Physical Therapy Protocols

What to expect in physical therapy after joint replacement

Total knee arthroplasty (TKA)

1st day in PT (evaluation)

• Please arrive 15-20 minutes early to complete required paperwork.
• The physical therapist (PT) will perform an evaluation to determine your needs for therapy. They will:
  • obtain measurements of knee motion and flexibility and lower extremity strength and
  • assess your gait and correct as needed for proper mechanics with a walker or cane.
• A home exercise program will be developed specific to your needs, and all exercises will be reviewed with the therapist or aide. These exercises will be performed daily at home.
• Depending on how you are feeling that day, a gym program may be started for you, which includes performing exercises using the clinic equipment.
• At the end of your session, a cold pack will be applied to the knee for 15 minutes.
• Plan to spend about 60-75 minutes in the clinic your first day.

Follow-up visits

• after a total knee replacement, you can expect to continue physical therapy sessions 2-3x/week for an average of 3 months.*
• Each follow up session averages 60-75 minutes
• During each session, you will work 1 on 1 with the PT for about 25-30 minutes to work on stretching, strengthening and functional exercises, gait training (including progression from a rolling walker -> cane -> no assisted device) etc.
• You will also work with the PT aides for an average of 20-30 minutes to perform a gym program designed by your PT, specifically for your needs.
• After all exercises are complete, ice will be applied to the knee for 15 minutes.
• Each month the PT will write a note to discuss the plan of care with you and your physician.

General time-lines/goals*

• After the start of PT, most patients will use a rolling walker for about 2 weeks. Then a cane will be used for the following 4-8 weeks.
• After starting PT, most patients will start going up stairs with a normal pattern in 3-6 weeks, and down stairs with a normal pattern in 8-12 weeks.
• Sleeping for 6+ hours without significant disruptions occurs after about 8 weeks from surgery.
• Driving can usually be resumed after 2-4 weeks (left leg surgery) or 4-6 weeks (right leg surgery), pending physician instructions and pain medication use.
• The knee should have motion of 90 degrees of bending when starting physical therapy.
• The knee should have motion of 120 degrees of bending in about 8-12 weeks (it takes about 110 degrees to make a full cycle on a stationary exercise bike).
• The knee should have full extension (achieve a fully straightened position) in 4-8 weeks

Total hip arthroplasty (THA)

1st day in PT (evaluation)

• Please arrive 15-20 minutes early to complete required paperwork.
• The physical therapist (PT) will perform an evaluation to determine your needs for therapy. They will:
  • obtain measurements of hip motion and flexibility and lower extremity strength and
  • assess your gait and correct as needed for proper mechanics with a walker or cane.
• The PT will review the precautions you must take based on the type of surgery you had.
  • anterior: no hyper extension, no external rotation (ie: crossing your ankle to the opposite thigh), no crossing midline with the leg, no pivoting on the standing leg
  • posterior: no hip flexion beyond 90 degrees, no internal rotation (your foot rotating outward from your body while the knee moves inward), no crossing midline with the leg, no pivoting on the standing leg
  • lateral: no flexion beyond 90 degrees, no crossing midline, no extreme external or internal rotation
• A home exercise program will be developed specific to your needs, and all exercises will be reviewed with the therapist or aide. These exercises will be performed daily, at home.
• Depending on how you are feeling that day, a gym program may be started for you, which includes performing exercises using the clinic equipment.
• At the end of your session, a cold pack will be applied to the hip for 15 minutes.
• Plan to spend about 60-75 minutes in the clinic your first day.

Follow-up visits

• After a total hip replacement, the patient can expect to continue physical therapy sessions 2-3x/week for an average of 3 months.*
• Each follow up session averages 60-75 minutes.
• During each session, you will work 1 on 1 with the PT for about 25-30 minutes to work on stretching, strengthening and functional exercises, gait training (including progression from a rolling walker cane no assisted device) etc.
• You will also work with the PT aides for an average of 20-30 minutes to perform a gym program designed by your PT, specifically for your needs.
• After all exercises are complete, ice will be applied to the hip for 15 minutes.

• Each month the PT will write a note to discuss the plan of care with you and your physician.

