THE McACL PROGRAMME by Paul McCormac M.C.S.P.
INTRODUCTION It was in 1991 when we completed our first rehab programme for a player following ACL reconstruction. Guidelines for that programme were based on those tested and researched at the MAYO CLINIC - perhaps the top rehabilitation experts in the USA where most of the ACL techniques have been pioneered, and at the F.A. Centre at Lilleshall, England.
Since then we have developed and changed the programme in conjunction with the latest literature and data, as well as the changes in the surgical technique and recommendations from our local surgeons. Our programme has been tried tested and modified on over 300 patients.
OUR RESULTS At present June 2003 - we have put approx 300 players and athletes through our programme, mostly County or Elite Club Gaelic Footballers, Irish League Soccer, and League of Ireland Rugby. All back to full competition with no complications - one opted to retire as referee.To date we have had two patients requiring a revision op – difficult to predict the exact cause but they were patienst who did not follow our protocol as per instructed or put in the time and effort required. As our technique has improved we have seen the time factor drop from one year to just over 7 months (for some).
THE TIME FACTOR Patients especially motivated athletes want back to their sport 'yesterday' and over the last number of years we have seen the recovery time drop - partially due to the change in surgical technique partially due to advanced accelerated rehabilitation techniques. However there are certain risks to rushing back.
WARNING:Rehab will take time from 9 months to one year for some. It is impossible to give you an exact 'BACK BY' date as individuals progress will vary.
PHASE THE McACL PROGRAMME APPROX. START / FINISH TIME
1) POST OP MOBILISATION (Day 1 to Week 1)
2) MUSCLE RE-EDUCATION (Week 1 to Week 2-3)
3) STRENGTH PROPRIOCEPTION GYM - Early (Intro) (Week 2-3 to Week 6)
Full Programme (Week 6-10 to ongoing)
4) PITCH PROPRIOCEPTIVE DRILLS (Week 12-16 to ongoing)
5) PROTECTED TURNS & TACKLES (approx Week 16-18 depending on progress at Phase 3-4)
6) FULL TURNS & TACKLES (& FINAL PLYOMETRIC PHASE) (Month 5+)
7) RESTRICTED SQUAD TRAINING Once satisfactory completion
8) RETURN FULL SQUAD TRAINING of Phase 6 and completed
9) CHAMPIONSHIP TIMING McACL testing
10) FINAL CHAMPIONSHIP SELECTION
AVERAGE 10 PHASE COMPLETION TIME IS 5 TO 14 months: depends on individual, work rate and Physio input. *N.B.* Working harder does not mean rushing through the phases - you must be checked by McACL PHYSIO before progress from each phase - you may also have small set-backs along the way - but the more you rush, not following our guidelines - the greater the risk of injury!
ACKNOLGEMENTS: grateful appreciation in the development of the 'McACL' to the following:
MR. RAYMOND MORAN M.Ch. (Orth.), FRCSI
MR. RICHARD NICHOLAS BDS, MD, FRC (Orth.), FRCSI
MR. IAN CORRY BDS, MD, FRC (Orth.), FRCSI
and the PHYSIO DEPARTMENT at BELFAST CITY HOSPITAL.
THE McACL PROGRAMME
DAY TO WEEK PROTOCOL
PRE-OP STRENGTHENING as able-weights + + +, general fitness - however if meniscal problems or if causes pain then rest pre surgery.
Practice co-contraction exercises.
PRACTICE PRE-OP EXERCISES.
POST OP McACL
McACL PHASE I EARLY MOBILISATION (Time spent : daily)
DAY 1 to DISCHARGE FROM HOSPITAL - on guidance of hospital based physiotherapist.
-Weight Bearing (WB) as able - use crutches.
-Encourage straight leg raise (SLR).
-Encourage straightening in sitting over edge of bed - use other leg to assist initially.
-Encourage Flexion (bending) - Extension (straightening).
-aim for 90 degrees flexion by discharge - stretching slow to end range (pain) - no sudden jerks.
-May have sutures or staples - which may remain in until weeks 2-3 or may have disolvable sutures.
-Take care to keep wound clean
-May have drain inserted if fluid gathers - normally removed day one post op.
-NORMAL DISCHARGE FROM HOSPITAL 1-3 days - depending on surgeon.
DAY 1 post op discharge on crutches weight bearing as able, partial to full weight bearing (FWB). If painful take GP advice on use of NSAIDS (Ibufren/Iboprofren) or painkillers.
If swelling persists may use ice, Cryocuff system and/or tubigrip.
SEE PHYSIO BY DAY 5 - 6 - 7.
