Mental Preparation

The second important factor in the preoperative preparation of an ACL reconstruction procedure is the mental preparation of the patient. Physical therapists follow patients closely and communicate with the surgeon regarding a patient’s mental and physical preparation for surgery, as the success of reconstruction depends on both factors.¹⁰ The physician must explain the nature of the injury to the athlete and family. The patient benefits from a detailed explanation of the operative procedure and the postoperative rehabilitation. The physical therapist should also review with the patient exactly what will be performed in all phases of the postoperative rehabilitation and how each phase of rehabilitation will be accomplished. The patient should approach the reconstruction procedure with a positive mental outlook. A “let’s just get it over with” attitude is not acceptable and can lead to less than superior results, even with perfect surgical and rehabilitation techniques. The patient should arrive in the operating room ready to go with an attitude of looking forward to the reconstructive procedure and with an understanding of the postoperative rehabilitation.

Ipsilateral or Contralateral Graft

Rehabilitation after ACL reconstruction involves two different rehabilitation efforts with different goals. First is the rehabilitation of the knee as it pertains to the placement of the ACL graft intraarticularly. Second is the rehabilitation of the graft donor site. To do both effectively in the same knee, one rehabilitation effort must take precedence over the other to prevent the main complication of arthrofibrosis in the knee. Of utmost importance for the ACL graft in the short and long term is achieving full knee range of motion equal to the normal knee. This includes full hyperextension and the patient’s ability to kneel and sit back on his or her heels, as shown in Figs. 65-1 to 65-3. To rehabilitate the graft donor site, repetitive stress must be applied to the patellar tendon to stimulate it to regrow in size and strength. The sooner this repetitive stress can be provided, the more one can take advantage of the inflammatory response from harvesting the middle third of the patellar tendon. These two immediate goals for the ACL graft and the graft donor site are difficult to achieve simultaneously in the same knee without causing swelling and difficulty with achieving full range of motion. Therefore when a graft is harvested from the ipsilateral knee, the goal of achieving full range of motion takes precedence over rehabilitating the graft donor site.

Our choice of whether to use an ipsilateral or a contralateral patellar tendon graft is based solely on the individual patient goals. The senior author used ipsilateral grafts for primary ACL surgery from 1982 to 1994 but used contralateral grafts during that time period for revision ACL reconstruction when patients had already had the patellar tendon graft used in their involved knees for primary reconstruction. We observed the ease of rehabilitation experienced by patients when the contralateral patellar tendon was used for revision surgery, especially with regard to the quick return of knee range of motion in the ACL reconstructed knee.^10–12 Patients also reported that the ACL reconstructed knee felt normal to them very early after surgery, and they were able to return to their normal activities and sports very quickly. We initially began using the contralateral graft for primary ACL reconstruction in high-level athletes who wanted a quick return to sport. With its success and ease for achieving full symmetrical range of motion and strength, we realized that the use of the contralateral graft was appropriate for any patient.¹³ We currently use the contralateral graft source for about 75% of patients.

The rehabilitation program explained in this chapter can be followed regardless of the graft source or surgical technique used because the principles of rehabilitation and goals for patients are the same: to obtain knee symmetry for range of motion, strength, stability, and function. If the rehabilitation program provided follows the progression shown in Fig. 65-5, all the patient’s goals can be met.

Fig. 65-5 Effective rehabilitation involves following a progression of rehabilitation goals before and after anterior cruciate ligament (ACL) reconstruction. ROM, Range of motion.

Operative Considerations

Postoperative rehabilitation begins in the operating room after graft placement. It is critical that full range of motion, including hyperextension and flexion so that the patient’s heel touches his or her buttocks, is achieved at this point to ensure the graft has not been overtensioned, resulting in a captured joint that prevents full motion. The success of the operation is initially dependent upon correct graft placement and then subsequently dependent upon providing proper rehabilitation to the ACL graft and the graft donor site in the knee.

We apply a local anesthetic to the patellar tendon in the operating room. This allows for relatively painless flexion exercises to begin permitting the tendon to remain at its full length. Later, heel-slide exercises and quadriceps muscle contractions during weight bearing and straight leg raises will similarly draw the patella proximally and stretch the tendon to its full length. The combination of these two exercises decreases patellar tendon stiffness and contracture, processes that could otherwise occur after graft harvest and cause donor site pain.