General time-lines/goals*

• After the start of PT, most patients will use a rolling walker for about 2-4 weeks. Then a cane will be used for the following 4-8 weeks.
• After starting PT, most patients will start going up stairs with a normal pattern in 4-6 weeks, and down stairs with a normal pattern in 8-10 weeks.
• Sleeping for 6+ hours without significant disruptions occurs after about 6-8 weeks from surgery.
• Driving can usually be resumed after 2-4 weeks (left leg surgery) or 4-6 weeks (right leg surgery), pending physician instructions and pain medication use.
• The hip precautions specific to your procedure will be adhered to for about 6 weeks.

Total Shoulder Arthroplasty (TSA)

1st day in PT (evaluation)

• Please arrive 15-20 minutes early to complete required paperwork.
• The physical therapist (PT) will perform an evaluation to determine your needs for therapy. They will:
  • obtain measurements of the shoulder motion and flexibility;
  • assess your posture and adjust your sling if needed; and
  • review positions and movements to avoid.
    • No active movement of the shoulder is allowed from the shoulder (ie: reaching activities) for the first 4-6 weeks.
    • No bearing weight through the affected arm or excessive movement behind the back for 4-6 weeks
• A home exercise program will be developed specific to your needs, and all exercises will be reviewed with the therapist or aide. These exercises will be performed daily at home
• Depending on how you are feeling that day, a gym program may be started for you, which includes performing exercises using the clinic equipment
• At the end of your session, a cold pack will be applied to the shoulder for 15 minutes.
• Plan to spend about 45-60 minutes in the clinic your first day.

Follow-up visits

• After a total shoulder replacement, the patient can expect to continue physical therapy sessions 2-3x/week for an average of 3 months.*
• Each follow up session averages 60-75 minutes.
• During each session, you will work 1 on 1 with the PT for about 25-30 minutes to work on stretching, strengthening and functional exercises, etc.
• The patient will also work with the PT aides for an average of 15-30 minutes to perform a gym program designed by your PT, specifically for your needs.
• After all exercises are complete, ice will be applied to the shoulder for 15 minutes.
• Each month the PT will write a note to discuss the plan of care with you and your physician.

General time-lines/goals*

• The sling will be worn for 3-4 weeks.
• Driving can be resumed after 3-4 weeks.
• Use of the arm independently can resume after 4 weeks, but the arm should not be used for lifting items heavier than a coffee cup.
• The arm should have enough range of motion to perform low overhead reaching activities (ie: pulling a shirt on overhead, reaching for a glass from a low cabinet shelf) at about 6-8 weeks.
• Moderately challenging activities (carrying items such as a full pot/pan or laundry basket) can usually be resumed after 12 weeks.
• Recreational activities (gardening, golf, etc) can be resumed after 16 weeks.

*Every individual responds differently to their surgery, and no two surgeries are the same. The numbers provided are a general guideline. Please consult with your physician about any specific questions regarding your surgery.

Physical therapy protocol for ACL reconstruction with allograft

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft.

Post-op Program

POD 1-2

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change: remove bulky dressing, leave clear dressing in place
7. Sleep with brace locked in full extension
8. Quad sets
9. Encourage full extension and flexion to 90

POW 1-4

1. Continue as above
2. Start SLR’s: start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion and encourage full extension
5. Passive ROM to 90, progress as tolerated
6. With good quad control, may wean from brace. Usually by 2 weeks.
7. Teach gait training. Emphasize heel-toe, good quad isolation, normal knee flexion and push-off.
8. Start the following open chain exercises
   1. Sidelying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance.
9. Begin closed chain knee exercises
   ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 4-12

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. leg press
   4. squats
   5. lunges (front/side/back)
   6. step-ups
   7. leg curls
   8. hip strengthening
   9. resisted walking
3. Exercises for balance and proprioception
   1. progress from local to whole body
      1. mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 12-28

1. Continue as above but slowly progress weight and decrease reps (8-10)
2. Progress walking to a fast walk then walk/jog on treadmill
3. Begin jumping rope.
4. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. jog

POW 28 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria — 9 months

• Satisfactory clinical exam
• <10% isokinetic strength deficit (Leg Press)
• Completion of sport replication activity
• Single leg hop test

Physical therapy protocol for ACL reconstruction with hamstring autograft

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft.

