Anterior Cruciate Ligament Reconstruction Guidelines

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Department of Rehabilitation Services

Anterior Cruciate Ligament Reconstruction Guidelines

Successful completion of this 6 month program is dependent on compliance with the home exercise program listed below. Progression through the program requires the completion of physical performance tests, indicating readiness to advance to more challenging exercises and activities. Work related and sport specific activities are blended into the program to meet the individual needs of patients. For example, completing the walking sport cord tests allows the patient to begin a gradual return to fitness walking. The exit criteria, indicating completion of formal rehabilitation and the beginning of an independent home exercise program, consists of a series of physical tests based on a patient's most challenging physical requirements for work, school, or recreational pursuits.

Postoperative Rehabilitation:

Phase I: 0-1 weeks

Treatment Goals:

·  Pt. education

·  Pain control and exercise tolerance

·  Independent use of cryocuff, range of motion brace, and crutches

·  Independent performance of therapeutic exercises to

o  initiate muscle function in the thigh,

o  demonstrate partial weight bearing ambulation with crutches using existing range of motion,

o  reduce postoperative swelling,

o  achieve full passive knee extension in prone position

Patient education

·  Wear range of motion brace set at 0 – 90 degrees anytime patient leaves the home, is in between exercise sessions, and at night.

·  Patient uses crutches for walking around the house or outside. Emphasize short stride, heel to toe gait pattern, and gradually increasing weight bearing on the postoperative limb.

·  Begin weaning from crutches after 2 weeks Post Op.

·  Patients progress from bilateral crutches, to unilateral crutches, to no crutches. Crutches are discontinued if patients can walk without a limp.

·  Encourage frequent icing using the cryocuff, the knee elevated above the level of the heart, in the supine knee hang icing position. Instruct patient to check skin temperature in between frequent sessions of icing, and to manage posterior knee pain during supine knee icing technique.

·  Instruct patient in prone knee hang position to monitor progress towards full passive knee extension.

·  Explain methods to measure exercise tolerance to patients so they can incrementally increase exercise volumes as tolerance allows.

·  Encourage patients to use prescribed medications as directed. If they experience stomach upset they should discontinue and contact their physician.

Therapeutic exercises: performed in sequence 2 times daily. (brace off)

·  Non-surgical leg cycling, resting the surgical leg on a chair. Adjust bike’s seat so the uninvolved leg is slightly bent when the pedal is in the down position. Pedal forwards or backwards with the uninvolved leg. Cycle for 10 – 15 minutes.

·  Sitting carpet drags with contralateral assist in a pain free range flexion and extension, 3 sets of 20.

·  Sitting, alternating toe and heel raises, 3 sets of 30 reps.

·  Standing lateral weight shifting, standing inside crutches, progressing from 1 to 3 minutes.

·  Quadriceps sets in supine or semi-recumbent position. Some patients may require bilateral performance for adequate quadriceps requirement. Hold time is 7 seconds, and perform 3 sets of 20 repetitions.

·  Straight leg raises in supine with uninvolved knee bent, foot resting on surface. Lift postoperative leg parallel to opposite thigh, keeping knee locked into extension, and hold for 5 sec. Use 5 sec. to return the leg to the surface, and relax. Repeat sequence performing 3 sets of 20 repetitions.

·  Hamstring sets in supine or semi recumbent position, 7 sec. holds performed in 3 sets of 20.

·  Supine knee hang icing, 20 minutes. Instruct in measures to maintain elevation in knee hang position to allow tolerance for 20 minutes.

Physical performance test:

·  Cephalad movement of patella during all quadriceps exercises.

Phase 2 (1-3 Weeks Post Op)

Treatment Goals:

·  Patient education

·  Pain Control

·  Post-operative swelling reduction

·  Full passive knee extension in prone

·  Walking independently over level surfaces

·  Ascending and descending stairs independently

Patient education

·  Continue wearing range of motion brace between exercise sessions, ambulating outside, and at night.

·  Continue partial weight bearing crutch progression.

·  Continue frequent supine knee hang icing for swelling reduction and pain control. Encourage patients returning to work or school to “hang” and ice the knee frequently throughout the work and school day. Some schools request a note.

·  Increasing the number of repetitions, resistance, or number of different exercises depends on patient tolerance. Tolerance is measured twice, once during exercise and once the morning after.

