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The goal of this protocol is to provide a clinical guideline for the post-surgical course of physical therapy for a patient who has had a hamstring tendon allograft Anterior Cruciate Ligament (ACL) reconstruction. This is not intended to substitute clinical decision making regarding the patient’s proper progression based on evaluation findings, individual progress, and if/when post-operative complications arise. If a clinician requires assistance in the progression of a post-surgical patient the surgeon should be consulted.
GENERAL GUIDELINES:
- Protection of the graft during the primary re-vascularization phase (8 weeks) and graft fixation phase (8-12 weeks)
- Continuous passive motion machine not commonly used
- For ACL reconstruction, with associated meniscus repair, defer to ROM and weight bearing precautions outlined in the meniscus repair protocol
- The physician may change the time guidelines for braces and crutches
- Supervised physical therapy takes place for 4-7 months
- Use caution with hamstring stretching/strengthening; based on donor site morbidity and with meniscus repair.
GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING (ADLs)
- No bathing/showering until after suture removal. Sponge bath only. Brace may be removed for bathing/showering.
- Sleep with brace locked in extension for 1 week or as directed by PT/MD for maintenance of full extension.
- Driving:
- 1 week for automatic cars, left leg surgery
- 2-4 weeks for standard cars, or right leg surgery
- Post-op brace:
- Week 0-1: Locked in full extension for ambulation and sleeping
- Week 2-3: Unlock brace (< 90°) as quad control improves
- Week 3-4: Wean off brace if patient demonstrates good quad control and normal gait
- Use of crutches/brace for 4 weeks with adequate quad function
- Partial weight bearing (PWB) for 0-1 weeks with crutches and brace
- Pass VTFC Knee Functional Performance Test 1 at 3 months
- Pass VTFC Knee Functional Performance Test 2 at 6 months
- Return to work as directed by PT/MD based on work demands
Rehabilitation Progression
PHASE I: Week 0 – 4:
Goals:
- Protect graft and graft fixation with use of brace and specific exercises
- Minimize effects of immobilization
- Promote an optimal healing environment and control inflammation and swelling
- Full active and passive extension/hyperextension ROM. Caution: avoid hyperextension > 10°
- Educate patient on rehabilitation progression
- Flexion to 90° only in order to protect graft fixation
- Facilitate quadriceps control to minimize quad lag
- Restore normal gait on level surfaces
Brace:
- Week 0-1: Brace locked in full extension for ambulation and sleeping
- Week 1-4: Unlock brace (< 90°) and wean from brace as quad control allows and normal gait.
- Week 4-8: Only use brace in vulnerable situations (ie. crowds, uneven terrain, etc)
Weight Bearing Status:
- Week 0-1: As able. May require 2 crutches for partial weight bearing based on post-op instructions
- Week 1-4: As able. May require PWB to full weight bearing with normal gait mechanics
- > Week 4: Wean from brace/crutches by 4 weeks as patient demonstrates normal gait mechanics and good quad control with no quadriceps/extension lag
Exercises:
- Active-assisted leg curls (0-1 week)
- Progress to active as tolerated after 1 week. Delay strengthening for 12 weeks.
- Knee ROM: Bike – no resistance (PRN) with rock and roll. Heel slides to 90°
- Quad sets (Consider NMES for poor quad control)
- Gastroc/Soleus strengthening
- Gentle hamstring stretching at 1 week, Calf stretches non-weight bearing
- Initiate Closed Kinetic Chain quad strengthening and progress as tolerated (wall sits, step-ups, mini-squats, Leg Press 90°-30°, multi-directional lunges slides, lunges, mini step-down heel touches)
- SLR, all planes, with brace in full extension until quadriceps strength sufficient to prevent extension lag.
- Add weight as tolerated to hip abduction, hip adduction, and extension
- Quadriceps isometrics 60° and 90° (resistance proximal and not distal to protect graft fixation)
- Limited Range Seated Quadriceps Extension with ankle weight (90° – 40° extension)
- If available, aquatic therapy (once sutures removed) for normalized gait, weight bearing strengthening, deep water aqua jogging for ROM and swelling.