Post-op program

POD 1-2

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change: remove bulky dressing, leave clear dressing in place
7. Sleep with brace locked in full extension
8. Quad sets
9. Encourage full extension and flexion to 90

POW 1-4

1. Continue as above
2. Start SLR’s: start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion and encourage full extension
5. Passive ROM to 90, progress as tolerated
6. With good quad control, may wean from brace. Usually by 2 weeks.
7. Teach gait training, emphasizing heel-toe, good quad isolation, normal knee flexion and push-off.
8. Start the following open chain exercises
   1. Sidelying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance without resistance and progress as tolerated.
9. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 4-10

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. progress from double to single leg and concentric to eccentric
   3. emphasis on closed chain activities only
      1. leg press
      2. squats
      3. lunges (front/side/back)
      4. step-ups
      5. leg curls
      6. hip strengthening
      7. resisted walking
3. Exercises for balance and proprioception -progress from local to whole body
   1. mini-tramp
   2. Sport cord
   3. Slide board
   4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 10-18

1. Continue as above but slowly progress weight and decrease reps (8-10)
2. Progress walking to a fast walk then walk/jog on treadmill. Usually begin jogging by 10 weeks.
3. Begin jumping rope.
4. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. jog

POW 18 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Physical therapy protocol for ACL reconstruction with patellar tendon autograft

Pre-op education

Instruct the patient in ankle pumps, quad sets, seated knee flexion, supine SLR, hamstring stretches, gait training with crutches and protection of the graft.

Post-op program

POD 1-2

1. Ankle pumps: 20-25 per hour
2. Active flexion as tolerated
3. Gait with crutches and brace locked in full extension. (WBAT)
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change:  remove bulky dressing, leave clear dressing in place
7. Sleep with brace locked in full extension
8. Quad sets

POW 1-4

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Progress active flexion and encourage full extension
5. Begin passive ROM to 90
6. With good quad control, may wean from brace.  Usually in 2 -3 weeks.
7. Teach gait training.  Emphasize heel-toe, good quad isolation, normal knee flexion and push-off.
8. Start the following open chain exercises:
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: begin level and progress to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 4-10

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 10-16

1. Continue as above but slowly progress weight and decrease reps (8-10)
   1. Increase load
   2. Decrease time and increase power
2. Progress walking to a fast walk then walk/jog on treadmill.
   ?Typically begin jogging around 10 weeks.
   1. High knee march
   2. Figure of “8”
3. Begin jumping rope.
   1. Shuttle

POW 16 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Physical therapy protocol for arthroscopic rotator cuff repair

Phase I protective phase

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 6

1. Elbow, wrist and hand AROM (EWH)
2. Codman’s pendulum exercises as tolerated
3. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 10 reps, 2 x day
4. Supine passive external rotation (PER) to tolerance with T-stick in
   1. 0-20 degrees flexion and 20 degrees abduction
   2. 10 reps, 2 x day
5. C-spine AROM
6. Ice
7. Positioning full time in sling with abduction pillow
8. Shoulder shrugs and retractions (no weight)
9. ***Pain control modalities PRN
10. ***Aquatics PROM after sutures are out
11. Slowly progress PROM to full in all planes
12. Complications/Cautions
    1. If pain level is not dissipating, decrease intensity and volume of exercises.
    2. Assure normal neurovascular status
    3. No AAROM or AROM until 6 weeks
    4. No Pulley until 6 weeks

Weeks 6 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable at 6 weeks
3. Achieve PROM goals in FE (full)
4. Achieve PROM goals in ER at 20 deg and 90 deg abduction (full)
5. Initiate posterior capsule stretching
6. Isometrics, keeping elbow flexed to 90 degrees
   1.  Sub maximal, pain free
7. Theraband scapula retractions
8. ***Aquatics
9. ***Mobilizations PRN
10. ***Trunk stabilization/strengthening
11. Start AAFE and progress to AFE
12. Start periscapular strengthening
13.  Very low weight and high repetitions
14. Cautions
    1. Do not initiate rotator cuff strengthening until 12 weeks