Therapeutic exercises: performed in sequence 2 times daily

·  Stationary Cycling (brace off)

o  Little to no resistance on the bike

o  Seat positioned so knee is flexed slightly at the bottom of the down stroke

o  Partial revolutions within pain free range of motion with a goal of full revolution in retro-cycling prior to forward cycling

o  Non-surgical leg is driver and post-surgical leg determines range of motion

o  Prevent hip and ankle substitutions

o  10 – 15 minutes and gradually increase if time allows

o  Encourage use in between exercise sessions

·  Inverted/supine heel slides (brace off)

o  Used as a substitute for stationary bike

·  Long sitting belt stretch, 10 second holds, over 3 to 5 minutes. Thigh must stay down but heel can elevate slightly off the table.

·  Quadriceps sets with straight leg raises, 2 sets of 20

o  supine with uninvolved leg flexed at the knee, foot resting on the surface

o  quadriceps set with cephalad patellar movement

o  raise involved leg parallel to uninvolved thigh and hold for 5 sec.

o  slowly lower the involved leg to the table using 5 sec.

o  some patients require assist to achieve independence

·  Ambulatory progression

o  Optional, used as an adjunct exercise for those patients independent with quadriceps setting but having difficulty restoring normal gait pattern

o  Patients progress from less time to more time as tolerated

o  Lateral weight shifting, 1-3 min.

o  Lateral weight shifting plus uninvolved step (1 step), 3 min.

o  Lateral weight shifting plus uninvolved and involved step (2 step), 3-5 min.

o  High knees and backwards walking Black resistance cord exercises, 3-5 min.

o  Short stride slow rate walking progress to normal stride and rate walking

·  Entry level black cord strengthening exercises

o  Initiated after full knee extension in prone and independent level surface gait

o  Exercises performed in controlled manner to optimize muscle recruitment

o  Explain tolerance measures so patient can add/subtract 5 reps. per exercise day advancing from 3 x 15 to 3 x 50 over time.

o  Standing 1/3 knee bends

·  Requires set-up instruction

·  Standing on black band perform knee bends 1/3 as previously instructed

·  Identify and address alignment issues

·  Encourage “conscious” effort to fully extend the knee in upright position.

o  Seated leg press (gas pedal)

·  Requires set-up instruction

·  Patient seated, thighs not touching seat, back against back rest, pillow behind back if needed

·  Attach exercise band securely to foot and hold ends of band in both hands against the chest but under the chin

·  Flex hip and knee as far as comfortable. Straighten leg, simultaneous hip and knee extension, as if reaching for the gas pedal, obtaining full knee extension with each repetition.

·  Every fifth repetition patient performs 10 sec. isometric contract in the fully extended position

·  Identify and address alignment issues

·  Explain tolerance measures so patient can add/subtract 5 reps. per exercise day advancing from 3 x 15 to 3 x 50 over time

o  Seated hamstrings curls (carpet drags)

·  Requires set-up instruction

·  From a seated position, attach safety strap around ankle, placing foot in handle and plastic plug outside door close to the floor

·  Patient slides or “drags” foot backwards until ankle is directly under the knee

·  Identify and address alignment issues

·  Explain tolerance measures so patient can add/subtract 5 reps. per exercise day advancing from 3 x 10 to 3 x 20 over time

·  Supine knee hang icing

o  Patient in supine with ankle resting on elevation placing the knee above the level of the heart

o  Cryocuff placed on knee

o  Teach patient to shorten distance between ankle and knee to moderate stretch pain over the course of 20 minutes of icing

o  Patients can also perform mild quadriceps contractions while in this position

Physical Performance tests:

·  Full knee extension in prone.

·  Walking over level surface 200 feet x 2.

·  Ascend and descend 12 steps independently, i.e. without mechanical jerk

Phase 3 (3-6 Weeks Post-Op)

Treatment Goals:

·  Patient education

·  No negative reaction to steadily increasing exercise volume

·  Assist patients in managing exercise tolerance with activities of daily living

·  Add balance reaction exercises

·  Generate demonstrable muscle definition prior to brace measurement/fitting

·  Begin aerobic conditioning

Patient education

·  The most vulnerable time for bone-tendon-bone patellar tendon graft reconstruction is between 1 and 3 months post-operatively. It is during this time frame that the graft needs protection, and the time in which the graft attempts to re-establish its circulation so that it becomes viable, dynamic tissue again. Gradually increasing exercise volume is the stimulus promoting circulatory growth into the graft. This exercise progression must be tolerable at all times.

