled body motions, especially deceleration and pivoting manoeuvres  Train landing with increased flexion at knee and hip  Contributors to initial injury  quadriceps dominance  leg dominance  core dysfunction  functional risk position  Train controlled body motions, especially deceleration and pivoting manoeuvres  Train landing with increased flexion at knee and hip