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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.
- 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.
- 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.
PHASE I: Week 0 – 4:
- ∙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
- 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.
- 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
- 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.
- 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
- 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
- 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
- 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
- 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
- Safe return to athletics/work
- Maintenance of strength, endurance, proprioception
- Patient education with regards to any possible limitations
- Gradual return to sports participation
- Maintenance program for strength, endurance
- Functional brace generally not used, but may be recommended by the physician on an individual basis.