Nathan Lilley, MPT, OCS, CSCS, earned his Bachelors degree in Biology as well as his Masters degree in Physical Therapy from Rockhurst University in Kansas City, Missouri. Nate has been in the orthopedic clinical setting for the last 11 years. In 2005, Nate was recognized as a Board Certified Clinical Specialist in Orthopedic Physical Therapy from the American Physical Therapy Association. In addition, he is a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association. Nate is co-owner of Physio Pro Physical Therapy in Denver Colorado. His clinic specializes in orthopedic and manual physical therapy with a strong emphasis in sports medicine, and general care in youth through geriatric patient populations. Over the years, he has worked with numerous collegiate athletes as well as local professional athletes affiliated with the NBA, NHL, AFL, and PGA. He developed and implemented the Physio Pro ACL Performance Enhancement Program in 2001. Nate continues to promote wellness, injury prevention, and sports enhancement to the local community as well as many local youth athletic teams. Steven M. Traina, M.D., is a fellowship trained Board Certified Orthopedic Surgeon. He practices in Denver, Colorado with Western Orthopaedics. Dr. Traina has been serving as the team physician for the Denver Nuggets for the last 24 years and in the past has been a consultant for the Denver Broncos football team and the Colorado Avalanche hockey team. He has published and spoken extensively on sports medicine topics. 1
Exercise Protocol The following is an evidenced based Functional Testing Algorithm (FTA) protocol that has specific guidelines for progressing treatment based off selected objective criteria. Before entering the next phase of rehab, specific goals must be met. Specific functional tests must be completed with satisfactory results before the next phase of rehabilitation may begin. High intensity plyometrics are integrated into the final phase of the protocol. This portion of the program stems largely from the last 15 years of research coming from the Cincinnati Sports Medicine Research and Education Foundation. Our complete Impact protocol is outlined but please reference the training manual and DVD for a complete profile of the program. The entire protocol is derived from the latest research. All references can be found at the end of the DVD. Patients must commit themselves to a vigorous but four to six month rehab regime to help protect their new ACL before returning to unrestricted activities. The first seven weeks of rehab are not outlined. The standard ACL protocol for the first seven weeks should be at the hands of surgeon and physical therapist depending upon the severity of the patient s surgery. The program should not begin any sooner than eight weeks post op and the patient must meet the criteria in order to enter the performance enhancement program. Progression of the program is at the discretion of the therapist/physician. Sound clinical judgment is essential for progression. If the criteria are not met then standard therapy will continue until objective measures are adequate. There are a total of five phases of rehabilitation to complete before a return to competition can be considered. Although estimated time frames are outlined, not all patients will progress equally as there may be complicating factors that may hinder or expedite rehabilitation. Below are the criteria for progression through the various phases of our protocol. Anticipated timelines and suggested interventions are found on the following pages. Steven Traina, MD Western Orthopaedics Denver, Colorado Nathan Lilley, MPT, OCS, CSCS Physio Pro Denver, Colorado 2
