ACL Hamstring Autograft Rehab Protocol

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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