GENERAL GUIDELINES
- Allograft revascularization is slower than for autografts. Therefore, crutches and brace are continued for 6 weeks
- CPM not commonly used
- ACL reconstructions performed with meniscal repair or transplant follow the ACL protocol with avoidance of open kinetic chain hamstring work for 6 weeks. Time frames for use of brace and crutches may be extended by the physician
GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING
Patients may begin the following activities at the dates indicated (unless otherwise specified by the physician):
- Bathing /showering without brace after suture removal
- Sleep with brace locked in extension for 1 week
- Driving: 1 week for automatic cars, left leg surgery, 4-6 weeks for standard cars or right leg surgery
- Brace locked in extension for 1 week for ambulation
- Use of crutches, brace for ambulation for 4-6 weeks
- Weight-bearing – PWB of 50%
PHYSICAL THERAPY ATTENDANCE
The following is an approximate schedule for supervised physical therapy visits:
| Phase I | (0-6 weeks): | 1 visit / week |
| Phase II | (4-6 weeks): | 2-3 visits / week |
| Phase III | (2–6 months): | 2-3 visits / week |
| Phase IIII | (6 months+): | Discharge after completion of appropriate functional progression |
REHABILITATION PROGRESSION
The following is a general guideline for progression of rehabilitation following ACL patellar tendon autograft reconstruction. Progression through each phase should take physician advisement. Please consult the physician if there is any uncertainty concerning advancement of a patient to the next phase of rehabilitation.
PHASE I
Begins immediately post-op through approximately 4 weeks
Goals:
- Protect graft fixation
- Minimize effects of immobilization
- Control inflammation
- Full extension range of motion
- Educate patient on rehabilitation progression
Brace:
| 0-1 week: | locked in full extension for ambulation, sleeping |
| 1-4 weeks: | unlocked for ambulation, remove for sleeping |
Weight-Bearing Status:
| 0-4 weeks: | PWB (50%) with 2 crutches |
Therapeutic Exercises:
- Heel slides
- Quad sets, hamstring sets (consider NMES for poor quad sets)
- Patellar mobilization
- Non-weight bearing gastroc/soles, hamstring stretches
- SLR, all planes, with brace in full extension until quadriceps is sufficient to prevent extension lag
- Quadriceps isometrics at 60º and 90º
PHASE II
Begins approximately 4 weeks post-op and extends to approximately 6 weeks
Criteria for advancement to Phase II:
- Good quad set, SLR without extension lag
- Approximately 90 degrees of flexion
- Full extension
- No signs of active inflammation
Goals:
- Initiate closed chain kinetic exercises
- Restore normal gait
- Protect graft fixation
Brace / Weight-Bearing Status:
- Discontinue use of brace and crutches as allowed by physician when the patient has full extension and can SLR without extension lag
- Patient must exhibit non-antalgic gait pattern. Consider using single crutch or cane until gait is normalized
Therapeutic Exercises:
- Wall slides 0-45 degrees progressing to mini squats
- 4 way hip
- Stationary bike (begin with high seat, low tension to promote ROM, progress to single leg)
- Closed chain terminal extension with resistive tubing or weight machine
- Toe raises
- Balance exercises (e.g. single-leg balance, KAT)
- Hamstring curls
- Aquatic therapy with emphasis on normalization of gait
- Continue hamstring stretches, progress to weight-bearing gastroc / soleus stretches
PHASE III
Begins at approximately 6 weeks and extends through approximately 6 months
Goals:
- Full range of motion
- Improve strength, endurance and proprioception of the lower extremity to prepare for functional activities
- Avoid overstressing the graft fixation
- Protect the patellofemoral joint
Therapeutic Exercises:
- Continue and progress previous flexibility and strengthening activities
- Stairmaster (begin with short steps and avoid hyperextension)
- Nordic Track
- Knee extensions 90-45 degrees and progress to eccentrics
- Advance closed kinetic chain activities (leg press, one-leg mini squats 0-45 degrees of flexion, step-ups beginning at 2” and progress to 8, etc.)
- Progress proprioception activities (slide board, use of ball, racquet with balance activities, etc.)
- Progress aquatic program to include pool running, swimming (no breaststroke)
PHASE IV
Begins at approximately 6 months and extends through approximately 9 months
Criteria for advancement to Phase IV:
- Full, pain free ROM
- No evidence of patellofemoral joint irritation
- Sufficient strength and proprioception to initiate functional activities
- Physician clearance to initiate advanced closed kinetic chain exercises and functional progression
Goal:
- Continue and progress previous flexibility and strengthening activities
- Functional progression including:
- Walking / job progression
- Forward / backward running at ½, ¾ and full speed
PHASE V
Begins at approximately 9 months post-op
Criteria for advancement to Phase V:
- No patellofemoral or soft tissue complaint
- Necessary joint ROM, strength, endurance and proprioception to safely return to work or athletics
- Physician clearance to resume partial or full activity
Goals:
- Initiate cutting and jumping activities
- Completion of appropriate functional progression
- Maintenance of strength, endurance and proprioception
- Patient education with regards to any possible limitations
Therapeutic Exercises:
- Functional progression, including but not limited to:
- Walk / job progression
- Forward / backward running at ½, ¾ and full speed
- Cutting, cross-over carioca, etc.
- Plyometric activities as appropriate to patient’s goals
- Sport-specific drills
- Safe, gradual return to sports after successful completion of functional progression
- Maintenance program for strength and endurance
Bracing:
Functional brace may be recommended by the physician for use during sports for the first 1-2 years after surgery