Another important concept we use, allowing the patient to fully participate in phase I rehabilitation, is the avoidance of narcotic medications in the perioperative period. Although the occasional use of oral narcotic medication is necessary for some patients, parenteral narcotics decrease a patient’s ability to physically and cognitively participate in the exercise program. With the use of a ketorolac infusion, continuous cold/compression therapy, supplemental oral nonnarcotic pain medication, and immediate motion, narcotics can be avoided altogether in most instances. A regimen focused on preventing rather than treating pain increases both patient participation and satisfaction. Since instituting this pain prevention program, the average amount of nonnarcotic pain medication needed for patients has been 1.3 doses/day, with 73% of patients taking no pain medication by 6 days after surgery.

Finally, in the operating room, external drains are placed in the region of the fat pad. Along with leg elevation and cold/compression therapy, external drains decrease the incidence and volume of postoperative hemarthrosis. Patients are kept in 23-hour outpatient observation to prevent hemarthrosis and allow initiation of immediate rehabilitation.

Prior to leaving the operating room, antiembolism stockings are placed on both lower extremities. A Cryo/Cuff is placed on the ACL reconstructed knee, and an elastic sleeve with a frozen gel pack (Durasoft Patellar Tendon Wrap, DJ Orthopedics, Vista, CA) is placed over the contralateral donor side. Suprapatellar compression is not needed on the graft donor knee because graft harvest is an extraarticular procedure and there is no risk for an intraarticular effusion.

As the patient arrives in the postoperative recovery area, the ACL reconstructed leg is placed into a continuous passive motion (CPM) machine set to move the knee from 0 to 30 degrees of flexion. CPM not only provides gentle motion, but more importantly also elevates the lower leg. The graft donor leg is also elevated on pillows to the same level to avoid increased strain on the lower back that can lead to lumbosacral pain. Both knees are elevated above the level of the heart (Fig. 65-6).

Fig. 65-6 After surgery, the anterior cruciate ligament (ACL) reconstructed leg is placed in a continuous passive motion machine so that the knee is elevated above the heart.

Outpatient Anterior Cruciate Ligament Surgery

Most ACL surgery in the United States is performed on an outpatient basis, with the regular routine being that the patient goes home the day of surgery and then goes to a physical therapy unit a day or so after surgery to begin physical therapy. We believe that by having the patient stay in the hospital overnight, we have the means to prevent a hemarthrosis from forming in the knee. The patient’s ACL reconstructed leg remains elevated with the cold compression device on the knee except when specific exercises are being performed. Preventing hemarthrosis is key for controlling pain, preventing a quadriceps muscle shutdown, and achieving full knee range of motion. When the patient is sent home a few hours after surgery, the activity of getting out of bed, getting to a car, riding home, and getting into the house causes the knee to swell, which is contrary to the primary goal of preventing a hemarthrosis after surgery. Then when the patient is required to leave the house for physical therapy a day or so after surgery or several times in the first week after surgery, a knee hemarthrosis is almost inevitable.

We believe that the success of our rehabilitation program may lie in our requiring our patients to remain in the hospital overnight, receive patient education before going home, and remain on bedrest for the first 5 days after surgery. If the surgeon must do ACL reconstructions on an outpatient basis and send the patient home the day of surgery, major swelling in the knee may still be able to be prevented by having the patient understand and perform rehabilitation exercises at home. The physical therapist can communicate with the patient before surgery and daily after surgery to monitor the patient’s progress, and the patient could be actively treated by the physical therapist 5 to 7 days after surgery. This approach does require that the surgeon work with physical therapists who fully understand the rehabilitation program, that patients undergo preoperative rehabilitation and patient education, and that the physical therapist contact the patient daily by phone to monitor the patient’s progress.

Phase I: Early Postoperative Period

Phase I rehabilitation continues on arrival to the outpatient hospital unit where targeted physical therapy begins. The patient and the family caregiver are given an exercise diary that outlines the rehabilitation exercises to be performed. Checkmarks or measurements are placed in boxes next to each exercise as they are completed. This practice aids in compliance by giving the patient a visual reference to specific exercises. Another additional benefit of performing preoperative rehabilitation is that the patient can become familiar with the postoperative exercises to be performed, thus reducing the chance of confusion or improper exercise technique.

