Post-op Protocol - Anterior Cruciate Ligament (ACL) Reconstruction

ACL Reconstruction with or without Meniscus Repair

This protocol is a general outline.  Progression and return to sport may vary between individual patients and will be guided by your provider’s team (physician, physician assistant, athletic trainer, and therapist) input and appropriate testing. Weight bearing status, brace and range of motion guidelines are dependent upon the patient’s specific surgery. Please refer to the physical therapy script that was provided for weight-bearing, range of motion and brace recommendations.

Meniscus Repair

□ YES             □ NO

□ Medial          □ Lateral

Weight-Bearing:

□ Weight bearing as tolerated (WBAT) with crutches for comfort

□ Touchdown weight bearing for ____ weeks then WBAT

□ Non-weight bearing for ____ weeks

Range of Motion:

□ As Tolerated

□ 0-30 x 2 weeks, then progress to full

□ 0-30 x 2 weeks, 0-60 x 2 weeks, 0-90 x 2 weeks

□ 0-90 x 2 weeks

Brace:

□ Hinged knee brace locked in extension for sleep x 3 weeks

□ Hinged knee brace locked in extension for ambulation until adequate quadriceps control demonstrated with SLR without extensor lag. May unlock brace to sit.

 

Immediate Phase: 0-2 Weeks

Goals:
  • Restore patellar mobility
  • Decrease swelling
  • Control Pain
  • Establish full knee extension
  • Quadriceps activation
  • Open chain glute/hip/hamstring strengthening 
Modalities: 
  • Quadriceps activation w/NMES - minimum of 8 weeks or until 70% LSI.
  • BFR if applicable - Recommended for 8-12 weeks
  • Cryotherapy/Compression
  • Stationary bike for ROM (following ROM restrictions above)

Phase 2: 3-6 Weeks

Goals:
  • Start to normalize gait based on WB restrictions above
  • Continue with patellar mobilization and scar mobilization
  • Maintain full extension, continue to progress full flexion
  • Cont. to push quadriceps activation
Therapeutic Exercise:    
  • Stationary bike – initially for promotion of ROM – can progress light resistance as tolerated
  • Quadriceps activation and strengthening with NMES
    • Examples: NMES w: TKE, shuttle/leg press, step up, 90/60 deg isometrics, and LAQ
  • Initiate LAQ when ROM and pain-free movement allow
  • Progress from isometrics to open chain isotonics 
  • Cont. with BFR if applicable
  • Eccentric quadriceps strengthening
  • Cont. with glute and hip strengthening – progressing to closed chain
  • Introduce balance/proprioception exercises
  • Core strengthening

Phase 3: 6-12 Weeks

Goals:
  • Normalize gait and stair ambulation.  
  • ROM – maintain full extension, progress flexion to full if restricted initially
  • Safely progress strengthening in various planes of motion for the lower extremity
  • Promote proper movement patterns
  • Cont. with core strengthening
  • Establish a gym program
Therapeutic Exercise:
  • Continue with NMES to improve force production and steadiness
  • Continue closed kinetic chain strengthening with PROGRESSIVE LOADING (a suggested RPE of 7/10)
  • Continue with open chain quadriceps strengthening
  • Prioritize SL strengthening 
  • Continue with BFR if applicable
  • Continue with core strengthening
  • Continue with proprioception exercises
Progression Criteria:
  • 3-month strength assessment will be performed at the 12-week post-op visit. Isometric Quadriceps and Hamstring results will be sent back to treating physical therapist to guide progression
  • NO running, jumping/plyometric activities until cleared by MD

Phase 4: 12-26 Weeks

Goals:
  • Address lower extremity muscular strength, power/endurance, and rate of force development
  • Initiate impact activities (jump/landing prep) and running based on results of 3-month strength assessment
Therapeutic Exercise:
  • Continue with double and single leg progressive loading and eccentric quadriceps control
  • Continue open and closed chain quadriceps strengthening
  • Continue with core and hip strengthening
  • When cleared, initiate sagittal plane double leg plyometrics, progressing double leg and single leg landing drills
  • Initiate running progression as determined by surgeon
  • AGILITY - Ladder drills (single plane)
Progression Criteria:
  • 6-month strength evaluation will be performed to include isometric/isokinetic quadriceps & hamstring strength as well as single leg hopping tasks. Results will be sent back to treating physical therapist to guide progression.

Phase 5: Months 7-12

Goals:
  • Continue with lower extremity muscular strength, power and endurance training either in the clinic or with a home program/with personal trainer
  • Continue with lower extremity neuromuscular control training
  • Initiate sport specific agility/pivoting drills
  • Emphasize symmetric movement patterns/weight acceptance with good neuromuscular 
Progression Criteria:
  • 9-month strength evaluation will be performed to include isometric/isokinetic quadriceps & hamstring strength as well as single leg hopping tasks. Results will be sent back to treating physical therapist to guide progression