PHASE II: Weeks 4-12:
Criteria to advance to Phase II:
- Full extension
- Good quad set, SLR, without extension lag
- Flexion to 90°
- Minimal swelling/inflammation
- Normal gait on level surfaces
Goals:
- Restore normal gait with stair climbing
- Maintain full extension, progress toward full flexion ROM
- Protect graft and graft fixation
- Increase hip, quadriceps, and calf strength
- Increase proprioception
- Pass VTFC Knee Functional Performance Test I
Brace/Weight Bearing Status:
- Full weight bearing, no brace
Exercises:
- Complete VTFC Knee Functional Performance Test 1
- Continue with ROM/flexibility exercises as appropriate
- Progressive hip, hamstring, calf strengthening.
- Week 12: Gradually add resistance to open chain hamstring exercises
- Continue hamstring, gastroc/soleus stretches
- Stairmaster (begin with short steps, avoid hyperextension)
- Conditioning: Elliptical machine / Nordic Trac / Stationary bike (progressive time and resistance)
- Single leg balance/proprioception work
- Week 8-12: Jogging/running intervals in aquatic treadmill
Phase III: Week 12 to 18 – 20 (4.5 – 5 months):
Criteria to advance to Phase III:
- No patellofemoral pain
- Minimum of 120° of flexion
- Sufficient strength and proprioception to initiate running (unweighted or in pool)
- Minimal swelling/inflammation
- Pass VTFC Knee Functional Performance Test 1
Goals:
- Full ROM (comparable to uninvolved side, if normal)
- Improve strength, endurance, and proprioception of the lower extremity to prepare for sports
- Isokinetics (with anti-shear device)
- Begin with mid-range speeds (120°/sec – 240°/sec)
- Progress towards full weight bearing running at about 16 weeks
- Knee Extensions
- Begin swimming if desired
- Recommend isokinetic test with anti-shear device at 14-16 weeks to guide continued strengthening
- Progressive hip, quad, hamstring, and calf strengthening
- Cardiovascular endurance training via stairmaster, versaclimber, elliptical, bike
- Advance proprioceptive training activities
Phase IV: 4.5–5 months through 6-7 months:
Criteria for advancement to Phase IV:
- No significant swelling/inflammation
- Full, pain-free ROM
- No evidence of patellofemoral joint irritation
- Strength approximately 70% of uninvolved lower extremity per isokinetic evaluation
- Sufficient strength and proprioception to initiate agility activities
- Normal running gait
Goals:
- Symmetric performance of basic and sport specific agility drills
- Single hop and three hop tests 85% of uninvolved leg
- Quadriceps and hamstrings strength at least 85% of uninvolved lower extremity per testing
Exercises:
- Complete VTFC Knee Functional Performance Test 2
- Continue and progress flexibility and strengthening program based on individual needs and deficits
- Initiate plyometric program as appropriate for patient’s athletic goals
- Agility progression including, but not limited to:
- Side steps, Crossovers, Figure 8 running, Shuttle running
- One leg and two leg jumping
- Broad jumps while sticking landing, 3 hop jumps
- Two legged 90° turns with landing (cw/ccw turns), progressing to single leg
- Cutting
- Acceleration/deceleration springs
- Agility ladder drills
- Continue progression of running distance based on patient needs
- Initiate sport-specific drills as appropriate for patient
Phase V: Begins at post-operative months 6-7:
Criteria for advancement to Phase V:
- No patellofemoral pain or soft tissue complaints
- Necessary joint ROM, strength, endurance, and proprioception to safely return to work/athletics
- Physician clearance to resume partial or full activity
- Pass VTFC Knee Functional Performance Test 2
Goals:
- Safe return to athletics/work
- Maintenance of strength, endurance, and proprioception
- Patient education with regards to any possible limitations
Exercises:
- Gradual return to sports participation
- Maintenance program for strength, endurance
Bracing:
- Functional brace generally not used, but may be recommended by the physician on an individual basis