Phase II progressive strengthening

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula, deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula
   1.  Rhythmic stabilization or slow reversal hold
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening
    1.  Isolated pain free, elbow by side
12. Progress to isotonic dumbbell exercises for deltoid, supraspinatus
    1.  Up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain level is low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress only without signs of increasing inflammation
    4. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2x/day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/and scapula strengthening as above
   1.  5lbs max for isotonic strengthening
   2. Follow the below progression:
      1. Prone isotonic strengthening PRN
      2. Decreasing amounts of external stabilization provided to shoulder girdle
      3. Integrate functional patterns
      4. Increase speed of movements
      5. Integrate kinesthetic awareness drills into strengthening activities
      6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses at
      1. Waist level
      2. Overhead
      3. Diagonal
   5. 1-handed stability drills
   6. 1-handed tosses
      1. vary amount of abduction, UE support, amount of protected ER
4. May begin Interval Throwing Program after 3-6 weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

Physical therapy protocol for arthroscopic slap repair

Phase I immediate post-operative phase (restrictive motion)

Goals

• Protect the anatomic repair
• Prevent negative effects of immobilization
• Promote dynamic stability
• Decrease pain and inflammation

Weeks 0 to 4

1. Sling for 4 weeks
2. Sleep in immobilizer for 4 weeks
3. Elbow, wrist and hand ROM exercises
4. Hand gripping exercises
5. ***No active elbow flexion
6. Cryotherapy, modalities as indicated
7. No AROM, ER, extension or abduction

 Week 4

1. Discontinue sling at 4 weeks
2. May use immobilizer for sleep
3. ROM exercises (PROM and AAROM)
   1. Flexion to 90-110
   2. Abduction to 75-85
   3. ER in scapular plane to 15-20
   4. IR in scapular plane to 55-60
4. Progress ROM and initiate AROM after 4 weeks
5. Continue modalities and cryotherapy

Weeks 4 to 6

1. Gradually improve ROM
   1. Flexion:  140
   2. ER at 45 degrees abduction:  25-30
   3. IR at 45 degrees abduction:  55-60
2. PNF manual resistance
3. May initiate gentle stretching
4. Posterior Capsular Stretching
5. No biceps strengthening

Phase II intermediate phase (moderate protection)

Goals

• Gradually restore full ROM
• Preserve the integrity of the surgical repair
• Restore muscular strength and balance

Weeks 6 to 10

1. Gradually progress ROM
   1. Full flexion
   2. ER at 90 abduction:  45-70
   3. IR at 90 abduction:  60-70
2. Initiate exercise tubing ER and IR (arm at side)
3. Initiate isotonic dumbbell exercises for deltoid, supraspinatus
   1. up to 3 lbs. max (once full AFE is achieved)
4. PNF strengthening

Weeks 10 to 14

1. Slightly more aggressive strengthening
2. Continue all stretching exercises
3. ***Progress ROM to functional demands

Phase III minimal protection phase

Goals

• Establish and maintain full ROM
• Improve muscular strength, power and endurance
• Gradually initiate functional activities

Criteria to enter phase III

1. Full pain-free ROM
2. Satisfactory stability
3. Strength improving
4. No pain or tenderness

Weeks 14 to 18

1. Continue all stretching exercises
2. Continue strengthening exercises
   1. Fundamental throwing exercises
   2. PNF manual resistance
   3. Endurance training
   4. Initiate light plyometrics
   5. Light swimming
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula.
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
      1. 2-handed tosses
         1. overhand
         2. Underhand
         3. Diagonal
      2. 1-handed stability drills
      3. 1-handed tosses (vary amount of abduction, UE support, amount of protected ER)

Weeks 18 to 20

1. Continue all above exercises
2. Initiate ITP

Phase IV advanced strengthening phase

Goals

• Enhance strength, power and endurance
• Progress functional activities
• Maintain shoulder mobility

