What Many of Us Never Learned About ACL Rehab

The Problem

Raise your hand if you feel like your success rate with ACLs is 100%.

What about 90%?
80%?
70%?

How do you measure your success rate? Arden et al1 found successful return to prior level of sport to only be 43%! There are many reasons for this, but one of the most common we find occurs in the first few weeks of rehab: returning extension ROM.

The most common issue my co-founder Doug Adams and I see when we consult for patients struggling with their rehab is that the patient did not recover his/her full knee extension after surgery (Doug is the author of Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation Progression.2). I do not mean recover 0 degrees of extension, but full symmetrical hyperextension.3 Failing to recover hyperextension leads to all kinds of issues, including never fully returning quad control and strength.4 It can lead to increased joint loading and I would hypothesize may increase the rate of osteoarthritis development (although this is only a hypothesis at this point).

The Quick Fix

The easiest fix to prevent poor extension ROM is to fix it before it happens. Your initial treatment plan should have an incredible focus on returning fully symmetrical hyperextension, a perfect quad set, and straight leg raise without a lag. This simple aspect of treatment far outweighs the effect of the mid and late stage rehab principles for the sole reason of setting a baseline ability to function.  If your motion is poor, your strength will be poor. If your strength is poor, your functional testing will be poor. 5 If your functional testing is poor….. you get the point. Forgetting to return hyperextension and a great quad set is like trying to build a pyramid and forgetting the bottom layer!

But What If I missed It?

The good news is you still have a chance to improve hyperextension. Most protocols will suggest intense stretching, usually through prone hangs.   These can be incredibly effective methods, but do not encompass all the possible treatment options. There are some patients who are just slow to respond and we are not sure why. One possible reason may be due to infrapatellar fat pad impingement. Fortunately, there is a simple way to identify this!

Put overpressure on your patient’s knee, pushing it into gentle hyperextension and ask, “Where do you feel this?” The typical response from a patient should be that he/she feels it in the back. After all, isn’t that what we are stretching? But what if the patient reports feeling the “stretch” in the front. This may be due to impingement of the fat pad and your success of regaining extension is going to be limited until you move the fat pad out of the way. Simple mobilizations of the fat pad can achieve this.

Mobilizing the Fat Pad

  • Check the area just medial and lateral to the patella tendon. Fat PadIMG_2825
    • It should be mobile and easy to push back and forth.
    • If you find it to be stiff (compare it to the contralateral knee), you may consider mobilization.
    • Push into the fat pad, attempting to move it in all directions, similar to a scar massage. It initially may be painful, so explain it to the patient!
    • Use the ACE Treatment Philosophy to check if it worked.

Interested in learning more about treating the knee? Join us in Wisconsin on April 9th for Knee Pain: Complete Management from Start to Finish






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  1. Arden CL, Taylor NF, Fellar JA, Webster KE. Return-to-sport-outcomes at 2 to 7 years after anterior ruciate ligament reconstruction surgery. The American Journal of Sports Medicine. Jan 2012;40(1):41-48.
  2. Adams D, Logerstedt D, Hunter-Giordano A, et al. Current concepts for anterior cruciate ligament reconstruction: A criterion-based rehabilitation progression. J Orthop Sports Phys Ther. 2012;42(7)601-614.
  3. De Carlo MS, Sell KE. Normative data for range of motion and single-leg hop in high school athletes. J Sport Rehab 1997;6:246–55.)
  4. Shelbourne KD, Biggs A, Gray T. Deconditioned Knee: The Effectiveness of a Rehabilitation Program that Restores Normal Knee Motion to Improve Symptoms and Function. Am J Sports Phys Ther. May 2007; 2(2): 81–89.
  5. Schmitt LC, Paterno MV, Hewett TE. The Impact of Quadriceps Femoris Strength Asymmetry on Functional Performance at Return to Sport Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther 2012;42(9):750-759.

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