Brooke Army Medical Center Sports Medicine
Outpatient Rehabilitation Protocol
Anterior Cruciate Ligament Reconstruction
Bone Tendon Bone (BTB) & Hamstring (Quad HS) Graft Reconstructions
BAMC Ortho: 210-916-1242
BAMC PT: 210-916-1920
This Rehab Protocol is a guideline. Specific exercises and time frames may be altered
depending on patient progression except italicized and bolded items.
INPATIENT: Post-operative day (POD) 1 through discharge (d/c) from hospital
PT Sessions: Morning and afternoon sessions each day
Ambulation: Crutches – Progressive weight-bearing as tolerated (WBAT)
Brace:
1.
2.
3.
Knee immobilizer or hinged range-of-motion (ROM) brace
Wear at all times while in bed (maintain full extension)
Ambulate in locked ROM brace
Remove knee immobilizer or ROM brace for rehabilitation exercises
Exercise:
1.
2.
3.
Calf / ankle pumps
Static quad sets or straight leg raises (SLR) in full extension
Assisted heel slides
Inpatient DC Goals:
1.
Full Extension
2.
Good quadriceps contraction
3.
Independent in WBAT ambulation with crutches
4.
Patient demonstrates understanding of positioning & effusion control,
cryotherapy at least 3 x day indep with home use
5.
Outpatient therapy appointment coordinated by house ortho staff
PHASE I: Hospital d/c through Week 4 – PROTECTION AND PAIN/EFFUSION
CONTROL
PT Sessions: 3-5 supervised sessions per week with outpatient physical therapist
Ambulation: Crutches –WBAT; d/c when satisfactory quad strength (30 SLRs w/o lag)
and normal gait.
Brace:
Wear at night for 6 weeks
Discontinued during gait when quad strength is good and gait is normal.
Exercise:
1. ROM:
a. Bike (in available range. Should not be painful.)
b. Patella mobilization (emphasize superior glides)
c. PROM, AAROM, AROM as tolerated
i. Heel slides (AAROM/PROM w/ HS graft)
ii. Supine extension on bolster or prone hang
2. OKC strengthening:
a. SLR x 4 on mat – add light ankle weights if quad control is maintained
(less or no resistance for ADD)
b. Electrical stimulation (PRN) in full extension with quad sets and SLR.
Biofeedback when patient demonstrates good quad contraction
c. HS isometrics. Progress to curls (prone or standing) for BTB only
d. No resisted OKC extension 0-30 deg x 6 mo
3. CKC strengthening
a. wall squats
b. Total Gym – progress levels of mini-squats as tolerated
c. Forward, lateral, and retro step downs in parallel bars
-no knee flexion past 30 degrees
d. Bilateral heel raises. Progress to single leg as tolerated
4.
Scar massage when incision healed
5.
Gait training
6.
Proprioceptive training
a. Wt shift to single leg stance
7.
Ice x 15-20 minutes in full extension after each exercise session.
Monitor effusion and pain carefully
Goals and Criteria for Progression to PHASE II:
1.
Full passive and active ROM and good patella mobility
(Flexion to 90 by 1 wk, 110 by 2wks, 120 by 4 wks, full flexion AROM
by 6wks; Extension equal to opposite side by 2 weeks)
2.
Good quad control (No extensor lag; biofeedback to 80% vs. uninvolved
side; >2 cm superior patella glide w/ quad set)
3.
Single leg stance x 30 seconds, eyes open
4.
Pain under control and minimal effusion
5.
Normal gait without crutches
PHASE II: Week 4 through Week 12 – STRENGTHENING PHASE
PT Sessions: 3 supervised sessions per week with outpatient physical therapist
Ambulation: Crutches should be discontinued
Brace: none required
Exercise:
1.
2.
3.
4.
5.
6.
7.
