ACL Reconstruction Delayed Rehabilitation

16-03-16_Physical-Therapy-Rehabilitation

Delayed Rehabilitation Protocol

This rehabilitation protocol has been designed for patients who have undergone an ACL reconstruction with other surgical issues that may prolong or otherwise change the rehabilitation process. This protocol also may be slightly deviated depending upon the particular procedure. The ACL Rehabilitation protocol for all grafts is the same with the following exceptions:

  • If a hamstring autograft was used:
    • when performing heel slides, make sure that a towel/sheet is used to avoid actively contracting the hamstrings.
  • Do not perform isolated hamstring exercises until the 4th week postop.

The following may be considered criteria for this protocol:

  • Concomitant meniscal repair
  • Concomitant ligament reconstruction
  • Concomitant patellofemoral realignment procedure
  • ACL revision reconstruction

The protocol is divided into several phases according to postoperative weeks and each phase has anticipated goals for the individual patient to reach. The overall goals of the reconstruction and the rehabilitation are to:

  • Control joint pain, swelling, hemarthrosis
  • Regain normal knee range of motion
  • Regain a normal gait pattern and neuromuscular stability for ambulation
  • Regain normal lower extremity strength
  • Regain normal proprioception, balance, and coordination for daily activities
  • Achieve the level of function based on the orthopedic and patient goals

The physical therapy is to begin after the 2nd day post-op. It is extremely important for the supervised rehabilitation to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility.

Important post-op signs to monitor:

  • Swelling of the knee or surrounding soft tissue
  • Abnormal pain response, hypersensitive
  • Abnormal gait pattern, with or without assistive device
  • Limited range of motion
  • Weakness in the lower extremity musculature (quadriceps, hamstring)
  • Insufficient lower extremity flexibility

Return to activity requires both time and clinic evaluation. To safely and most efficiently return to normal or high level functional activity, the patient requires adequate strength, flexibility, and endurance. Isokinetic testing and functional evaluation are both methods of evaluating a patient’s readiness to return to activity.

Rehabilitation Protocols

Phase 1: Week 1-2 ACL Delayed Protocol

1ROM

  • Meniscus repair, MCL, ACL revision 0-90°
  • Patellar realignment 0-75°
  • Patellar mobilizations
  • Ankle pumps
  • Gastroc/soleus stretches
  • Heel slides
  • Wall slides

2STRENGTH

  • Quad sets x 10 minutes
  • SLR (flex and abd)
  • Heel raise/Toe raise
  • Wall squats

3WEIGHT BEARING

  • Meniscus repair – NWB
  • MCL – wt bearing as tolerated
  • ACL revision – wt bearing as tolerated

4MODALITIES

  • Electrical stimulation as needed
  • Ice 15-20 minutes with knee at 0° ext

5BRACE

  • Remove brace to perform ROM activities
  • Post-op brace when walking with crutches

GOALS OF PHASE:

  • ROM (see above, depends on procedure)
  • Control pain, inflammation, and effusion
  • Adequate quad contraction
  • NWB to TDWB per Dr. (depends on procedure)

Phase 2: Week 2-4 ACL Delayed Protocol

1ROM

  • Passive, 0-90°
  • Patellar mobilizations
  • Ankle pumps
  • Gastoc/soleus stretch
  • Light hamstring stretch at wk 4
  • Heel/Wall slides to reach goa

2STRENGTH

  • Multi-angle isometrics (90-60°)
  • Quad sets with biofeedback
  • SLR (flex, abd, add)
  • Wall Squats
  • Heel raise/Toe raise

3BALANCE TRAINING

  • Weight shifts (side/side, fwd/bkwd)
  • Single leg balance (dependent upon procedure)

4MODALITIES

  • E-stim/biofeedback as needed
  • Ice 15-20 minutes

5BRACE

  • Post-op brace when walking with crutches

GOALS OF PHASE:

  • ROM to 90° flexion and 0° extension
  • Diminish pain, inflammation, and effusion
  • Quad control
  • Initiate weight bearing as permitted

Phase 3: Week 4-6 ACL Delayed Protocol

1ROM

  • Passive, 0-125°
  • Gastoc/soleus/hs stretch
  • Heel/wall slides to reach goal

