ACL Reconstruction Functional Rehabilitation Protocol

Formal physical therapy and sport specific training will last 8-12 months. All patients will be issued a neuromuscular electric stimulation unit (NMES) for home use with guidelines.

Activities of Daily Living Guidelines Following Surgery

Patients may begin the following activities at the timeframes indicated (unless otherwise specified by the physician):

• No bathing or submerging the wound in water until the sutures have been removed, the scabs have fallen off, and the skin is completely closed
• Showering is allowed after the surgical dressing is removed; a waterproof dressing is not needed as the incision can get wet. A shower seat is advised to avoid falls
• The brace will be locked in extension for gait and sleep for the first week
• Use of crutches and brace for ambulation for 4-6 weeks. Must be cleared by physician and/or physical therapist to begin walking without assistive devices
• Weight-bearing as tolerated immediately after surgery unless otherwise instructed
• For R knee surgery, no driving for 4-6 weeks. As long as they are in the brace, patients are medically liable if in an accident.  For L knee surgery, patients may drive after 1 week as long as they have an automatic and have stopped taking narcotics.
  • Must pass driving test for R knee: While sitting, complete 8 fast foot taps over shoe then stand up

Brace and Crutch Use Guidelines

Patients will be WBAT after surgery. The post-op brace is locked in extension initially for the first week with the exception that it may be unlocked for post-op exercises and CPM use. It is unlocked for walking once the patient reaches full knee hyperextension, usually 1 week post-op.

BRACE IS DISCONTINUED WHEN:

• The patient is at least 4-6 weeks post-op
• The patient has full and equal passive and active knee hyperextension and >100° flexion
  • Active knee extension is measured via straight leg raise
• The patient demonstrates normal pain-free walking without an increase in swelling

CRUTCHES ARE DISCONTINUED WHEN:

• The patient will initially be WBAT with 2 crutches for 4 weeks; they will then transition to one crutch before walking without the crutches over the next 2 weeks
• The patient has full and equal passive and active knee hyperextension and >100° flexion
• The patient is able to walk and maintain the knee in full extension without use of assistive device (i.e. does not walk with “bent knee” gait pattern)
• The patient has no increased knee pain or swelling with independent weightbearing

Special weightbearing guidelines for concomitant procedures

• The brace will be worn at least 6 weeks for combined ACL/MCL procedures, concomitant meniscal repairs, and microfracture procedures
• MENISCUS REPAIR: Patients that also undergo a meniscus repair procedure will be NWB for 4 weeks, 50% WB for 2 weeks, then WBAT after 6 weeks
• MICROFRACTURE or ARTICULAR CARTILAGE PROCEDURE: Patients that also undergo a microfracture or articular cartilage procedure will be NWB for 4 weeks, 50% WB for 2 weeks, then WBAT after 6 weeks

Estimated Return to Sport Milestones (based on graft healing time and passing functional testing):

	Jogging	Low-level Agility	Jumping	Cutting	Return to Sport
Bone-Patellar Tendon-Bone Autograft	4-5 months	5-6 months	6-7 months	7-8 months	9+ months
Hamstring/Quad Tendon Autograft	4-5 months	5-6 months	6-7 months	7-8 months	9+ months
Bone-Patellar Tendon-Bone Allograft	5-6 months	6-7 months	7-8 months	8-9 months	10+ months
Soft Tissue Allograft	5-6 months	6-7 months	7-8 months	8-9 months	10-12+ months

These times are estimated based on graft healing and are dependent upon the patient passing functional testing in physical therapy that assesses strength and neuromuscular control. These times may be longer if the patient also had a concomitant procedure such as a meniscal repair, microfracture/articular cartilage procedure and other ligament injury or procedure. They physician may also order an MRI to assess graft healing to assist in making return to sports activity decisions.

Phase 1: Initial Post-Op Care

Goals for Phase 1 include restoration of ROM and mobility, management of pain and edema, and initiation of strengthening with emphasis on the quadriceps. The post-operative brace may be removed for treatment. Closed kinetic chain (CKC) exercises should be performed in the protected range of 0-45° of flexion and open kinetic chain (OKC) knee extension exercises should stay in the protected range of 90-60° of flexion. Exercises should include but are not limited to:

Weeks 1-4:

