284 Knee Injuries

REHABILITATION PROTOCOL 4-1

Criteria-Based Postoperative ACL Reconstruction Rehabilitation Protocol
Michael Duke, PT, CSCS, S. Brent Brotzman, MD

Phase I (Days 1–7) Begin partial weight mini-squats (0–30 deg) on total
Weightbearing status gym/shuttle
Two crutches, locked knee brace, weightbearing as tolerated Heel raises
after nerve block wears off Continue SLR, all four directions
Exercises Terminal knee extension in standing with band
Heel slides/wall slides/sitting assisted knee flexion Prone knee bridges
Ankle pumps Active standing hamstring curls (do not perform for
Isometric quad sets in full extension with and without postoperative hamstring autograft reconstruction)
neuromuscular electrical stimulation (NMES) or biofeedback Manual Therapy
Hamstring sets (not for hamstring autograft) Continue patellar mobs as indicated
Gluteal sets Continue hamstring mobs as indicated
Straight leg raise (SLR) flexion, abduction, extension with brace Goals
locked in full extension AROM 0–120 degrees within 3 weeks
Prone hangs or heel propped in supine for passive knee extension SLR without quad lag
Weight shifting in standing for weightbearing tolerance Normal gait pattern with single crutch and unlocked brace
(anteroposterior and side to side)
Continuous passive motion (CPM) 6 hours/day, increasing 5–10 Criteria to Progress to Phase III
degrees/day AROM 0–90 degrees
Gait training with crutches and brace, level ground and stairs SLR with minimal quad lag
Cryotherapy to reduce edema Normal gait with least restrictive assistive device
Manual Therapy Single-leg stance on involved limb with hand-assist
Patellar mobilizations Phase III (Weeks 2–4)
Soft tissue mobilizations to hamstrings for spasm control Weightbearing Status
Goals FWB, normal gait without assistive device or brace by 3 weeks
Active range of motion (AROM) 0–90 degrees within 10 days Exercises
Good, active quadriceps contraction Stationary bike with gradual progressive resistance for
Full weightbearing (FWB) with crutches and brace endurance
Edema control Isometric quad sets in full extension and at 90 to 60 degrees
Graft protection flexion with and without NMES or biofeedback until equal
quad contraction bilaterally
Wound healing
Closed kinetic chain squat/leg press 0 to 60 degrees, gradual
Criteria to Progress to Phase II progressive resistance
SLR with or without lag in brace Balance board bilateral in multiple planes
Clean and dry wound Single-leg balance eyes open/closed, variable surfaces
Progressing range of motion (ROM) Sport cord or treadmill walking forward and backward
Able to bear weight on involved limb Standing SLRs, each LE and with resistance
Phase II (Days 8–14) Manual Therapy
Weightbearing Status Continue patellar mobilizations as indicated
Weightbearing as tolerated Initiate scar mobilizations as needed
Two crutches to single crutch Manual extension or flexion ROM as needed
Brace unlocked gradually as quad control improves (SLR
without lag before unlocking brace beyond 30 degrees) Goals
Full AROM, equal to nonsurgical knee
Exercises
Normal gait without assistive device
Stationary bike for ROM (from rocking to full revolutions)
Independent activities of daily living (downstairs may still be
Isometric quad sets in full extension and at 90 degrees with difficult)
and without NMES or biofeedback
Single-leg stance in brace Criteria for Progression to Phase IV
Balance board anteroposterior in bilateral stance Equal bilateral knee AROM
Continue ROM exercises Normal gait without assistive device
Gait training: single-leg walk (pawing) on treadmill, step-over Understanding of precautions regarding state of graft
cones forward Single-leg standing without assistance
 Criteria-Based Postoperative ACL Reconstruction Rehabilitation Protocol 285

Criteria-Based Postoperative ACL Reconstruction Rehabilitation Protocol (Continued)