Functional Testing Exercise No. of Reps/Time Squat Test 10 reps I min. Eccentric Step Down Test I min. (Ea. Leg) Broad Jump Test (Warm up: 2 x 50%, 2 x 75%), 3x 100% Single Leg Hop Test (Warm up: 2 x 50%, 2 x 75%), 3x 100% (Ea. Leg) Vertical Jump Assessment 3 x (Warm Up), 3 x 100% 3
Impact Phase A: Criteria Estimated Weeks 8 10 ROM 0 0 125 Effusion Minimal to none, no joint line tenderness Strength 65% Quadriceps, 50% HS/Quad Ratio Special Testing Satisfactory Lachman/Drawer Test Functional Score >6 score on Cinti Knee Rating System Functional Testing 1min. Step Test >60% Satisfactory Squat Test, Step Down Test 4
Impact Phase A: Entry Level Plyometrics Estimated Weeks 8 10 Week 8 Shuttle Bilateral Shuttle Alternating Lateral Bounding in Place Slide Board 3 x 20 reps 3 x 20 reps 3 x 30 sec. 3 x 30 sec. Week 9 Shuttle Bilateral Shuttle Alternating Lateral Bounding in Place Slide Board Jog in Place High Knees in Place Gluteal Kicks in Place 3 x 20 reps 3 x 20 reps 3 x 30 sec. 3 x 30 sec. 3 x 30 sec. 3 x 30 sec. 3 x 30 sec. 5
Impact Phase B: Criteria Estimated Weeks 10 12 ROM 0 0 130 Effusion Minimal to none, no joint line tenderness Strength 70% Quadriceps, 60% HS/Quad Ratio Special Testing Satisfactory Lachman/Drawer Test Functional Score >6 score on Cinti Knee Rating System Functional Testing None 6
Impact Phase B: Transitional Plyometrics/Phase Level I Agility Estimated Weeks 10 12 Week 10 Shuttle Bilateral Grid Jumps Shuttle Alternating Shuttle Unilateral Grid Hops Lateral Bounding in Place 3 Point Lateral Bounding with Rotation 20 reps CW, 20 reps CCW 2 x 20 reps 20 reps CW, 20 reps CCW 3 x 40 sec. 1 x 30 sec. R, 1 x 30 sec. L Week 11 Shuttle Bilateral Grid Jumps Shuttle Alternating Shuttle Unilateral Grid Hops Lateral Bounding in Place 3 Point Lateral Bounding with Rotation Step Work: Quick Feet Step Work: Ali Shuffle Step Work: Lateral Quick Feet Step Work: Lateral Skaters Return to Jogging Program (Treadmill) 20 reps CW, 20 reps CCW 2 x 20 reps 20 reps CW, 20 reps CCW 3 x 40 sec. 1 x 30 sec. R, 1 x 30 sec. L 1 x 30 sec. 1 x 30 sec. 1 x 30 sec. 1 x 30 sec. 3W 1J 1W 3J 3W 5J 1W 7
Impact Phase C: Criteria Estimated Weeks 12 14 ROM 0 0 135 Effusion Minimal to none, no joint line tenderness Strength 75% Quadriceps, 60 65% HS/Quad Ratio Special Testing Satisfactory Lachman/Drawer Test Functional Score >7 score on Cinti Knee Rating System Functional Testing No pain, gait deviation with 10min. jog 8
Impact Phase C: Level II Agility, Sport Specific Movement Estimated Weeks 12 14 Dynamic Sports Routine Warm Up Jog in Place Giant Arm Circles Trunk Rotation Pelvic Circle Hip Circumduction Hip Step w/ Exaggerated Arm Swing Gluteal Kicks Skipping Bound Side Shuttle Cariokas High Knees Sprint/Back Pedal Ankle Hops 20 30 sec. 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Leg) 10 sec. 9
Impact Phase C: Level II Agility, Sport Specific Movement Estimated Weeks 12 14 Week 12 Jump Rope: Bilateral Jump Rope: Alternating Step Work: Quick Feet Step Work: Lateral Quick Feet Step Work: Ali Shuffle Step Work: Lateral Skaters Lateral Bounding with Rotation 3 Point Sport Cord: Forward Sport Cord: Backwards Sport Cord: 3 Point Lateral Bounding Week 13 1 x 1 min. 1 min. R, 1 min. L 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. R, 2 x 30 sec. L 2 x 20 reps (1/2 Speed) 2 x 20 reps (1/2 Speed) 2 x 30 sec. R, 2 x 30 sec. L Jump Rope: Bilateral Jump Rope: Alternating Step Work: Quick Feet Step Work: Lateral Quick Feet Step Work: Ali Shuffle Step Work: Lateral Skaters Lateral Bounding with Rotation 3 Point Sport Cord: Forward Sport Cord: Backwards Dynamic Sports Routine Agility Ladder: High Knees Agility Ladder: Lateral High Knees Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Ali Shuffle Agility Ladder: Icky Shuffle 1 x 1 min. 1 min. R, 1 min. L 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. 2 x 30 sec. R, 2 x 30 sec. L 2 x 20 reps (1/2 Speed) 2 x 20 reps (1/2 Speed) 1x 3x (Down & Back) 3x (Down & Back) 3x (Front Lead) (Down & Back) 3x (Back Lead) (Down & Back) 3x (Down & Back) 3x (Down & Back) 10