McACL PHASE II MUSCLE RE-EDUCATION (Time spent : daily)
DAY 5/6:
-Should be PWB to FWB
-May be walking at home without crutches
-Use crutches for outdoors
-If FWB can you balance on that leg
-Should be bending (flexion) 90 degrees plus
-Should be straightening knee
-Wound should be clean and well closed
EXERCISES
(1) CO-CONTRACTION EXERCISES
(2) [i] SLR
[ii] SLR to flexion along bed - heel sliding 3 x 10 reps
[iii] SLR to flexion along bed - heel off bed
Can use a scarf / bandage to assist initially.
(3) Gentle push above/below knee to encourage extension if tight (check with physio if appropriate)
(4) SLR on bed over rolled up towel, plastic bottle or wedge to get end range extension, pull toes back push back of knee into bottle .
DO 3 sets 20 reps
(5) Leg press with dynaband if able -
PRONE (LYING ON FRONT)
(6) Flexion using good foot to assist or bandage / scarf to assist
(7) Extension (hip extension) with heel to wall/board (can also try with dynaband)
(8) If appropriate : Prone lying to encourage knee extension - let the weight of your foot straighten out your knee.
SITTING
(9) Flexion assisted stretch then straighten to SLR. (10) Bending to pull foot under chair can use other to assist
(11) Leg press with dynaband in sitting.
STANDING
(11) Lift Knee bending to the front - return to neutral- then bring heel to bottom
(12) Weight-bearing try to straighten knee - weight through heel
WALL EXERCISES
(13) Push back of knee into wall / slide heel up / then slide down to stretch / use other leg to assist.
WALKING
(14) Ensure walking pattern is natural
- ensure no limp if problem see physio ASAP
-POOL EXERCISES : ( from day 7)*
-may need waterproof dressing for wound.
-AQUA JOGGING (FLOATATION BELT)
(see appendix for programme)
-MAY EXERCISE IN POOL
-NO SWIMMING (especially no breast stroke)
-CAN UNI LEG CYCLE 20mins x 3 for stamina
-CAN DO UPPERBODY WEIGHTS
-N.B.* NO LEG QUADS WEIGHTS OPEN CHAIN
NO EXTENSION MACHINES
NO QUADS BAR WITH WEIGHTS
NO OUTER RANGE UNTIL MONTH 5
NO INNER RANGE UNTIL MONTH 9
*N.B.* CHECK THAT YOUR PHYSIO IS UP TO DATE ON THIS DATA
* ALL RECENT EVIDENCE AND RESEARCH SUGGESTS THAT OPEN CHAIN QUADS EXERCISES CAN STRETCH THE GRAFT AND MAY BE RESPONSIBLE FOR THE LACK OF SUCCESS OF A SMALL PERCENT OF THE PROCEDURES IN THE USA.
CLOSED CHAIN QUADS ARE SAFE (see phase III)
McACL PHASE III INTRO - STRENGTH PROPRIOCEPTION GYM - EARLY STAGE
Review by Day 14 - 21 maximum (daily if rehab at Physio Gym)
- Should now be FWB
-Off crutches
-No limp with good gait pattern
-Full SLR with no LAG
-Have full EXTENSION with no LACK
-Have 90 degrees + flexion
DANGEROUS COMPLICATION: PATELLAR GRAFTS : TENDONITIS AT INF. PATELLAR TENDON …. IF PAIN DEVELOPS STOP EVERYTHING
ROUTINE COMPLICATION HAMSTRING GRAFT : SPRAIN DISTAL HAMSTRING TENDON – TREAT AS ROUTINE HAMSTRING SPRAIN – PARTIAL TEAR
McACL PHYSIO TO TEST FOR REHAB:
(1) STEP UPS (2) STEP DOWNS (3) STEP BACKS
(4) Raised seat CYCLE - slow initially progress to 4 x 5 mins slow to moderate speed
(5) One third WALL SQUAT / PROGRESS TO carefully SQUAT AT CHAIR
(6) POOL AQUA JOGGING
(7) ROWING MACHINE - Small range initially
(8) LIGHT HAMSTRING Closed Chain – leg press
(9) DYNABAND unisquats : 3 x 5 each direction.
(10) PROPRIOCEPTIVE. BALL BALANCE EXERCISE : 5 mins.
