King Khalid University Hospital Rehabilitation Department Ortho Group Rehabilitation Protocol: ACL RECONSTRUCTION +/- MENSICAL REPAIR 1. General Guidelines: Time lines in this rehabilitation protocol are approximate. If the physiotherapist feels the patient is not ready for progression (due to pain, swelling, inadequate ROM or strength), the time line should be extended to suit the patient. Assume 8-12 weeks for adequate incorporation of ACL graft and healing of Meniscal repair. Supervised physiotherapy takes place for 3-6 months as needed depending on patient s progress, activity level, and goals. Patients are to be discharged after completion of all appropriate functional progressions and adequate performance on strength and functional tests. Patients should be encouraged to exercise independently 3-5 times / week in addition to formal physiotherapy during phase II, III, and IV. Functional Milestones: Common functional activities the patient is expected to perform during each rehabilitation phase. Advancement Criteria: Objective criteria used to judge whether or not a patient is ready for progression to the next phase of rehabilitation (see Rehabilitation Progression below). 2. General Precautions: Isolated ACL: Avoid placing excessive strain on ACL reconstruction by avoiding open chain knee extension exercises. Patellar tendon graft emphasize patellar mobilizations. Hamstring graft avoid resisted hamstring strengthening exercises for 4 weeks. Multiple ligaments: ACL + MCL avoid valgus stress, hinged knee rehab brace for 4 6 weeks. ACL + LCL / Posterolateral Corner avoid varus stress, hinged knee rehab brace for 6 weeks. Meniscal repairs: Knee flexion 90 o on all weight bearing exercises (squats) x 4 weeks. Avoid weight bearing + twisting exercises (i.e. BAPS board) for a minimum of 6-8 weeks post op. Medial Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% Body weight) up to 4 weeks post op. Full weight bearing at 4 weeks as directed by surgeon. Lateral Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% Body weight) up to 6 weeks post op. Full weight bearing at 4-6 weeks as directed by surgeon. 3. Rehabilitation Progression: The following is a guideline for progression through the rehabilitation process. Progression is based on achieving advancement criteria for the next phase of rehabilitation and should take into account the patient s status and the surgeon s advisement If the patient does NOT meet the advancement criteria, extend the time in the current phase of rehabilitation. If the patient achieves the advancement criteria early, the physiotherapist may choose to advance the patient only AFTER 6 weeks post-op. If there is ANY uncertainty concerning the patient, please contact the surgeon. 4. Surgeon Advisement:
PHASE I Immediate Post-Op - 3 Weeks Post-Op Protect the ACL graft fixation. Decrease post-op pain and inflammation (can utilize Cryo-cuff for 8-12 hours/day x 2 weeks). MUST emphasize full knee extension equal to normal side (use knee immobilizer at night). Minimize the effects of immobilization (can utilize C.P.M. for 8-12 hours/day x 2 weeks). Educate patient on rehabilitation progression. 2. Brace / Crutches / Weight Bearing: Brace (Knee Immobilizer): Week 0 2: Elastic dressing worn at all times to keep compression on the knee. Brace worn at all times, except when under the supervision of the physiotherapist and when bathing. Week 2 3: Isolated ACL: Brace worn while sleeping up to week 3 or until patient has full extension. May discontinue brace for ambulation when patient has no quad lag. Meniscal repair / Multi-ligament: Continue brace x 4-6 weeks for sleeping and ambulation. Crutches / Weight Bearing: Crutches 2 to 3 weeks, weight bearing as tolerated. May discontinue crutches when patient has normal pain free gait. Meniscal repair / Multi-ligament: crutches 4 to 6 weeks, Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% WB) x 4-6 weeks (medial 4 weeks / lateral 4-6 weeks as directed by surgeon). Ice after exercise program x 15 min. Week 0 2: PROM exercise as tolerated (i.e. prone extension hang, heel slides, wall slides) (Meniscal repair: Knee flexion 90 o and Non-weight Bearing for all exercises). Quad sets and hamstring sets (may consider muscle stimulation if poor quads). Isometric quad exercises, multi-angle 90 o / 60 o (not < 60 o ). Straight leg raise (with brace until no quad lag) in all planes. Hamstring / Gastroc & Soleus stretches. Patellar mobilization as required (especially patellar tendon grafts). Week 2 3: Begin Active Assisted ROM exercises including low resistance stationary cycling (begin with high seat and progressively lower to promote ROM) (Meniscal repair: Knee flexion 90 o and 50% WB for all exercises). Double leg squat or leg press (do not bend knee past 45 o ). Step-Ups (start with 4 block and progress to 6-8 block). Heel rises on surgical leg and gastroc / soleus stretches. Proprioceptive exercises: Protected single leg stand on surgical leg. Normal walking pattern without crutches ( 50% WB on operative leg for Meniscal Repair). 5. Advancement Criteria for Phase II: Full extension Approximately 90 o of flexion No signs of active inflammation Good Quad Set and Straight leg raise without quad lag. ACL Rehab Protocol 1/16/2014 2