We start with exercises for range of motion with assisted flexion in a CPM machine for the ACL reconstructed leg. The patient is instructed to maximally flex the CPM to 125 degrees and hold this position for a period of 3 minutes. The CPM is progressed to maximum flexion slowly and as tolerated by the patient. Heel-slide exercises are performed next for both the ACL reconstructed leg and the contralateral donor site leg. A yardstick is positioned next to the leg with the zero end aligned with the end of the heel (Fig. 65-7). The yardstick provides a visual cue for patients to easily monitor the progress of knee flexion. Next, the patient flexes the knee with the help of a towel looped under the thigh until further flexion becomes difficult. Terminal flexion is held for 1 minute. The number of centimeters the heel has traveled is recorded. This number makes it easy for the patient and physical therapist to communicate changes in range of motion over the phone during the first week when the patient is at home. Flexion in the ACL reconstructed leg should be approximately 110 to 120 degrees immediately postoperatively. Flexion in the contralateral graft donor knee should be full and equal to preoperative measurements because harvesting the graft alone does not cause swelling and the patellar tendon has been stretched to maximal length while still in the operating room.

Fig. 65-7 A yardstick is positioned next to the leg with the zero end aligned with the end of the heel. With heel-slide exercises (A), the patient can easily monitor the amount of flexion as it corresponds to the number of centimeters on the yardstick (B).

The patient then props both legs into extension with the heels resting on the Cryo/Cuff canister, allowing for any hyperextension. A small 2.5-pound weight is placed just distal to the incision on the ACL reconstructed leg. This exercise is maintained for 10 minutes. Following the heel prop exercise, the patient performs three to five knee thunk exercises on each knee, in which the patient flexes the knee to a height of several inches and then allows the leg to relax and “thunk” into hyperextension. Thunk exercises can be difficult for patients to perform on the ACL reconstructed leg at first for fear of damaging the ACL reconstruction. Typically, therefore, thunk exercises are performed first on the graft donor leg so that the patient understands how hyperextension feels. Five to ten towel stretch exercises are performed for each leg as described previously. Active heel-lift exercises are combined with the towel stretch to achieve good quadriceps control (Fig. 65-8).

Fig. 65-8 Active heel-lift exercise. After the patient does a towel stretch exercise, he or she contracts the quadriceps muscle to actively lift the heel into extension.

Straight leg raise exercises for leg control are performed on both legs by having the patient first initiate a quadriceps muscle contraction and then focus on maintaining the knee in a locked-out position while lifting the leg so that the heel is 2 to 3 feet in the air above the mattress (Fig. 65-9). To provide high repetition stress to the graft donor site while still remaining in bed, we use the Shuttle (Contemporary Design, Glacier, WA). The Shuttle is a light-weight, low-resistance portable leg press machine (Fig. 65-10). Resistance is provided by the placement of weighted rubber cords, each adding additional resistance. This weight is applied during both the concentric and eccentric movements. Twenty-five repetitions with one cord (7 pounds) are then completed with the emphasis on slow, controlled motion.

Fig. 65-9 The straight leg raise exercise facilitates good leg control.

Fig. 65-10 The Shuttle machine provides a means for the patient to perform low-resistance leg press exercise while still remaining in bed.

Following these exercises, the Cryo/Cuff and gel pack are applied to the ACL reconstructed knee and graft donor knee, respectively, and the ACL reconstructed leg is placed back into the CPM set from 0 to 30 degrees, with the graft donor leg again propped up on pillows. The water in the Cryo/Cuff is changed once every waking hour. The patient is confined to bedrest with the use of a portable urinal and bedpan if needed. The patient may ambulate at this time but does so at the risk of developing a hemarthrosis.

The drains are removed from both knees the following morning, and an identical set of exercises is performed. At the end of this session, the patient ambulates for the first time. This is accomplished carefully to avoid a fall. First, the patient sits at the edge of the bed and, when it is clear that the patient is steady and not dizzy, standing is encouraged. Standing is allowed for a few minutes, with the clinician close by to make sure a vasovagal episode does not occur. Next, the patient is instructed to shift his or her weight over to the ACL reconstructed leg and lock that leg into hyperextension with a quadriceps muscle contraction (Fig. 65-11). The patient then ambulates to the door of the room and back using small steps and focusing on a point high on the wall in the direction of ambulation. Patients are allowed to ambulate with full weight bearing as tolerated; however, the use of crutches or a walker is allowed for patients who are unsteady on their feet and are at risk of falling.

Fig. 65-11 Standing habit. The patient is instructed to stand on the anterior cruciate ligament (ACL) reconstructed leg so that the leg is extended into full hyperextension.

