OA

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ACL Reconstruction Rehabilitation Protocol

The protocols provided by Orthopedic Associates of Portland are examples of those used by our physicians and may not be appropriate for every patient. You should use these only if your treating physician has reviewed the protocol and approves of its use for your recovery.


This is a general outline for you as a patient to better understand the guidelines and time frames used to progress ACL Reconstruction patients through their rehabilitation. Please keep in mind that these are general guidelines and may not be met by all patients at each specific timeline due to differences in healing and tolerance to the surgery. Progression should occur at your own pace, keeping in mind that gains should be made on a daily and weekly basis to achieve progression with the protocol. You will be evaluated at regular intervals throughout the rehabilitation process, and will be progressed appropriately by your therapist and physician.

The primary goals for you to strive for early in the protocol are:

1. Regain normal motion in the knee as soon as possible.
2. Increase weight bearing to minimize limping as early as possible.
3. Early recognition and treatment of any problems--i.e. pain, stiffness, swelling, or severe muscle weakness.
4. Return to normal activities as soon as possible with deficits.

The Rehabilitation Program has been divided into phases for your benefit:

Pre-operative Visit - the purpose of this visit is to:

1. Introduce you to the physical therapy team that will be guiding your post-operative rehabilitation.
2. Orient you to the Physical Therapy Center.
3. Instruct you in the correct pre-, and post-operative home exercises.
4. Familiarize you with the rehabilitation protocol and goals.

 

ACL Visit Progression

This is the anticipated schedule of visits for ACL reconstruction post-op therapy. This is a guideline to be followed as appropriate pending each individual patient's tolerance and post-op presentation of pain, swelling, and leg control:

Pre-op visit 1x prior to surgery for evaluation & review of parameters for HEP (home exercise program).
Starting at:
Phase I  1 Week Post-op 1x visit at the PTC (pre-scheduled)
2 Weeks  1x (pre-scheduled)
Phase II 3 Weeks 3x
4 Weeks    3x
Begin weaning to 1x/week independent workouts.
Phase III 5 Weeks 2x
6 Weeks 2x
7 Weeks 2x
Begin weaning to 2x/week independent workouts.
Phase IV 8 Weeks 1x
9 Weeks 1x
10 Weeks 1x
Wean to independent program at conclusion of week 10.
Phase V 14 Weeks 1x for Cybex strength evaluation; functional evaluation and review of progress
18 Weeks 1x for advanced functional agility/sport specific parameters.
24 Weeks 1x for Cybex strength evaluation & functional evaluation.


ACL Physical Therapy Protocol

TIME POST-OP

# of visits

Progression of program

Additional if tolerated

Pre-op visit

1x

Evaluation and patient education. Instruction in Home Exercise Program (HEP) per handout.
Review of crutch, brace, and ice parameters.
1Week Post- operative

1x

Re-evaluation and review of HEP. Begin weaning from crutches to increase WB.
2 Weeks post-op

3x

Re-evaluation and review of HEP for progression of ex's. Rx to begin with manual therapy & modalities as appropriate. Emphasis on VMO (vastus medialis obliquus  quad) control with all ex's, progressing to leg press, street bike and Theraband squats.

Wean from immobilizer

3 Weeks post-op

3x

Continue manual Rx. Reinforce quad leg control and timing in closed chain activities. Initiate aquatic exercise (pool or large whirlpool) if available and indicated. Advanced gait training: marching, retro-walking, side-stepping, and modalities as indicated.

Add leg curl and step-down

4 Weeks post-op

3x/ week if appropriate

Progression of ex's to emphasize single leg workouts with increased weight as tolerated. Re-evaluate after 4 weeks to determine if the patent is appropriate for weaning to 2 PT sessions per week and 1 independent session in Fitness program.

Add Smith press, stairmaster and focus on PRE'S with single leg work on machines.