PHASE II 3 Weeks Post-Op - 6 Weeks Post-Op Protect ACL graft fixation. Control swelling. Restore normal gait. Maintain full extension ROM. Progress with flexion ROM. Return to work: light duties (avoid prolonged standing). 2. Brace / Crutches: Isolated ACL: May discontinue knee immobilizer when patient has full extension and no quad lag. May discontinue crutches when patient has normal pain free gait. Meniscal repair / Multi-ligament: Brace worn while sleeping up to week 3 or until patient has full extension. Continue partial weight bearing ( 50% WB) x 4-6 weeks (medial 4 weeks / lateral 4-6 weeks as directed by surgeon), then progressive protected weight bearing as tolerated. Discontinue crutches at 4-6 weeks when full weight bearing, as directed by surgeon. Patients may choose to wear ACL Knee Brace during rehabilitation. Ice after exercise program x 15 min Week 3 4: Continue low to moderate resistance stationary cycling (increase RPM and/or resistance to increase quad strengthening once adequate ROM achieved) (Meniscal repair: Knee flexion 90 o and 50% WB for all exercises). Continue double leg squat or leg press (do not bend knee past 60 o ) May progress to single leg squats. Continue Step-Ups on 8 block or stairs, Begin Step-Downs on 4 block. Begin hip flexor / abductor Theraband exercises. Proprioceptive exercises: Double leg wobble board. Begin Aquatic Exercises: water walking, hip exercises, swim with upper body (incisions must be fully healed) Week 4 6: Meniscal repair: Begin Full ROM, Full Weight Bearing: medial 4 weeks / lateral 4-6 weeks as directed by surgeon. Continue moderate resistance stationary cycling. Begin resisted hamstring exercises (may begin week 3-4 for patellar tendon graft). Begin Wall Squats at 45 o and StairMaster. Proprioceptive exercises: Single leg wobble board, BAPS board Aquatic Exercises: may begin flutter kicks at side of pool (no whip kick). Theraband / Ankle Weights for resisted quadriceps and hamstring in home exercise program. Normal gait without crutches. Progressive increase in ROM and quad strength. StairMaster at 4 weeks. Light occupational duties (i.e. desk work). Driving automatic or standard vehicle with involved leg at 6 weeks. 5. Advancement Criteria for Phase III: Full active ROM: Full Extension to 120 o Flexion. Strength: Grade 4 / 5 isometric in hamstrings and quadriceps strength (no extensor quad lag). Normal gait on level surfaces. ACL Rehab Protocol 1/16/2014 3
PHASE III 6 Weeks Post-Op - 12 Weeks Post-Op Full ROM. Increase leg strength, endurance and proprioception. Avoid overstressing graft during remodeling period (may lead to graft laxity). Increase functional activities. Begin cross-training to maintain general fitness. Return to work: modified duties (avoid heavy lifting, squatting and kneeling). 2. Brace: Patients may choose to wear ACL Knee Brace during rehabilitation if they have one. Week 6 9: Continue Passive / Active Assisted / Active ROM exercises as needed to achieve full ROM. Begin Stationary Cycling interval training (no standing out of saddle). Progress Wall Squats to 60 o - 90 o (x 2 minutes). Proprioceptive exercises: slide board / fitter board. Aquatic Exercises: progress to water running and flutter board (no whip kick). Begin power walking at 6 weeks. Begin outdoor cycling at 8 weeks (level terrain, low gear, no toe clips). Week 9-12: Continue Wall Squats at 90 o (increase time). Begin Lunges to 90 o with surgical leg in front at 10 weeks (20 reps.). Advance closed chain strengthening exercises. Begin isokinetic hamstring and quadriceps strengthening (use anti-shear device for isokinetic quadriceps exercises only). Proprioceptive exercises: mini-tramp or skipping (begin bilateral and progress to single leg). Aquatic Exercises: progress swimming (no whip kick). Begin straight line running (10 weeks) (begin walk / run intervals and progress to running at therapist discretion no evidence of patellofemoral irritation needed to progress). Interval training on stationary bike at 6 weeks. Power walking at 6 weeks. Outdoor road cycling at 8 weeks (no toe clips). Straight line running at 10 weeks (begin with run/walk program). Light or modified occupational duties to accommodate functional limitations. 5. Advancement Criteria for Phase IV: Full pain free ROM. Strength: Grade 4 to 5 / 5 (75% of normal on leg press and hamstring curl). Normal gait on stairs. No evidence of patellofemoral joint irritation. ACL Rehab Protocol 1/16/2014 4
PHASE IV 3 Months Post-Op - 6 Months Post-Op Increase and maintain strength, endurance, and proprioception. Sport specific functional exercises. Progressive return to sport after adequate performance on strength and functional tests. Return to work: for activity intensive occupations. Patient education regarding possible restrictions / limitations. 2. Brace: Patients may choose to wear ACL Knee Brace during early return to sport, up to 12 months post-op if they have one. Months 3 4: Begin weight training / Nautilus equipment strengthening exercise program. Begin sport specific strengthening exercises. Begin plyometric program as appropriate for patient s functional goals. Begin agility training. Begin functional progressions: Directional running: forward, backward, and sideways. ½ to ¾ to full speed running. Running up and down stairs. Cutting, crossover, carioca and agility drills. Swimming whip kick. Months 4-5: Months 5 6: Maintenance program for strength and endurance. Begin sport specific drills as appropriate. Gradual return to Light Sport Activity (ie: golf, skating, cross-country skiing) if: No inflammation or effusion. Full ROM. >75% quadriceps and hamstring strength. Single leg hop test for distance >75% of normal side. Progress to Pivoting and Contact Sports (ie: racket sports, court sports, and field sports, hockey, downhill skiing) if: No inflammation or effusion Full ROM Single leg hop test for distance >90% of normal side >90% quadriceps and hamstring strength on instrumented strength testing (i.e. Lido, Biodex, Cybex) Return to Light Sports Activity at 4 5 months 90 100% leg strength with operative to non-operative side comparison. Return to Pivoting and Contact Sports at 5 6 months. Return to work: full duties. ACL Rehab Protocol 1/16/2014 5