physiotherapy management in acl injuries

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acl injuries

The ACL is one of the most important ligaments of the knee, giving it stability. The ACL achieves this role by preventing excessive twisting , straightening of the knee ( hyperextension) and forward movement of the tibia on the femur. When these movements are excessive and beyond what the ACL can with stand, tearing to the ACL occurs .This condition is known as an ACL tear and may range from a small  partial tear resulting in minimal pain ,to a complete rupture of the ACL resulting in significant pain and disability, requiring comprehensive rehabilitation and potentially surgery .


grades of acl tear

  • Grade 1:- A small number of fibers are torn resulting in some pain but the joint will function relatively normally.
  • Grade 2:- A large number of fibers are torn and the knee joint will lose a lot of functionality.
  • Grade 3:- The ACL ligament is completely torn and the knee becomes unstable . there will be very little if no function of the knee. In this grade most likely surgery is required.


  • Violent over –twisting of the knee
  • Sudden change in direction
  • Common in skiing
  • Hyperextension or excessive force on the back of the lower leg.
  • Frequently seen in contact sports .
  • Sports in which require rapid change in direction such as football , rugby, basketball and skiing.


  • Audible pop sound at time of the injury
  • Minor tears – slight pain at start, increasing
  • Swelling and stiffness
  • Unnatural movement of knee joint.
  • Major tear – leg will not hold weight.

the major goals of rehabilitation of the acl injured

  • Gain good functional stability
  • Repair muscle strength
  • Reach the best possible functional level
  • Decrease the risk for re-injury.

physical therapy

Before any treatment , encourage strengthening of the quadriceps and hamstrings, as well as ROM exercises. Performance of ROM helps reduce the amount of effusion and help the patient regain motion and strength.

acute phase

PRICE –should be used in order to reduce swelling and pain , to attempt full range of motion and to decrease joint effusion.

Exercises should encourage:

  • ROM

Rehabilitation protocol in acute phase

  • Static quads/SLR
  • Ankle DF/PF circulation
  • Knee flexion /extension in sitting
  • Patellar mobilisations
  • Gluteal medius work in side lying
  • Glute exercises in prone
  • Knee flexion in prone
  • Weight transfers in standing ( forwards/ backwards/ side to side )
  • Neuromuscular electrical stimulation (NMES) combined with exercise is more effective improving quadriceps strength than exercise alone.

post operative treatment

Closed chain exercises are used to emphasize early and long term maintenance of full extension.

The therapy protocol may be divided into 4 phases

Phase 1

This is the preoperative period when the goal is to maintain full ROM

Phase 2 (0-2 week)

The goal is to achieve full extension , maintain quadriceps control, minimize swelling, and achieve flexion to 90 degree.

Phase 3 (3-5 week)

Maintain full extension and increase flexion up to full ROM . stair climbers and bicycle may be used.

Phase 4 (6 week)

Increase strength and agility, progressive return to sports .Return to all sports without activity may take 6-9 months and should be closely monitored by the surgeon and physical therapist

Other treatment – (injection , manipulation )

knee brace

The use of knee braces remains a highly controversial topic, braces are well accepted by the patient ,but most biomechanical studies do not support their use. Studies have shown that functional bracing can limit anterior translation of the tibia at low loads. Most braces have been found to decrease the reaction time of the hamstring muscles.

open chain exercises

This is a maintenance phase .The patient’s timeframe for returning to sports depends on his/her  strength, ROM ,and the type of fixation that was performed.

To know more, download Portea’s Mobile App and chat with a doctor for free.

Avail Physiotherapy at home from the experts.

Dr Pinki .

Dr. Pinki is a M.P.T in Ortho with 3+ years of experience. She is currently working at Portea Medical.
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