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Planning for Surgery
Rehabilitation Protocol:
ACL RECONSTRUCTION SURGERY
PREOPERATIVE PHYSICAL THERAPY
- Preoperative orientation visit, review protocol
- Gait train on crutches
- Instruction in home exercise program (SLR, Quad sets, short arc quads, ankle pumps, and heel slides)
- Instruction in ROM exercises, patellar mobilization, and proper icing techniques.
- Schedule first post-op physical therapy visit beginning 7-10 days after surgery.
OUTPATIENT PHYSICAL THERAPY:
Phase 1: Immediately post-op to 2 weeks
Goals: To protect graft fixation, decrease effects of immobilization, control inflammation, normalize gait pattern, and achieve quadriceps control, full extension, and flexion to 100º.
Brace: Locked in full extension during sleep and ambulation.
Weight-bearing status: WBAT. Discontinue crutches when gait is normalized, unless otherwise instructed.
Therapeutic exercises:
- SLR (in supine, prone, and side-lying positions) with brace locked in full extension until quadriceps can resist lag
- Active gravity extension 90º to 30º
- Active gravity resistance hamstring curls 0º to 90º
- Aggressive patellar mobilization
- Quad-sets at full extension with EMS or biofeedback
- Ankle pumps with elevation
- Prone hangs
- Heel slides
- Non-weight bearing calf and hamstring stretches
- Seated/supine assisted flexion hangs
- Upper body cycling
- Begin well leg cycling on stationary bike with high seat
- Proprioception training on stable platform
Phase 2: 2 to 6 weeks post-op
Goals: Restore normal gait, full extension, full flexion, protect graft fixation, improve strength, endurance, and proprioception.
Brace: Locked in full extension during sleep and ambulation.
Patellar tendon grafts - may remove brace for ROM exercises, may unlock hinges while sitting.
Hamstring and allografts - may remove brace when normal gait pattern and quad control is achieved.
Weight-bearing status: WBAT. Discontinue crutches when gait is normalized, unless otherwise instructed.
Therapeutic exercises:
- Wall sit to 70°, mini squats to 45°
- Continue prone hangs with progressive weights
- Proprioception training (BAPS board)
- Continue multi-plane SLR add weights as tolerated
- Closed-chain leg press 0° to 45°
- Seated and standing toe-raises
- Progress to weight bearing calf and hamstring stretches
- Lateral step-ups 1-5" block
- Once incision is completely healed - start pool jogging in water vest (if available)
- Continue stationary bike
- Continue hamstring curls with progressive weights
- Use EMS or biofeedback as indicated
- At week 5 start single leg stance on mini trampoline
- Continue upper body cycling
- Continue cryo cuff
Phase 3: 6 weeks to 4 months
Goals: To improve confidence in the knee, avoid overstressing the graft, protect the patellofemoral joint, progress strength, power, and proprioception.
Therapeutic exercises:
- Continue lateral step-ups (4-8" blocks)
- Add lunges if no PF issues
- Continue progressive weight hamstring curls
- Cross-country ski machine or elliptical stepper
- Continue flexibility exercises as appropriate for the patient
- Continue upper and lower body cycling
- Continue pool jogging/swimming
- Advance closed chain strengthening (one legged squats, leg press 0° to 60°)
- Lateral slide board at 3 months
- Begin straight ahead jogging at 3 months (if full ROM and no effusion)
- Progress to figure of eight pattern by 4 months
- To begin after 3 months:
- Crossovers
- Lateral steps 1-2 feet
- Box jumps
- Continue proprioception work
- Add sport-specific activities (1/4 to ½ speed)
Phase 4: 4 to 6 months
Criteria: Full pain-free ROM, no evidence of PF irritation
Goals: Return to activities
Therapeutic exercises:
- Continue and progress flexibility and strengthening program
- Continue aerobic training
- Continue running progressing to small circles
- Start cutting drills
- Advanced height box jumps
- Full speed straight running
- Advanced sport-specific activities (full speed)
Return to full unrestricted sports only after clearance the doctor.
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