Physical Therapy

Protocols

Prepared by:

The Committee of Physical therapy Protocol

Office of Physical Therapy
Ministry of Health, Kuwait
 Physical Therapy
Protocol For Anterior
Cruciate Ligament
(ACL)

The protocol provided by the office of

Physical Therapy affairs, Kuwait -
Ministry of Health, Protocol Team.
This Protocol is a guideline only and
may vary slightly from patient to patient

Functional Anatomy

The anterior cruciate ligament (ACL) is a broad ligament joining

the anterior tibial plateau to the posterior femoral intercondylar
notch. The tibial attachment is to a facet, in front of, and lateral to the
tibial spine. The femoral attachment is high on the posterior aspect of
the lateral wall of the intercondylar notch. The biomechanical
function of the ACL is complex for it provides both mechanical
stability and proprioceptive feedback to the knee.

Causes of ACL Rupture

The most common cause of ACL rupture is a traumatic force

being applied to the knee in a twisting movement. This can occur
with either a direct or an indirect force. In some cases of ACL
rupture occur without contact, i.e. while side stepping, pivoting or
landing from a jump. The other associated with some type of contact,
whether it is on the football field, on inexperienced skier.

Physical Therapy Goal

The goal of physical therapy program is to return the patient to

pre-injury level of activity. This involves restoration of normal range
of motion, strength, and stability of the knee to allow return of
functional activities. In Athletes, physical therapy program must also
strive to restore agility, skills and speed, as well as functionally
stable knee that can with stand all rigors of sport-related activities.

Preoperative Program:
The Preoperative program of acute ACL injury should focus
on the following:

1. Decreasing joint effusion: with limb elevation, cryotherapy,

and compression.
2. Decreasing pain: some modalities that can reduce pain
(Interferential, TENS).
3. Restoring full ROM
4. Strengthening the quadriceps and hamstring muscle
 Principles of ACL Program:

1. No straight leg raising (especially in patellar tendon cases) if

the knee is not fully extended.
2. Early full passive knee extension.
3. Early weight bearing as tolerated.
4. Early resisted hamstring exercise.
5. Close Kinetic Chain (CKC) exercise, more than Open
Kinetic Chain (OKC).
6. In (OKC) extension exercises using quadriceps bench, avoid
terminal last degree of quadriceps resisted exercise.
7. Hamstring has more emphasis than quadriceps.
8. Progression in phases is not related to time, but related to
joint ROM, Muscle power, soft tissue healing and swelling.

Post Operative Program:

●This protocol is usrd for orthroscopy procedure.
• Phase 1 (1 - 7 days)
• Phase 2 (day 7 - 8 weeks)
• Phase 3 (8 - 16 weeks)
• Phase 4 (16 - 24 weeks)
 Phase 1
Goals
Early controlled force on
healing collagen tissues.
Decrease pain and disuse
Minimize the swelling or
effusion
Maintains available ROM
90° flexion & full extension.
Maintains muscle power.
• Static quadriceps with small
• Straight leg raises
Maintains nutrition
articulator cartilage
Limited Ambulating
(1-7 days)
Method
Knee brace 0-90, out of brace 4 to 5
time daily to perform free range of
movement,
for greater degree of protection
during the rehabilitation program
Therapeutic modalities, Interferential
or TENS to control pain.
Ice compression 20 minutes as
necessary and elevates with knee
extension.
R.O.M exercise (full ROM expected
after 6 weeks).
• Prone passive knee bending or
prone weight hang 2-3 kg, 3-4 times
/ daily for 20 minutes.
rolled towel under heel.
using C.P.M. (if there’s cartilage
injury)
Weight bearing advises (two crutches
as tolerated and Gradually increase
walking distance as comfortable).
 Phase 2 (7 days – 8 weeks)
Goals
Absolute control of external
forces and protect graft.
Nourish articulator cartilage
Decrease patella-femoral
adhesions and fibrosis.
Minimize the pain level
Minimize the swelling or
effusion
Increase ROM more than
90° flexion and full
extension.
Prepare for walking without
crutches.
Restore the balance
proprioception
Increase muscle power as
tolerated
Methods.
Brace – discontinue locked brace. Brace
opened 0°-125°
Passive R.O.M exercises
Patellar mobilization.
Therapeutic modalities, IF / TENS to
control pain.
Swelling control, continue ice,
compression, and elevation
• Hydrotherapy: under water massage
and mobilizing exercise
• pool walking program
Wean of crutches as tolerated
Balance restoring: balance board
exercises
Active resistive exercises:
• Active static quadriceps Sets SLR,
hip add & abd, and hip extension in
prone position on bed
• Active knee flexion (Prone
position)
• Active calf exercises (toe push off)
• Hamstring Curl Open Kinetic Chain
exercises (OKC). Double leg & Single
leg
• CKC leg presses single & double
• active weight training in 4 direction
of hip add, abd, flex, and ext. pulling
system from standing
• mini squatting or knee flexion with
back facing the wall
 Phase 3 (8-16 weeks)

Goals
Maximal strengthening of lowers
limbs.
Increased proprioceptive awareness
F.W.B ( No limping gait) Treadmill training, forward and
Increase ROM 0° - 115° or full
flexion
Methods
Isotropic exercise, continues
strengthening exercise.
(Hydrotherapy).
• Close Kinetic Chain
exercise. Continue agility
drills. Single step – up,
Double Step-up.
• Balancing exercises,
wobble board
backward walking.
Continue hydrotherapy.
 Phase 4 (16-24 weeks)
Goals
Achieve maximum strength and
improve endurance.
Regain functions and prevent re-
injury.
Gradual return to the field
Improve general fitness, and
return to full sport participation.
Methods.
Continue isotonic exercises.
( isokinetic exercise )
stepping program (Stair master)
• Treadmill forward & backward
walking, running with deferent
speeds (more than 8 Km/hr. For
10 minutes)
• Continue corridor walking
moderate speed foreword,
backward running, and fast
break.
• Continue treatment balance
exercise.
• Sport pool therapy ( jogging,
running inside water)
• Start field training and
continue at least 2 weeks with:
- Zigzag running, high speed
walking, General fitness
exercises (Cardio- respiratory
training), lateral shuffles,
figure 8 running, side walking
and running- start ball
exercise.
Physical Therapy Protocol Committee:-

• Ali Al-Mohanna (Al-Farwaniya Hospital)

• Abdulla Al-Hadad (PMR Hospital)
• Khadijah Al-Ramezi (Ibn Sina Hospital)
• Saud Mohammad (Al-Amiri Hospital)
• Khadijah Al-Estad (PMR Hospital)
• Seham Al-Jadaan (Al-Razi Hospital)