Sydney Inner West Allied Health Centre
leaders in Physiotherapy, Psychology, Podiatry, Ex Physiology, DEXA scanning, fitness training

ACL rupture and rehab

Tearing or rupturing the anteriorcruciate ligament (ACL) results in loss of stability in the knee. You will findit difficult walking downstairs and pivoting on your foot. The ACL is integral for playing sport. Loss of stability of the knee is demonstrated during your physio assessment with a pivot shift test. Rupture of the ACL may require surgery depending on your lifestyle.A hamstring tendon called semitendonosis is commonly used to substitute for the lost ACL. The image on the lower left illustrates a ruptured ACL. A normal ACL is rope- like and appears as a thick black line running diagonally from the lower edge of the femur (thigh bone) to the top of the tibia (shin bone). The MRI illustrates an ACL that looks like cotton wool. This is because the ACL has ruptured and frayed. This cannnot be reattached.

Your physio is initially responsible for managing swelling, as seen in the image on the lower right. This is another sign you have ruptured your ACL: the knee usually swells quickly. The most important aspect of preop physio is improving range beyond 90 degrees flexion and full knee extension. The MRI images below are taken of a female kick boxer who suffered a strong kick to her shin. She was given a preop exercise program to improve movement and maintain muscle contraction for her hamstring, vastus medialis oblique (VMO), hip flexors, calf, and quads. The preop program will improve post op recovery as she has managed to practice a lot of technical exercises prior to the graft.

Post op physio commences immediately after surgery to manage swelling and engage the knee and hip muscles as soon as possible. Return to full function takes 6-12 months depending on the extent of damage to the other ligaments and joint surface.                                          

ruptured ACL lateral view MRI
ACL rupture anterior view MRI
MRI of swelling in the knee due to ACL rupture

Pre operative rehabilitation for ACL injuries

We focus on pre operative rehabilitation (or prehab) for all injured patients attending the clinic. There is strong evidence on the benefits achieved with pre op rehab.(1)


 2009 May;43(5):371-6. doi: 10.1136/bjsm.2008.057059. Epub 2009 Feb 17.

Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction.

Improving Dynamic Stability of your injured ACL knee

A ruptured or torn ACL is a serious problem requiring time off work, leisure and sport.

Long term problems can arise such as osteoarthritis, especially if the meniscus is damaged as well.

Returning to pre-injury activities depends on a successful dynamic knee stability training regime.

We use tests that have been standardized and validated to screen and classify newly injured ACL injured patients into potential copers and non copers. The physical tests compare the injured knee to the uninjured side and 2 questionnaires on knee function and self evaluation are used. The physical tests include maximal strength of quads and hamstrings and 4 single leg hopping tests. The last criteria used is the number of episodes of the knee giving way. Non copers are subsequently referred to orthopeadic specialists for reconstructive surgery.

Timing of surgery is discretionary. Recent research has demonstrated that the functional status of the knee at the time of surgery is more important than the time span since the date of injury. Reconstructive surgery will reestablish mechanical stability of the knee, but has not been proven to provide sufficient dynamic stability or make the patient able to return to their pre-injury activity level. 

Dynamic stability training will enable you to hop, pivot, jump, balance and run with more certainty and safety. Examples of dynamic stability training include hopping and stepping drills and squats on unstable surfaces.

Rehabilitation after ACL reconstruction

Intensive rehabilitation following ACL reconstruction is necessary for successful post-operative outcomes. Twenty nine Level 1 and 2 studies between 2006 and 2010 came up with the following findings: bracing is not necessary following ACL surgery; range of motion, strengthening and functional exercises are the foundation of successful treatment outcomes. Adjunctive therapies including neuromuscular training, vibration training, home exercise programs and accelerated programs can all add value to the rehab program but should not substitute for the core rehab principles described above. (2)


Rehabilitation After Anterior Cruciate Ligament Reconstruction

A Systematic Review
L.M. Kruse, MD,1 B. Gray, MD,1 and R.W. Wright, MD1
J Bone Joint Surg Am. 2012 October 3; 94(19): 1737–1748.