• 4-way patella mobilization
• High intensity neuromuscular electrical stimulation
• Exercises to regain hyperextension – hamstring and gastrocnemius stretching, prone hang, manual overpressure, seated heel props with bag hang and/or with cuff weights
• Exercises to regain full flexion – heelslides, posterior tibial mobilizations
  • Flexion is limited to 90° for 4 weeks with concomitant meniscus repairs
• Early strengthening – quad sets in full knee hyperextension, 4-way straight leg raises, terminal knee extension (CKC), mini-squats, isometric quadriceps setting at 90° and 60° of knee flexion
• Balance and proprioception exercises – progressing from weight shifting during bilateral stance progressing to unilateral stance exercises on stable and unstable surfaces, with eyes open and eyes closed
• Gait training – weight-shifts (side to side and forward/backward)
• Progress strengthening to include – leg press (single leg), OKC knee extension from 90-60° with ankle cuff weights, step-ups, step-downs, bridges, hamstring curls, wall slides
• No OKC hamstring curls with concomitant meniscal repair or hamstring autograft for first 6 weeks

Goals at 2 weeks post-op include:

• Passive and active hyperextension (as measured when doing a straight leg raise) should be equal to the uninvolved side and flexion >100°
• Reduced pain and swelling (rated 2+ or less via Stroke Test)
• If SLR doesn’t reach neutral extension (0°) by 2 weeks post-op, increase frequency of PT and notify the physician

Goals at 4 weeks post-op include:

• Full flexion (unless ROM restriction from concomitant meniscus repair)
• No active inflammation (i.e. no increased pain, swelling or warmth) as a result of exercise. Swelling should be rated 1+ or less via Stroke Test
• Preparation for full weightbearing and independent gait

The patient’s visit frequency will be set by the PT for 1-3 times per week. If the patient is not meeting the range of motion milestones or if they are having difficulty with regaining quadriceps control/have a knee extensor lag, the MD should be notified and visit frequency should increase.

Weeks 4-16:

• Stretching exercises and manual therapy if flexion or extension is still limited
• Cardio – bike, elliptical
• Gait training on treadmill progressing to fast treadmill walking
• Aquatic therapy (if available) – 4-way straight leg raises, squats, bicycle kicking, fast walking progressing to a jog
• Progress strengthening to include – OKC knee extension (90-60° for the first 10 weeks, 90-45° for weeks 10-16), single leg squats, lunges, mini-band walking, deadlifts, step and holds
• Perturbation training

PT should focus on aggressive strengthening, particularly of the quadriceps. Visit frequency may be reduced if the patient has regular access to weight training equipment at a gym.

Weeks 16-20:

• CKC exercises should be progressed to ~60-75° of knee flexion provided that this does not cause any patellofemoral pain.
• OKC exercises should be progressed to full range 90-0° provided that this does not cause any patellofemoral pain.
• Prepare to pass screening exam to begin running

Goal at 4-6 months post-op (depending on graft type): PASS SCREENING TEST TO BEGIN RUNNING

• No abnormal gait patterns while walking as fast as they can on the treadmill for 15 minutes
• 30 step and holds without loss of balance or excessive motion outside of the sagittal plane
• 10 consecutive single leg squats to 45° of knee flexion without loss of balance, abnormal trunk movement, Trendelenburg sign, femoral IR or the knee deviating medially causing the tibial tuberosity to cross an imaginary vertical line over the medial border of the foot
• ≥ 80% 1-repetition maximum (1-RM) on the leg press (90-0°)
• ≥ 80% 1-repetition maximum (1-RM) on the knee extension machine (90-45°)
• ≥ 90% composite score on Y-balance test. Composite score = (anterior reach + posteromedial reach + posterolateral reach)/(3 x limb length)

Phase 2: Running

Begin jogging on a treadmill or a track when the patient passes the screening exam AND is cleared by the physician. Running should begin at slow, comfortable speeds for short durations and distances. The patient may progress in speed, time and distance as long as there is no development or increase in pain, swelling, warmth, or gait deviations. See Running Progression Guidelines handout.

The patient should be seen by the physical therapist once every 2-3 weeks while running tolerance and endurance progresses. Aggressive strengthening should continue in preparation to pass the screening test to begin agility drills.

Patients who undergo a Quadriceps tendon autograft with bone plug will need an x-ray at their 6 month post-op visit in order to be cleared for Biodex testing to ensure healing of the harvest site.

Goals at 5-7 months post-op: PASS SCREENING TEST TO BEGIN
LOW-LEVEL AGILITY DRILLS

• ≥ 85% 1-RM on the leg press (90-0°)
• ≥ 85% 1-RM on the knee extension machine (90-0°) or Biodex testing if available
• 10 consecutive single leg squats >45° of knee flexion without loss of balance, abnormal trunk movement, Trendelenburg sign, femoral IR or the knee deviating medially causing the tibial tuberosity to cross an imaginary vertical line over the medial border of the foot while holding ≥ 75% extra weight compared to the other side (dumbbells, weight vest, etc.) Body weight is not part of the equation
• 100% composite score on Y-balance test. Composite score = (anterior reach + posteromedial reach + posterolateral reach)/(3 x limb length)
• Be able to run 2 miles continuously without pain, swelling, warmth or gait deviations

Phase 3: Agility Training

When the patient passes the screening exam AND is cleared by the physician, they may begin agility drills that include lateral shuffling, forward/backward shuttle runs, carioca, and ladder drills.