(11) continue with gentle stretching into flexion as appropriate – do not push or force to end range
McACL PHASE III FULL STRENGTH/PROPRIOCEPTIVE PROGRAMME
(Start approximately week 6-10 to ongoing)
-Should have full ROM
-Able to do FRONT STEP UPS
-Light hamstring Open/Closed Chain
-One third/one half wall squat
-Step downs short height
-Step backs
-Row / Cycle / Aqua Jog
GYM PROGRAMME - PHASE III (3-5 sessions per week / step downs daily)
(1) CYCLE WARM UP 5 mins
(2) STRETCH
(3) ENDURANCE CYCLE 20 min programme
(4) STRETCH
STEP PROGRAMME
1st WEEK PROGRESS TO
(5) STEP UPS 2 x 25 2 x 50
(6) STEP BACK 2 x 25 1 x 25
(7) SIDE X 2 x 25 2 x 50
(8) SPLIT single 2 x 25 1 x 50
(9) SPLIT double 1 x 50 2 x 50
(10) STEP DOWN 2 x 10 2 x 25 each leg
(11) SHORT HOP UP 1 x 10 1 x 10
(12) HOP DOWN Short x 10 *Long x 10 ( don't start until 2nd week Phase III )
*With twist x 5 each direction
(13) RUNNING PATTER ON SPOT 1 min SLOW
30 secs FAST
1 min MED
*CAN USE MINITRAMP 1 min FAST
IF AVAILABLE* 30 sec MED
30 sec FAST
30 sec MED to FINISH
(14) SQUAT with BALL to CHAIR 2 x 25 (can do as Plyometrics)
(15) HEEL FLICKS x 1 min
(16) LEG PRESS 3 X 10 ( 2 legs build to 50% then 100% - eventually 200% BODY WEIGHT
(17) SQUAT LUNGES (as comfortable) Build to 2 x 25
(18) STEP MACHINE if available 1 - 2 sessions per week (5 mins progress to 20 mins)
(19) BALL BALANCE 2-3 MINUTES
Week 8 - 10 - CONE DRILLS - SINGLE LEG HOPS
(22) HOP TO CONES x 5 sets (Stretch out to reach - vary distance) one foot to other.
(23) HOP BETWEEN CONES CAPS EACH DIRECTION
(24) SHUFFLE - THE GORMLEY SHUFFLE as above but 2 over and 1 back - each direction
(repeat x 4 each direction)
(28) OUTDOOR - use MOUNTAIN/ROAD BIKE - 20 mins plus for stamina
NB* STRENTHENING / WEIGHT TRAINING PLEASE READ.
OPEN KINETIC CHAIN vs
All torsion or force transmits directly through the knee joint and through the ACL which acts as hinge or turning point for the weight - producing a pull on the graft which could stretch it and potentially undo the purpose of the repair. The graft would not 'pop' or rupture but would be simply ineffective.
EXAMPLES OPEN CHAIN (BANNED)
-Seated Leg Extensions - with cable or free weights
-Quads Bar with weight
-Seated Leg Boot
-Isokinetic machine open chain
-Prone Leg weights (Westminister Pully)
-Manual Resistance*
-Dynaband*
(*can be modified to closed chain)
-Kicking
CLOSED KINETIC CHAIN
All torsion or force is transmitted through the limbs - from foot to lower leg to femur to hip - using the various muscle groups with a minimal even force - no directed torsion on the knee or any other joint - safe but effective way of strengthening QUADS in the first 6 to 9 months.
EXAMPLES CLOSE CHAIN (SAFE)
-Leg Press
-Squats - Body weight
- Free weight
-Step Machine
-Squat Lunge
-Step ups
-Cycling
-Rowing Machine
-Isokinetic Machine - Closed chain set up
-Plyometrics
McACL PHASE IV PITCH PROPRIOCEPTIVE DRILLS (week 12/16+)
-GYM PROGRAMME - continue step ups / weights etc.
-START LIGHT PLYOMETRICS WITH McACL PHYSIO,-small range bounding (both legs)
-tyre drills
-low hurdle - front/side on. Progress as able.
-ON THE PITCH (Early stage) (TO BE TESTED BY McACL PHYSIO)
Drills primarily suited for GAELIC FOOTBALL, SOCCER, AND RUGBY, but can be adapted to suit sport as appropriate.
1) Light Jog - increase over weeks to one half then three quarters pace
2) Side steps with cross overs
3) Hill/Slope - Hops each direction x 6 reps : try wet / muddy conditions.
4) Backward running
5) Hops over ball - landing one leg / then with twist - keep balance
6) Cones as gym programme
(Late stage/2-3 weeks later)
7) Up/Down drill ( 'Death Squats') 2 x 10
8) Mirror drill 6 sets ( 1st 30 secs / then 5 x 15 secs)
9) Push over drill - running deceleration / acceleration ( approx 10 each)
FITNESS -running progress to 8 lengths/8 breadths - one half to three quarters pace. Interval running with no break.
-progress to slopes - hill jogging.( AVIOD STEEP DOWN HILL)
GAA - running toe to hand with ball.
RUGBY - running passing drills
SOCCER / BASKETBALL - running dribbling drill
-mountain bike 2-3 per week.