Patients are released home from the hospital the day after surgery. Before release from the hospital, each patient must demonstrate full extension of the ACL reconstructed leg equal to the contralateral graft donor leg, flexion of at least 110 degrees on the ACL reconstructed leg, full or near-full flexion of the graft donor leg, the ability to lift both legs independently with quadriceps muscle contraction, the ability to ambulate independently, and a complete understanding of the home exercise program. Patients are advised that flexion may decrease from the previous day in the ACL reconstructed knee, but the flexion obtained initially after surgery should return gradually by 2 to 3 days after surgery. In general, patients are counseled against pushing flexion too hard in this period, as maintaining full extension is more important. Flexion in the contralateral graft donor knee should remain full.

Following discharge from the hospital, physical therapists call patients at home daily for the first week to monitor progress and answer questions that might arise. The previous list of exercises is carried out five to six times daily with the exception of the Shuttle, which is used three times daily and on the contralateral donor leg only. Patients are instructed not to use the Shuttle at the first morning exercise session and to discontinue its use until further instructed by the physical therapist if the knee becomes too sore at the graft site or if they begin to lose knee flexion on daily measurements. Daily flexion measurements are made using the yardstick, measuring the distance the heel travels on both knees. Barring these events, patients are allowed to increase the number of repetitions performed during each session on a daily basis, up to 10 additional repetitions per day. When 100 repetitions become easy for the patient, an additional cord can be added for progressive resistance, but the number of repetitions is decreased to 50 per session. The patient is allowed to then begin progressing up to 100 repetitions again with the increased weight. If flexion in the graft donor leg starts to decrease (as measured by yardstick daily), the patient is advised to either decrease the Shuttle exercise weight, frequency, or both until full flexion returns in the graft donor leg.

In the ACL reconstructed leg, knee extension is emphasized more than flexion during this phase. If the amount of knee extension plateaus or decreases, the amount of exercise to increase flexion should be deceased accordingly. Patients are warned that exercises will become more difficult at day 2 or 3 after surgery before gradually improving as a result of the body metabolizing the ketorolac medication from the hospital. During the first week after surgery, patients are allowed out of bed only two to three times daily for bathroom needs.

Postoperative Rehabilitation Phase II

The first postoperative visit is at 1 week after surgery. Rehabilitation remains unique to each leg. The patient continues to work on maintaining full extension of the ACL reconstructed knee while concentrating on patellar tendon remodeling and regrowth in the graft donor knee through the use of strengthening exercises and maintaining full flexion.

The primary goal is full extension of the ACL reconstructed leg; 110 degrees of knee flexion is a secondary goal and represents the average flexion in this period. No patients should have less than 90 degrees of flexion. Full flexion is expected in the graft donor knee.

Next, quadriceps muscle control is assessed. Each patient should be able to perform a straight leg raise without a lag and perform an active heel lift, contracting the quadriceps muscle with the knee in a hyperextended position. The patient should also have sufficient quadriceps muscle control to ambulate stairs using only the handrail for balance. If achieving an active heel lift through voluntary contraction is not possible, the condition may be a result of quadriceps muscle inhibition. Clinically, this condition manifests itself in a poor gait pattern. Stance and gait training includes using a mirror to help the patient visualize and understand the correct position of a hyperextended knee in stance, as well as working on gait using a decreased step length and focusing on terminal extension during initial contact with overemphasized heel contact.

Whenever sitting, the patient should be performing a heel prop to work on passive extension on the ACL reconstructed leg. Whenever standing, weight should be shifted to the ACL reconstructed leg locking the knee into hyperextension. Towel stretches are continued through this phase. The importance of full symmetrical hyperextension cannot be overemphasized. If asymmetrical hyperextension is noted and not correctable by the end of this follow-up appointment, then a more vigorous technique to regain full extension is needed. These techniques will be explained later in this chapter with regard to problems with rehabilitation.

Knee flexion exercises are also implemented for the ACL reconstructed knee. The goal for the end of week 2 is 120 degrees. Exercises including heel slides and wall slides are routinely given. Flexion hangs, which involve holding the posterior thigh with the hip flexed to 90 degrees and allowing gravity to passively flex the knee, can be added at this point for patients whose flexion is less than 120 degrees. All range of motion exercises are performed two to four times a day during the intermediate phase.

