PHASE AND TIME FRAME | MAXIMUM PROTECTION PHASE: DAY 1 TO WEEK 4 | MODERATE PROTECTION PHASE: WEEK 4 TO 10 | MINIMUM PROTECTION PHASE: WEEK 11-24 | RETURN-TO-ACTIVITY PHASE: 6 MOS. AND BEYOND |
PATIENT PRESENTATION | q Post-operative hemarthrosis q Post-operative pain q Decreased ROM q Diminished voluntary quadriceps activation q Ambulation with crutches q Protective bracing (may or may not be worn) | q Pain controlled q Joint effusion controlled q Full or near full ROM q Fair plus to good muscle strength (3+/5 – 4/5) q Muscular control of joint q Independent ambulation | q No instability q No swelling q No pain q Good to normal muscle strength (4/5 – 5/5 on MMT) q Unrestricted ADL function q Possible use of functional brace | q No instability q Muscle function 70% of noninvolved extremity q No symptoms of instability, pain or swelling during the previous phase q Possible use of functional brace or sleeve during high-demand work or sports |
KEY EXAMINATION PROCEDURES | q Pain scale q Joint effusion – girth q Ligaments stability – joint arthrometer (days 7-14) q ROM q Patellar mobility q Muscle control q Functional status | q Pain scale q Joint effusion – girth q Ligament stability – joint arthrometer q ROM q Patellar mobility q Muscle strength q Functional status | q Ligament stability – joint arthometer q Muscle strength q Functional status | q Full clinical examination q Ligament stability q Muscle strength q Functional testing |
GOALS | q Protect healing tissues q Prevent reflex inhibition q Decrease joint effusion q ROM 0° - 110° q Active control of ROM q Weight bearing 75% to WBAT q Establish home exercise program | q Full pain-free ROM q 4/5 Muscular strength (MMT) q Dynamic control of knee q Improved kinesthetic awareness q Normalize gait pattern and ADL function q Adherence to home program | q Increase strength q Increase power q Increase muscular endurance q Improve neuromuscular control, dynamic stability and balance q Improve cardiopulmonary fitness | q Increase strength q Increase power q Increase endurance q Regain ability to function at highest desired level q Transition to maintenance program q Reduce risk of re-injury |
PHASE AND TIME FRAME | MAXIMUM PROTECTION PHASE: DAY 1 TO WEEK 4 | MODERATE PROTECTION PHASE: WEEK 4 TO 10 | MINIMUM PROTECTION PHASE: WEEK 11-24 | RETURN-TO-ACTIVITY PHASE: 6 MOS. AND BEYOND |
INTERVENTION | PHASE I: (PRE-OPERATIVE PHASE) q Prepare for ACL surgery q Educate on type of operation q Concentrate on maintaining quadriceps strength q Obtain full range of motion of the involved knee PHASE II A (1 - 7 days)q Minimize pain and swelling with PRICE (protective bracing, rest, icing, compression, elevation q CPM set at 0 to 30 degrees q Hyperextension maintained with 10 minutes of heel props q Quadriceps, hamstrings and adductors at multiple angles (may augment with electrical stimulation) q Assisted SLR in supine or unassisted with brace locked in extension q Ankle ABC’s or ankle pumping exercise q Heel slides q Gait training with B/L axillary crutches, weight bearing to be determined by surgeon PHASE 11 B (7 - 14 days)q CPM continues until 90 degrees q Gait training with crutches, progress to PWB, encourage WBAT q Single leg stance on the involved leg q Hamstrings curls q Quarter squats q Calf raises q Patellar mobilization if would is fully healed q Use of modalities as necessary, e.g., ice, ultrasound, TENS/IFT or ES (be aware of screws and staples) q Icing at end of treatments PHASE III (2 - 4 weeks)q Continue as above q Progress to FWB without assistive device q Begin closed-chain exercises q Heel/toe raises q SLR, unassisted in four planes, multi-angle (30, 60, 90 degrees) q Initiate open-chain knee extension (range 90-40 degrees) start at 1 lb, and add 1 lb every week q Aerobic conditioning (stationary bicycle) q Step ups q Start stairmaster at end of 4th week, begin at 2-3 minutes without resistance | EARLY PHASE (5 – 6 weeks) q Multiple angle isometrics q Advance closed-chain strengthening and PRE (deep squats, lunges q Lower extremity stretching program q Endurance training (e.g., bicycle, swimming) q Proprioceptive training: single leg stance, tilt board, BAPS board q Stabilization exercises, elastic bands, band walking LATE PHASE: (7 – 10 weeks) q Isokinetic evaluation q Continue as above; advance strengthening (include PNF patterns), endurance and flexibility q Advance proprioceptive training to high speed stepping drills, unstable surface challenge drills, and balance beam q Initiate a walk/jog program in treadmill machine at the end of this phase q Initiate plyometric drills: bouncing, jumping | q Continue lower extremity stretching program q Advance PRE/initiate isokinetic training q Advanced closed-chain exercises, plyometric drills (bouncing, jumping rope, box jumps: double/single leg) q Advanced proprioceptive training q Progressive agility drills (figure 8, skill specific patterns) q Simulated work or sport-specific endurance training q Progress running program: full speed jogging, sprints, running and cutting | q Continue to progress PRE and flexibility exercises q Advance agility drills q Advance running drills q Implement drills specific to sport or occupation q Determine the need for protective bracing prior to return to sport or work |
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