2STRENGTH

  • Progressive isometric program
  • SLR in 4 planes with ankle weight/tubing
  • Heel raise/Toe raise
  • Mini-squats/Wall squats
  • Initiate isolated hamstring curls
  • Multi-hip machine in 4 planes
  • Leg Press-double leg eccentric
  • Initiate bike when 110° flexion
  • EFX/Retro treadmill
  • Lateral/Forward step-ups/downs
  • Lunges

3BALANCE TRAINING

  • Single leg stance
  • Weight shift
  • Balance board/two-legged
  • Cup walking/hesitation walking

4WEIGHT BEARING

  • PWB to FWB as allowed by quad control
  • Discontinue crutches when FWB is allowed

5MODALITIES

  • Ice 15-20 minutes

6BRACE

  • Discontinue post-op brace
  • Measure for functional brace

GOALS OF PHASE:

  • ROM 0-125°
  • Increase lower extremity strength and endurance
  • Minimize pain, swelling, and effusion
  • Increase weight-bearing status from PWB to FWB

Phase 4: Week 6-10 ACL Delayed Protocol

1ROM

  • Passive, 0-135°
  • Gastoc/soleus/hs stretch

2STRENGTH

  • Continue exercises from wk 4-6
  • Leg Press-single leg eccentric
  • Lateral lunges

3BALANCE TRAINING

  • Two-legged balance board
  • Single leg stance with plyotoss
  • Cup walking
  • ½ Foam roller work

4MODALITIES

  • Ice 15-20 minutes

5BRACE

  • Functional brace as needed

Phase 4: Week 10-12 ACL Delayed Protocol

1ROM

  • Passive, 0-135°
  • Gastoc/soleus/hs stretch

2STRENGTH

  • Continue exercises from wk 4-10
  • Initiate jogging protocol-start on minitramp as tolerated, progress to treadmill
  • Progress with proprioception training
  • Walking program
  • Bicycle for endurance

3MODALITIES

  • Ice 15-20 minutes

GOALS OF PHASE:

  • Full weight bearing, normal gait
  • Restore full knee ROM (0-135°)
  • Increase strength and endurance
  • Enhance proprioception, balance, and neuromuscular control

Phase 5: Week 12-16 ACL Delayed Protocol

1ROM

  • Continue all stretching activities

2STRENGTH

  • Continue exercises from wk 4-12
  • Initiate plyometric training drills
  • Progress jogging/running program
  • Initiate isokinetic training (90-30°), (120-240°/sec)

3MODALITIES

  • Ice 15-20 minutes as needed

GOALS OF PHASE:

  • Restore functional capability and confidence
  • Restore full knee ROM (0-135°)
  • Enhance lower extremity strength and endurance

Phase 5: Week 16-20 ACL Delayed Protocol

1ROM

  • Continue advanced strengthening

2STRENGTH

  • Continue all exercises from previous phases
  • Progress plyometric program
  • Increase jogging/running program
  • Swimming (kicking)
  • Backward running

3FUNCTIONAL PROGRAM

  • Sport specific drills

4CUTTING PROGRAM

  • Lateral movement
  • Carioca, figure 8’s

5MODALITIES

  • Ice 15-20 minutes as needed

GOALS OF PHASE:

  • Maintain muscular strength and endurance
  • Perform selected sport-specific activity
  • Progress skill training
  • Enhance neuromuscular control

Phase 5: Week 20-36 ACL Delayed Protocol

1ROM

  • Continue advanced strengthening

2FUCNTIONAL PROGRAM

  • Progress running/swimming program
  • Progress plyometric program
  • Progress sport training program
  • Progress neuromuscular program

3MODALITIES

  • Ice 15-20 minutes as needed

GOALS OF PHASE:

  • Return to unrestricted sporting activity
  • Achieve maximal strength and endurance
  • Progress independent skill training
  • Normalize neuromuscular control drills

At six and twelve months, a follow-up isokinetic test is suggested to guarantee maintenance of strength and endurance. Advanced weight training and sport specific drills are advised to maintain a higher level of competition.

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