During week 2, the CPM is discontinued while cold/compression therapy continues. The cold/compression device is used by the patient as needed throughout the day to control swelling, and continued use throughout the night is encouraged but is not required if swelling is adequately controlled. Shuttle exercises for the contralateral graft donor leg are progressed as described previously as long as the patient retains full flexion. Front step-down exercises are initiated at this point, and patients start with 50 repetitions three times per day on the 2-inch step. This is progressed in a similar manner to the Shuttle until the patient is performing 100 repetitions on the 2-inch step. The patient independently advances this progression based on the amount of donor site soreness. The step box, a hinged, foldable device, allows step exercises from heights up to 8 inches. Patients are instructed to perform front step-down exercises, focusing on quality of form and technique rather than quantity of the number performed (Fig. 65-12). Balancing on the graft donor leg with the hands placed on the hips, the patient lowers the heel of the opposite leg to the floor in front of the step box until it touches the floor. It is important for the patient to keep the pelvis in a neutral position during the descent phase to prevent compensation from the hip musculature.

Fig. 65-12 Step-down exercise provides light strengthening. The patient stands on the step and lowers the heel of the opposite leg to the floor while keeping the pelvis in a neutral position.

If the patient continues to maintain good knee motion and avoid joint effusion during the second postoperative week, he or she is allowed to increase the time spent upright by 1 to 2 hours per day. Patients can usually attend school or work half-days starting about 1.5 weeks postoperatively. By day 10 to 12 postoperatively, if motion remains good and effusion is not an issue, patients are allowed to be up for 1 full day with brief periods of elevated rest as needed.

The second postoperative visit takes place 2 weeks after surgery. Knee range of motion, gait, and quadriceps muscle control are again carefully examined. By this time, patients should report that they are back to performing their full normal activities of daily living independently without difficulty or other compensatory strategies. In the ACL reconstructed knee, 120 degrees of flexion is expected in addition to full extension. Effusion should be well controlled. Excessive effusion is indicative of an overly intense activity level and should be addressed immediately. Patients should be instructed to return to a decreased level of activity with the leg elevated on pillows and continuous usage of the Cryo/Cuff until the swelling level has returned to an expected baseline amount of swelling. During this time, patients still perform range of motion exercises. Full flexion and extension in the graft donor knee should be maintained. Normal gait should be demonstrated, and patients should be able to ambulate up and down stairs without holding onto the handrail.

When a graft from the contralateral knee is used, the goal of rehabilitation for the graft donor site between weeks 2 and 4 is remodeling and regrowth of the donor patellar tendon through high-repetition, low-resistance exercise carried out several times daily. These exercises are essential to avoid long-term donor site pain. Patients are instructed in leg press and knee extension exercises, as well as continuation of the step-down exercises. These exercises should not be performed on the ACL reconstructed leg until full knee range of motion is obtained. Typically, patients are asked to start with half their body weight or less for the leg press and 2 to 5 pounds with the knee extension exercise. These exercises can be performed every other day to ensure that the graft donor site does not become overly sore. Three to five sets of 10 to 12 repetitions of each exercise are usually sufficient. The weight used for both exercises can be progressed slowly as the patient improves in strength.

In our experience, patients can easily overexert themselves with either the leg press or the knee extensions and make the donor tendon site sore. If the patient develops soreness that persists and is not decreased with cryotherapy, these exercises may need to be discontinued for a period of time. Most important is that the patient continues to demonstrate full range of motion with continued strength improvement without developing unrelenting donor site pain. Step-down exercises are progressed during this visit as able so that they are providing an appropriate challenge to the patient. If the patient has maximized the number of repetitions during the second week (100 reps, four to six times per day), he or she is allowed to progress up to the 4-inch step; otherwise the patient stays at 2 inches and continues to progress on the 2-inch step. The number of repetitions is decreased to 50 on the 4-inch step, and the patient can progress this number back up to 100 per session as able. Once 100 repetitions is reached on the 4-inch step, the patient is allowed to go up to the 6-inch step, again reducing the number of repetitions performed to 50 and progressing the number performed as able. Soreness in the tendon should be relieved with cryotherapy, not interfere with normal gait or stairs, and be absent from the tendon prior to the next session. If the graft donor leg begins to become overly sore or if a decrease in knee flexion is noticed during exercises, the graft donor leg strengthening intensity should be decreased until full flexion returns. It remains vital to maintain full extension of the ACL reconstructed knee and to make progress in flexion.

By the 1-month visit, the goal is for patients to be able to comfortably sit on their heels with their ankles in maximal plantarflexion, indicative of full knee flexion. Motion exercises for the ACL reconstructed knee remain the same as weeks 1 and 2. Extension habits are again reviewed and reinforced because some patients have trouble integrating them into their daily routine.

