Surgical Explanations
Rehabilitation Protocols
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ACL
ACL
Rehabilitation of an ACL repair requires careful communication with the referral source.
CONSIDERATIONS:
Type of graft used (allograft vs. autograft) (central quadriceps tendon autograft)
Past medical history: anti-inflammatory use, pain medicine use, history of previous corticosteroid use
Age
Activity level prior to surgery, desired post-operative activity level
Previous injury to knee: past surgical history, arthritis, joint dislocation, etc
This protocol outlines the rehabilitation procedures for a patient that has received an allograft AND autograft ACL repair.
Although the allograft is largely avascular, these patients may have prolonged inflammatory issues due to the presence of foreign tissue in the knee. Thus, swelling control via the RICE principle, electric stimulation via high volt galvanic or high frequency inferential treatments may be used to modulate swelling control.
It is important to obtain early ROM in extension to prevent arthrofibrosis and to allow easier quadriceps recruitment. ROM in flexion will take longer, often 4-6 weeks due to the persistent inflammation that occurs and to prevent “overstretching” of the anterior-medial fibers of the graft before it can histologically become a ligament complete with elastin-type connective tissue to allow for the graft to obtain the elastic properties of a ligament.
PHASE 1:WEEKS 1-2
GOALS OF PHASE:
Decrease swelling
Obtain full extension
Minimize quadriceps atrophy
Initiate weight bearing as tolerated
Crutch walking: WBAT assuming no co-morbid pathology to the knee was repaired
EXERCISES:
Quad sets: high repetitions for 10-15 minutes
SLR 4-way: hip abduction, hip extension, SLR, hip adduction: high repetitions, low resistance: 20-25 reps
Knee flexion ROM: heel slides / wall slides done 2-3 times per day
Prone lying: 10 minutes to facilitate knee extension
Multi Hip
Calf raises
Patellar mobilization: superior glide, medial glides
Weight shifting: side to side, forward –backwards
Single leg stance balance when crutches discontinued
Stationary bike non resistance when 110 – 115 flexion is achieved, do not force ROM
PHASE 2: WEEKS 2-4
EXERCISES:
Continue with ROM progression to obtain full knee flexion and extension
Add closed chain strengthening exercises: Total Gym® or leg press: low resistance and high repetition from 0-60 degree , mini squats, forward step-up, forward cone walking
Unilateral standing balance progressing to plyotoss
Heel raises
Patient usually will discontinue crutches at this time if the following criteria has been met:
Patient is able to perform a straight leg raise with 0 degree quad lag
Patient is able to assume unilateral stance for 5 seconds
Patient has obtained full extension within 5 degrees
Patient is able to ambulate with minimal gait deviations
*See attached API week 3 testing
PHASE 3: WEEKS 4-8
EXERCISES:
Leg curl
Progress number of sets on total gym or leg press to 3 sets of 20 reps
Thera-Band® four-way hip strengthening
Forward chair scooting
Wall squatting with 10 second hold
Sports cord weight shifting
Cone stepping backwards, sideways.
Resisted side stepping with Thera-Band® at 6-8 weeks
Straight leg dead lifts: high repetitions with low resistance
Lateral step-ups
Lunges: forward, reverse; slide lunges week 5 - 6
Proprioceptive activities on uneven surfaces: foam roller, wobble board, BOSU® ball
UE dumbbell strengthening
Supine Theraball or foam roller bridging with knee flexion and extension
PHASE 4: WEEKS 8-12
GOALS OF PHASE:
To prepare for functional activities
*See attached API week 10 testing
EXERCISES:
Increase weight and low resistance on all previous activities
Increase previous exercises to 3-4 sets of 8-12 reps
Multi-angle lunges
Lower extremity cone agility exercises in multiple planes
Resisted side stepping with multiple directions (forward – backward, side to side and diagonals)
PHASE 5: WEEKS 12-14
EXERCISES:
Initiate functional activity progression assuming the following criteria has been met:
Patient has full ROM in knee flexion and extension
If isokinetic testing is available
Patient presents with quadriceps deficit of 20% as compared to the contralateral extremity and a hamstring deficit of 15% as compared to the contralateral extremity
If isokinetic testing is not available
10 single-leg squats while maintaining the knee over the second toe to minimize valgus stress at the knee, flexing to approximately 45-60 degrees without Trendelenberg at the pelvis
For males—single leg press using 100% body weight
For females—single leg press using 60-70% body weight
Jogging on treadmill
Work on increasing speed
PHASE 6: WEEKS 14-16
EXERCISES:
Continue with above activities
Incorporate jumping rope
PHASE 7: WEEKS 16-20
EXERCISES:
Continue with previous exercises
*see week 16 API hop test for baseline measurements
Again assess patient’s physical strength to determine readiness
If isokinetic testing is available
Patient presents with quadriceps deficit of 15% as compared to the contralateral extremity and a hamstring deficit of 10% as compared to the contralateral extremity
If isokinetic testing is not available
Patient should be able to perform 10 two-legged squat under 100% body weight in 10 seconds
If one of these stipulations is met:
Initiate plyometric activities (jumping on a flat surface, double leg hops, vertical jumps)
***NOTE: Emphasize quality of reps, not quantity—BUT KEEP COUNT AND MONITOR!!
Ensure “soft landing”—don’t land in valgus position, bend hips and knees to absorb shock
This routine should be performed 2-3 times per week, with at least 48 hours rest between sessions
Cutting drills
Shuttle run
Figure 8’s
Zig-zags, starting at 45° angles and working up to 90°
*See attached Post Sportsmetrics API hop test
PHASE 8: WEEK 20
EXERCISES:
Return to activity with brace assuming:
15%/10% rule has been achieved
Successful completion of a plyometric program |
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