Table 1.

Anterior cruciate ligament (BTB) rehabilitation guideline

Post-operative phase I (weeks 0–2)

Goals:

▪ Emphasis on full passive extension

▪ Control post-operative pain/swelling

▪ Range of motion 0° → 90°

▪ Early progressive weight bearing

▪ Prevent quadriceps inhibition

▪ Independence in home therapeutic exercise program

Precautions:

▪ Avoid active knee extension 40° → 0°

▪ Avoid ambulation without brace locked at 0°

▪ Avoid heat application

▪ Avoid prolonged standing/walking

Treatment strategies:

▪ Towel extensions, prone hangs, etc.

▪ Quadriceps re-education (quad sets with EMS or EMG)

▪ Progressive weight bearing

▪ PWB → WBAT (patella tendon) with brace locked at 0° with crutches

▪ Patella mobilization

▪ Active flexion/active-assisted extension 90° → 0° exercise

▪ SLR’s (all planes)

▪ Brace locked at 0° for SLR (supine)

▪ Short crank ergometry

▪ Hip progressive resisted exercises

▪ Proprioception board/balance system (bilateral weight bearing)

▪ Leg press (bilateral/80° → 5° arc) (if ROM >90°)

▪ Upper extremity cardiovascular exercises as tolerated

▪ Cryotherapy

▪ Home therapeutic exercise program: evaluation based

▪ Emphasize patient compliance to home therapeutic exercise program and weight bearing precautions/progression

Criteria for advancement:

▪ Ability to SLR without quadricep lag

▪ ROM 0° → 90°

▪ Demonstrate ability to unilateral (involved extremity) weight bear without pain

Post-operative phase 2 (weeks 2–6)

Goals:

▪ ROM 0° → 130°

▪ Good patella mobility

▪ Minimal swelling

▪ Restore normal gait (non-antalgic)

▪ Ascend 8″ stairs with good control without pain

Precautions:

▪ Avoid descending stairs reciprocally until adequate quadriceps control and lower extremity alignment

▪ Avoid pain with therapeutic exercise and functional activities

Treatment strategies:

▪ Progressive weight bearing/WBAT (patella tendon) with crutches brace opened 0° → 50°, if good quadriceps control (good quad set/ability to SLR without lag or pain)

▪ D/C crutches when gait is non-antalgic

▪ Brace changed to MD preference (OTS brace, patella sleeve, etc.)

▪ Standard ergometry (if knee ROM >115°)

▪ Leg press (90° → 0° arc)

▪ AAROM exercises

▪ Mini squats/weight shifts

▪ Proprioception training: prop board/balance system/contralateral Theraband exercises

▪ Initiate forward step-up program

▪ Stairmaster

▪ Aquaciser (gait training) if incision benign

▪ SLR’s (progressive resistance)

▪ Hamstring/calf flexibility exercises

▪ Hip/hamstring PRE

▪ Core stabilization exercises

▪ Retrograde incline treadmill ambulation

▪ Active knee extension to 40°

▪ Home therapeutic exercise program: Individualized

Criteria for advancement:

▪ ROM 0° → 125°

▪ Normal gait pattern

▪ Demonstrate ability to ascend 8″ step

▪ Good patella mobility

Post-operative phase 3 (weeks 6–14)

Goals:

▪ Restore Full ROM

▪ Demonstrate ability to descend 8″ stairs with good leg control without pain

▪ Improve ADL endurance

▪ Improve lower extremity flexibility

▪ Protect patellofemoral joint

Precautions:

▪ Avoid pain with therapeutic exercise and functional activities

▪ Avoid running and sport activity till adequate strength development and MD clearance

Treatment strategies:

▪ Progress squat program

▪ Initiate step down program

▪ Leg press

▪ Lunges

▪ Isometric → isotonic knee extensions 90° → 40°

▪ Advanced proprioception training (perturbations)

▪ Agility exercises (sport cord)

▪ Retrograde treadmill ambulation/running

▪ Quadriceps stretching

▪ KT 1000 knee ligament arthrometer exam at 3 months

▪ Home therapeutic exercise program: evaluation based

Criteria for advancement:

▪ ROM to WNL

▪ Ability to descend 8″ stairs with good leg control/alignment without pain

▪ Functional progression pending KT1000 and functional assessment

Post-operative phase 4 (weeks 14–22)

Goals:

▪ Demonstrate ability to run pain free

▪ Maximize strength and flexibility as to meet demands of activities of daily living

▪ Isokinetic test ≥85% limb symmetry

Precautions:

▪ Avoid pain with therapeutic exercise and functional activities

▪ Avoid sport activity till adequate strength development and MD clearance

Treatment strategies:

▪ Start forward running (treadmill) program when 8″ step down satisfactory

▪ Continue LE strengthening and flexibility programs

▪ Advance agility program/sport specific

▪ Start plyometric program when strength base sufficient

▪ Isotonic knee extension (full arc/pain and crepitus free)

▪ Isokinetic training (fast → moderate velocities)

▪ Home therapeutic exercise program: Individualized

Criteria for advancement:

▪ Symptom-free running

▪ Isokinetic test ≥85% limb symmetry

▪ Lack of apprehension with plyometric and agility activities to date

Post-operative phase 5—return to sport (weeks 22–?)

Goals:

▪ Lack of apprehension with sport specific movements

▪ Maximize strength and flexibility as to meet demands of individual’s sport activity

▪ Isokinetic test ≥90% limb symmetry

▪ Hop test ≥90% limb symmetry

▪ Acceptable quality movement assessment

Precautions:

▪ Avoid pain with therapeutic exercise and functional activities

▪ Avoid sport activity till adequate strength development and MD clearance

Treatment strategies:

▪ Continue to advance LE strengthening, flexibility, and agility programs

▪ Advance plyometric program

▪ Brace for sport activity (MD preference)

▪ Monitor patient’s activity level throughout course of rehabilitation

▪ Reassess patient’s complaint’s (i.e., pain/swelling daily—adjust program accordingly)

▪ Encourage compliance to home therapeutic exercise program

▪ KT 1000 knee ligament arthrometer exam, isokinetic test, hop test(s), quality movement assessment at 6 months

▪ Home therapeutic exercise program: Individualized

Criteria for discharge:

▪ Isokinetic and functional hop test(s) ≥ 90% limb symmetry

▪ Acceptable quality movement assessment

▪ Lack of apprehension with sport specific movements

▪ Flexibility to accepted levels of sport performance

▪ Independence with gym program for maintenance and progression of therapeutic exercise program at discharge

Adapted from “Anterior Cruciate Ligament Reconstruction” Cavanaugh JT, Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician Cioppa-Mosca J, Cahill JB, Cavanaugh JT, Corradi-Scalise D, Rudnick H, Wollf AL, (eds) Elsevier Publishers pp.425–438, 2006