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ACL reconstruction rehab protocol

General considerations

  • Progression should be based on careful monitoring by the Physical Therapist of the patient's functional status.
  • Early emphasis on achieving full extension equal to the opposite side (including hyperextension within normal range, 10*).
  • Avoid direct palpation and mobilization on incisions/portals for 4 weeks.
  • Exercises should focus on proper patella tracking and recruitment of the Vastus Medialis Oblique (VMO).
  • Exercises should focus on lumbopelvic stabilization in all planes of motion and all transfers.
  • No resisted leg extension machines (isotonic or isokinetic) at any point in the rehab process.
  • No cutting or twisting until cleared by Sports Test I.
  • Patient should be well aware that healing and tissue maturation continue to take place for 1 year after surgery.
  • Patients are given Sports Test I at 3 months , Sports Test II at 6 months, Sports Test III at 1 year.

Weeks 1 - 2

  • Nurse appt on day 2 for dressing change and review of home program.
  • Ice/elevation every 2 hours for 15 minutes to minimize edema and promote healing (please refer to Icing handout).

Manual

  • Soft tissue treatment to quads, posterior musculature, suprapatellar pouch, popliteal fossa, iliotibial band and Hoffa’s fat pad. Extensive patellar mobilization.
  • No direct scar mobilization x 4 weeks.

Exercises

  • Seated edge of bed dangle for knee flexion; prop for knee extension.
  • Quad sets/straight leg raises, hip abduction, calf presses, glut sets, and core exercises.
  • Upper body conditioning, well-leg stationary cycling or Upper Body Ergometer.
  • Gait training progression towards minimizing Assistive Devices (walker, crutches, etc).

Goals

  • Range of motion: 0-90 degrees.
  • Pain < 3/10. Minimal Edema.
  • Gait weight-bearing as tolerated;
  • Good quality gait with least amount of Assistive Device.

Weeks 2 - 4

  • Nurse appt for suture removal on day 14.
  • Walking for exercise for 15-20 minutes if no limp or swelling present.

Manual

  • Continue with soft tissue treatment, effleurage for edema.
  • Extensive patellar mobilization.
  • No direct scar mobilization x 4weeks.

Exercises

Range of motion and functional strengthening exercises:

  • Squats/Leg Press, Bridges/Hamstring Curls.
  • 2” step up/down, intense core training.
  • Aerobic exercises as tolerated (bilateral stationary bike, Elliptical, arm bike).

Goals

  • Active range of motion equal extension to uninvolved side and flexion to 120 degrees. No edema. Full weight-bearing; normal gait without assistive device. Single leg balance 60 seconds on level surface.

Weeks 4 - 6

  • MD appt at 4 weeks.
  • Walk up to 1 hour for exercise.

Manual

  • Continue with soft tissue mobilization. Apply direct scar tissue mobilization; can use instruments/tools.

Exercises

  • Emphasize self stretching to both lower extremities.
  • Increase intensity of resistance exercises (i.e. standing resisted squats, lunges, etc).
  • Introduce eccentric exercises (4-6” steps).
  • Increase single leg strength, challenge proprioceptive training.

Goals

  • Full Range Of Motion equal to uninvolved leg.
  • Perform 4 inch step down.
  • Bike with minimal resistance for 20-30 minutes (in saddle), walking for 30 minutes, Elliptical, water-walking.

Weeks 6 - 10

Manual

  • Soft tissue mobilization and joint mobilization as needed.

Exercises

  • Add lateral training exercises (lateral step ups, lunges, step overs).
  • Initiate tri-planar activities with the exception of closed-chain rotation (pivots).
  • No cutting or pivoting.

Goals

  • Activities should be pain-free:
  • Able to descend stairs, double leg squat hold for >1 minute.
  • Bike >30 minutes with moderate resistance, Elliptical with interval training, Flutter-style for swimming (no flippers, no breast-stroke kick).

Weeks 10 - 16

  • MD visit at 3 months.
  • Complete sports Test I and return to pre-running program at 3 months (see handout for specific details)
  • Fit for functional knee brace if requested by MD.
  • Incorporate bilateral, low level jumping exercises.
  • Continue to increase strength, endurance, and add sport specific training drills.

Goals

  • Pass Sports Test I.

Weeks 16+

  • MD visit at 6 months.
  • Sport test 2 at 6 months. Initiate return to run program.
  • Implementation of jump training, agility training. Education of “at risk sports”.
  • After 6 months add lateral plyometric type drills, agility ladder

Goals

  • Initiate sagittal plane plyometrics, work towards single leg plyometrics. Clearance by MD and pass Sportsmetric training before returning to full athletics.

NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.

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