Criteria to enter phase IV

1. Full pain-free ROM
2. Satisfactory static stability
3. Strength 75-80% of contralateral side
4. No pain or tenderness

Weeks 20 to 24

1. Continue flexibility exercises
2. Continue isotonic strengthening program
3. PNF manual resistance patterns
4. Plyometric strengthening
5. Progress ITP

Phase V return to activity phase (6 to 9 months after surgery)

1. Gradually progress sport activities to unrestricted
2. Discharge/Return to sport criteria
   1. PROM WNL for ADL’s/work/sports
   2. MMT 5/5 shoulder girdle and/or satisfactory isokinetic test
   3. Complete plyometric program, if applicable
   4. Complete interval return to sport program, if applicable

Physical therapy protocol for arthroscopic subacromial decompression with or without excision of distal clavicle

POD 1

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive forward elevation in plane of scapula (PFE) to tolerance
   1. 10-20 reps, 2 x day
3. Supine passive external rotation (PER) to tolerance
   1. T-stick in 0-20 degrees flexion and 20 degrees abduction
   2. 10-20 reps, 2 x day
4. C-spine AROM
5. Ice
6. Positioning full time in sling until block has worn off
7. Shoulder shrugs and retractions (no weight)
8. ***Pain control modalities PRN
9. D/C sling as tolerated
10. Slowly achieve full PROM in all planes
11. Complications/cautions
    1. If pain level is not dissipating, decrease intensity and volume of exercises.
    2. Assure normal neurovascular status

Weeks 1 to 4

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Achieve PROM goals to full in FE
4. Achieve PROM goals in ER at 20 deg and 90 deg abduction to full
5. Initiate posterior capsule stretching
6. Isometrics, keeping elbow flexed to 90 degrees
   1. Sub maximal, pain free
7. Theraband scapula retractions
8. ***Aquatics
9. ***Mobilizations PRN
10. ***Trunk stabilization/strengthening
11. Start AAFE and progress to AFE
12. Start periscapular strengthening
    1. Very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 3-4 weeks and until night pain has subsided and overall pain level is low

Weeks 4 to 8

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula, deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula
   1. Rhythmic stabilization or slow reversal hold
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening
12. Isolated pain free, elbow by side
13. Progress to isotonic dumbbell exercises for deltoid and supraspinatus
14. Cautions
    1. Assure normal scapulohumeral rhythm with AAFE and AFE
    2. Strengthening program should progress only without signs of increasing inflammation
    3. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2 x day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 2 to 6

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening as above with the following progressions:
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Physical therapy protocol for knee arthroscopy

POW 1-2

1. Patellar Mobilizations
2. Cryotherapy
3. Quad sets
4. SLR’s: supine
5. May use e-stim to promote quad recruitment
6. Progress ROM to full actively and passively
7. Teach gait training
   1. Emphasize heel-toe, good quad isolation, normal knee flexion and push-off
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press
   7. Stationary bike
10. Encourage upper extremity strengthening for overall conditioning
11. Continue modalities

POW 2-4

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 4-6

1. Continue as above but slowly progress weight and decrease reps (8-10)
   1. Increase load
   2. Decrease time and increase power
2. Progress walking to a fast walk then walk/jog on treadmill
   1. High knee march
   2. Figure of “8”
3. Begin jumping rope.
   1. Shuttle

POW 6 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Physical therapy protocol for large rotator cuff repair

ROM Goals

• POW2
  • PFE: 60°-90°
  • PER@20: 0°-20°
  • PER@90: N/A
  • AFE: N/A
• POW6
  • PFE: 90°-120°
  • PER@20: 20°-30°
  • PER@90: N/A
  • AFE: to 90°
• POW9
  • PFE: 130°-155°
  • PER@20: 30°-45°
  • PER@90: 45°-60°
  • AFE: 90°-120°
• POW12
  • PFE: 140°-WNL
  • PER@20: 30°-WNL
  • PER@90: 75°-WNL
  • AFE: 120°-WNL