Impact Phase D: Criteria Estimated Weeks 14 16 ROM Effusion Strength Special Testing Functional Score Functional Testing Within 90% contralateral limb Minimal to none, no joint line tenderness 75 80% Quadriceps, 50 70% HS/Quad Ratio Satisfactory Lachman/Drawer Test >7 score on Cinti Knee Rating System SL hop 50%, Broad Jump with sound mechanics 11
Impact Phase D: Level IIII Agility, Level Sport Specific Movement Estimated Weeks 14 16 Dynamic Sports Routine Warm Up Jog in Place Giant Arm Circles Trunk Rotation Pelvic Circle Hip Circumduction Hip Step w/ Exaggerated Arm Swing Gluteal Kicks Skipping Bound Side Shuttle Cariokas High Knees Sprint/Back Pedal Ankle Hops 20 30 sec. 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Leg) 10 sec. 12
Impact Phase D: Level III Agility, High Level Sport Specific Movement Estimated Weeks 14 16 Week 14 Dynamic Sports Routine (Warmup) Sport Cord: Forward Sport Cord: Backwards Sport Cord: Lateral Shuffles Sport Cord: 3 Point Lateral Bounding w/ Rotation Agility Ladder: High Knees Agility Ladder: Lateral High Knees Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Lateral Quick Feet Ins & Outs 1x 2 x 20 reps (3/4 Speed) 2 x 20 reps (3/4 Speed) 1 x 20 reps R Lead, 1 x 20 reps L Lead 2 x 30 sec. (Ea. Side) 4x (Down & Back) 4x (Down & Back) 4x (Front Lead) (Down & Back) 4x (Back Lead) (Down & Back) Week 15 Dynamic Sports Routine (Warmup) Sport Cord: Forward Sport Cord: Backwards Sport Cord: Lateral Shuffles Sport Cord: 3 Point Lateral Bounding w/ Rotation Sport Cord: 3 Point Drill (Forward) Sport Cord: 3 Point Drill (Backwards) Agility Ladder: High Knees Agility Ladder: Lateral High Knees Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Lateral Quick Feet Ins & Outs Agility Ladder: Ali Shuffle Agility Ladder: Icky Shuffle 1x 2 x 20 reps (3/4 Speed) 2 x 20 reps (3/4 Speed) 1 x 20 reps R Lead, 1 x 20 reps L Lead 2 x 30 sec. (Ea. Side) 20x 20x 4x (Down & Back) 4x (Down & Back) 4x (Front Lead) (Down & Back) 4x (Back Lead) (Down & Back) 4x (Down & Back) 4x (Down & Back) 13
Impact Phase E: Criteria Estimated Weeks 16 22 ROM Effusion Strength Special Testing Functional Score Functional Testing Within 90% contralateral limb Minimal to none, no joint line tenderness 75 80% Quadriceps, 65 70% HS/Quad Ratio Satisfactory Lachman/Drawer Test >7 score on Cinti Knee Rating System SL hop 60%, Broach Jump with sound mechanics, Good form with Eccentric Step Down Test 14
Impact Phase E: Jump Program Estimated Weeks 16 22 Dynamic Sports Routine Warm Up (Utilized all 6 weeks) Jog in Place Giant Arm Circles Trunk Rotation Pelvic Circle Hip Circumduction Hip Step w/ Exaggerated Arm Swing Gluteal Kicks Skipping Bound Side Shuttle Cariokas High Knees Sprint/Back Pedal Ankle Hops 20 30 sec. 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Direction) 20 reps (Ea. Leg) 10 sec. 15
Impact Phase E: Jump Program Estimated Weeks 16 22 Plyometrics Phase I: Week 16 Wall/Block Jump Broad Jump Squat/Vertical Jump 180/Half Spin Jump Lateral Bounding in Place Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side 20 sec. 5 reps 20 sec. 20 sec. 20 sec. 20 sec. 20 sec. 20 sec. Plyometrics Phase I: Week 16 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 30 sec. 2 x 10 reps 2 x 10 reps 2 x 10 reps 5 sec. Hold 5x Thru ea. Position 3x (Down & Back) 2 x 10 reps 2 x 10 reps 25 Forward, 25 Backward 16
