PT PROTOCOLS

Post-operative Rehabilitation Program for ACL Reconstruction
(from Ellman MB et al: Return to Play Following ACL Reconstruction. J Am Acad Orthop Surg 2015;23(5):283-296)

  • The protocols for ACL reconstructions using patellar tendon grafts and hamstring grafts are the same with the following exceptions:
    • when performing heal slides, make sure that a towel is used to avoid activating the hamstring muscles
    • do not perform isolated hamstring exercises

Phase 1: Immediate post-op phase = days 1-7

Goals

  • restore full passive knee extension
  • diminish joint swelling and pain
  • restore patellar mobility
  • reestablish quadriceps control
  • restore ambulation

Brace/Modalities

  • knee braced locked in full extension except for when doing exercises
  • WBAT with crutches; discontinue crutches to tolerance once gait is normalized and SLR with no lag
  • Cryotherapy
  • Elevation
  • Electrical stimulation to quadriceps

Exercises

  • ankle pumps, calf and gentle hamstring stretches, patellar mobs
  • SLR, quad sets
  • ROM: Full extension to at least 90 degrees passive flexion with heel slides, wall slides or chair flexion (supine wall slides preferred for hamstring grafts), prone hangs
  • Strengthening: CKC exercises (mini-squats, lunges, step-ups)
  • Cycling: may begin stationary cycling with no resistance when patient can flex to 110 degrees; do not use bike to increase flexion
  • NM/Proprioception: POD 4-7: +/- OKC passive/active joint repositioning at 90 degrees, 60 degrees

Criteria for Progression to Phase 2

  • quadriceps control (ability to perform SLR)
  • full passive knee extension
  • ROM 0-90 degrees
  • good patellar mobility
  • minimal joint effusion
  • independent ambulation

Phase 2: Early phase = weeks 2-4

Goals

  • decrease pain and swelling
  • full knee extension by 2 weeks
  • normalize patellar mobility
  • reestablish quadriceps control
  • restore ambulation

Brace/Modalities

  • knee braced unlocked if achieved SLR without lag
  • WBAT
  • Cryotherapy as needed
  • Electrical stimulation to quadriceps

Exercises

  • as above
  • SLR with weights when no extensor lag
  • ROM: progress through passive, active and resisted ROM as tolerated
  • Strengthening: CKC exercises (0-45 degrees), extension board and prone hang with ankle weights (up to 10 lbs), no restrictions to ankle/hip strengthening
  • Cycling: may use cycling to increase flexion
  • NM/Proprioception: OKC passive/active joint repositioning, CKC repositioning during squats/lunges, squats on tilt board, biofeedback if needed to enhance VMO contraction

Criteria for Progression to Phase 3

  • active ROM 0-115 degrees
  • quadriceps strength >/= 60% of contralateral side
  • minimal to no joint effusion
  • no joint line or PF pain

Phase 3: NM control phase = weeks 4-10

Goals

  • restore full ROM
  • improve strength
  • enhance proprioception, balance, and NM control
  • improve muscular endurance
  • add core strengthening exercises

Brace/Modalities

  • functional knee brace may be given at this time
  • Cryotherapy as needed
  • Electrical stimulation to quadriceps as needed

Exercises

  • as above
  • ROM: self ROM 4-5 times daily with emphasis on 0 degrees passive extension, passive ROM 0-125 degrees at week 4
  • Strengthening: initiate isolated hamstring curls at week 6, increase CKC exercises (0-90 degrees), add core strengthening exercises, add side lunges, pulley weights, bands, stair stepper, bicycle
  • NM/Proprioception: tilt board squats, OKC passive/active joint repositioning, CKC repositioning on tilt board, CKC lunges, light plyometric jump training (week 8)

Criteria for Progression to Phase 4

  • subjective Noyes knee scoring >80 points
  • active ROM 0-125 degrees
  • quadriceps strength >/= 80% of contralateral side
  • knee extensor:flexor ratio 70%:75%
  • no pain or joint effusion
  • negative Lachman and pivot shift tests
  • hamstring strength equal bilaterally, hamstring:quadriceps ratio 66%:75%
  • single-leg hop test >/= 80% of contralateral leg

Phase 4: Strength and Performance phase = weeks 10-20

Goals

  • - normalize strength
  • - enhance power and endurance
  • - improve NM control
  • - perform selected sport specific drills

Brace/Modalities

  • - functional knee brace may be given at this time
  • - Cryotherapy as needed

Exercises

  • as above
  • ROM: full active and passive
  • Strengthening: advance as tolerated, increase resistance
  • NM/Proprioception: advance plyometrics as tolerated
  • initiate running program, light sports program (ex. golf)
  • initiate agility training at week 14 (figures of eight, cutting drills, etc.)
  • begin to wean from formal supervised therapy, continue HEP, possibly consider strength and conditioning program with trainer preparing for return to sport possibly at 6 months

Phase 5: Return to Play = months 6-9

Criteria for full return to play

  • Noyes scoring system >90, Lysholm >75, no sense of instability, normal ADLs
  • full AROM
  • negative Lachman and pivot shift tests
  • no pain or joint effusion
  • NM testing: quadriceps atrophy <2cm, quadriceps strength >/= 85% of c/l side, hamstring strength 100% of c/l side, hamstring:quadriceps strength ratio >70%
  • Single-leg press>90% of normal, single-leg squat >60 degrees with normal pelvic balance/no valgus (normalization of hip abduction)
  • Functional tests: vertical jump; single-leg hop, triple hop and cross-over hop for distance and timed single-leg hop over 20 feet tests >85% of c/l side; cross-over hop test with normal frontal plane control; drop to jump tests must maintain upright trunk and no presence of valgus or excessive tibial rotation