Phase I protective phase) – NO PROM UNTIL POW 2

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 6

1. Elbow, wrist and hand AROM (EWH)
2. Supine passive external rotation (PER)
   1. T-stick in 0-20 deg flexion and 20 deg abduction
   2. 10 reps, 2 x day
3. Supine passive forward elevation in plane of scapula
   1. 90 after the first 2 weeks
   2. 10-20 reps, 2 x day
   3. Do not begin passive forward elevation until 2 weeks post op
4. C-spine AROM
5. Ice
6. Positioning full time in sling with abduction pillow
7. Shoulder shrugs and retractions (no weight)
8. ***Pain control modalities PRN
9. Complications/Cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises.
   2. Assure normal neurovascular status
   3. No AAROM or AROM until 6 weeks
   4. No pulley until 6 weeks

Weeks 6 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Progress PROM goals
4. Achieve PROM goals in ER at 20 degrees and 90 degrees abduction
5. Start AAFE and progress to AFE
6. Initiate posterior capsule stretching
7. Isometrics, keeping elbow flexed to 90 degrees (Sub maximal, pain free)
8. Theraband scapula retractions
9. ***Aquatics
10. ***Mobilizations PRN
11. ***Trunk stabilization/strengthening
12. Start periscapular strengthening with very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 12 weeks and until night pain has subsided and overall pain level is low

Phase II progressive strengthening

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold)
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening (isolated pain free, elbow by side)
12. Progress to isotonic dumbbell exercises for deltoid, supraspinatus, up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain level is low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress only without signs of increasing inflammation
    4. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2 x day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening as above (5lbs max for isotonic strengthening) with the following progressions:
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuff and scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses
      1. waist level
      2. Overhead
      3. Diagonal
   5. 1-handed stability drills
   6. 1-handed tosses (vary amount of abduction, UE support, amount of protected ER)
4. May begin Interval Throwing Program after 3-6  weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

Physical therapy protocol for massive rotator cuff repair

Phase I protective phase)

Goals

• Minimize pain and inflammatory response
• Achieve ROM goals
• Establish stable scapula

Weeks 0 to 8

1. Elbow, wrist and hand AROM (EWH)
2. Passive forward elevation in plane of scapula (PFE) (supine ) to 90 after the first 6 weeks; 10-20 reps, 2 x day. Do not begin PROM until 6 weeks post op.
3. Supine passive external rotation (PER) to tolerance with T-stick in 0-20 degrees flexion and 20 degrees abduction; 10-20 reps, 2 x day beginning week 6.
4. C-spine AROM
5. Ice
6. Positioning full time in sling with abduction pillow
7. Shoulder shrugs and retractions (no weight)
8. ***Pain control modalities PRN
9. Complications/Cautions
   1. If pain level is not dissipating, decrease intensity and volume of exercises.
   2. Assure normal neurovascular status
   3. No AAROM or AROM until 12 weeks

Weeks 8 to 12

1. Heat/ice PRN to help obtain motion
2. D/C sling as comfortable
3. Progress PROM goals to full in all planes
4. Achieve  PROM goals in ER at 20 degrees and 90 degrees abduction (full)
5. Start AAFE and progress to AFEat 12 weeks
6. Initiate posterior capsule stretching
7. Isometrics, keeping elbow flexed to 90 degrees (Sub maximal, pain free)
8. Theraband scapula retractions
9. ***Aquatics
10. ***Mobilizations PRN
11. ***Trunk stabilization/strengthening
12. Start periscapular strengthening with very low weight and high repetitions
13. Cautions
    1. Do not initiate rotator cuff strengthening until 16 weeks and until night pain has subsided and overall pain level is low

Phase II progressive strengthening)

Goals

• Achieve staged ROM goals
• Eliminate shoulder pain
• Improve strength, endurance and power
• Increase functional activities

Months 3 to 4

1. Continue as above
2. ROM should be full in all planes
3. Progress isometrics
4. Advance scapula strengthening
5. ***Mobilizations PRN
6. ***Aquatics for strengthening
7. ***CKC activities for dynamic stability of scapula deltoid and cuff
8. ***Trunk stabilization/strengthening
9. ***Light PNF D1, D2 and manual resistance for cuff/deltoid/scapula (rhythmic stabilization or slow reversal hold)
10. Initiate theraband ER and IR strengthening
11. Progressive serratus anterior strengthening (isolated pain free, elbow by side)
12. Progress to isotonic dumbbell exercises for deltoid,supraspinatus, up to 3 lbs max
13. Cautions
    1. Do not initiate AAFE or theraband rotator cuff strengthening until overall pain level is low
    2. Assure normal scapulohumeral rhythm with AAFE and AFE
    3. Strengthening program should progress only without signs of increasing inflammation
    4. Strengthening program should emphasize high repetitions, low weight and should be performed a maximum of 2 x day