McACL PHASE V PROTECTED TURNS & TACKLES
(approx week 16-18 depending on progress phase 3-4)
-continue FITNESS WORK
-continue WEIGHTS/STEP UPS 2 nights at least
-continue PITCH CONE DRILLS
-continue MIRROR one on one drill
PROTECTED TURNS & TACKLES (TO BE TESTED BY McACL PHYSIO - Essential)
-may wear a PROTECTIVE BRACE early stages if needed.
-must do each drill slow then build on speed/angle of turn
PROTECTED TURNS & TACKLES (TO BE TESTED BY McACL PHYSIO - Essential)
1) Jog at half to three quarters around cone/corner flag over 10-15m. Repeat both directions x 15 sharp on turn / no braking - Build to sprint.
START
SHARP TURN
2) CROSS OVER DRILL
3) CROSS over introduce Ball pick up at each side.
4) CROSS OVER DRILL - introduce player at centre cone to light tackle - force side step.
5) RUN THE GAUNTLET : A &B race on diagonal runs around the cones, encouraging turns and side-step, possible bodycheck or shoulder tackle.
6) SPEED DRILLS - SPRINTS with turns
-SPRINT from press up position
-SPRINT to recover ball kicked between cones.
7) BALL WORK -AS APPROPRIATE TO SPORT.
SOCCER / GAELIC KICKING start initially with kids light ball for kicking.
GAELIC take care 1st kicking full weight O'Neill's, but CATCH AND KICK with plenty of running to meet the ball/turning/fist etc. can do 20 mins work 1-2 per week - excellent drill!
PHASE VI - FULL TURNS & TACKLES (month 5+)
- TO HAVE COMPLETED PHASE V & McACL PHYSIO TESTING.
- NOW WITHOUT BRACE IF POSSIBLE.
1) ONE ON ONE FULL TACKLING - SPORT SPECIFIC
high
trainer throws in ball between 2 chest ADAPT TO SUIT: RUGBY; GAELIC;
low BASKETBALL etc.
trainer rolls ball along ground.
2) with PARTNERS 2 on 2 - full tackling drill - for example passing ball between 2 on 2 - score 1st to get 4 consecutive passes - enourage opposition to put in full shoulder/bodycheck tackle - push and pull etc.
3) if larger number available try above with 3 on 3 and 4 on 4 etc.
-do drill over small area to encourage contact.
PHASE VIII TO X ON COMPLETION OF & McACL PHYSIO TEST OF PHASE VI
*SPEND TIME AT EACH PHASE VII TO IX UNTIL CONFIDENT (normal 2-6 weeks each)
*MAXIMUM USE OF COACH TO WATCH, CHECK, CORRECT TECHNIQUE.
APPENDIX
Mc AQUA-JOG PROGRAMME
Swimming has long been recognised as a popular form of rehabilitation, however one of it’s drawbacks is that it dosn’t isolate the muscles used for running, and swimming may apply unwanted torsional or twisting forces to those with knee injuries.
In response to this AQUA JOGGING or DEEP WATER RUNNING has been developed and used effectively to allow the athlete to maintain levels of both cardiovascular fitness, local muscle endurance and SPEED.
A recent study at QUB SPORTS’ PHYSIOLOGY DEPT. has shown that Footballers will NOT LOOSE BUT CAN ACTUALLY BUILD ON THEIR LEVEL OF FITNESS by deep water running. At whatever rate running : 1/2, 3/4 or sprint - one circuit of a diving pool has a similar effect to one circuit of a pitch.
Keep the running action to that of running in a high sprint. If you lean forward you will move forward down the pool.
NB* IT IS VERY IMPORTANT TO STRETCH AND WARM-UP EVEN BEFORE YOU HIT THE WATER AS MUSCLES ARE MORE LIKELY TO CRAMP WHILE IN COOL WATER.
WARM-UP: OUT OF :POOL STRETCH ALL MUSCLE GROUPS
WARM-UP: IN POOL:DO 2 LAPS OF DIVING POOL/ OR 8 WIDTH’S OF SWIMMING POOL AT 50% MAX. ( FINISH WITH STRETCH IN THE POOL).
STAMINA BASE: 5 LAPS OF DIVING POOL/ OR 20 WIDTH’S OF SWIMMING POOL (CONTINUOUS- NONSTOP RUNNING AT 60% MAX ;BUILD AT SESSION 2 TO 75%;SESSION 3 TO 80% FOR MAX EFFECT).
SPEED WORK: SPRINT 10metre x 5
SPRINT 20metre x 5
SPRINT 10metre x 5
WARM DOWN: 1 LAP OF DIVING POOL/ OR 4 WIDTH’S OF SWIMMING POOL AT 30-40% MAX/ STRETCH SLOWLY AND DO NOT BOUNCE INTO IT, ON LEAVING THE POOL.
FREQUENCY: MAX:DAILY / MIN: 3 SESSIONS PER WEEK.
STOP 2 DAYS BEFORE A GAME.