Knee Rehabilitation ACL Protocol

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Knee Rehabilitation ACL Protocol

ACL Rehabilitation Guidelines

Phase O: Pre-operative Recommendations

  • Normal gait
  • AROM 0 to 120 degrees of flexion
  • Strength: 20 SLR with no lag
  • Minimal effusion
  • Patient education on post-operative exercises and need for compliance
  • Educated in ambulation with crutches
  • Wound care instructions
  • Educated in MOON follow-up expectations

Phase 1: Immediate Post-operative Phase (Approximate time-frame: Surgery to 2 weeks)

Goals

  • Full Knee extension ROM
  • Good quadriceps control (> 20 no lag SLR)
  • Minimize pain
  • Minimize swelling
  • Normal gait pattern

Crutch Use: WBAT with crutches (beginning the day of surgery)
Crutch D/C Criteria: Normal gait pattern
Ability to safely ascend/descend stairs without noteworthy pain or
Instability (reciprocal stair climbing)

Knee Immobilizer: None (Exception: First 24 hours after a femoral nerve block)

Cryotherapy: Cold with compression/elevation (e.g. Cryo-cuff, ice with compressive stocking)

  • First 24 hours or until acute inflammation is controlled: every hour for 15 minutes
  • After acute inflammation is controlled: 3 times a day for 15 minutes
  • Crushed ice in the clinic (post-acute stage until D/C)

EXERCISE SUGGESTIONS ROM

  • Extension: Low load, long duration (~5 minutes) stretching (e.g., heel prop, prone hand minimizing co-contraction and nocioceptor response)
  • Flexion: Wall slides, heel slides, seated assisted knee flexion, bike: rocking-for-range
  • Patellarmobilization (medial/lateral mobilization initially followed by superior/inferior direction while monitoring reaction to effusion and ROM)

Muscle Activation/Strength

  • Quadriceps sets emphasizing vastus lateralis and vastus medialis activation
  • SLR emphasizing no lag
  • Electric Stimulation: Optional if unable to perform no lag SLR

Discontinue use when able to perform 20 no lag SLR

  • Doug-leg quarter squats
  • Standing theraband resisted terminal knee extension (TKE)
  • Hamstring sets
  • Hamstring curls
  • Side-lying hip adduction/abduction (Avoid adduction moment in this phase with concomitant grade II – III MCLinjury)
  • Quad/ham co-contractionsupine
  • Prone HipExtension
  • Ankle pumps with theraband
  • Heel raises (calf press)

Cardiopulmonary

  • UBE or similar exercise is recommended Scar Massage (when incision is fully healed) CRITERIA FOR PROGRESSION TO PHASE2
  • 20 no lag SLR
  • Normal gait
  • Crutch/Immobilizer D/C
  • ROM: no greater than 5° active extension lag, 110° active flexion

PHASE 2: Early Rehabilitation Phase (Approximate time-frame: weeks 2 to 6)

GOALS

  • Full ROM
  • Improve muscle strength
  • Progress neuro-muscular retraining

EXERCISE SUGGESTIONS ROM

  • Low load, long duration (assisted prn)
  • Heel slides/wall slides
  • Heel prop/prone hand (minimize co-contraction / nocioceptor response)
  • Bike (rocking-for-range – riding with low seat height)
  • Flexibility stretching all major groups

Strengthening

Quadriceps:

  • Quadsets
  • Mini-squats/wall-squats
  • Step-ups
  • Knee extension from 90° to 40°
  • Legpress
  • Shuttle Press without jumping action

Hamstrings:

  • Hamstringcurls
  • Resistive SLR with sports cord

Other Musculature:

  • Hip adduction/abduction: SLR or with equipment
  • Standing heel raises: progress from double to single leg support
  • Seated calf press against resistance

Multi-hip machine in all directions with proximal pad placement Neuromuscular training