Phase III return to activity/advanced conditioning

Goals

• Normalize strength, endurance and power
• Return to full ADL’s and recreational activities

Month 4 to 6

1. Stretching PRN
2. Continue deltoid/cuff/and scapula strengthening asabove (5lbs max for isotonic strengthening) with thefollowing progressions
   1. Prone isotonic strengthening PRN
   2. Decreasing amounts of external stabilization provided to shoulder girdle
   3. Integrate functional patterns
   4. Increase speed of movements
   5. Integrate kinesthetic awareness drills into strengthening activities
   6. Decrease in rest time to improve endurance
3. May begin tennis ground stroke/batting/return to golf after completing strengthening progression
4. ***Progressive CKC dynamic stability activities
5. ***Impulse
6. ***Initiate isokinetic strengthening
7. ***Mobilizations PRN
8. ***Trunk stabilization/strengthening

Month 6 to 8

1. Stretching PRN
2. Continue deltoid/cuff/scapula strengthening program
3. Initiate plyometric program (if needed)
   1. Do not begin until 5/5 MMT for rotator cuffand scapula
   2. QD at most
   3. Begin with beach ball/tennis ball progressing to weighted balls
   4. 2-handed tosses
      1. waist-level
      2. overhead
      3. diagonal
   5. 1-handed stability drills
   6. 1-handed tosses (vary amount of abduction, UE support, amount of protectedER)
4. May begin Interval Throwing Program after 3-6 weeks of plyometrics
5. Initiate progressive replication of demanding ADL/work activities

Discharge/return to sport criteria

1. PROM WNL for ADL’s/work/sports
2. MMT 5/5shoulder girdle and/or satisfactory isokinetic test
3. Complete plyometric program, if applicable
4. Complete interval return to sport program, if applicable

Physical therapy protocol for meniscal repair

POD 1

1. Ankle pumps: 20-25 per hour
2. Active flexion to 90 as tolerated
3. Strict NWB.  Brace locked in extension at all times unless performing exercises.
4. Gait with crutches.
5. Patellar mobilizations
6. Polar care/ cryotherapy
7. Dressing change: remove bulky dressing, leave clear dressing intact
8. Quad sets

POW 1-4

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Continue active flexion and encourage full extension
5. Begin active ROM to full at 4 weeks
6. Gait training with assistive device
7. Continue NWB
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Encourage upper extremity strengthening for overall conditioning

POW 4-12

1. Continue as above
2. Be sure to advance knee to full ROM
3. Begin weight bearing
   1. Progress from PWB to WBAT with brace locked in extension.
   2. Unlock brace at 6 weeks
   3. D/C brace at 8 weeks
4. Aquatic therapy may start at 8 weeks for LE strengthening
5. Stationary bike with low resistance and seat up high to avoid hyperflexion
6. Standing terminal knee extension with theraband.
7. May increase resistance on stationary bike at 10 weeks

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. Jog
3. Continue modalities
4. Encourage upper extremity strengthening for overall conditioning

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Leg press
      2. Squats
      3. Lunges (front/side/back)
      4. Step-ups
      5. Leg curls
      6. Hip strengthening
      7. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Physical therapy protocol for patellar tendon repair

POD 1

1. Ankle pumps: 20-25 per hour
2. Active/active assisted knee flexion to 30 degrees as tolerated
3. Strict NWB. Brace locked in extension at all times unless performing exercises.
4. Gait with crutches
5. Patellar mobilizations
6. Polar care/ cryotherapy
7. Dressing change: remove bulky dressing, leave clear dressing intact
8. Quad sets

