Phase 1           

It is during the first phase (the acute phase) that we want to a) control swelling, b) control pain, c) to gain quadriceps activation, and d) gain early knee extension.  The acute stage will last for the first week, and the physiologic response to the secondary trauma of surgery needs to be controlled.  By achieving these four goals we believe that patient will avoid chronic swelling, lessen the chance of arthrofibrosis, gain full range of motion and improve the outcome of rehabilitation.  In addition to going to Physical Therapy and doing the prescribed exercises, we want the patient to ice and elevate and minimize any gravity dependent positions.  Another tool for edema control is regular soft tissue treatments using retrograde massage, and patellar mobilzation.  The body’s natural response is to create a flexion contracture at the knee with trauma, so we emphasize a straight leg elevation without any knee flexion along with hourly quad sets.  Quad atrophy is also a response to surgery, so quad activation is started with quad sets immediately after the procedure and followed up with Nueromuscular Electrical Stimulation in the clinic. A home unit is prescribed if the patient demonstrates any significant difficulty with quad setting. 

Phase 2

After the first week, the knee enters the subacute phase and we are no longer seeking maximal protection.  We enter the period where Wolf’s Law comes in to effect, that is the physiologic equivalent of  “use it, or lose it”.  The early movement helps to stimulate the revascularization and fibroblastic changes of the new ligament and careful closed chain exercises and normalized gait patterns will direct the body in laying down the new collagen in the correct direction.  Caution is taken in progressing too aggressively because the healing process is still working on the tissues and might react negatively to being over-stressed.  Though we allow increased stance time, progressive closed chain exercises, and weaning off of crutches we continue to emphasize edema reduction.  If the soft tissue is not managed correctly during this time, the possibility of scar tissue formation is higher, the range of motion is not achieved as fast, and the quadriceps may have increased atrophy.   The patient will take on more activities of daily living, and in most cases will return to work but will still be limited in overall standing and walking time to avoid additional edema.

Phase 3

We continue soft tissue mobilization as needed should any edema persist or PFJ problems associated with increased activity but lagging strength appear.  We always pay attention to the inferior pouch of the patella and the poplitues and posterior capsule regions. These tend to be the greatest soft tissue blocks to fluid motion at this stage.  We emphasize bilateral stretching and single leg strengthening to both integrate and isolate the surgical knee.  The goal is to foster symmetry in the lower extremities.  We want to have equal flexibility and to begin to equalize strength as soon as possible.  The patient will often not recognize the amount of compensation being done by the uninvolved leg until unilateral exercises are introduced.

This phase is essentially where the therapy moves to a training mode and the surgical leg is reintegrated as a functional part of the body.  There is still a large element of protection in this phase and exercises in the extremes of range are avoided. This phase is about good quality of movement and getting excellent range of motion before strenuous strengthening.  The patient should be feeling confident in the knee but should not be “testing” it.  Biomechanics and gait should be perfected here.

Phase 4

At this phase the patient should be ready to challenge the knee in more planes of motion and with greater excursions. This phase integrating the fundamentals of the patients sport and modifying the exercises as needed to promote the best quality of movement.  It is also about continue to intensify training in safe planes and ranges of motion to greatly increase overall strength.

Phase 5

This phase gets even more sport specific and functionally challenging. In this phase the therapist continue to challenge the patient in strength and proprioceptive areas.  The PT is looking for any subtle compensatory changes that may occur as the intensity is raised.  This phase is also quite important for extensive patient education on goals and limits.  A challenging but safe home exercise program is established.