Impact Phase E: Jump Program Estimated Weeks 16 22 Plyometrics Phase I: Week 17 Wall/Block Jump Broad Jump Squat/Vertical Jump 180/Half Spin Jump Lateral Bounding in Place Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side 25 sec. 10 reps 25 sec. 25 sec. 25 sec. 25 sec. 25 sec. 25 sec. Plyometrics Phase I: Week 17 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 30 sec. 2 x 10 reps 2 x 10 reps 2 x 10 reps 5 sec. Hold 5x Thru ea. Position 3x (Down & Back) 2 x 10 reps 2 x 10 reps 25 Forward, 25 Backward 17
Impact Phase E: Jump Program Estimated Weeks 16 22 Plyometrics Phase II: Week 18 Wall/Block Jump Tuck Jump Jump, Jump, Jump, Vertical Jump Squat/Vertical Jump Lateral Bounding for Distance Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Hop, Hop, Hop, Stick 30 sec. 30 sec. 5 reps 30 sec. 2 runs 30 sec. 30 sec. 30 sec. 30 sec. 30 sec. 5 reps Plyometrics Phase II: Week 18 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 40 sec. 2 x 12 reps 2 x 12 reps 2 x 12 reps 5 sec. Hold 8x Ea. Position 5x (Down & Back) 2 x 12 reps 2 x 12 reps 25 Forward, 25 Backward 18
Impact Phase E: Jump Program Estimated Weeks 16 22 Plyometrics Phase II: Week 19 Wall/Block Jump Tuck Jump Jump, Jump, Jump, Vertical Jump Squat/Vertical Jump Lateral Bounding for Distance Scissors/Rudder Jump Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Hop, Hop, Hop, Stick 35 sec. 35 sec. 8 reps 35 sec. 4 runs 35 sec. 35 sec. 35 sec. 35 sec. 35 sec. 8 reps Plyometrics Phase II: Week 19 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 40 sec. 2 x 12 reps 2 x 12 reps 2 x 12 reps 5 sec. Hold 8x Ea. Position 5x (Down & Back) 2 x 12 reps 2 x 12 reps 25 Forward, 25 Backward 19
Impact Phase E: Jump Program Estimated Weeks 16 22 Plyometrics Phase III: Week 20 Squat/Vertical Jump Jump Up, Jump Down, Vertical Jump Tuck Jump Scissors/Rudder Jump Jump Into Bounding for Distance Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Single Leg Hop, Hop, Hop, Stick 45 sec. 10 reps 35 sec. 40 sec. 3 runs Ea. Leg 35 sec. 35 sec. 35 sec. 35 sec. 8 reps Plyometrics Phase III: Week 20 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 50 sec. 2 x 15 reps 2 x 15 reps 2 x 15 reps 5 sec. Hold 10x Ea. Position 5x (Down & Back) 2 x 15 reps 2x 15 reps 25 Forward, 25 Backward 20
Impact Phase E: Jump Program Estimated Weeks 16 22 Plyometrics Phase III: Week 21 Squat/Vertical Jump Jump Up, Jump Down, Vertical Jump Tuck Jump Scissors/Rudder Jump Jump Into Bounding for Distance Richochets Bilateral Back to Front Richochets Bilateral Side to Side Richochets Unilateral Back to Front Richochets Unilateral Side to Side Single Leg Hop, Hop, Hop, Stick 45 sec. 12 reps 40 sec. 45 sec. 4 runs Ea. Leg 40 sec. 40 sec. 40 sec. 40 sec. 10 reps Plyometrics Phase III: Week 21 Functional Strengthening Exercise No. of Reps/Time Day 2 Day 4 Day 6 Hip Hinges: Sustained Isometric Squat Cook Hip Lift Fire Hydrants Split Leg Squat/Chair Dip Isometric Plank x4 Multidirectional Lunge Unilateral Straight Leg Dead Lift Straight Leg Abduction with External Rotation Lunge Walk 2 x 50 sec. 2 x 15 reps 2 x 15 reps 2 x 15 reps 5 sec. Hold 10x Ea. Position 5x (Down & Back) 2 x 15 reps 2x 15 reps 25 Forward, 25 Backward 21
Return to Competition Criteria/Release Form Date of Test: Doctor: Dx: Age: Height: DOI: P/O Week: Sport/Position: Girth: R: 10cm 20cm Total: L: 10cm 20cm Total: Joint Exam: Broad Jump Norms: M 90-100% Height, F 80-90% Height #1 #2 #3 Ave. Percentile Quality P F G E Standing Vertical Jump Norms: M < 14:11, 14-16:16, 17-18:19, > 18:22 F < 14:10, 14-16:11, 17-18:13, > 18:15 Jump #1 Jump #2 Jump #3 Mean Jump Height Percentile Quality P F G E Single Hop For Distance Norms: M 90% Height, F 80% Height R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality % P F G E 22
