Postoperative Rehabilitation Protocol ACL Reconstruction Quad Tendon Autograft

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

*This protocol applies to ACL reconstruction using Quadriceps Tendon Autograft. If meniscal repair is performed the patient should adhere to NO weightbearing flexion of the knee greater than 90 degrees until a minimum of 6 weeks post-op. 

*Return to play is sport-specific.  Contact sports require a minimum 6-9 month rehabilitation period.  Any athlete wishing to resume play must undergo evaluation in the office prior to obtaining clearance.  Customized ACL braces, while not routinely necessary, will be ordered/fitted once the patient has achieved full recovery. 

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

*A word about “pain” and management of anticipated discomfort following ACL Reconstruction…

Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  



Phase 1- Early Post-Operative Phase (Post-op Day 0-14)

The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity, and maximize the patient’s mobility with a goal of functional independence.  Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential. Use of a knee immobilizer/brace is not mandatory beyond Phase I unless concomitant ligamentous repair (MCL, LCL, ALL) is performed and/or directed specifically by our team. 

Goals: 

  1. Full weight bearing ability on the operative extremity
  2. Ambulate 150 ft. continuously with minimal or no assistive device 
  3. Achieve Passive Range of Motion (PROM) equal to or greater than 100 degrees of flexion and maintain passive extension to 5 degrees from zero or less.  Both PROM and AROM may be progressed as tolerated 
  4. Perform independent Straight Leg Raise (SLR) in immobilizer/brace 
  5. Implement use of nonpharmacologic modalities to control pain and swelling such as circulating cryotherapy pumps, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. Assess surgical wound for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess pre-treatment and post-treatment AROM/PROM, efficiency/safety/necessity of ambulatory assistive devices
  5. Assess for signs of large intra-articular effusion, DVT (Homan’s sign, calf circumference, Well’s Criteria), PE (pulmonary embolism), Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Isometric quadriceps, hamstring, and gluteal exercises
  2. Heel slides
  3. Straight leg raises (flexion,extension,ADDuction, ABDuction) 
  4. Gastroc/soleus stretching
  5. Assess balance, gait pattern, and weight transfer 
  6. Ensure neutral hip motion and address any core/postural deficiencies

Precautions:

  1. WBAT (Weight Bearing As Tolerated), initially with assistive devices and wean use as patient demonstrates sufficient locomotor proficiency
  2. Avoid weights or resistance bands
  3. Avoid rotational torque and/or twisting of the knee while weight bearing
  4. Avoid kneeling or direct pressure on the incision/anterior knee
  5. Avoid placing supports behind the surgical knee to facilitate obtaining full extension

*Patient may progress to Phase II when able to demonstrate sufficient quadriceps activation, independent SLR, Active ROM 10-100 degrees flexion or greater, adequate pain control, ability to transfer independently, and ambulate greater than 150 ft with minimal or no assistive devices.  

Phase II (Post-op Week 2-6)

Goals:

  1. Improve PROM with a goal of 0-125 degrees flexion by end of phase II

*No WB flexion > 90 degrees if medial AND/OR lateral meniscus repair performed

  1. Minimize compensatory gait  
  2. Continue proprioceptive training and gait training (Encourage early discontinuation of assistive devices and immobilizer/brace)
  3. Decrease swelling/inflammation

Assessment by Therapist:

  1. Monitor wound for signs of infection, dehiscence, or complications of skin closure devices (Dermabond, Zip-line, sutures, staples)
  2. Monitor for signs/symptoms of DVT/PE and intra-articular effusion(hemarthrosis)
  3. Assess use of narcotic and non-narcotic analgesics
  4. Assess pre-treatment and post-treatment PROM/AROM 


Therapeutic Exercises:

Week 1-4

  1. Encourage AROM flexion/extension exercises
  2. Patella mobilizations 
  3. Continue isometric hamstring, gastroc/soleus, and core/gluteal exercises. Avoid quad isometrics if painful 
  4. Supine Heel Slides and seated Long Arc Quad (LAQ)
  5. SLR in all planes (flexion, extension, ADDuction, ABDuction)
  6. Begin stationary bike with no/minimal resistance if flexion >90 degrees
  7.  NMES of quads based on necessity (lack of appropriate activation).  May progress NMES from isometric to isotonic and functional activity

Week 4-6

  1. Continue Phase I exercises
  2. Front and Lateral step up/down
  3. Begin toe raises, balance exercises, resisted hamstring curls
  4. Begin shallow lunge (25% depth)
  5. May incorporate resisted seated rowing exercises as tolerated
  6. Consider aqua therapy if wound healed and available access to safe entry/exit pool 

Precautions:

  1. Wean assistive devices only when the patient is supervised by a therapist and the patient is able to demonstrate minimal compensatory gait. There is no mandatory time frame for use of assistive devices and duration of time before weaning is based on multiple factors including patient apprehension, fall risk, gait pattern kinematics, pre-operative need for such devices, and muscle activation/performance
  2. Monitor for increase in edema/swelling with increased activity levels, consider graduated compression stockings or knee compression sleeve if accepted/indicated

*Patient may progress to Phase III after achieving PROM 0-125 degrees or greater, adequate quadriceps activation, and able to ambulate > 500 ft uninterrupted without assistive device or significant gait disturbance

 

Phase III (Post-op Week 6-12)

Goals:

  1. Maintain Full PROM and progress AROM flexion
  2. Demonstrate Normal Gait pattern
  3. No extensor lag with SLR 
  4. Establish Home/Gym Exercise Plan in conjunction with therapist recommendations
  5. Return to work for professions not requiring manual labor, heavy lifting, climbing stairs, shifts requiring standing > 4 hours without breaks or steps > 5-10K per day

Therapeutic Exercises:

  1. Continue Phase II exercises and progress resistance, strengthening, and repetitions as tolerated
  2. Lunge depth 50-75% if sufficient quad strength
  3. Progress balance and proprioceptive exercises as appropriate
  4. +/- NMES 

Precautions:

  1. No running, jumping, sprinting, cutting, pivoting, plyometrics

*Patient may progress to Phase IV when able to complete Phase III without pain and quad strength 4+/5

Phase IV (Post-op Week 12-16)

Goals:

  1. Full PROM and AROM without pain 
  2. Continue Phase II and III exercises
  3. Return to work without restrictions all professions
  4. Achieve strength measurements within 75% of contralateral extremity

Therapeutic Exercises:

  1. Advance closed chain strengthening exercises
  2. Introduce open chain exercises
  3. Begin stairmaster, elliptical, straight line jogging
  4. Full depth lunges 

Phase V (Post-op Week 16+)

Goals:

  1. Begin sport specific drills
  2. Achieve strength measurements comparable to contralateral extremity

Therapeutic Exercises:

  1. Jumping, running, sprinting, pivoting, directional changes, plyometrics

Precautions: 

  1. No return to sport until cleared by physician, typically 9-12 months post-op depending on sport 
  2. No fitting of custom ACL brace until seen by physician