General Considerations:

• Progression should be based on careful monitoring of the patient's functional status
• Early emphasis on achieving full hyperextension equal to the opposite side
• Passive and active range of motion as tolerated. CPM will be used 4-6 hours per day until patient reaches 120 degrees of flexion.
• Full weight bearing as soon as tolerated with no limp (unless otherwise indicated)
• Regular manual treatment should be conducted to the patella and all incisions
• Controlled exercises can be performed without the use of the brace ( post-op brace issued on individual basis)
• Exercises should focus on proper patella tracking and recruitment of the VMO
• Early recruitment of the VMO using home electrical stimulation unit if necessary
• No resisted leg extension machines (isotonic or isokinetic) at any point in the rehab process
• Patient should be well aware that healing and tissue maturation continue to take place for 1 year after surgery
• Patients are given a functional assessment/sport test at 3 and 6 months and 1 year post-op
• Rationale for phases

PHASE I (Approx. Weeks1-2)

Max protection phase

• M.D. visit day 1 post-op to change dressing and review home program
• M.D. visit at 8 - 10 days for suture removal and check-up
• Icing and elevation as much as able to minimize edema and promote healing
• Use of a CPM at home for 4 - 6 hours a day.
• Gait training to promote best quality of gait with the least amount of assistance
• Passive and active range of motion exercises
• Balance/proprioception exercises in a protected environment
• Well-leg stationary cycling, upper body conditioning, core conditioning
• Soft tissue treatments to posterior musculature, quads, and infrapatellar pouch
• Extensive patellar mobilizations, superior, inferior glides and patellar tipping

***Passive range of motion should be 0 degrees or hyperextension to 90 degrees flexion, minimal pain and edema, unassisted good quality gait before moving onto Phase II.

PHASE II (Approx.2 to 4 week)

Moderate protection phase

• M.D. visit at 4 weeks (post op brace may be discontinued as soon appropriate muscular control is achieved)
• Patient still needs to be somewhat restful with low impact on knee, must elevate and ice daily
• Walking for exercise limited to 15-20 minutes per day if no swelling or limping
• Continue with range of motion, gait training, soft tissue treatments and balance exercises
• Incorporate functional exercises/ eccentrics (i.e. squats, bridging, intense core training and 2 inch step downs)
• Leg weight machines PRE’s (i.e. leg press, hamstring curls, calf raises, abduction/adduction)
• Aerobic exercises as tolerated (i.e. bilateral stationary cycling, UBE, Elliptical)
• Pool workouts including deep water running, waist high fast walking in all directions

***Range of motion should be equal extension bilaterally to 120 degrees flexion, normal gait without assist, single leg balance ability, no significant edema before moving to Phase III. CPM can be discontinued if ROM goals reached.

PHASE III (Approx 4-6 weeks)

Return to function/strengthening phase

• Continue any necessary soft tissue mobilization required
• Emphasize self stretching of both lower extremities
• Increase the intensity of functional exercises (i.e. progress cycling, o.k for road cycling, increase resistance in exercises, up to 1 hour walking for exercise, add stair climber or versa climber, increase challenge of proprioceptive training and eccentric exercises i.e. 4-6 inch step downs) All exercises still in a controlled environment
• Greater emphasis on single leg strength exercises such as leg press and single leg squats.

***Patients should have full hyperextension and 80- 90 % of full flexion, able to do 4 inch single leg step down, and bike with minimal+ resistance for 20-30 minutes before moving to Phase IV.

PHASE IV (Approx. 6-10 weeks)

Progressive Activity phase

• Add lateral training exercises (i.e. lateral lunges, lateral step-ups, step overs)
• Begin to incorporate sport-specific training (i.e. volleyball bumping, easy hiking, functional training exercises in ALL planes of motion) No cutting or pivoting.
• Focus on good quality eccentric strength and continue to increase challenge and complexity of proprioceptive exercises

***All activities should be pain free without swelling, descending stairs should be smooth and pain free, single leg squatting for 30 seconds should be of good quality and pain free before moving to Phase V.

PHASE V (Approx. 10-16 weeks)

Training for Sport phase

• M.D. visit at 3 months and functional test
• Incorporate bilateral, low level jumping exercises. Watch for compensatory patterns with take-offs or landings
• Progress to running if able to demonstrate good mechanics and appropriate strength at 12 weeks
• Add appropriate agility training with progressive complexity and challenge still cautious with cutting and pivoting
• Patients should be weaned into a home program with exercises specific to their particular activity/sport, aggressive road cycling is encouraged
• Fit for functional knee brace if requested by M.D.

***Single leg squat test for 1 minute must be at least 80% of uninvolved leg, moderate resistance biking for 30 minutes should be easily tolerated, patient should be confident with all ADLs and independent in an appropriate gym and outdoor training program before moving to Phase IV. Pt should be well educated on avoiding cutting sports. Conditioning should be emphasized in this phase rather than playing a sport.

PHASE VI (6-12 months)

Return to Sport phase

• MD visit and sport test
• Progression of program of increasing intensity to return to sports, increasing plyometric training with appropriate progression and emphasis on form
• Patient should be adequately informed of higher risk activities and instructed on appropriate training for safest progression to those specific activities i.e. skiing, basketball, and soccer.

***Patient must pass sport test and MD exam before being released to full athletics

Functional Test at 12 weeks:
Comparison of involved and uninvolved leg in the following tests:

• Single leg squat for 1 minute comparison of repetitions achieved in 1 minute
• Lateral excursion test : patient to stand on test leg attempt to tap (touch toe only) as far out laterally as possible with opposite leg. Distance recorded and compared for 3 attempts on each side
• Posterior excursion test: same as above with patient tapping toe posteriorly
• Cariocas: patient to demonstrate good quality movement and control with ½ speed cariocas over 40 feet
• Lateral leaps: Patient to leap laterally at ½ speed touching markers set 3-4 feet apart for 1 minute with excellent control and form.

Sport Test at 6 months and 1 year:

• ¾ to full speed cariocas over 40 feet with good control and form
• Single leg contralateral reach downs: patient to stand on test leg, with contralateral hand to touch floor at test leg’s ankle repeat over 1 minute and compare number of successful touches to uninvolved side
• Forward leap: Patient to leap forward (striding) with alternating legs over 40 feet to see quality and willing of single leg push off and landing
• Lateral leap with resistance. Same test as 12 week but with added resistance cord around waist in line with direction of leap

At one year:

• Add test of single leg hop for distance 3 hop trials per leg.
• Add change of direction drill patient begin running forward and on command reverse direction to backwards run, on next command turn and run right, on next command turn and run left, etc. for 1 minute-evaluate quality and control of movement.