Jason Boyer MD OrthoWashington 12707 120 th Ave NE Suite 203 Kirkland, WA 98034 (425) 820-1221 ACL Rehabilitation Protocol Phase 1- Post Operative and safe zone 1-60 days I. Principles Now that you have had your surgery, progressive rehabilitation of the quadriceps and hamstrings is vital to ensure an optimal outcome. In an ACL injured knee, there is a failure of mechanoreceptors in the ligament that causes the loss of muscular reflexes responsible for joint stability, thereby increasing joint laxity. Exercise has been shown to induce a proprioceptive improvement in the muscle receptors. It is important to recondition the proprioceptive capacities of the knee early on. We believe this can be maximized by initiating early active motion and a functional rehabilitation program that maximizes overall fitness levels to improve muscular reflexes and afferent innervations of the knee. This conditioning program will increase overall strength and hopefully prevent further knee injury in the future. II. Detailed Early Rehabilitation Protocol 0-48 hours a. Early Mobilization Goal to get range of motion of 0-90 degrees b. You will begin with active peddling motion exercises using a portable Pedlar in the recovery room as soon as you have recovered from your anesthetic. You will use the Pedlar 10 minutes every hour during the day. Resistance will be increased later in the post-operative course. We believe that immediate stimulation and recruitment of the quadriceps and hamstrings leads to a more expeditious recovery time. You will continue to use the portable bicycle until they were able to ride the stationary bicycle by day 7-10 c. Other exercises in the immediate post-operative period include: I. Quadriceps sets II. Straight leg lifts III. Range of motion exercises 0 to 100 degrees (10 repetitions times 15-20 sets per day for each exercise) IV. Maintain the leg fully straight with yoga style stretch. d. Use the ice machine for compression and cold to minimize swelling, diminish your pain and improve your range of motion. e. You will be partial weight bearing for 14 days then advance to full-weight bearing status (unless there has been an articular cartilage or meniscal repair procedure which would require six weeks of partial weight bearing)
III. The First Visit and the next 2-3 days a. Early Mobilization Range of motion with a goal to achieve range of motion 0-90 degrees b. The dressing is changed and drains removed at the first visit c. If drains are removed, the Pedlar is discontinued for 48 hours to allow knee to seal and stop draining. Then resume Pedlar starting at 10 minutes 3x/day and start increasing at one minute intervals d. You will discuss the surgical procedure, look at the pictures and go over plans for the future. You will receive a second visit appointment 7-10 days later. IV. The 2 nd visit 7-10 days a. Return for suture removal b. Discontinue Pedlar and transition to stationary bike 10min/day. Increase this time by one minute intervals each day to achieve 1 hour/day by 6 weeks on stationary bike. c. Ice machine for compression and icing Phase 2- Early Post Operative Phases Day 7 to 60: I. Discontinue crutches at 14 days in transition and progression. Be careful not to walk too much for total of 42 days (6 weeks). No pleasure walking, shopping or standing for long periods. If you do, your knee will swell and the progression will stall. This ACL Rehabilitation/Restoration/Performance and Prevention program incorporates all dimensions of performance including aerobic and anaerobic fitness, power, strength, agility, and specific athletic function. During the first 3 weeks, the emphasis is on range of motion exercises, quadriceps strengthening, agility exercises and riding the stationary bicycle. II. Detailed Rehabilitation Protocol Day 10-60 a. Quad sets to make sure the knee can totally straighten to full extension are essential. If extension is incomplete, will need yoga style progressions to achieve full extension immediately b. Stationary bike progresses towards 1hr/day. By the end of 42 days this can be done with an outside bicycle following same progression. c. Sports specific agility exercises are incorporated early. i. Soccer athletes start early doing the box progression at week 2. This is done without the ball in the beginning until week 12. ii. Basketball athletes start in the gym around the second postoperative week, walking around the court, shooting foul shots, and shagging balls. iii. During the 2nd week, the tennis player is instructed to begin to hit balls against a backboard. iv. The volleyball athlete will begin gently bumping and setting at week 2. d. The box drill is to optimize restoration of Proprioceptive function. i. This is set up with 4 cones, 5 yards apart making a box. The patient walks toward the first cone, then side steps to the next, backpedals to the
third and side steps to the last. Always face the same direction while walking the box. The box is initially walked slowly in both directions. As comfort and stability increase, the pace of the drill increases but not more than a brisk walk until 12 weeks. ii. The box is progressively enlarged to 10 yards by 4 weeks, 20 yards at 8 weeks and 40 yards by 12 weeks. At twelve weeks, the box should be walked, then jogged in a stepwise progression. e. A gentle walk/jog program will be incorporated at week 6-8 depending upon the individual progress, as follows: a. Pool Program ( see table 1) and Swimming is encouraged as early as 2 weeks post-operatively for cross training once the wounds are closed. The freestyle stroke is ideal but breaststroke must be avoided due to additional stresses on the knee. Aqua jogging with a belt or vest is also excellent exercise beginning at six weeks. Pool progressive exercises are in Table 1. b. If flying long distances (more than 2 hours), prophylaxis for blood clots with Lovenox will be prescribed. Phase 3 Conditioning, Proprioception 60-120 days I. 60 to 90 days Training Phases a. Gym and PT ( see Table 2) b. Core strengthening good c. Pool and Swimming progression 1 hour Including Aqua jogging with Buoyancy vest (see table 1) d. Continuation of Bike 1hr/day with progression of time, load and speed e. Stairmaster, Elliptical to enhance cross training diversity. f. Box progressions daily in house g. Walking minimal for exercise h. Core strengthening good II. 90 to 120 days Training Phases The running progression starts when you are able to walk for 30 minutes without a limp. Begin by alternating walking for 5 minutes and jogging for 5 minutes. Once comfortable, increase the jogging interval in a stepwise manner such as walk 5 minutes and jog for 10 minutes; then walk for 5 minutes and jog for 15 minutes and so on. a. Gym and PT ( see table 2) b. Pool and Swimming progression 1 hour Including Aqua jogging with Buoyancy vest (table 1) c. Continuation of Bike 1hr/day with progression of time, load and speed d. Stairmaster, Elliptical to enhance cross training diversity e. Box progressions on field or court. Put your boots or shoes on and begin to have fun!
