We see two kind of patients for physiotherapy after ACL injury. The ones that get the ligament repaired surgically and the ones that do not undergo surgery. Not everyone needs a surgery.

If there is a partial tear and not a complete one, surgery can be avoided. People with a sedentary life style can opt to go for a conservative treatment rather than getting it operated. Younger people with more active lifestyles especially sports persons should get it surgically repaired.

If the knee is not buckling while walking, surgery can be avoided. Also small children are advised against it as their growth plates are still open.

In the acute phase, right after the injury, the joint will be painful, swollen and there will be difficulty in putting weight on it. The acute phase can be managed at home or with physiotherapy keeping in mind the principles of PRICE.

P; Protection of the knee. From any further injury or damage. Avoid the movements that are painful. Brace is recommended in this stage to immobilize. Activity modification techniques are taught to make it simpler.

R; Rest. Rest the knee. It helps in relieving pain. Brace and taping are recommended in this stage.

I; Icing. Take cold packs on the affected knee to reduce pain and swelling. Hot packs is a complete NO.

C; Compression helps in reducing pain and swelling. Keep in mind the compression should not be too tight. This can increase swelling and cause numbness.

E; Elevation of the knee above the heart level. Keep pillows under the knee.

Anti- inflammatory medicines are also recommended.

In 2-3 days as the pain and swelling reduces, we should start with gentle exercises.

• Isometric Quadriceps (press the knee down by keeping a pillow under it.)
• Isometric Hamstrings- press the heels down.
• Gentle knee movements; knee flexion and extension with heel slides.
• Isometric glutes.
• Hip abduction in side lying.
• Ankle movements.
• Patellar glides; superior-inferior and medio-lateral.

Isometric quadriceps can be done along with electric muscle stimulation. This is less painful and gives better and faster recovery. Our main motive in this phase is to get rid of the brace. Also, to maintain range of movement of the knee joint. Accordingly, the movements could be active or active-assisted.

This acute phase is similar whether the patient is planning to go for a surgery or not. If the surgery is not indicated or if the patient decides against it then we move on to sub-acute phase of the physiotherapy programme. Our main aim is to;

• Increase the strength of the muscles around the joint for easier movements.
• Training the patient to reduce the risk of any further injury.
• Improve the range of movement in the joint.
• Work further on any pain and swelling.

The focus being the knee stability, the patient needs special exercises and a structured physiotherapy programme. For the next couple of weeks the focus is on-

• Getting complete range of flexion.
• No extension lag.
• Good balance. Work with balance boards. Progress to one limb standing. Add walking on treadmill, cycling on stationary bike.
• Stretches.
• Side jumps, lunges, squats.

Depending on the patient and his symptoms, introduce therabands for resisted exercises. Sandbags are also added and the weight increased gradually.

This complete programme can take anywhere between 3 to 6 months. Non operative ACL injury leaves some limitation and residual weakness. So if you are a sportsperson or with an active lifestyle, then opt for a surgical repair.

It is advisable to prepare a patient for surgery. This is same to the acute phase that we discussed that reduces pain and swelling.

• Post-surgery, the first week is to reduce pain and inflammation. This involves icing and elevation.
• Gentle knee mobilization is done. It could be passive or active assisted depending on the patient and his surgery.
• Patellar mobilization is started.
• Knee brace can be suggested for initial couple of days.
• Walker may be used as assistance for walking.
• Isometric quadriceps and hamstring strengthening is begun.

Four weeks post op we are aiming at,

• Minimum 90degrees of knee flexion with complete extension.
• Good hamstring and quadriceps strength.
• Reduced knee brace use.
• Independent walking without any assistance.
• Strengthening exercises with increased weights and bands depending on the recovery of the patient.
• Independent stepping up and down the stairs.
• Better balance.

As therapists, we aim to get the near normal knee by 12 to 16 weeks;

This would mean..

• Normal strength.
• Normal balance.
• Complete range of movement.
• Good endurance.

If he is a sportsperson, he should be back to his sports activity. This would mean along with other exercises the person is able to do all movements including jumping, landing, one leg jumps, hopping, squats, lunges.