Download ACL Postoperative Rehabilitation Protocol

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Department of Rehabilitation Services
Anterior Cruciate Ligament Reconstruction Guidelines
Successful completion of this 6 month program is dependent on compliance with the home
exercise program listed below. Progression through the program requires the completion of
physical performance tests, indicating readiness to advance to more challenging exercises and
activities. Work related and sport specific activities are blended into the program to meet the
individual needs of patients. For example, completing the walking sport cord tests allows the
patient to begin a gradual return to fitness walking. The exit criteria, indicating completion of
formal rehabilitation and the beginning of an independent home exercise program, consists of a
series of physical tests based on a patient's most challenging physical requirements for work,
school, or recreational pursuits.
Postoperative Rehabilitation:
Phase I: 0-1 weeks
Treatment Goals:
 Pt. education
 Pain control and exercise tolerance
 Independent use of cryocuff, range of motion brace, and crutches
 Independent performance of therapeutic exercises to
o initiate muscle function in the thigh,
o demonstrate partial weight bearing ambulation with crutches using existing range
of motion,
o reduce postoperative swelling,
o achieve full passive knee extension in prone position
Patient education
 Wear range of motion brace set at 0 – 90 degrees anytime patient leaves the home, is in
between exercise sessions, and at night.
 Patient uses crutches for walking around the house or outside. Emphasize short stride,
heel to toe gait pattern, and gradually increasing weight bearing on the postoperative
limb.
 Begin weaning from crutches after 2 weeks Post Op.
 Patients progress from bilateral crutches, to unilateral crutches, to no crutches.
Crutches are discontinued if patients can walk without a limp.
 Encourage frequent icing using the cryocuff, the knee elevated above the level of the
heart, in the supine knee hang icing position. Instruct patient to check skin
temperature in between frequent sessions of icing, and to manage posterior knee pain
during supine knee icing technique.
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Instruct patient in prone knee hang position to monitor progress towards full passive
knee extension.
Explain methods to measure exercise tolerance to patients so they can incrementally
increase exercise volumes as tolerance allows.
Encourage patients to use prescribed medications as directed. If they experience
stomach upset they should discontinue and contact their physician.
Therapeutic exercises: performed in sequence 2 times daily. (brace off)
 Non-surgical leg cycling, resting the surgical leg on a chair. Adjust bike’s seat so the
uninvolved leg is slightly bent when the pedal is in the down position. Pedal forwards
or backwards with the uninvolved leg. Cycle for 10 – 15 minutes.
 Sitting carpet drags with contralateral assist in a pain free range flexion and
extension, 3 sets of 20.
 Sitting, alternating toe and heel raises, 3 sets of 30 reps.
 Standing lateral weight shifting, standing inside crutches, progressing from 1 to 3
minutes.
 Quadriceps sets in supine or semi-recumbent position. Some patients may require
bilateral performance for adequate quadriceps requirement. Hold time is 7 seconds,
and perform 3 sets of 20 repetitions.
 Straight leg raises in supine with uninvolved knee bent, foot resting on surface. Lift
postoperative leg parallel to opposite thigh, keeping knee locked into extension, and
hold for 5 sec. Use 5 sec. to return the leg to the surface, and relax. Repeat sequence
performing 3 sets of 20 repetitions.
 Hamstring sets in supine or semi recumbent position, 7 sec. holds performed in 3 sets
of 20.
 Supine knee hang icing, 20 minutes. Instruct in measures to maintain elevation in
knee hang position to allow tolerance for 20 minutes.
Physical performance test:
 Cephalad movement of patella during all quadriceps exercises.
Phase 2 (1-3 Weeks Post Op)
Treatment Goals:
 Patient education
 Pain Control
 Post-operative swelling reduction
 Full passive knee extension in prone
 Walking independently over level surfaces
 Ascending and descending stairs independently
Patient education
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Continue wearing range of motion brace between exercise sessions, ambulating
outside, and at night.
Continue partial weight bearing crutch progression.
Continue frequent supine knee hang icing for swelling reduction and pain control.
Encourage patients returning to work or school to “hang” and ice the knee frequently
throughout the work and school day. Some schools request a note.