Patellar mobilization, AROM, PROM with end-range stretching as
needed
OKC strengthening
a. Initiate Hamstring curls, standing or prone, for hamstring grafts as
tolerated
b. No resisted OKC extension 0-30 deg x 6 mo
c. Week 6: Start isokinetic quadriceps exercises 90-40 deg (180/300
/sec)
CKC strengthening
a. Standing 4-way hip strengthening
b. Single leg press; single leg total gym mini squats
c. Single leg wall squat
d. Step ups
e. Lunges
Continue scar massage
Initiate cardiovascular exercise
stationary bike (when range at least 0-110)
treadmill walking – forward and backward
Proprioception drills:
a. single leg body blade, ball toss, foam pad, etc.
b. BAPS board
c. Wobble board
Aquatic (pool) therapy
a. pool walking – forward and lateral
b. flutter kicks (knee remains extended)
c. weightless jogging
d. Pool plyometric program at 8 weeks
Goals and Criteria for Progression to PHASE III:
1.
Full AROM
2.
Normal quad and HS control
3.
Single leg stance x 30 sec, eyes closed
4.
Minimal pain; no effusion
5.
Normal patellar mobility
PHASE III: Week 12 through Week 18 – ADVANCED STRENGTHENING PHASE:
PT sessions: Necessity of supervised sessions to be determined by physical
therapist. If good ROM and muscle control, may progress to independent rehab program.
Exercise:
1.
2.
3.
4.
5.
Progress with PHASE II exercises
Functional activities
a.
Fitter
b.
Lateral walking
c.
Figure 8s
Cardiovascular exercise:
a.
Elliptical trainer, bicycle, swimming
b.
No running until 4 months or until passing isokinetic strength
test (> 80%). No fast cutting, twisting or contact sports until
6 months or until phase IV goals met.
No resisted OKC extension 0-30 deg x 6 mo
Advanced pool therapy
a.
Treading water
b.
Kickboard swimming
c.
Pool running, shuffling, and carioca
d.
Modified aquatic sports
Biodex Isokinetic Strength Test at 12 – 16 weeks blocked from 0-30
Goals and Criteria for Progression to PHASE IV:
1.
No pain or swelling
2.
No giving-way
3.
Walk 3 miles at 15 min/mile pace
4.
Isokinetic testing 80% vs. uninvolved side
PHASE IV: Week 18 through Week 24 –BASIC FUNCTIONAL TRAINING:
PT sessions: Necessity of supervised sessions to be determined by physical
therapist. If good ROM and muscle control, may progress to independent rehab program.
Optional: Biodex Isokinetic Strength Test at 20-24 weeks blocked from 0-10
Functional Tests:
1.
Single leg hop for distance
2.
Timed 6 meter hop
3.
Triple hop for distance
4.
Crossover: 3 controlled hops, measure for distance and time
Exercises:
1.
2.
3.
Continue with PHASE III exercises with increasing weight/intensity
Progressive agility and proprioception exercises
Begin impact activities (running, plyometrics)
4.
No resisted OKC extension 0-30 deg x 6 mo
Goals and Criteria for Progression to PHASE V:
1.
No pain or swelling
2.
Slow, controlled, alternating gait up and down stairs
3.
Functional tests 85% uninvolved side
4.
Isokinetic tests 90% of uninvolved side, if performed
PHASE V: 6 Months + -- ADVANCED FUNCTIONAL TRAINING
PT sessions: Supervised sessions to be determined by outpatient physical therapist.
Minimum monthly follow-up visit if patient has HEP.
Exercises:
1.
2.
3.
4.
5.
6.
7.
Continue with PHASE IV exercises with increasing weight and difficulty
Plyometrics
Jumping / hopping progression
Running progression
Functional hop test as appropriate when running is normal
Functional progression to cutting and jumping
Return to sports prn when full strength and agility achieved
Goals: Return to full duty and sport if (Low-profile ACL sports brace when required
by surgeon):
1.
Functional tests 85% of uninvolved side
2.
Isometric tests 90% of uninvolved side, if performed
3.
No pain or effusion
4.
Full ROM
5.
MD approval
_____________________
David R. Brown, MD
LTC, MC
Orthopedics
_________________________
KATHLEEN S. ZURAWEL, PT, OCS
COL, SP
Chief, Physical Therapy
APPROVE / DISAPPROVE
APPROVE / DISAPPROVE
Updated 19 July 2006