Name: ID: Date Of Surgery :DD / MM / YYYY Procedure: ACL REHABILITATION PROTOCOL Note :If another procedure like meniscus repair or OATS (Osteochondralautograft transfer) has been done along with ACL reconstruction the protocol gets modified. Please consult your surgeon for the modified physical therapy protocol to be followed. Usually the one which is slower in progression is followed. Pre-operative exercises Before the operation it is important that you have as near to full pain free movement as possible. Ideally a few weeks before the surgery you should start exercises building up your quadriceps and hamstring strength. This trains the muscles up and makes it easier to get going after the surgery. Phase I: 0 to 2 Weeks Goals Protect graft and graft fixation with use of brace and specific exercises Control inflammation and swelling Early range of motion (ROM) with emphasis on full extension, patella mobilizations and flexion Caution: avoid hyperextension greater than 10 Educate patient on rehabilitation progression Restore normal gait on level surfaces Brace Post op brace worn locked in extension for ambulation and sleeping May unlock for ROM exercises Weight bearing status Weightbearing as tolerated with crutches and brace locked in extension If meniscal repair or microfracture, non-weightbearing for 4 weeks This phase involves regaining a full range of movement (especially full extension). It is important that these exercises are performed for short periods but regularly (rather than
one longer period) Sleep in brace locked in extension ROM exercises Extension- no active terminal extension from 40 to 0 degree Passive extension Sit in a chair and place your heel on the edge of a stool or chair. Relax thigh muscles and let the knee sag under its own weight until maximum extension is achieved. Heel props Sitting on a bed, place a rolled up towel under the heel and allow leg to sag down. Prone hangs lie face down on a bed/table with legs hanging off the edge of the table. Allow the legs to sag into full extension. Flexion limit to 90 degree Passive flexion Sit on a chair or the edge of a bed; let the knee bend under gravity. May use the other leg to support or control flexion. Wall Slides Lie on the back with the foot of the operated leg on the wall. Allow the foot to slide down the wall by bending the knee. Use other leg to apply pressure downwards. Heel slides- Use the good leg to pull the involved heel towards the buttocks, flexing the knee. Hold for 5 seconds. Straighten the leg by sliding the heel downwards and hold for 5 seconds.
Quadriceps setting To maintain muscle tone in the thigh muscles and straighten the knee. Lie or sit with knee extended. Tighten and hold the front thigh muscles making the knee flat and straight. The knee should straighten and push against the bed or floor. Hold for 10 seconds and do 20 repetitions three times a day. Straight leg raises (SLR) with brace locked in extension Tighten the quadriceps (like quadriceps setting) as hard as possible Lift the heel 4-6 inches off the floor keeping the quadriceps muscle tight. Hold for 10 seconds, and then keep it down and relax for 5 seconds. Repeat this 20 times. Hamstring sets Keep the ROM brace on, with flexion set to 90 degrees. Bend knee slightly.keep your heel down.dig heel into the surface as if you were trying to bend your knee.hold for 10 seconds, relax for 5 seconds. Repeat this 20 times. Patellar mobilizations(emphasize superior/inferior glides) Isometric hip Abduction / Adduction Sit on a chair, knee bend and feet planted on the floor. Hands placed on either side of the outer knees as shown. Try to push the knees outwards and resist with the hands. Hold for 10 seconds, relax for 5 seconds. Repeat this 20 times. Ankle ROM and Gastrosoleus strengthening using Therabands Sit on a bed or table with the operated limb straight and supported on the floor. Place the elastic band around the affected foot, just under the toes. Hold one end of the band with each hand. Keeping the knee
straight, flex your foot downwards so that your toes are directed away from your body. Hold for 10 seconds, relax for 5 seconds. Repeat this 20 times.