Increasing the number of repetitions, resistance, or number of different exercises
depends on patient tolerance. Tolerance is measured twice, once during exercise and
once the morning after.
Therapeutic exercises: performed in sequence 2 times daily
 Stationary Cycling (brace off)
o Little to no resistance on the bike
o Seat positioned so knee is flexed slightly at the bottom of the down stroke
o Partial revolutions within pain free range of motion with a goal of full revolution
in retro-cycling prior to forward cycling
o Non-surgical leg is driver and post-surgical leg determines range of motion
o Prevent hip and ankle substitutions
o 10 – 15 minutes and gradually increase if time allows
o Encourage use in between exercise sessions
 Inverted/supine heel slides (brace off)
o Used as a substitute for stationary bike
 Long sitting belt stretch, 10 second holds, over 3 to 5 minutes. Thigh must stay down but
heel can elevate slightly off the table.
 Quadriceps sets with straight leg raises, 2 sets of 20
o supine with uninvolved leg flexed at the knee, foot resting on the surface
o quadriceps set with cephalad patellar movement
o raise involved leg parallel to uninvolved thigh and hold for 5 sec.
o slowly lower the involved leg to the table using 5 sec.
o some patients require assist to achieve independence
 Ambulatory progression
o Optional, used as an adjunct exercise for those patients independent with
quadriceps setting but having difficulty restoring normal gait pattern
o Patients progress from less time to more time as tolerated
o Lateral weight shifting, 1-3 min.
o Lateral weight shifting plus uninvolved step (1 step), 3 min.
o Lateral weight shifting plus uninvolved and involved step (2 step), 3-5 min.
o High knees and backwards walking Black resistance cord exercises, 3-5 min.
o Short stride slow rate walking progress to normal stride and rate walking
 Entry level black cord strengthening exercises
o Initiated after full knee extension in prone and independent level surface gait
o Exercises performed in controlled manner to optimize muscle recruitment
o Explain tolerance measures so patient can add/subtract 5 reps. per exercise day
advancing from 3 x 15 to 3 x 50 over time.
o Standing 1/3 knee bends
 Requires set-up instruction
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 Standing on black band perform knee bends 1/3 as previously instructed
 Identify and address alignment issues
 Encourage “conscious” effort to fully extend the knee in upright position.
o Seated leg press (gas pedal)
 Requires set-up instruction
 Patient seated, thighs not touching seat, back against back rest, pillow
behind back if needed
 Attach exercise band securely to foot and hold ends of band in both hands
against the chest but under the chin
 Flex hip and knee as far as comfortable. Straighten leg, simultaneous hip
and knee extension, as if reaching for the gas pedal, obtaining full knee
extension with each repetition.
 Every fifth repetition patient performs 10 sec. isometric contract in the
fully extended position
 Identify and address alignment issues
 Explain tolerance measures so patient can add/subtract 5 reps. per exercise
day advancing from 3 x 15 to 3 x 50 over time
o Seated hamstrings curls (carpet drags)
 Requires set-up instruction
 From a seated position, attach safety strap around ankle, placing foot in
handle and plastic plug outside door close to the floor
 Patient slides or “drags” foot backwards until ankle is directly under the
knee
 Identify and address alignment issues
 Explain tolerance measures so patient can add/subtract 5 reps. per exercise
day advancing from 3 x 10 to 3 x 20 over time
Supine knee hang icing
o Patient in supine with ankle resting on elevation placing the knee above the level
of the heart
o Cryocuff placed on knee
o Teach patient to shorten distance between ankle and knee to moderate stretch pain
over the course of 20 minutes of icing
o Patients can also perform mild quadriceps contractions while in this position
Physical Performance tests:
 Full knee extension in prone.
 Walking over level surface 200 feet x 2.
 Ascend and descend 12 steps independently, i.e. without mechanical jerk
Phase 3 (3-6 Weeks Post-Op)
Treatment Goals:
 Patient education
 No negative reaction to steadily increasing exercise volume
 Assist patients in managing exercise tolerance with activities of daily living
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Add balance reaction exercises
Generate demonstrable muscle definition prior to brace measurement/fitting
Begin aerobic conditioning
Patient education
 The most vulnerable time for bone-tendon-bone patellar tendon graft reconstruction is
between 1 and 3 months post-operatively. It is during this time frame that the graft needs
protection, and the time in which the graft attempts to re-establish its circulation so that it
becomes viable, dynamic tissue again. Gradually increasing exercise volume is the
stimulus promoting circulatory growth into the graft. This exercise progression must be
tolerable at all times.