  • Wobble board
  • Rocker board
  • Single-leg stance with or without equipment (e.g. instrumented balance system)
  • Slideboard
  • Fitter

Cardio-pulmonary

  • Bike
  • Elliptical trainer
  • Stairmaster

CRITERIA FOR PROGRESSION TO PHASE 3

  • Full ROM
  • Minimal effusion/pain
  • Functional strength and control in daily activities
  • IKDC Question # 10 (Global Rating of Function) score of > 7)

PHASE 3: Strengthening & Control Phase (Approximate time-frame: weeks 7 through 12)

GOALS

  • Maintain full ROM
  • Running without pain or swelling
  • Hopping without pain, swelling or giving-way

EXERCISE SUGGESTIONS

Strengthening

  • Squats
  • Legpress
  • Hamstringcurl
  • Knee extension 90° to 0°
  • Step-ups/down
  • Lunges
  • Shuttle
  • Sportscord
  • Wallsquats

Neuromuscular Training

  • Wobble board / rocker board / roller board
  • Perturbation training
  • Instrumental testing systems
  • Varied surfaces

Cardio-pulmonary

  • Straight line running on treadmill or in a protected environment (NO cutting or pivoting)
  • All other cardio-pulmonary equipment

CRITERIA FOR PROGRESSION TO PHASE 4

  • Running without pain or swelling
  • Hopping without pain or swelling (Bilateral and Unilateral)
  • Neuromuscular and strength training exercises without difficulty

PHASE 4: Advanced Training Phase (Approximate time-frame: weeks 13 to 16)

GOALS

  • Running patterns (Figure-8, pivot drills, etc.) at 75% speed without difficulty
  • Jumping without difficulty
  • Hop tests at 75% contra-lateral values (Cincinnati hop tests: single-leg hop for distance, triple-hop for distance, crossover hop for distance, 6-meter timed hop)

EXERCISE SUGGESTIONS

Aggressive Strengthening

  • Squats
  • Lunges
  • Plyometrics

Agility Drills

  • Shuffling
  • Hopping
  • Carioca
  • Vertical jumps
  • Running patterns at 50 to 75% speed (e.g.Figure-8)
  • Initial sports specific drill patterns at 50 75% effort

Neuromuscular Training

  • Wobble board / rocker board / roller board
  • Perturbation training
  • Instrumented testing systems
  • Variedsurfaces

Cardiopulmonary

  • Running
  • Other cardio-pulmonary exercises

CRITERIA FOR PROGRESSION TO PHASE 5

  • Maximum vertical jump without pain or instability
  • 75% of contra-lateral on hop tests
  • Figure-8 run at 75% speed without difficulty
  • IKDC Question # 10 (Global Rating of Knee Function) score of > 8

PHASE 5: Return-to-Sport Phase (Approximate time-frame: weeks 17 to 20)

GOALS

  • 85% contra-lateral strength
  • 85% contra-lateral on hop tests
  • Sport specific training without pain, swelling or difficulty

EXERCISE SUGGESTIONS

Aggressive Strengthening

  • Squats
  • Lunges
  • Plyometrics

Sport Specific Activities

  • Interval training programs
  • Running patterns in football
  • Sprinting
  • Change of direction
  • Pivot and drive in basketball
  • Kicking in soccer
  • Spiking in volley ball
  • Skill / bio-mechanical analysis with coaches and sports medicine team

RETURN-TO-SPORT EVALUATION RECOMMENDATIONS:

  • Hop tests (single-leg hop, triple hop, cross-over hop, 6 meter timed-hop)
  • Isokinetic strength test(60°/second)
  • VerticalJump
  • Deceleration shuttle test
  • MOON outcomes measure packet (mandatory; should be completed post-testing)

RETURN-TO-SPORT CRITERIA:

  • No functional complaints
  • Confidence when running, cutting, jumping at full speed
  • 85% contra-lateral values on hop tests
  • IKDC Question # 10 (Global Rating of Knee Function) of > 9