i. Start at 15 minutes. Box at 10 yards and 40 yards. Clockwise and Counterclockwise. Start slow jog and progressively increase the pace with and without the ball. Should be sprinting by 120 days. ii. This is confidence building activity, endurance, proprioceptive and game and practice simulation. iii. PEP program (See ACL Prevention Program) to start as a 15-20 minute warm up 3x /week to all field training, all elements (See table 4) Phase 4 Return to Sports, Practice, Play and Prevention 120-180 days I. Return to Practice Progression 120-150 days a. Gym and PT (see table 2) b. Pool and Swimming progression 1 hour Including Aqua jogging with Buoyancy vest (table 1) c. Continuation of Bike 1hr/day with progression of time, load and speed d. Stairmaster, Elliptical to enhance cross training diversity. e. PEP program to start as a 15-20 minute warm up 3x /week to all field training, all elements (See ACL Prevention Program) f. Run and Sprint Box progressions on field or court. Start at 15 minutes. Box at 10 yards lengthening to 40 yards. You must be able to sprint box both ways by 120 days. Once you are at full speed on the box drill, then you may begin to return to practice as outlined below. You must continue box on daily basis even though you transition back into practice! g. Practice criteria and on field progressions non-contact drills only during practice x 28 days h. Practice May play criteria on field progressions contact drills only during practice x 28 days once safely and effectively passed non-contact drills II. Return to Play/Practice/Compete Progression 150-180 days a. Gym and PT ( see table 2) b. Pool and Swimming progression 1 hour Including Aqua jogging with Buoyancy vest (table 1) c. Continuation of Bike 1hr/day with progression of time, load and speed d. Stairmaster, Elliptical to enhance cross training diversity. e. PEP program (See ACL Prevention) to start as a 15-20 minute warm up 3x /week to all field training, all elements f. Run and Sprint Box progressions on field or court. Start at 15 minutes. Box at 10 yards lengthening to 40 yards. You must continue box on daily basis even though move into practice! i. Continue on field progressions contact drills only during practice x 28 days. Once you have safely and effectively passed contact drills then you are ready for competition progression, can progressively start games 15 minutes, 20, 25, 30. Up to 90 minutes
by 180 days. Full release when one can play 90 minutes with comfort. Phase 5: Prevention180 days and beyond All reconstructed players must be treated differently than normal player I. They must have workouts include more cross training II. PEP prevention programs to prevent graft failure and other knee III. Perhaps some orthobiological management including Hyaluronic acid and PRP in specific cases. IV. All patients are given Glucosamine Sulfate 1500 and Chrondroitin Sulfate 1200 mg /day to help protect the joint for always as a preventative See Tables Below
TABLE 1 - POOL REHABILITATION PROTOCOL EARLY EXERCISES (from 2 to 4-6 weeks after surgery) Gait training (about 10 min): High water walking using a correct gait cycle (stance, pre-swing, swing), forward-backwardcombined. Stretching and ROM exercises: Bilateral stretching exercises of the hamstrings and triceps surae (2'x2 each): o High/Low water, using lifebelts of different size o Stretching exercises are performed several times during rehab session, particularly after strength exercises Hydro-bike in high water with rubber tubes or lifebelt ROM recovery without forcing for 10 min Seated passive knee motion Manual mobilization of the patella at the pool side at the end of the session (up-down and side-toside) Muscular strengthening (usually 5 set of 15): CKC exercises with board or lifebelt ( without recruiting ST-G muscles for hamstring grafts) Hip abduction and adduction with no weight added and progressively using a lifebelt Hip extension with lifebelt Flex-extension and active ankle circumduction in supine position Bipedal Toe raises in high water (reducing sets and repetitions) Exercises for recruitment and control of transverse abdominal muscle (15" contraction - 15" rest x 5 min) Proprioception and sport skill exercises: Sitting exercises with propriocetptive board without weight bearing (bi and monopodalic) in multiple planes When full weight bearing is reached, perform same exercises in standing position (bi and monopodalic) Proprioceptive exercises for the trunk sitting on a surf board Exercises with specific tool (using a ball: heading, practise with hands, passing, ) LATE EXERCISES (from 4-6 to 8-10 weeks after surgery) Gait training (about 10 min): Low water walking using a correct gait cycle (stance, pre-swing, swing), forward-backwardcombined. Stretching and ROM exercises:
