Exploring the Factors Contributing to Post-Operative ACL Dysfunction

PATIENT PROFILE

Age: 22

Gender: Male

Occupation: Student

CHIEF COMPLAINTS

The patient presented with pain, swelling in the left knee and difficulty in walking following surgery.

HISTORY

The patient sustained an injury to his left knee in July 2025 while playing football. During the game, he experienced a sudden twisting movement, following which he developed pain and swelling in his left knee, accompanied by difficulty walking.

Towards the July 2025, the patient consulted a doctor, who advised him to use a knee brace, which he wore for a short duration. He was also instructed to perform basic exercises.

As the symptoms persisted, the patient underwent an MRI scan at the end of July 2025. The MRI findings revealed:

  • Complete tear of the Anterior Cruciate Ligament (ACL)
  • Bone contusion
  • Partial meniscal tear

Following the MRI report, the patient consulted an orthopaedic surgeon, and surgical intervention was advised. The patient subsequently underwent left knee ACL reconstruction surgery on end of July. Post-operatively, he was admitted to the hospital for 3–4 days, during which he performed basic post-operative exercises.

After discharge, the patient continued only basic exercises at home for approximately one month, without structured physiotherapy.

In September 2025, the patient presented to our physiotherapy department for consultation and rehabilitation with the intent to return to his sporting activities.

Activity Level (Pre-Injury):

Recreational football, low-structured conditioning.
 
Surgery Date:
28th July 2025
 
Rehab Initiation:
September (≈1 month post-op without structured physiotherapy)

 

Overview:

  • The patient is in post-operative status after left knee ACL reconstruction.
  • Complaints of knee stiffness 
  • Difficulty in bending and straightening the knee
  • Difficulty in walking and climbing stairs

 

Physical Activity Status:

Previously, the patient had a moderate level of physical activity as he played football occasionally without regular strength or conditioning.

Sleep
6-7 hours a day

Stress Levels
The patient reported a low stress level.

PAIN ANALYSIS

Aggravating factors: Prolonged walking, Stair climbing, squatting and kneeling

Relieving factor: Rest

Location: pain is located over the anterior and medial aspect of the knee joint.

Irritability: Low

Sensitivity: Mild

Fear of movement: Hesitation to move the knee flexion fully. Avoids activities that cause pain or instability. 

Lifestyle impact: 

Limited daily activities, stopped sports and running and reduced confidence in movement

Takeaway From History And Pain Analysis

  • Patient demonstrates movement avoidance due to pain provocation. Kinesiophobia (fear of re-injury) is evident. 
  • Further physical examination is needed to guide his management and train him to return to sports.

PHYSICAL EXAMINATION:

Observational findings:

  • Limping gait
  • Mild swelling
  • Left Quadriceps wasting
  • Terminal Extension lag on the left knee joint

Mobility screening:

Knee flexion ROM: Reduced in left side

Knee extension: Lag was present in the left knee. Incomplete knee extension.

Overhead squat: Reduced depth with a slight right-sided weight shift

INVESTIGATIONS:

MRI – MRI was taken on 26 July 2025. It showed a complete ACL tear with associated partial meniscal tear and bone contusion, with mild joint effusion.

DIAGNOSIS:

1. Belief and expectation of the patient:

The patient believes that surgery and physiotherapy will help him return to football and expects to regain full knee strength and stability. He is highly motivated to return to his pre-injury level of sports participation and is committed to the rehabilitation process. 

2. Patient’s perception of pain:

The patient perceives the pain as mild to moderate and activity-related, especially during weight-bearing and knee-bending activities. 

He understands that the pain is part of the normal post-operative healing process and expects it to gradually reduce with rehabilitation.

3. Psycho-social factor analysis:

  • Cognitive: Mild fear of re-injury and movement hesitation
  • Affective: Emotional concern due to reduced activity level and sports restriction.   
  • Social: No significant social limitation

4. Diagnosis with Clear Explanation:

POST-OPERATIVE ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION – LEFT KNEE. 

The patient’s current complaints are associated with the following clinical findings:

  • Post-surgical pain with mild joint swelling
  • Reduced knee range of motion
  • Quadriceps and hamstring muscle weakness (identified through Limb Symmetry Index comparison)

TREATMENT PLANNING:

Detailed Treatment Strategies

Phase 1: Sessions 1–5

Focus: Pain control, swelling reduction, and full ROM

Goals

  • Reduce pain and effusion
  • Achieve full knee extension
  • Gradually improve knee flexion ROM
  • Activate quadriceps
  • Initiate safe weight bearing

Interventions

Pain & Swelling Management

Range of Motion

  • Passive and active-assisted knee extension
  • Heel prop / towel under ankle for extension
  • Heel slides for knee flexion
  • Wall-assisted flexion exercises

Muscle Activation (Assisted Strengthening)

  • Quadriceps setting (isometrics)
  • Hamstring isometrics
  • Leg extension isometric (with assistance if needed)
  • Assisted hip abduction/adduction

Gait Training

  • Partial to full weight bearing as tolerated
  • Emphasis on heel strike and knee extension

Phase 2: Sessions 6–10

Focus: Bilateral strengthening and functional control 

Goals

  • Achieve near full ROM
  • Improve muscle strength
  • Initiate closed-chain activities
  • Improve weight-bearing symmetry

Interventions

Closed Chain Strengthening

  • Assisted bilateral squats
  • Sit-to-stand training
  • Mini squats (0–45°)
  • Wall squats

Lower Limb Strength

  • Step-ups (low height)
  • Assisted lunges (bilateral support)
  • Leg press (light resistance)

Hip & Core Stability

  • Clamshells
  • Side-lying hip abduction
  • Bridging
  • Side plank (basic)

Phase 3: Sessions 11–20

Strength Symmetry Phase

Strength analysis:  

Limb Symmetrical Index (post-rehab status)

Muscle GroupRightLeft
Single Leg Squats11 reps12 reps
Hamstring Crane Scale29.0 kg27.0 kg
Side Plank Leg Lift (Hold)51 sec1:10 sec
Calf Raise25 reps25 reps

Unilateral Strengthening

  • Single-leg squats
  • Step-downs
  • Single-leg leg press
  • Bulgarian split squats
  • Single-leg bridge

Phase 4:Plyometric

Goals

  • Improve power and landing mechanics
  • Achieve symmetrical performance

Plyometric Training 

Double-leg

  • Jump and hold
  • Squat jumps
  • Box jumps (low height)

Unilateral

  • Single-leg hop and hold
  • Forward hop
  • Lateral hops
  • Triple hop

Agility & Sport-Specific

  • Side shuffles
  • Cutting drills
  • Acceleration–deceleration drills

Landing Training

Emphasis on:

  • Soft landing
  • Knee alignment (avoid valgus)