ACL Bone - Patellar Tendon - Bone Autograft Rehab Protocol

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The intent of this protocol is to provide the clinician with a guideline for the post-operative rehabilitation course of a patient that has undergone an ACL bone-patellar tendon-bone autograft reconstruction. It is by no  means intended to be a substitute for one’s clinical decision making regarding the progression of a patient’s  post-operative course based on their physical exam/findings, individual progress, and/or the presence of post operative complications. If a clinician requires assistance in the progression of a post-operative patient they  should consult with the referring surgeon.  

GENERAL GUIDELINES: 

• Focus on protection of graft during primary revascularization (8 weeks) and graft fixation (4-6 weeks.)  ∙ CPM not commonly used 
• For ACL reconstruction performed with meniscal repair or transplant, defer to ROM and weight bearing precautions outlined in the meniscal repair/transplant protocol. 
• The physician may alter time frames for use of brace and crutches. 
• Supervised physical therapy takes place for 3-6 months. 

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING (ADLs) 

• No bathing/showering (sponge bath only) until after suture removal. 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 
• Weight-bearing as tolerated immediately post-op 
• Brace locked in extension for ambulation until patient demonstrates full extension with good quad  control. The brace can then be unlocked based on patient range of motion. 
• Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates normal gait mechanics  and good quad control as defined by absence of quadriceps lag. 
• 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 Minimize effects of immobilization  
• Promote an optimal healing environment and control inflammation/swelling  
• Full active and passive extension/hyperextension range of motion.  
• Caution: avoid hyperextension greater than 10 degrees.  
• Educate patient on rehabilitation progression Restore normal gait on level surfaces  

Brace: 

• Sleep with brace locked in extension for 1 week or as directed for maintenance of full extension.  ∙ Brace locked in extension for ambulation until patient demonstrates full extension with good quad  control.  
• The brace can then be unlocked based on patient range of motion.  

Weight Bearing Status: 

• Weight-bearing as tolerated immediately post-op with crutches and brace. 
• Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates normal gait mechanics  and good quad control. 

Exercises: 

• Patellar mobilization/scar mobilization Heel slides Quad sets (consider NMES for poor quad sets) ∙ Hamstring curls – add weight as tolerated Gastroc/Soleus 
• Hamstring stretches  
• Gastroc/Soleus strengthening 
• SLR, all planes, with brace in full extension until quadriceps strength is sufficient to prevent extension  lag – add weight as tolerated to hip abduction, adduction and extension.  
• Closed Kinetic Chain Quadriceps strengthening activities as tolerated (wall sit, step ups, mini squats, leg  press 90-30 degrees)  
• Quadriceps isometrics at 60° and 90° 
• Aquatic Treadmill for normalizing gait, weightbearing strengthening 
• Single leg balance  
• Stationary cycling – initially for promotion of ROM – progress light resistance as tolerated 

PHASE II: Weeks 4-12: 

Criteria to advance to Phase II: 

• Full extension/hyperextension  
• Good quad set, SLR without extension lag  
• Minimum of 90° of flexion  
• Minimal swelling/inflammation  
• Normal gait on level surfaces  

Goals: 

• Restore normal gait with stairclimbing 
• Maintain full extension, progress toward full flexion range of motion 
• Protect graft and graft fixation 
• Increase hip, quadriceps, hamstring and calf strength 
• Increase proprioception 
• Complete VTFC Knee Functional Performance Test 1 

Brace/Weight Bearing Status: 

• If necessary, continue to wean from crutches and brace. 

Exercises: 

• Continue with range of motion/flexibility exercises as appropriate for the patient. ∙ Continue closed kinetic chain strengthening as above, progressing as tolerated – can include one-leg  squats, leg press, step ups at increased height, partial lunges, deeper wall sits.  
• Begin open chain knee extensions in shortened range with low resistance 
• Stairmaster (begin with short steps, avoid hyperextension), Nordic Trac, Elliptical machine for  conditioning. Stationary biking- progress time and resistance as tolerated. 
• Continue to progress proprioceptive activities. 
• Continue hamstring, gastroc/soleus stretches.  
• Continue to progress hip, hamstring and calf strengthening.  
• If available, begin running in the pool or on an unweighted treadmill at 8 weeks. 

Phase III: Week 10 to 18 – 20 (4.5 – 5 months): 

Criteria to advance to Phase III: 

• No patellofemoral pain 
• Minimum of 120 degrees of flexion 
• Sufficient strength and proprioception to initiate land-based running 
• Minimal swelling/inflammation 
• Pass VTFC Knee Functional Performance Test 1

Goals: 

• Full range of motion 
• Improve strength, endurance and proprioception of the lower extremity to prepare for sport activities ∙ Avoid overstressing the graft 
• Protect patellofemoral joint 
• Normal running mechanics 
• Strength approximately 70% of the uninvolved lower extremity  

Exercises: 

• Continue flexibility and ROM exercises as appropriate for patient 
• Knee extensions progressing to full range 
• Progress toward full weightbearing running at 12 weeks. 
• Begin swimming if desired  
• Progressive hip, quadriceps, hamstring, calf strengthening 
• Cardiovascular/endurance training via Stairmaster, elliptical, bike 
• Advance proprioceptive 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 >75% of uninvolved lower extremity  
• Sufficient strength and proprioception to initiate agility activities  
• Normal running gait  

Goals: 

• Symmetric performance of basic and sport specific agility drills  
• Single hop and 3 hop tests 85% of uninvolved lower extremity  
• Quadriceps and hamstring strength at least 85% of uninvolved lower extremity ∙
• Complete VTFC Knee Functional Performance Test 2 

Exercises: 

• 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  
  • Cutting Acceleration/deceleration/sprints  
  • 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 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 
• Pass VTFC Knee Functional Performance Test 2 

Goals: 

• Safe return to athletics/work 
• Maintenance of strength, endurance, 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.