The following criteria to be evaluated:

-Ability to single leg stand 30 sec.
-No antalgia (limping) on level surfaces.
-Normal ascend and minimal assist descending stairs.
-ROM (range of motion) 0-115° with minimal discomfort.
-Minimal to no pain or swelling with current program.

If the criteria are not met, continue with formal PT 3x/week. Continue with manual Rx. and modalities as needed.

5 weeks post-op

2x/week

Continue to progress Progressive Resistance Exercises (PRE's). Walk-through low level functional/agility exercises-those with no impact, twisting, or turning. Examples: defensive slide (1/2 speed), sport cord weight-shifting. Progress to trunk/sport cord challenges (manual resistance to trunk with walking, side stepping etc.). Continue manual therapy as needed.

Single leg stand LE reach (ground clock)

6 weeks post-op

2x/week

At 6 weeks, most patients should be decreased to 2x/wk of supervised PT unless unforeseen circumstances arise. Manual Rx. and aquatic therapy if necessary. Shallow and deep water jogging is acceptable. Low level functional/agility at low speed and impact. No cutting or twisting. Increase resistance on trunk challenges. Discontinue low level exercises and wean from HEP control ex's while progressing aerobic, gym PRE's, and functional/agility ex's. Treadmill walking with slight incline only if tolerated.
7 weeks

1x/week

Wean to 1x/week at the conclusion of 7 weeks if appropriate with patient progressing 2x/week independently. Wean from manual and aquatic therapy at therapist's discretion.
8 weeks

1x

At 8 weeks, the therapy team will determine whether the patient needs to be seen on a regular basis or to check in periodically (every 2 weeks) to progress program. Possible exercises to add: BAPS board in standing, Vew -Do board, medicine ball toss with balancing or uni-lateral stance.
The following functional test can be used to assist in making that decision: Ability to do 4" step down. PROM (passive range of motion) 0-125° with full active extension. Low speed low level agility without pain. Ground clock 10 reps. Ability to perform current exercise program without pain or swelling.

At 8 week visit, continue to progress aerobic, gym exercises. This is the earliest cut-off to start a jogging progression. Still no running. Keep in mind that some physicians prefer to have12 week Cybex test results before allowing a patient to run.
10 weeks

1x

Continue with current program progressing as tolerated. Progress jogging program. Increase speed on low level functional/agility and progress to intermediate functional activity. Aggressive resistance with trunk challenges and sport cord. Examples of intermediate functional activity: Quick steps, two leg hopping, vertical leaps, and cariocas
12 weeks

1x

Review program and parameters.
14 weeks

1x

Cybex strength test.
Patient will perform functional tests at this visit. It will consist of the following:

¾ speed carioca
Unilateral squat for depth

Data will be recorded. Review program and increase intensity exercises

If ROM is normal and patient is progressing with minimal pain and trace swelling, they will not need to be seen in PT again for 4 weeks.
18 weeks

1x

 Review program. Increase intensity as appropriate. Instruct in advanced functional/agility: sprinting, cutting and sports specific drills as tolerated.
 24 weeks Final Cybex strength test and 24 Week Functional Test. Patient returns to sports if cleared by physician.

24 Week Functional Tests:

One-legged hop for distance:
Patient performs one-legged hop, which consist of recording the distance a patient travels in one hop on a single leg. Each patient is allowed one trial for each leg, then performs two hops per leg for maximum measurement.
Timed one-legged hop:
A measured distance of twenty feet is marked out, at the word "go", the patient begins a series of one legged hops from start line to finish line. The patient is timed from the start line to the finish line.
Each patient is allowed to complete a slow trial and then two tests are completed on the uninvolved leg and two on the involved leg.
¾ speed carioca:
Patient is tested in their ability to perform thirty feet of carioca both directions without visible antalgia, pain, or compensation.
One legged squat for depth:
Patient is tested in their ability to perform a one legged mini-squat to touch floor with opposite hand with moderate trunk flexion.