 Continue wearing post-operative range of motion brace.
o Therapeutic exercise progression is designed to create demonstrable muscle
definition to transition into a functional brace at approximately 6 weeks postoperative. However, there must be muscle mass in the thigh that supports and
holds the brace in place.
 Continue to apply exercise tolerance measures.
 Balance activities of daily living and job requirements with therapeutic exercise program
to meet exercise tolerance measures.
 Continue supine knee hang icing and “hanging” the knee at work and school if still
progressing to full passive knee extension.
Therapeutic Exercise: performed in sequence 2 times per day
 Continue strength interval cycling progression
 Static balance exercises (brace on)
o Manipulate balance variables promoting co-contractions in the involved lower
extremity with the patient in unilateral stance
o Options include;
 Balance reach activities, G. Gray, Total Functional Profile, Wynn
Marketing, 2001
 Eyes open eyes closed unilateral balance
 Top down driving with Bilateral UE multi-plane movements
 Multi-plane head movements, eyes open
 360 degree catch
 Bosu Ball
 Black cord exercises continued. Patients progressing towards maximum number of
repetitions per exercise using tolerance measures to add/subtract repetitions per set.
o Bilateral 1/3 knee bends
o Seated leg press
o Seated hamstring curls
 Walking Black cord test elements, sagittal plane only
o Forwards and backwards walking
o Progress using interval training format; 1 min. work: 30 sec. rest, for each
activity. Add one interval per exercise day until reaching 5 intervals. Once 5
intervals achieved gradually decrease and eventually eliminate rest periods to
perform 5 minutes of continuous activity.
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Continue supine knee hang icing
Optional Exercises
o Pool program
o Free weights and machines in supported positions(seated or supine)
 Upper Extremity or trunk only
 Light weight, 60-65% of 2 repetition maximum (2RM)
 Moderate to high repetitions (6-12)
Physical Performance tests
 Complete 3 sets of maximum reps for entry level black cord exercises.
 Successfully fitted with functional brace
Phase 4 (6-12 1/2 weeks post-op)
Patient Education
 Functional brace worn for all activities
 Exercises should provoke fatigue in the musculature without pain or swelling in the knee.
Fatigue stimulates compensation for increased strength and muscular endurance needed
to complete walking black cord test.
Treatment Goals
 Continue monitoring exercise tolerance measures as exercise volume and intensity
increase
 Progress from static to dynamic balance exercises
 Add remaining walking black cord exercises (frontal plane) and unilateral 1/3 knee bend
 Continue advancing aerobic conditioning
 Progress from black cord exercises to selectorized resistance machines or free weights to
advance strength program
 Complete walking black cord test at 12 ½ weeks post-op and begin walking program
Therapeutic Exercise in sequence 1 time per day 5 days per week, 2 days of recovery
 Continue strength interval cycling or progress to stair master at slower speeds
 Dynamic balance
o Options
 Multiplane lunges w/o weights to weighted vest
 Multiplane lunges with UE movements with and w/o weights
 Multiplane step up, step down, reverse step up
 Complete maximum repetitions of entry level black cord exercises and progress to squats,
leg press, and standing hamstring curls with free weights and selectorized machines.
o Patients without home gym, gym membership, or those in which advanced weight
training not indicated continue with black exercise cord
o Start with 60-65% of 2 RM for each of the above mentioned exercises.
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o Perform 3 sets of 10 repetitions of each exercise. After achieving this volume
increase weight by 5 to 10# and work towards completing this volume before
adding additional weight.
o DO NOT approach 90 degrees of knee flexion with the squat or the leg press
o Standing hamstring curls preferred to supine
Continue walking black cord test elements progressing to 5 minutes of continuous
activity for element until taking the test at 12 ½ weeks post-op.
