Enhanced accessibility to physical therapy now available for Virginia patients. Learn more >

ACL Bone - Patellar Tendon - Bone Autograft Rehab Protocol

ACL Bone - Patellar Tendon - Bone Autograft Rehab Protocol

Download PDF version to print

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.