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Knee & Shoulder Doctor

Accelerated Rehabilitation Protocol Following ACL Reconstruction

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The purpose of this protocol is to provide the physicians, therapists and other care providers with a guideline of the post-operative rehabilitation course.

This rehabilitation protocol has been formulated for ACL reconstruction patients with BTB autograft or allograft, hamstring autograft or soft tissue allograft, and Achilles tendon allograft.

The delayed rehabilitation protocol is utilized for ACL reconstruction with meniscal repair, other ligament reconstruction, in revision settings and cartilage repair/restoration.

Goals of ACL reconstruction:

  1. Diminish inflammation, pain and swelling
  2. Obtain normal knee range of motion (focus on knee extension)
  3. Regain voluntary muscle activation
  4. Obtain normal proprioception, balance and coordination for daily activities
  5. Return to sport

During your postoperative course, it is imperative to be mindful of:

  1. Persistent swelling
  2. Abnormal pain or hypersensitivity
  3. Limited range of motion
  4. Weakness of quadriceps
  5. Avoid active hamstring exercises until sixth week postop – use towel for heel slides when hamstring autograft used

Return to sport/activity

This is dependent on time and clinical progression. Full return to activity requires good strength, flexibility and endurance. These can be tested with multiple clinical and physical therapy parameters. ​

Phase 1: Week 1-3

Week 1-3:

Goals:

  • Diminish knee effusion, pain and inflammation
  • Obtain 0-110 degrees ROM
  • Obtain good quad contraction
  • Progress to FWB 
  • Patellar mobilization

Strength and Exercises:

  • SLR in flexion, abduction and adduction
  • Quad sets
  • Leg press
  • Low flexion squats
  • Multi angle isometrics at 90 and 60 degrees of extension
  • Weight shifts
  • Standing hamstring curls 
  • Sitting calf raises, calf stretches
  • Wall and heel slides

Weight Bearing:

  • WBAT with two crutches
  • Continue crutches until adequate quad control
  • Wean off crutches when able to ambulate without limp

Stationary bike:

  • May begin when patient obtains 110 degrees of flexion

Modalities:

  • Cryotherapy 
  • Elevate leg in full extension
  • Electrical stimulation

Brace:

  • May remove for exercises
  • Must use when ambulating

Phase 2: Week 3-5

Week 3-5:

Goals:

  • Obtain 0-130 degrees ROM
  • Improve quad tone
  • Improve muscle strengthening and endurance
  • Restore proprioception
  • Patellar mobilization

Strength and Exercises:

  • Continue SLR in flexion, abduction adduction, add extension
  • Quad sets
  • Leg press
  • Low flexion squats, wall squats
  • Front lunges
  • Multi angle isometrics at 90 and 60 degrees of extension
  • Sitting calf raises, calf stretches
  • Wall squats
  • Continue stationary bike

Weight Bearing:

  • WBAT without crutches if adequate quad control

Modalities:

  • Cryotherapy
  • Elevate leg in full extension
  • Electrical stimulation with biofeedback

Brace:

  • May remove for exercises
  • Must use when ambulating
  • Measure for custom ACL brace between weeks 4 and 6

 

Phase 3: Week 5-12

Week 5-12:

Goals:

  • Obtain 0-140 degrees ROM or full ROM
  • Improve lower extremity strength, proprioception, balance and control
  • Restore confidence

Strength and Exercises:

  • Continue SLR in flexion, abduction, adduction, extension with weights
  • Leg press – single leg eccentric
  • Start isolated hamstring curls at week 6
  • Low flexion squats, wall squats, vertical squats
  • Front and lateral lunges
  • Progress multi angle isometrics program
  • Continue stationary bike program
  • Walking program starting at week 8-10

Balance Training:

  • Single leg stance
  • Balance board, foam roller board
  • Proprioceptive exercises

Modalities:

  • Electrical stimulation with biofeedback

Brace:

  • Measure for custom ACL brace btw weeks 4 and 6

Phase 4: Week 12-16

Week 12-16:

Goals:

  • Maintain full knee ROM
  • Maintain strength and endurance
  • Improve neuromuscular control
  • Continue skill training

Strength and Exercises:

  • Continue Phase 3 exercises
  • Start jogging at week 16
  • May start swimming (kicking)

Balance Training:

  • Balance board, foam roller board
  • Proprioceptive exercises

Phase 5: Week 16-36

Week 16-36:

Goals:

  • Gradual return to sporting activity:
  • Full contact: Typically Autografts at 6-7 months, Allografts at 9 months
  • Achieve maximum strength and endurance

Strength and Exercises:

  • Continue advanced training

Functional and Balance Training:

  • Progress running and swimming program
  • Advance running program
  • May start backward running program
  • Start plyometric exercises
  • Start sports metric program:
  • Autografts between weeks 20-24
  • Allografts between weeks 24-28
  • ACL functional test after sports metrics completion
  • Progress neuromuscular training program
  • Single leg hop test (90% of contralateral extremity)

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