Rehabilitation Protocol for Unhappy Triad of ACL, MCL, and Meniscus Tears

Phase I (first 6 to 8 weeks post-op)

Rehabilitation Goals - Control pain and inflammation

- Eliminate edema
- Initiate ROM (knee flexion and extension)
- Light strengthening
Precautions - NWB for 3-6 weeks
- Use of crutches with 25-50% WB
- Avoid OKC exercises
- Avoid excessive hamstring stretching till close of phase
- Must wear brace at all times (removed for showering)
- Graft is weakest around 6-8 weeks, avoid
strengthening during this time
- Core strengthening allowed
ROM - No limits on flexion
- 90 degrees of flexion by halfway mark of phase I
- Prone hangs (3 x 30 sec)
- SAQ sets (3 x 10)
- Heel slides/Wall slides (3 x 10)
- Ankle pumps 4-way (3 x 10)
- Gastroc-soleus stretching (3 x 30 sec)
- Hip ROM 4-way
- Stationary bike (seat adjusted to allow tolerable knee
flexion) (5-10 min)
Therapeutic Modalities/Exercise - Cryocuff, or ice (10-15 min)
- NMES (quad control)
30 - 35Hz @ 400 µs
usually 10 sec ON / OFF
- Self-mobilization of patella
- SLR 4 way (3 x 10)
Once flexion has reached 90°:
- CKC mini squats (3 x 10)
- Lateral step ups, bilateral (3 x 10)
- In-line lunges, bilateral (3 x 10)
- Leg press, progress to weighted (3 x 10)
- TKE (3 x 10)
- Seated BAPS board 4-way, (3 x 10)
Cardiovascular Exercise - Upper body ergometer (UBE) 5-10 min
- Swimming at close of phase
Progression Criteria - 75% to full WB as tolerated
- Greater than 110° of flexion
- Little to no edema
- Little to no pain
Additional notes:
- Use of treadmill (no incline) can begin around week 3 or 4 if tolerated
- Exercise prescription to be modified as needed. Let pain be your guide
Phase II (8 to 16 weeks post-op)

Rehabilitation Goals - Increase strength (emphasis on hamstrings)

- Full flexion
- Return to normal gait
- Treadmill (progress fast walk to jog toward close of
phase)
Precautions - ACL graft is weakest at start of phase
- No hyperextension
- Continuation of core strengthening
- Ice as needed
ROM - Continue ROM exercises
- Progress hip ROM to hip strengthening (t-band, 3 x 10)
Therapeutic Exercises - Continue exercises following 90° goal
- Progress leg press to single leg
- Add lateral lunges towards close of phase (3 x 10)
- Standing wall squat (3 x 15 sec)
- Functional PNF patterns D1/D2
- Toe raises weighted (3 x 10)
- Weighted SLR 4-way (3 x 10
- Progress BAPS board to standing (balance, 3 x 30 sec)
Cardiovascular Exercise - Continue from phase I
- Add stationary bike (light resistance towards close of
phase)
Progression Criteria - Normalized gait
- Full ROM
- Light jog to run with normal gait
- Single leg stance
Additional notes:
- Initiate plyometric drills at close of phase

Phase III (16 to 24 weeks post-op)

Rehabilitation Goals - OKC exercises

- Implement agility drills
- Progress plyometrics
- Initiate sport-specific activity at close of phase
Precautions - Isokinetic testing
- Continuation of core strengthening
ROM - See additional notes
Therapeutic Exercises - Continue phase II exercises
- Ladder drills (down and back, twice)
Cardiovascular Exercise - Continue from phase II
- Increase resistance of stationary bike PRN
 - Stairmaster
- Elliptical
Progression Criteria - Ability to run with normal gait
- No pain with plyometrics
- Good performance with multi-planar functional
movements
Additional notes:

- Full ROM has been completed, ROM should be continued resistively

- Ex. of ladder drills: carioca, figure 8, backward running
- Ensure soreness does not surpass 3 to 5 days (note what elicits pain or soreness)

Phase IV (24 weeks+ post-op)

Rehabilitation Goals - Complete sport-specific activity

- Advanced functional training
Precautions - Continuation of core strengthening
ROM - Continue resistive ROM
Therapeutic Exercises - One foot multiplanar activities
- Sport-specific plyometrics/agility drills
Cardiovascular Exercise - Continue from phase III
Progression Criteria - Ability to run with normal gait and no pain
- Quad and Ham strength at least 80% of uninvolved
side (see additional notes)
- No swelling
- No restrictions of ROM
- Sport-specific qualifications
- Functional testing
Additional notes:

- As a result of severity of injury, greater than 80% strength bilaterally is suggested before RTP

http://www.electrotherapy.org/assets/Downloads/NMES%20Muscle%20Stimulation%20march%202013
.pdf

http://www.aclreconstructionhouston.com/pdf/acl-standard-protocol.pdf

https://www.sportsmednorth.com/sites/sportsmednorth.com/files/ACL-Reconstruction-Protocol.pdf

https://pdfs.semanticscholar.org/presentation/0074/e0a5dbb739e4875c34deb0277f148c334176.pdf

https://www.uwhealth.org/files/uwhealth/docs/pdf5/MultiLigament.pdf