Brooke Army Medical Center Sports Medicine
Outpatient Rehabilitation Protocol
Anterior Cruciate Ligament Reconstruction + Meniscus Repair
Bone Tendon Bone (BTB) & Hamstring (Quad HS) Graft Reconstructions
Inside-out & All-inside Meniscus Repairs
 Wt bearing and ROM may be altered based on location and size of meniscal
repair
 No resisted hamstring x 9 weeks
INPATIENT: Post-operative day (POD) 1 through discharge (d/c) from hospital
PT Sessions: Afternoon visit on DOS; morning and afternoon sessions each day
Ambulation: Crutches – Foot-flat weight bearing (FFWB)
Brace:
1.
2.
3.
Hinged range-of-motion (ROM) brace
Wear at all times while in bed (locked in full extension)
Ambulate with brace locked at 0 flexion
Remove hinged ROM brace for rehabilitation exercises or CPM
CPM:
on 4 hours, off 2 hours; may leave off at bedtime prn
set to start at 0 - 60
increase by 10 every hour until prn until reaches goal of 90 flexion
1.
2.
Exercise:
1.
2.
3.
Calf / ankle pumps
Static quad sets or straight leg raises (SLR) in full extension
Passive extension / flexion heel slides with assist
Inpatient D/C Goals:
1.
Full extension & 90 flexion
2.
Good quadriceps contraction
3.
Independent in TTWB ambulation with crutches
4.
Patient demonstrates understanding of positioning & effusion control
5.
Outpatient therapy appointment coordinated.
PHASE I: Hospital d/c through Week 6 – PROTECTION PHASE
PT Sessions: 5 supervised sessions per week with outpatient physical therapist
ROM: Per MD guidance, may be limited to 90 deg the 1st 6 weeks based on
complexity and location of meniscal repair
Ambulation: FFWB with crutches
Brace:
1.
CPM:
Exercise:
1.
2.
3.
4.
5.
6.
7.
8.
Ambulate with hinged ROM brace locked at 0 flexion until quads strong
enough to prevent knee from giving-way
per specific request of surgeon
(followed by 20 min ice with towel under heel cord – full extension)
Quadriceps E-stim x 15 min (muscle re-education)
Quad sets x 100, SLR x 10
Heel slides x 30
Prone hangs 5-10 min
Calf / ankle pumps with tubing
Gentle hamstring (HS) stretching
(wait until 9 weeks for resisted HS)
Patellar mobilizations
Hip strengthening
Goals and Criteria for Progression to PHASE II:
1.
Passive and active ROM of >90 and good patella mobility
2.
Good quad control (< 5 extensor lag)
3.
Pain under control and minimal effusion
PHASE II: Week 6 through Week 12 – FULL ROM & STRENGTHENING PHASE
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)
Brace:
1.
2.
2.
Exercise:
1.
2.
3.
3.
Discontinued after 8 weeks or when:
Pt has at least 0-120 AROM
Performs single leg balancing for 30 seconds
Demonstrates normal gait
Continue with PHASE I exercises
Initiate closed chain strengthening when gait is normal
a.
mini squats (if no pain or crepitus)
b.
heel raises and heel to toe rocking
c.
single leg press 25% of body wt
d.
leg press progression (no deep flexion)
e.
initiate resisted hamstring week 9
Initiate cardiovascular exercise
a.
stationary bike for ROM (low resistance, seat high)
b.
treadmill walking – forward
c.
elliptical trainer
Proprioception drills:
a.
single body blade
b.
BAPS board (progress through levels w/ eyes open & closed)
4.
c.
plyoback training
Aquatic (pool) therapy
a.
pool walking – forward and lateral
b.
flutter kicks (knee remains extended)
c.
weightless jogging
Goals and Criteria for Progression to PHASE III:
1.
Full AROM (95% strength of uninjured knee)
2.
Normal quad and HS control; no quadriceps extension lag
3.
Minimal pain; no effusion
4.
Normal patellar mobility
4.
Normal gait without crutches
5.
Stair ambulation w/ minimal difficulty (no sensation of giving-way)
PHASE III: Week 12 through Week 18 – ADVANCED STRENGTHENING PHASE:
PT sessions: 2-3 supervised sessions per week with outpatient physical therapist
Exercise:
1.
2.
3.
4.
Continue with PHASE II exercises
Muscle strengthening hip/knee/ankle/core
a.
Leg press progression up to 50% of body weight (single leg)
b.
Quad and HS strengthening – exercise to muscle failure
Cardiovascular exercise:
a.
Retro-walking on treadmill (2mph @ 1% grade – progress prn)
b.
Add resistance to stationary bike at 60 RPM (if no pain / crepitus)
c.
No cutting, jumping, twisting, or contact sports
Advanced pool therapy
a.
Treading water
b.
Kickboard swimming
c.
Pool running, shuffling, and carioca
d.
Modified aquatic sports
Goals and Criteria for Progression to PHASE IV:
1.
Full pain free ROM
2.
no effusion
3.
Biodex week 16 80% uninvolved strength
PHASE IV: Week 18 through Week 24 –BASIC FUNCTIONAL TRAINING:
PT sessions: 1-2 supervised sessions per week with outpatient physical therapist
Exercises:
1.
2.
3.
Continue with PHASE III exercises with increasing weight
Progress strengthening
Advanced proprioception exercises
4.
return to run and jump training as cleared by MD
Optional: Kincom/Biodex Isokinetic Strength Test @ 16 weeks blocked at 30-45
@ 20-24 weeks blocked at 10
PHASE V: 6 Months + -- ADVANCED FUNCTIONAL TRAINING
When rehabilitation goals are met
1.
Initiate straight line running when walk & slow jog is normal
2.
Functional hop test as appropriate when running is normal
3.
Functional progression to cutting and jumping
4.
Begin full body weight. plyometrics prn
5.
Return to sports prn when full strength and agility achieved
(Low-profile ACL sports brace when required by surgeon)
_______________________________
David R. Brown, MD
LTC, MC
Orthopedics
_______________________________
KATHLEEN S. ZURAWEL, PT, OCS
COL, SP
Chief, Physical Therapy
APPROVE / DISAPPROVE
APPROVE / DISAPPROVE
Updated October 2007