Phase IV (Weeks 4–8) Stationary bike intervals
Precautions Goals
State of graft at its weakest during this postoperative Equal quad girth (average gain of 1 cm per month after first
period. No impact activities such as running, jumping, pivoting, month with good strength program)
or cutting, and no deep squatting (limits remain 0–60 degrees) Single-leg squat to 60 degrees with good form
Pay attention to scar mobility; use manual soft tissue
mobilizations as indicated Criteria for Progression to Phase VI
Exercises Nearly equal quad girth (within 1cm)
Stationary bike: increase resistance and some light intervals Single-leg squat to 60 degrees
Squats/leg press: bilateral to unilateral (0–60 degrees) with Single-leg balance up to 60 seconds
progressive resistance Minimal, if any, edema with activity
Lunges (0–60 degrees)
Phase VI (Week 12–16)
Stairs: concentric and eccentric (not to exceed 60 degrees of
knee flexion) Things to Watch Out for/Correct
Calf raises: bilateral to unilateral Landing during exercises at low knee flexion angles (too close
to extension)
Contrakicks (steamboats) (Fig. 4-90): progress from
anteroposterior to side to side, then circles/random Landing during exercises with genu varum/valgum (watch for
dynamic valgus of knee and correct)
Rotational stability exercises: static lunge with lateral pulley
repetitions Landing and jumping with uninvolved limb dominating
effort
Sport cord resisted walking all four directions
Treadmill walking all four directions Exercises
Balance board: multiple planes, bilateral stance Elliptical trainer: forward and backward
Ball toss to mini-tramp or wall in single-leg stance Perturbation training*: balance board, roller board, roller board
Single-leg deadlifts (Fig. 4-91): wait for 6–8 weeks if hamstring with platform
autograft Shuttle jumping: bilateral to alternating to unilateral, emphasis
Core strengthening: supine and prone bridging, standing with on landing form
pulleys Mini-tramp bouncing: bilateral to alternating to unilateral,
Gait activities: cone obstacle courses at walking speeds in emphasis on landing form
multiple planes Jogging in place with sport cord: pulling from variable
Criteria for Progression to Phase V directions
Bilateral squat to 60 degrees (no more) with equal weight Movement speed increases for all exercises
distribution Slide board exercises
Quiet knee (minimal pain and effusion and no giving way) Aqua jogging
Quad girth within 1 to 2 cm of nonsurgical thigh at 10 cm
proximal to superior patella Criteria to Progress to Phase VII
Single-leg balance on involved limb >30 seconds with minimal Single-leg squat, 20 repetitions to 60 degrees of knee
movement flexion
Single-leg stance at least 60 seconds
Phase V (Weeks 8–12)
Single-leg calf raise 30 repetitions
Things to Watch Out for
Good landing form with bilateral vertical and horizontal
Patellar tendinitis jumping
Exercises Hop testing†: 80% of uninvolved limb performed prior to
Squats/leg press: bilateral to unilateral (0–60 degrees) running
progressive resistance
Lunges (0–60 degrees) Phase VII (Weeks 16–24)
Calf raises: bilateral to unilateral Exercises
Advance hamstring strengthening Progressive running program‡
Core strengthening Hop testing and training†
Combine strength and balance (e.g., ball toss to trampoline on
balance board, mini-squat on balance board, Sport Cord cone Progressive plyometrics (e.g., box jumps, bounding, standing
weaves, contrakicks) jumps, jumps in place, depth jumps, squat jumps, scissor jumps,
Advanced balance exercises (e.g., single-leg stance while jumping over barriers, skipping)
reaching to cones on floor with hands or opposite foot, single- Speed and agility drills (e.g., T-test, line drills) (make these
leg stance while pulling band laterally) similar in movement to specific sport of athlete).
Lap swimming generally fine with exception of breaststroke; Cutting drills begin week 20
caution with deep squat push-off and no use of fins yet Progress to sport-specific drills week 20

Continued on following page

286 Knee Injuries

Criteria-Based Postoperative ACL Reconstruction Rehabilitation Protocol (Continued)

Figure 4-91 Single-leg deadlift.

For Revision ACL Reconstructions

Per specific physician recommendation, follow typically
similar protocol until 12 weeks, then extend weeks 12
to 16 through to 5- to 6-month timeline, when patients
can then begin running and progress to functional sports
activities. See Figure 4-90 for an illustration of abduction
contrakicks/steamboats (flexion, extension, and adduction
contrakicks can be performed by rotating patient 90
degrees at a time).
Figure 4-90 Abduction contrakicks/steamboats.

*See section on perturbation training for ACL postoperative training progression.

†Hop Testing

Single-leg hop for distance: 80% minimum compared to nonsurgical side for running, 90% minimum for return to sport
Single-leg triple hop for distance: 80% for running, 90% for return to sport
Triple crossover hop for distance: 80% for running, 90% for return to sport
Timed 10-m single-leg hop: 80% for running, 90% for return to sport
Timed vertical hop test: 60 seconds with good form and steady rhythm considered passing
‡Progressive running program

Always begin with warmup on the stationary bike or elliptical for >10 minutes prior to initiation of running.
Patient should have no knee pain following run.
Week 1: Run: walk 30 seconds: 90 seconds every other day (qod) (10–15 minutes)
Week 2: Run: walk 60:60 qod (10–20 minutes)
Week 3: Run: walk 90:30 qod (15–20 minutes)
Week 4: Run: walk 90:30 3-4x/week (20–25 minutes)
Week 5: Run continuously 15–20 minutes 3–5x/week