·  Continue wearing post-operative range of motion brace.

o  Therapeutic exercise progression is designed to create demonstrable muscle definition to transition into a functional brace at approximately 6 weeks post-operative. However, there must be muscle mass in the thigh that supports and holds the brace in place.

·  Continue to apply exercise tolerance measures.

·  Balance activities of daily living and job requirements with therapeutic exercise program to meet exercise tolerance measures.

·  Continue supine knee hang icing and “hanging” the knee at work and school if still progressing to full passive knee extension.

Therapeutic Exercise: performed in sequence 2 times per day

·  Continue strength interval cycling progression

·  Static balance exercises (brace on)

o  Manipulate balance variables promoting co-contractions in the involved lower extremity with the patient in unilateral stance

o  Options include;

§  Balance reach activities, G. Gray, Total Functional Profile, Wynn Marketing, 2001

§  Eyes open eyes closed unilateral balance

§  Top down driving with Bilateral UE multi-plane movements

§  Multi-plane head movements, eyes open

§  360 degree catch

§  Bosu Ball

·  Black cord exercises continued. Patients progressing towards maximum number of repetitions per exercise using tolerance measures to add/subtract repetitions per set.

o  Bilateral 1/3 knee bends

o  Seated leg press

o  Seated hamstring curls

·  Walking Black cord test elements, sagittal plane only

o  Forwards and backwards walking

o  Progress using interval training format; 1 min. work: 30 sec. rest, for each activity. Add one interval per exercise day until reaching 5 intervals. Once 5 intervals achieved gradually decrease and eventually eliminate rest periods to perform 5 minutes of continuous activity.

·  Continue supine knee hang icing

·  Optional Exercises

o  Pool program

o  Free weights and machines in supported positions(seated or supine)

·  Upper Extremity or trunk only

·  Light weight, 60-65% of 2 repetition maximum (2RM)

·  Moderate to high repetitions (6-12)

Physical Performance tests

·  Complete 3 sets of maximum reps for entry level black cord exercises.

·  Successfully fitted with functional brace

Phase 4 (6-12 1/2 weeks post-op)

Patient Education

·  Functional brace worn for all activities

·  Exercises should provoke fatigue in the musculature without pain or swelling in the knee. Fatigue stimulates compensation for increased strength and muscular endurance needed to complete walking black cord test.

Treatment Goals

·  Continue monitoring exercise tolerance measures as exercise volume and intensity increase

·  Progress from static to dynamic balance exercises

·  Add remaining walking black cord exercises (frontal plane) and unilateral 1/3 knee bend

·  Continue advancing aerobic conditioning

·  Progress from black cord exercises to selectorized resistance machines or free weights to advance strength program

·  Complete walking black cord test at 12 ½ weeks post-op and begin walking program

Therapeutic Exercise in sequence 1 time per day 5 days per week, 2 days of recovery

·  Continue strength interval cycling or progress to stair master at slower speeds

·  Dynamic balance

o  Options

§  Multiplane lunges w/o weights to weighted vest

§  Multiplane lunges with UE movements with and w/o weights

§  Multiplane step up, step down, reverse step up

·  Complete maximum repetitions of entry level black cord exercises and progress to squats, leg press, and standing hamstring curls with free weights and selectorized machines.

o  Patients without home gym, gym membership, or those in which advanced weight training not indicated continue with black exercise cord

o  Start with 60-65% of 2 RM for each of the above mentioned exercises.

o  Perform 3 sets of 10 repetitions of each exercise. After achieving this volume increase weight by 5 to 10# and work towards completing this volume before adding additional weight.

o  DO NOT approach 90 degrees of knee flexion with the squat or the leg press

o  Standing hamstring curls preferred to supine

·  Continue walking black cord test elements progressing to 5 minutes of continuous activity for element until taking the test at 12 ½ weeks post-op.

·  Optional Exercises

o  Lateral step and gather, lateral ambulation, forwards/backwards walking for frontal plane hip strengthening.

o  Slide board

o  Water workout with Aqua-jogger and/or swimming-freestyle only

o  Stair stepper

o  Nordic Track

o  Rowing

·  Continue free weight or selectorized machine resistance training for U.E.’s

Physical Performance Test

·  Successfully complete walking black cord test at 12 ½ weeks post-op

Phase 5 (12 ½ to 16 ½ post-op weeks)

Patient education

·  Wear brace for all activities

·  Maximizing strength is emphasis