Phase II: 3 to 6 Weeks Goals Restore normal gait with stair climbing Maintain full extension, progress toward full flexion range of motion Protect graft and graft fixation Increase hip, quadriceps, hamstring and calf strength Increase proprioception Brace May wean out of brace at the end of 6 weeks, as the quad control improves. Weight bearing status Weight bearing as tolerated, wean off crutches Exercises Continue as above, maintaining full extension and progressing to 125 No active terminal extension from 40 to 0 Begin closed kinetic chain exercises Stationary bicycling - slow, progressing to low resistance Hamstring curls Hip abduction, adduction, extension At 4 6 weeks, 1 4 par al squats, use table for support ROM 0 to 120 degrees FWB without crutches, no limp MLB full ROM Progress ROM to 120 degrees by week 4 Progress SLR and prone/standing hamstring curls with weights Bike for ROM, begin low-resistance program when ROM adequate Stool scoots FWB with crutches; discontinue crutches when ambulating without limp Begin double-leg BAPS, progress to single leg Begin double-leg press with light weight/high repetitions Wall sits at 45-degree angle with tibia vertical, progress time Lateral step-ups (4 inches) when able to perform singleleg
quarter squat Hip machine and hamstring machine when able to perform SLR with 10 lb Treadmill (forward and backward) with emphasis on normal gait Knee extension 90 to 60 degrees (submaximal) with manual resistance by therapist 4 to 6 Weeks Progress to full ROM by 6 weeks Begin Kin-Com isokinetic hamstring progression (isotonic/ isokinetic) Begin Kin-Com dynamometer quadriceps work 90 to 40 degreesisotonics with antishear pad Stairmaster (forward and backward) Progress closed chain exercises At 6 weeks, begin Kin-Com dynamometer quadriceps work 90 to 40 degrees isokinetics (start with higher speed and work on endurance) Aquatic exercises 8 to 10 Weeks Progress above-listed exercises Slow-form running with sport cord (forward and backward) Isokinetic quadriceps work at different speeds (60, 90, 120 degrees per second) Begin lunges At 10 weeks, begin Fitter, slide board Phase III: 12 to 16 Weeks Full range isotonics on Kin-Com dynamometer (begin movingantishear pad down) Knee extension machine with low weight/high repetitions Lateral sport cord drills (slow, controlled) Kin-Com dynamometer test hamstrings, discontinue isokinetic hamstrings if 90% Progress isokinetic quadriceps to full extension by 16
weeks Phase IV: 16 to 18 Weeks Kin-Com dynamometer test for quadriceps, retest hamstrings if necessary Begin plyometric program with shuttle, minitrampoline, jump rope if quadriceps strength 65%, no effusion, full ROM, stable knee Begin jogging program if quadriceps strength is 65% Phase V: 5 to 6 Months Agility training Sport-specific drills (e.g., carioca, 45 cutting, figure-of-eight) Retest quadriceps if necessary Phase VI: 6 Months Return to sport if: Motion > 130 degrees Hamstrings > 90% Quadriceps > 85% Sport-specific agility training completed Maintenance exercises two to three times per week
ACL AND MENISCAL INJURY REHAB 0-2 WEEKS 5. 6. 7. Static quadriceps Ankle pumps Patellar gliding SLR Partial weight bearing with single elbow crutches Knee ROM 0-90 (passive extension) Knee immobilizer 2-4 WEEKS 5. 6. 4-6 WEEKS Partial weight bearing with single elbow crutches SLR + 1 kg Knee ROM 0-90 Prone knee ROM Active extension. Active extension with ½ kg weight Knee cap with Velcro( if comfortable) 5. 6-8 WEEKS Full weight bearing single elbow crutches Knee ROM 0-110 Prone knee ROM with weight SLR + 2kg WT Full weight bearing with single crutch Prone knee ROM + 3kg wt SLR + 3kg WT Knee full ROM High sitting with 2kg weight from week
2-3 month 5. 6. Wall slides and sit ups SLR + 3kg Wt High sitting with 3kg weight from 10week Static cycling Stepper Prone knee ROM + 3kg wt 3-4 month 5. 6. 7. Standing jogging for 10 Mnts Forward and Backward jogging for 10 Mnts 8 or Z Shape jogging for 5 Mnts Slow running and slowly goes to Fast running Prone knee ROM + 3kg wt High sitting with 3kg weight from 11 week SLR + 3kg WT 4-5 months Fast running and turning Quick stopping and quick starting Continue above exercises Running in figure of 8 manner 5-6 months climbing uphill continue above exercises 6 months plyometrics for lower leg- Jump Training running in figure of 8 manner single leg jumping
Refer to : Meniscus repair protocol for further details