Table 1.

Posterior cruciate ligament rehabilitation protocol

Post-operative phase	Treatment recommendations	Criteria for advancement
Phase 1 Weeks 0–2	• Patient education for compliance with home exercise program (HEP) and weight bearing precautions • Gait: toe-touch weight bearing (TTWB) with brace locked at 0° with crutches • Patellar mobilizations • Hamstring and calf stretching • Passive extension (pillow under calf) • Quadriceps re-education (quadriceps sets with EMS or EMG) • Active-assisted knee extension/passive flexion exercise (ROM 0° → 70°) • SLR (all planes) with brace locked at 0°, with progressive resistance as tolerated • Proximal (hip) strengthening progressive resistance exercise (PRE) • Cryotherapy • Cardiovascular exercises (e.g., upper body ergometer (UBE)), as tolerated	• Knee ROM 0° → 70° • Ability to SLR without quadriceps lag • Demonstrate progressive improvement of patellar mobility and proximal strength
Phase 2 Weeks 3–6	• Patient education for compliance with home exercise program (HEP) and weight bearing precautions • Gait: progress from TTWB to 75% partial WB by 6 weeks with brace locked at 0° with crutches • Patellar mobilizations • Hamstring and calf stretching • Passive extension (pillow under calf) • Quadriceps re-education (i.e., quadriceps sets with EMS or EMG) • Active-assisted knee extension/passive flexion exercise (ROM 0° → 70°) ◦ Progress to 90° as tolerated, weeks 4–6 • Multiple angle quadriceps isometrics (ROM 60° → 20°) • SLR (all planes) with brace locked at 0°, with progressive resistance as tolerated • Proximal (hip) strengthening PRE • Leg press (ROM 60–0° arc) (bilaterally) • Proprioception training (bilateral weight bearing) • Cryotherapy • Short crank ergometry (when 85° flexion achieved) • Cardiovascular exercises (e.g., UBE), as tolerated	• Knee ROM 0° → 90° • Ability to bear 75% of weight on involved extremity • Ability to SLR without quadriceps lag • Continued improvement in patella mobility and proximal strength
Phase 3 Weeks 7–12	• Patient education regarding monitoring of response to increase in activity level • Gait training (discharge crutches when gait is non-antalgic) • Underwater treadmill system and/or pool for gait training • Retrograde treadmill ambulation • Brace changed to surgeon preference (e.g., off the shelf brace, patella sleeve, unloader brace) • Flexibility exercises • Foam rolling • Active assisted ROM exercises • Perturbation training • Active knee extension – OKC PRE 60° → 0° (monitor patellar symptoms) • Core and LE strengthening • Leg press (progress to eccentrics) and mini squats (ROM 60° → 0° arc) • Initiate forward step-up program • Initiate step-down program • Proprioception training ◦ Multiplanar support surfaces ◦ Progress to unilateral support and contralateral exercises with elastic band • Step machine • Consider BFR program with FDA approved device if patient cleared by surgeon and qualified therapist available • Cryotherapy • Progressive home exercise program • Standard ergometry (if knee ROM > 110°)	• Knee ROM 0° → 130° • Normal gait pattern • Demonstrate ability to ascend 8-inch step • Demonstrate ability to descend a 6-inch step • Single leg bridge holding for 30 s • Symmetrical squat to 60° • Balance testing and quadriceps isometrics (@ 60°) at 70% of contralateral lower extremity
Phase 4 Weeks 13–24	• Patient education regarding monitoring of response to increase in activity level • Cryotherapy and/or compression therapy • Flexibility exercises and foam rolling • Core and UE strengthening • Continue exercises from phase 2 • Continue foundational hip-gluteal progressive resistive exercises • Progress squats to 0–90° knee flexion, initiating movement with hips • Progress leg press 0–90° knee flexion (eccentrics, progressing to unilateral) • Progress to single leg squats • Forward step-up and step-down progression • Progress lateral step-ups, crossovers • Initiate lunges • Progress proprioception training • Progress cardiovascular conditioning • Stationary bicycle • Elliptical • Incorporate agility and controlled sports-specific movements • Initiate running progression at week 16 upon meeting criteria ◦ Full ROM/Ability to descend 8″ step without pain or deviations • Initiate plyometric progression • Knee ligament arthrometer exam at 6 months • Progressive home exercise program • Consider BFR program with FDA-approved device if patient cleared by surgeon and qualified therapist available	• No swelling • Full LE ROM • Descending 8-inch steps without pain or deviation • Improved flexibility to meet demands of running and sport specific activities • Quantitative strength and functional assessments >85% of contralateral LE • Note: uninvolved side may be deconditioned; use pre-injury baseline or normative data for comparison, if available
Phase 5 Weeks 25+	• Address quadriceps and hamstring strength deficits • Gradually increase volume and load to mimic load necessary for return to activity • Progress movement patterns specific to patient’s desired sport or activity • Progression of agility work • Progression of plyometric training • Increase cardiovascular load to match that of desired activity • Collaborate with ATC, performance coach/strength and conditioning coach, skills coach, exercise physiologist, and/or personal trainer to monitor load and volume as return to participation • Consult with referring surgeon on timing return to sport including any recommended limitations	• Quantitative strength and functional assessments ≥ 90% of contralateral lower extremity • Movement patterns, functional strength, flexibility, motion, endurance, power, deceleration, and accuracy to meet demands of sport