Postoperative Rehabilitation Phase III: Advanced Strengthening

Four weeks after surgery, the patient returns for a full round of strength testing, as well as KT-1000 arthrometer evaluation. The single leg–hop test is not included in this visit usually because most patients have not had a full return in confidence and are not ready to return to sports activities. The results of these tests are helpful to assess the patient’s progress over the previous 4 weeks and to develop a plan for further activity.

When an ipsilateral graft is used, patients can begin strengthening the ACL reconstructed leg if the knee has full range of motion and very little swelling. The exercises and progression for strengthening the ACL reconstructed leg are the same as those prescribed for the graft donor leg, with the concentration on single leg strengthening exercises as described previously. The patient adjusts the amount and intensity of the strengthening exercises based on whether he or she experiences any decrease in range of motion or an increase in knee swelling. Typically, patients have about 60% quadriceps muscle strength in the ACL reconstructed leg compared with the normal leg. Patients should perform single leg strengthening until they achieve 90% strength in the ACL reconstructed leg; then they can continue with bilateral leg strengthening exercises.

When a contralateral graft is used, the recovery of strength to preoperative normal levels is not as important as symmetry between the ACL reconstructed leg and the graft donor leg. For a patient doing well, isokinetic strength in the graft donor leg should be within 10% of the ACL reconstructed knee.

The ability to return to activities depends on the strength of the graft donor knee, the presence of full motion in both knees, and the lack of an effusion in the ACL reconstructed knee. If symmetrical quadriceps muscle strength (differences of less than 10% on testing) is achieved, the patient begins bilateral strengthening and conditioning exercises. Leg press, knee extension, and step-down exercises are now performed on both legs, with the patient doing the exercises with each leg independently and continuing to progress the intensity by adding weight as able. If the quadriceps muscle strength is not within 10% between legs, the patient continues with strengthening the graft donor leg only.

Low-impact conditioning, including stationary bike, stair-stepping machine, or elliptical trainer, is added. These activities need to be started very slowly and cautiously as the amount of swelling in the ACL reconstructed knee is monitored. Typically, most patients tolerate starting with 10 minutes every other day and increasing to 20 to 30 minutes over the course of the next 4 weeks. Patients who have had an ipsilateral graft need to know that these low-impact conditioning exercises will not help to strengthen the leg. Given that both legs are involved, it is difficult for patients to use both legs equally when there is more than a 10% discrepancy in strength between legs. Therefore these exercises should not replace the specific single leg exercises prescribed.

Straight-line forward and backward jogging, lateral slides, and crossover agility steps can be introduced. Shooting baskets or other individual noncompetitive sport-specific drills are performed as tolerated. These agility activities are done in controlled situation and do much to keep athletes motivated toward their goals, but again these activities should not replace specific strengthening exercises. No competitive situations are allowed at this time.

Postoperative Rehabilitation Phase IV: Return to Competition

There are no strict guidelines as to when a patient may return to sports. Patients return to the clinic for follow-up testing and adjustment to their home exercise programs and activity level regularly at 2-, 4-, and 6-month visits. Rehabilitation continues to be monitored as the patient returns to his or her preoperative, fully competitive level of activity. Symmetry, in the form of equal strength, full range of motion, and joint effusion, is evaluated at each visit. Once symmetry is achieved between both knees, the level of activity can be increased slowly to include return to sports activities.

During the return to full activities, the patient must monitor swelling and range of motion daily. If swelling occurs or the knee loses any extension or flexion, the patient must back off on activities, ice the knee, and perform range of motion exercises. Increased activity causes stress on the ACL graft, which is desirable because it stimulates the graft to mature. However, the maturation process in the ACL graft causes it to become stiffer, and patients must fully extend and flex the knee several times daily to keep the ACL graft stretched and to prevent capturing the knee.

When the patient first returns to athletic practice or competition, it should be done on an every-other-day basis. The initial return to activities is similar to that of a weight-lifting program. The athlete, while doing the activity, may feel and perform normally but may become quite sore afterward. Thus the athlete can practice as usual one day but then needs to take a day off to allow the knee (or knees) to recover. We have found that coaches sometimes do not understand this process and put pressure on the athlete to practice and compete every day. It is important for the physician and physical therapist to communicate directly with the coach to explain that having athletes practice every other day will allow them to do the sport with better quality when they are practicing and to eventually return to full competition faster instead of having long-term problems with knee soreness that is difficult to resolve with everyday activity.