POW 1-6

1. Continue as above
2. Start SLR’s: start standing, then sitting, then supine
3. May use e-stim to promote quad recruitment
4. Continue active flexion and encourage full extension
5. Progress ROM 10 deg per week to achieve 90 deg by 6 weeks
6. Gait training with assistive device
7. Begin WBAT with brace locked in extension at 4 weeks
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
   4. Standing hamstring curls to tolerance
9. Encourage upper extremity strengthening for overall conditioning

POW 6-12

1. Continue as above
2. Be sure to advance knee to full ROM starting at 6 weeks
3. Unlock brace at 8 weeks
4. D/C brace at 10 weeks
5. Aquatic therapy may start at 8 weeks for LE strengthening
6. Stationary bike with low resistance and seat up high to avoid hyperflexion
7. Standing terminal knee extension with theraband
8. May increase resistance on stationary bike at 10 weeks

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Jog Progression
   1. Fast walk
   2. High knee march
   3. Figure 8
   4. 4 way reaction drill
   5. Jog
3. Continue modalities
4. Encourage upper extremity strengthening for overall conditioning

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Squats, leg press
      2. Lunges (front/side/back)
      3. Step-ups
      4. Leg curls
      5. Hip strengthening
      6. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test

Physical therapy protocol for quad tendon repair

POD 1

1. Ankle pumps: 20-25 per hour
2. Strict NWB.  Brace locked in extension at all times unless performing exercises.
3. Gait with crutches
4. Patellar mobilizations
5. Polar care/ cryotherapy
6. Dressing change
7. Quad sets in brace

POW 1-6

1. Continue as above
2. Start SLR’s:  start standing, then sitting, then supine in brace
3. May use e-stim to promote quad recruitment
4. Encourage full extension
5. Progress ROM 10 deg per week beginning week 4 to achieve 90 deg by 8 weeks
6. Gait training with assistive device
7. Begin WBAT with brace locked in extension at 4 weeks
8. Start the following open chain exercises
   1. Side lying hip abduction and adduction
   2. Sitting hip flexion
   3. Ankle theraband
9. Encourage upper extremity strengthening for overall conditioning

POW 6-12

1. Continue as above
2. Be sure to advance knee to full ROM starting at 8 weeks
3. Unlock brace at 8 weeks to ambulate
4. D/C brace at 10 weeks
5. Aquatic therapy may start at 8 weeks for LE strengthening
6. Stationary bike with low resistance and seat up high to avoid hyperflexion
7. Standing terminal knee extension with theraband.
8. May increase resistance on stationary bike at 10 week

POW 12-16

1. Begin closed chain knee exercises
   ?ENCOURAGE PROPER TECHNIQUE AT ALL TIMES.
   1. Single leg stance: level to unlevel surfaces
   2. Therakicks: progress resistance, speed, arc of motion
   3. Walking forward, retro, and sidestepping
   4. Standing calf raises, wobble board
   5. Wall slides
   6. Leg press with very light weights at 12 weeks
   7. Stationary bike
2. Jog Progression
   1.  Fast walk
   2. High knee march
   3.  Figure 8
   4. 4 way reaction drill
   5. Jog
3. Continue modalities
4. Encourage upper extremity strengthening for overall conditioning

POW 16-20

1. Continue as above
2. Progress exercises for building strength and endurance
   1. 4-6 sets of 15-20 reps
   2. Progress from double to single leg and concentric to eccentric
   3. Emphasis on closed chain activities only
      1. Squats, leg press
      2. Lunges (front/side/back)
      3. Step-ups
      4. Leg curls
      5. Hip strengthening
      6. Resisted walking
3. Exercises for balance and proprioception
   1. Progress from local to whole body
      1. Mini-tramp
      2. Sport cord
      3. Slide board
      4. Swiss ball
4. Exercises for endurance
   1. Bike
   2. Stairmaster
   3. Elliptical trainer
   4. Treadmill walking
   5. Aquatic exercise

POW 20 return to sport

1. Progress jump roping to line jumps, then box jumps, and then distance jumps
2. Begin sport specific drills
3. Progress speed and intensity of above activities

Return to athletics criteria

1. Satisfactory clinical exam
2. <10% isokinetic strength deficit (Leg Press)
3. Completion of sport replication activity
4. Single leg hop test