Bilateral stretching exercises of the hamstrings, triceps surae and quadriceps (same as early phase): Hydro-bike in high water with rubber tubes or lifebelt ROM recovery without forcing for 10 min Active flex-extension of the knee (lying in back position with the trunk, head and calfs supported by barges) Muscular strengthening (usually 6 set of 20): leg press with lifebelt Pendolo calciato (in equilibrio in acqua alta simulando il gesto del calciare per i calciatori) Active flexion with light weights Hip extension, abduction and adduction using a lifebelt with different sizes Bipodalic plantar flexion exercises in high water even in eccentric (reducing sets and repetitions) Exercises for recruitment and control of transverse abdominal muscle (20" contraction - 10" rest x 5 min) with destabilization Proprioception exercises: Exercises with propriocetptive board with full weight bearing (bi and monopodalic) in multiple planes Exercises with/without propioceptive board increasing their difficulty with external inputs (destabilizations, throwing a ball ) Proprioceptive exercises for the trunk sitting on a surf board Sport specific and skill exercises: Aerobic reconditioning exercises: cyclette (try to reach 15 min), Backstroke with flippers, Step, Running in high water with barges and in monopodalic standing/progressively in movement (6 repetition 1 min each), Skip forward/backward/side-to-side Exercises with specific tool (using a ball: heading, practise with hands, passing, ) High water jumping focusing on the loading phase, trying to reduce ROM and with better reactivity Jumps with short run followed by skipping and take-off (phase) Table 2 In Physical Therapy REHABILITATION PROTOCOL Physical Therapies: Low level laser therapy (HeNe) TENS Ice Massotherapy: Draining massotherapy of knee and calf Decontracting Massotherapy of the quadriceps and ITB Decontracting Massotherapy of the hamstrings muscles starting from week 2-3 (patients treated with autografts, paying attention to the harvesting area), or starting from week 1 (patients treated with allografts). ROM exercises and joint mobilization: Passive mobilization of the patella
Manual and self assisted passive mobilization in order to improve flex-extension Posterior chain stretch on the wall Active mobilization using a stationary bike (improving ROM as much as possible) or sliding the heel on the wall or following an imaginary path while lying on the bed Stretching: Hamstrings Triceps surae Quadriceps (when a 130 flexion is reached) Ilio-psoas Tensor fasciae latae Postures for the posterior muscular chain Strength recovery: Electrostimulation (even with co-contractions) Quadriceps/hamstrings co-contrazctions Hip Flexors, adductors, abductors and extensors with weights and tubing Soleus with tubing Knee flexors starting from week 4-5 (patients treated with ST-G grafts) or from week 3 (patients treated with PT grafts) Closed Kinetic Chain exercises: o Leg press with elastic resistance from week 2-3 o Leg press with weights, wall slide, step-up from week 4-5 Open Kinetic Chain exercises: o Last 30 knee extension (VMO) performed with natural weight from week 2-3, then using weights (from proximal to distal position) o Leg extension ROM 90-40 from week 5 High velocity isokinetic training (limited ROM ) from week 6 Full weight-bearing exercises: o Plantar flexion of the foot with full weight bearing in eccentric-concentric mode o Knee movement control exercises (varus-valgus) lateral step-up like o Strengthening exercises for trunk and deep abdominal muscles (core stability) o Eccentric control exercises with natural weight bearing using differents motor patterns Proprioception: Walking using a correct gait cycle Exercises with proprioceptive board without weight bearing (bi and monopodalic) progressively increasing weight in stand position Bipodalic and Monopodalic stops on bouncer Proprioceptive paths Proprioceptive exercises for trunk muscles (core stability) Sport specific and skill exercises: Running and skipping on bouncer Bipodalic and monopodalic jumps on elastic leg press (plyometric exercises) Aerobic training: stationary bike, stepper, cross trainer, running on treadmill at slow speed Sport spcific exercises using equipment specific to sport of desired return