Orthopaedic Surgeon
ACL Tear Nonoperative Rehabilitation
PHASE I - IMMEDIATE INJURY PHASE (Day 1 to Day 7)
Goals:
Restore full passive knee extension
Diminish joint swelling and pain
Restore patellar mobility
Gradually improve knee flexion
Re-establish quadriceps control
Restore independent ambulation
Post-Injury Day 1- 3
Brace: Brace/Immobilizer applied to knee, locked in full extension during ambulation as directed by physician
Weight Bearing: Two crutches, weight bearing as tolerated
Exercises:
*Ankle pumps
*Overpressure into full, passive knee extension
*Active and Passive knee flexion (90 degree by day 5)
*Straight leg raises (Flexion, Abduction, Adduction)
*Quadriceps isometric setting
*Hamstring stretches/ calf stretches
*Closed kinetic chain exercises: mini squats, weight shifts
Muscle Stimulation: Use muscle stimulation during active muscle exercises (4-6 hours per day)
Ice and Elevation: Ice 20 minutes out of every hour and elevate with knee in full extension, may
use e-stim for edema control
Post-Injury Day 3 to 7
Brace: Locked at zero degrees extension for ambulation and unlocked for sitting
Weight Bearing: Two crutches weight bearing as tolerated
Range of Motion: Remove brace to perform range of motion exercises 4-6 times per day, knee flexion 90 degrees by day 5, approximately 100 degrees by day 7
Exercises:
*Multi-angle isometrics at 90 and 60 degrees (knee extension)
*Knee Extension 90-40 degrees
*Overpressure into extension
*Patellar mobilization
*Ankle pumps
*Straight leg raises (3 directions)
*Mini squats and weight shifts
*Standing Hamstring curls
*Quadriceps isometric setting
*Proprioception and balance activities
*Continue Hamstring and calf stretching
Muscle Stimulation: Electrical muscle stimulation (continue 6 hours daily)
Ice and Elevation: Ice 20 minutes of every hour and elevate leg with knee full extension
PHASE II - INTERMEDIATE REHABILIATION PHASE (Week 2-4)
Criteria to Progress to Phase II
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Quad Control (ability to perform good quad set and SLR)
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Full passive knee extension
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PROM 0-90 degrees
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Good patellar mobility
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Minimal joint effusion
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Independent ambulation
Goals: Maintain full passive knee extension (at least 0 to 5-7 hyperextension)
Gradually increase knee flexion
Diminish swelling and pain
Muscle training
Restore proprioception
Patellar mobility
Week Two
Brace: Discontinue brace or immobilizer at 2 to 3 weeks per physician
Weight Bearing: As tolerated (goal is to discontinue crutches 10-14 days post injury)
Range of Motion: Self-ROM stretching (4-5 times daily), emphasis on maintaining full, passive range of motion progress flexion as tolerated
Exercises: *Muscle stimulation to quadriceps exercises
*Isometric quadriceps sets
*Straight Leg raises (4 planes)
*Leg Press (0-60 degrees)
*Knee extension 90-40 degrees
*Half squats (0-40)
*Weight shifts
*Gait training with cones
*Front and side lunges
*Hamstring Curls
*Bicycle
*Proprioception training
*Tilt board squats
*Dip walking
*Overpressure into extension
*Passive range of motion from 0 to 50 degrees
*Patellar mobilization
*Well leg exercises
*Progressive resistance extension program – start with 1 lb., progress 1 lb. per week
*Continue stretching program
Swelling control: Ice, compression, elevation, e-stim
Week Three
Brace: Discontinue
Range of Motion: PROM should be full or near full ROM
Passive Range of Motion: Continue range of motion stretching and overpressure into extension
Exercises: *Continue all exercises as in week two
*Passive Range of Motion as tolerated
*Bicycle for range of motion stimulus and endurance
*Pool walking program (if incision is closed)
*Eccentric quadriceps program 40-100 (isotonic only)
*Lateral lunges
*Lateral step ups
*Lateral cone step overs
*Stair-Stepper machine
*Progress Proprioception drills, neuromuscular control drills
PHASE III - ADVANCED STRENGTHENING/NEUROMUSCULAR CONTROL PHASE (Week 4-8)
Criteria to Enter Phase III
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Full ROM
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Quadriceps strength 60%>contralateral side (isometric test at 60 degree knee flexion)
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Minimal to no full joint effusion
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No joint line or patellofemoral pain
Goals: Maintain full knee range of motion (0 to 125 degrees)
Improve lower extremity strength
Enhance proprioception, balance, and neuromuscular control
Improve muscular endurance
Restore limb confidence and function
Brace: No immobilizer or brace, may use knee sleeve or fit for function all brace
Range of Motion: Self-ROM (4-5 times daily using the other leg to provide ROM), emphasis on
maintaining full ROM
Week 4
Exercises *Progress isometric strengthening program
*Leg Press
*Knee extension 90 to 40 degrees
*Hamstring curls
*Hip Abduction and Adduction
*Hip Flexion and Extension
*Lateral Step-Overs
*Lateral Lunges
*Lateral step ups
*Front step downs
*Wall Squats
*Vertical squats
*Toe Calf Raises
*Biodex Stability System (balance, squats, etc.)
*Proprioception drills
*Bicycle
*Stair climber machine
*Pool program (backward running, hip and leg exercises)
Week 6
Exercises: *Continue all exercises
*Pool running (forward) and agility drills, jumping
*Progress to balance and tilt board throws, perturbation training
*Advanced Neuromuscular control drills:
-CKC on unstable surfaces
-Lunges onto foam
-Step ups on foam
-Perturbation training
*Wall slides/squats
*Muscular training for fast reaction times
-High speed hamstring curls
*Progress dynamic stabilization drills
-Tilt board perturbations
PHASE IV - ADVANCED ACTIVITY PHASE (Week 8-12)
Criteria to Enter Phase IV
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Full ROM
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Quad strength 75% of contralateral side, knee extension flexor:extensor ratio 70% to 75%
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No pain or effusion
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Satisfactory clinical exam
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Satisfactory isokinetic test (values at 180 degrees)
Quadriceps bilateral comparison 75%
Hamstrings equal bilateral
Quadriceps peak torque/body weight 65% at 180o/s (males) 55% at 180o/s (females)
Hamstrings/quadriceps ratio 66% to 75%
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Subjective knee scoring >80%
Goals: Normalize lower extremity strength
Enhance muscular power and endurance
Improve neuromuscular control
Perform selected sport-specific drills
Exercises: *Continue all exercises
*Advanced Neuromuscular control drills:
*Plyometric program
-Leg press plyometrics
-Box jumps
PHASE V - RETURN TO ACTIVITY PHASE (Month 12-22)
Criteria to Enter Phase V
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Full Range of Motion
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Isokinetic Test that fulfills criteria if available
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Quadriceps bilateral comparison (80% or greater)
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Hamstring bilateral comparison (110% or greater)
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Quadriceps torque/body weight ratio (55% or greater)
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Hamstrings/Quadriceps ratio (70% or greater)
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Proprioceptive Test (100% of contralateral leg)
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Functional Test (85% or greater of contralateral side)
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Satisfactory clinical exam
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Subjective knee scoring >90%
Goals: Gradual return to full-unrestricted sports 8 activities
Achieve maximal strength and endurance
Normalize neuromuscular control
Progress skill training
Exercises: *Continue strengthening exercises
*Continue neuromuscular control drills
*Continue plyometrics drills
*Progress running and agility program
*Progress sport specific training