Return to Competition Criteria/Release Form Sport Specific Movements Quality Quality Forward/Backpedaling: P F G E Bounding: P F G E Side Shuttles: P F G E Shuttle Run: P F G E Carioca: P F G E High Knees: P F G E Gluteal Kicks P F G E Other: P F G E ROM Effusion Strength Special Testing Functional Score Functional Testing Pass Criteria Within 90% contralateral limb Minimal to none, no joint line tenderness 80 85% Quadriceps, 70 75% HS/Quad Ratio Satisfactory Lachman/Drawer Test >8 score on Cinti Knee Rating System SL hop 85%, Ability to pass sport specific movement & physician clearance Criteria Met ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Restrictions: Non Contact ( ) Release Pending MD Approval ( ) Contact with Brace ( ) Continue Therapy ( ) No Restrictions ( ) Evaluators Signature: Date: 23
Lower Extremity Functional Testing Record Date of Test: Doctor: Dx: Age: Height: DOI/DOS: P/O Week: Sport: Girth: R: 10cm 20cm Total: L: 10cm 20cm Total: % Joint Exam: Broad Jump Norms: M 90-100% Height, F 80-90% Height #1 #2 #3 Ave. Percentile Quality P F G E Standing Vertical Jump Norms: M < 14:11, 14-16:16, 17-18:19, > 18:22 F < 14:10, 14-16:11,: 17-18:13, > 18:15 Jump #1 Jump #2 Jump #3 Mean Jump Height Percentile Quality P F G E Single Hop For Distance Norms: M 90% Height, F 80% Height R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality % P F G E 24
Lower Extremity Functional Testing Record Timed One Minute Eccentric Step Down Test "Step R L F. E. R. Quality P F G E Step Down Test Squat Test R + -- L + -- Sport Specific Movements Quality Quality Forward/Backpedaling: P F G E Bounding: P F G E Side Shuttles: P F G E Shuttle Run: P F G E Carioca: P F G E High Knees: P F G E Gluteal Kicks P F G E Other: P F G E Recommendations: ( ) Continue Current Phase ( ) Progress to Next Phase Evaluators Signature: Date: 25
has completed the on and is released to return to sport. Restrictions:
This material is intended for educational purposes only. Any medical information included herein has a mere informative purpose and shall not be used in any way as substitute for professional advice provided by a physician or liscenced health care provider. It is not meant to replace the judgement of trained surgeons on the appropriate treatment of their patients and may not be appropriate for all ACL patients. Biomet does not practice medicine and does not recommend any particular orthopedic implant or surgical technique for use on a specific patient. This program was developed by Steven Traina, MD and Nathan Lilley, MPT, OCS, CSCS. The surgeon who performs any implant procedure is responsible for determining and utilizing the appropriate techniques for implanting prosthesis in each individual patient. Biomet is not responsible for selection of the appropriate orthopedic implant. This handbook and all content, artwork, photographs, names, logos and marks contained in it are protected by copyright, trademarks and other intellectual property rights owned by Biomet or licensed to Biomet. This handbook must not be used, copied or reproduced in whole or in part for any purposes other than marketing by Biomet or its authorized representatives. Any other purposes are prohibited. Biomet hereby explicitly excludes any and all liability of any kind that might be triggered by the unauthorized use of this publication or the information herein. 27
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