Physical therapy should focus on elimination of compensation patterns, particularly when the patient decelerates. Aggressive strengthening should continue in preparation to pass the screening test to begin jumping.

Patients may also enroll in the UPMC Return to Sport Program through UPMC Sports Performance at this time if they are planning to return to sports participation.

If the patient is not planning to return to sports participation, they may be discharged from PT once they are able to do agility training at sub-max speeds without new inflammation.

Goals at 6-8 months post-op: PASS SCREENING TEST TO BEGIN JUMPING

• ≥ 90% 1-RM on the leg press (90-0°)
• ≥ 90% 1-RM on the knee extension machine (90-0°) or Biodex testing if available
• 10 consecutive single leg squats to 60° of knee flexion without loss of balance, abnormal trunk movement, Trendelenburg sign, femoral IR or the knee deviating medially causing the tibial tuberosity to cross an imaginary vertical line over the medial border of the foot while holding ≥ 85% extra weight compared to the other side (dumbbells, weight vest, etc.). Body weight is not part of the equation
• No compensation patterns with deceleration during agility drills performed at near 100% effort

Phase 4: Jumping (Two Feet)

When the patient passes the screening exam AND is cleared by the physician, begin jumping. Jumping is with 2 feet, both taking off and landing.

Jumps should start with single vertical jumps and the physical therapist should watch for medial collapse of the knees both when loading into the jump and landing from the jump. When the patient demonstrates consistent equal weightbearing when landing, progress with forward, side to side, rotating, and box jumps. As the patient demonstrates consistent good form, progress from single jumps to consecutive jumps.

Physical therapy should focus on teaching the patient soft, athletic landings and avoidance of compensation strategies. Aggressive strengthening should continue in preparation to pass the screening test to begin hopping and cutting.

Goals at 7-9 months post-op: PASS SCREENING TEST TO BEGIN CUTTING AND HOPPING

• 10 consecutive single leg squats to 60° without loss of balance, abnormal trunk movement, Trendelenburg sign, femoral IR or the knee deviating medially causing the tibial tuberosity to cross an imaginary vertical line over the medial border of the foot while holding ≥ 90% extra weight compared to the other side (dumbbells, weight vest, etc.). Body weight is not part of the equation
• No display of medial collapse of the knees when loading into or landing from jumps, and equal weight distribution when initiating and landing the jumps

Phase 5: Hopping (Single Leg) and Cutting

When the patient passes the screening exam AND is cleared by the physician, they may begin hopping and cutting. Hopping is with 1 foot, both taking off and landing. Hopping should follow the same progression as jumping.

Patients should first practice running in an “S” pattern, then progress to 45° cuts, and then to sharper angles. Pivoting and cut and spinning should begin when the patient is competent with cutting at sharp angles. Patients should be able to tolerate cutting, pivoting and cut and spinning at full speed before practicing unanticipated cutting. The patient should not progress their speed if they demonstrate any excessive knee medial deviation or express a lack of confidence when cutting.

Sprinting should begin with transitions from running directly into sprinting short distances. Distance should be progressed to sprinting a 40 yard dash, then a 100 yard dash, and finally sprints to fatigue.

Physical therapy should focus on improving the form and speed of hopping and cutting. Aggressive strengthening should continue in preparation to return to sports participation.

Goals at 9-12 months: PREPARE TO TAKE RETURN TO SPORTS TEST

• Display a normal running pattern that does not increase pain, swelling, or warmth
• Practice and display no hesitation or compensation strategies during agility drills (particularly when decelerating) when performed at 100% effort
• Practice and display normal loading (no medial knee collapse) and soft, athletic landings from all jumps and hops
• Practice and display no hesitation or compensation strategies during cutting drills (particularly when decelerating) when performed at perceived 100% effort

Returning to Sports Participation

The patient should be able to perform all agility, plyometric, and cutting exercises at full speed without compensation patterns or complaints of pain, swelling, or warmth. Exercises should include anticipated and unanticipated cutting and jumping.

Physical therapy should be geared on sport specific training as per the patient’s sport and position.

The patient may return to sports participation when they pass the ACL Return to Sports Test AND receive clearance by the physician.