Optional Exercises
o Lateral step and gather, lateral ambulation, forwards/backwards walking for
frontal plane hip strengthening.
o Slide board
o Water workout with Aqua-jogger and/or swimming-freestyle only
o Stair stepper
o Nordic Track
o Rowing
Continue free weight or selectorized machine resistance training for U.E.’s
Physical Performance Test
 Successfully complete walking black cord test at 12 ½ weeks post-op
Phase 5 (12 ½ to 16 ½ post-op weeks)
Patient education
 Wear brace for all activities
 Maximizing strength is emphasis
 Continue 1:3, work to rest ratios @ 1x/day, 5 days/week to reach muscular fatigue
without joint irritation
 Continue 2 recovery days per week
 Continue advancing aerobic conditioning
Treatment Goals
 Maximize strength through traditional strengthening exercises and balance exercises
 Advance aerobic conditioning
 Successfully complete walking cord test
 Add walking progression
 Add stationary or walking sport/activity specific drills
 Pass running black cord test
Therapeutic exercise performed once per day in sequence
 Continue strength interval cycling / stair stepper progression focusing on slow to
moderate speeds through full range of motion
 Dynamic balance
o Step up, step downs in multiple planes
o Step up, step downs, reverse step ups in multiple planes
o Multiplane lunges step up, step downs (non-weighted to weighted)
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o Multiplane lunges step up, step downs, reverse step ups (non-weighted to
weighted)
o Can add sport/activity specific implement or ball
o Can add sport/activity specific drill
Continue strength training
o Progress squats, leg press, hamstring curls to 70 to 75% of 2 RM
o Perform in 3 sets of 10
o Add 5 to 10 # with successful completion of 3 x 10 up to but not beyond 80% of 2
RM
Convert walking black cord test to running using interval format
o Use the 1 min to 30 sec. rest interval format
o Begin day one with 1 interval of each element and add one element each exercise
day up to 5 intervals
o Gradually decrease and eliminate rest times until achieving 5 min. continuous
activity for each of the 5 elements
o Take running black cord test at 16 ½ weeks post-op
Add sport/recreational specific drills
o Most sports/activities have drills that can be performed with or without balls that
can be performed in place or at walking pace.
o If in season, athletes can do these drills at practice after completing the home
exercise program
Add walking progression
o Performed after exercise session
o Advance based on success only
o Level surface walking, 12.5 minutes out and 12.5 min. back. Progress to a total of
45 minutes, 22.5 min. out 22.5 min back
o Hill walking beginning 12.5 min. out 12.5 min. back and progress up to 45 min.
over time
o Hiking
Optional exercises
o Cycling
 Outdoor biking with brace and begin hills
o Free / machine weights for upper extremities and trunk in unsupported positions.
o Lateral walking and forwards to backwards walking
o Walking stadium steps
o Rowing
o Slide board
o Nordic track
Physical Performance test
 Running black cord test for 25 min., 5 min. continuous activity for each element
Phase 6 (16 ½ -20 ½ weeks post-op)
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Patient education
 Wear brace for all activities
 Emphasis is power development and L.E. and trunk alignment during take-off and
landing during all jumps and hops
 Work to rest ratio is 1:3 for strength schedule and 1:4 or 1:5 for power schedule
 Split schedule training, 1x/day 4 days/ week strength training and running progression;
1x/day 1 day/week for power training
 Two full days of recovery
 Add running progression and transfer to sport/activity specific drills
Treatment Goals
 Transform strength into power
 Shift from aerobic to anaerobic training
 Produce balanced take-offs and landings during all jumps and hops
 Reduce running distances while increasing running intensity towards sprinting
 Successfully complete jump testing
Therapeutic exercise performed in sequence on split schedule i.e. strength and power schedules
 Strength Schedule is 1x/day 4days/week, i.e. Mon., Tuesday, Thurs., and Fri.
 Dynamic Balance
o Multiple plane jumps, progressed to holds
o Multiple plane hops, progressed to holds
o Multiplane jumps and hops with sport/activity implement or ball
 Strength exercises
o Multiplane lunges with weight 2 x 5.
o Squats (no greater knee flexion than 85 degrees), leg press (no greater knee
flexion than 85 degrees), and hamstring curls progressed to 80 to 85 % of 2 RM
o Add push press and/or cleans at 65 to 70 % of 2 RM
 Success based running progression (no sprinting)
o Walk turns, jog straights beginning with 800m adding 400m each strength day
until 2 miles completed
o Complete following sequence; 1-800m strides/runs, recover breath; 2-400 m
run/strides and recover breath; 2-200m strides/run
o Complete following sequence; 1-400m runs recover breath; 2-200m runs and
recover breath; 2-100m runs and recover breath; 2-50m runs
 Power Schedule is 1x/day 1 day/week
o Phase 1 Jump training *Sportsmetrics
o Performed on padded surface, emphasizing soft landing (catching), toes to heels,
bending ankles, knees, hips; keeping knees over feet, shoulders over knees
 Wall jumps 20 seconds
 Tuck jumps 20 seconds
 Squat jumps 15 seconds
 Side to Side barrier jumps (6” barrier) 20 seconds
 Front to back barrier jumps (6” barrier) 20 seconds
 180 degree turn jumps 20 seconds
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 Long jumps 10 repetitions with 5 second hold
 Bounding in place 20 seconds
o Plyometric jumps
 From 8 to 10 inch height
 Landing pad
 Jump off box, soft landing and jump, soft landing and hold “catch”
position for 5 seconds
Optional
o Rollerblading
o Golfing
Physical performance test
 Successfully complete jump test
o Symmetrical hop for distance test
o Hop, hop, hop to 5 sec hold
o SHARK test
Phase 7 (20 ½ -24 ½ Weeks Post-op)
Patient education
 Wear brace for all activities
 Emphasis is power development
 Continued emphasis on anaerobic training
 Emphasize L.E. and trunk alignment with all jumps and hops
 Work to rest ratio is 1:3 for strength schedule and 1:4 or 1:5 for power schedule
 Split schedule training; strength training 1x/day 3 days/week and power 1x/day 2 days/
week
 Two full days of recovery
 Completion of physical performance tests reported to physician by physical therapist /
athletic trainer.
 Interscholastic athletes may require written approval from the physician to return to full
unrestricted athletics
Treatment Goals
 Begin gradual return to full activity
 Return to sport/activity specific drills
 Successfully complete the lower extremity functional test
 Independent with home exercise program
o In-season performance
o Out-of season performance
Therapeutic exercise performed in sequence on strength and power schedules
 Strength schedule is 1x/day 3 days/week
o Multiplane lunges performed in full range of motion at increasingly faster, but safe
speeds
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o Squats, leg press, hamstring curls, cleans at 85% to 90 % of 2 RM
o Running 1-400m run, 2-200m runs, 2-100m runs, 2-50m runs
Power Schedule is 1x/day 2days/week
o Lower extremity functional test progression based on success
 50 x 30 jog to sprint
 40 x 20 jog to sprint
 30 x 10 jog to sprint
o Phase I Jump Training * Sportsmetrics on padded surface emphasizing soft “catch’
position on take-off and landing
 Wall jumps 20 seconds
 Tuck jumps 20 seconds
 Squat jumps 15 seconds
 Side to side barrier jumps, 6” barrier, 20 seconds
 Front to back barrier jumps, 6’ barrier, 20 seconds
 180 degree turn jumps, 10 repetitions 5 second holds
 Long jumps 10 repetitions 5 second holds
 Bounding in place 20 seconds
Physical performance test
 Successfully complete lower extremity functional test in allotted time
LEFT TEST
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Anterior Cruciate Ligament Reconstruction: Criteria – Based Progression Through the
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3. Moisala A., Jarvala T., Kannus P., Jarvinen M.; Muscle Strength Evaluations after ACL
Reconstruction. Int J Sports Med 2007 28: 868-872.
4. Palmieri-Smith R. M, Thomas A. C, Wojtys E. M; Maximizing Quadriceps Strength
After ACL reconstruction. Clin Sports Med 2008 27: 405-427.
5. Meyer G. D, Paterno M. V, Ford K. R, Hewett T.E; Neuromuscular Training Techniques
to Target Deficits before Return to Sport after Anterior Cruciate Ligament
Reconstruction. J Strength and Conditioning Research 2008: 22(3) 987-1014.
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Rehabilitation. 1991: Sports Med. 11 (6): 402-413.