Brigham &amp Women's Hospital - Knee Rehabilitation PT Protocols

Department of Rehabilitation Services
ACL Patella Tendon Autograft Reconstruction Protocol

The intent of this protocol is to provide the clinician with a guideline for the post-operative
rehabilitation course of a patient that has undergone an ACL patellar tendon autograft
reconstruction. It is by no means intended to be a substitute for one’s clinical decision making
regarding the progression of a patient’s post-operative course based on their physical
exam/findings, individual progress, and/or the presence of post-operative complications. If a
clinician requires assistance in the progression of a post-operative patient they should consult
with the referring Surgeon.
GENERAL GUIDELINES
• Focus on protection of graft during primary revascularization (8 weeks) and graft
fixation (4-6 weeks.)
• CPM not commonly used
• For ACL reconstruction performed with meniscal repair or transplant, defer to ROM
and weightbearing precautions outlined in the meniscal repair/transplant protocol.
• The physician may alter time frames for use of brace and crutches.
• Supervised physical therapy takes place for 3-6 months.
GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

• No bathing/showering (sponge bath only) until after suture removal. Brace may be
removed for bathing/showering.
• Sleep with brace locked in extension for 1 week or as directed by PT/MD for
maintenance of full extension.
• Driving: 1 week for automatic cars, left leg surgery
2-4 weeks for standard cars, or right leg surgery
• Weight-bearing as tolerated immediately post-op
• Brace locked in extension for ambulation until patient demonstrates full extension
with good quad control. The brace can then be unlocked based on patient range of
motion.
• Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates normal
gait mechanics and good quad control as defined by absence of quadriceps lag.
• Return to work as directed by PT/MD based on work demands.

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REHABILITATION PROGRESSION
PHASE I: Immediately postoperatively to week 4
Goals:
• Protect graft and graft fixation
• Minimize effects of immobilization
• Control inflammation/swelling
• Full active and passive extension/hyperextension range of motion. Caution: avoid
hyperextension greater than 10 degrees.
• Educate patient on rehabilitation progression
• Restore normal gait on level surfaces
Brace:
• Sleep with brace locked in extension for 1 week or as directed for maintenance of full
extension.
• Brace locked in extension for ambulation until patient demonstrates full extension
with good quad control. The brace can then be unlocked based on patient range of
motion.
Weightbearing Status:
• Weight-bearing as tolerated immediately post-op with crutches and brace
gait mechanics and good quad control.
Exercises:
• Patellar mobilization/scar mobilization
• Heel slides
• Quad sets (consider NMES for poor quad sets)
• Hamstring curls – add weight as tolerated
• Gastroc/Soleus, Hamstring stretches
• Gastroc/Soleus strengthening
• SLR, all planes, with brace in full extension until quadriceps strength is sufficient to
prevent extension lag – add weight as tolerated to hip abduction, adduction and
extension.
• Closed Kinetic Chain Quadriceps strengthening activities as tolerated (wall sit, step
ups, mini squats, leg press 90-30 degrees)
• Quadriceps isometrics at 60° and 90°
•
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• If available, aquatics for normalizing gait, weightbearing strengthening, deep-water

aquajogging for ROM and swelling.
• Single leg balance, proprioception work
• Stationary cycling – initially for promotion of ROM – progress light resistance as
tolerated
PHASE II: Post-operative weeks 4 to 10
Criteria for advancement to Phase II:

• Full extension/hyperextension
• Good quad set, SLR without extension lag
• Minimum of 90° of flexion
• Minimal swelling/inflammation
• Normal gait on level surfaces
Goals:
• Restore normal gait with stairclimbing
• Maintain full extension, progress toward full flexion range of motion
• Increase hip, quadriceps, hamstring and calf strength
• Increase proprioception
Brace/Weightbearing Status:
• If necessary, continue to wean from crutches and brace.
Exercises:
• Continue with range of motion/flexibility exercises as appropriate for the patient
• Continue closed kinetic chain strengthening as above, progressing as tolerated – can
include one-leg squats, leg press, step ups at increased height, partial lunges, deeper
wall sits.
• Stairmaster (begin with short steps, avoid hyperextension)
• Nordic Trac, Elliptical machine for conditioning.
• Stationary biking- progress time and resistance as tolerated; progress to single leg
biking
• Continue to progress proprioceptive activities – ball toss, balance beam, mini-tramp
balance
• Continue hamstring, gastroc/soleus stretches
• Continue to progress hip, hamstring and calf strengthening
• If available, begin running in the pool (waist deep) or on an unweighted treadmill at 8
weeks.
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PHASE III: Post-operative weeks 10 to 16
Criteria to advance to Phase III include:

• No patellofemoral pain
• Minimum of 120 degrees of flexion
• Sufficient strength and proprioception to initiate running.
Goals:
• Full range of motion
• Improve strength, endurance and proprioception of the lower extremity to prepare for
sport activities
• Avoid overstressing the graft
• Protect the patellofemoral joint
• Normal running mechanics
• Strength approximately 70% of the uninvolved lower extremity per isokinetic
evaluation (if available)
Exercises:
• Continue flexibility and ROM exercises as appropriate for patient
• Knee extensions 90°-30°, progress to eccentrics
• If available, isokinetics (with anti-shear device) – begin with mid range speeds
(120o/sec- 240o/sec)
• Progress toward full weightbearing running at 12 weeks.
• Begin swimming if desired
• Recommend isokinetic test with anti-shear device at 12 weeks to guide continued
strengthening.
• Progressive hip, quadriceps, hamstring, calf strengthening
• Cardiovascular/endurance training via Stairmaster, elliptical, bike
• Advance proprioceptive activities

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PHASE IV: Post-operative months 4 through 6
Criteria for advancement to Phase IV:
• No significant swelling/inflammation.
• Full, pain-free ROM
• No evidence of patellofemoral joint irritation
• Strength approximately 70% of uninvolved lower extremity per isokinetic evaluation
• Sufficient strength and proprioception to initiate agility activities
• Normal running gait
Goals:
• Symmetric performance of basic and sport specific agility drills
• Single hop and 3 hop tests 85% of uninvolved lower extremity
• Quadriceps and hamstring strength at least 85% of uninvolved lower extremity per
isokinetic strength test
Exercises:
• Continue and progress flexibility and strengthening program based on individual
needs and deficits.
• Initiate plyometric program as appropriate for patient’s athletic goals
• Agility progression including, but not limited to:

Side steps
Crossovers
Figure 8 running
Shuttle running
One leg and two leg jumping
Cutting
Acceleration/deceleration/sprints
Agility ladder drills
• Continue progression of running distance based on patient needs.
• Initiate sport-specific drills as appropriate for patient

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PHASE V: Begins at approximately 6 months post-op
Criteria for advancement to Phase V:
• No patellofemoral or soft tissue complaint

• Necessary joint ROM, strength, endurance, and proprioception to safely return to
work or athletics
• Physician clearance to resume partial or full activity
Goals:
• Safe return to athletics/work
• Maintenance of strength, endurance, proprioception
• Patient education with regards to any possible limitations
Exercises:
• Gradual return to sports participation
• Maintenance program for strength, endurance
Bracing:
• Functional brace generally not used, but may be recommended by the physician on an
individual basis.
Formatted: Mike Cowell Reviewers: Reg Wilcox III

Marie-Josee Paris
4/2006

6
Physical Therapy
ACL Hamstring Tendon Autograft Reconstruction Protocol
rehabilitation course of a patient that has undergone an ACL hamstring tendon autograft
reconstruction. It is no means intended to be a substitute for one’s clinical decision making
regarding the progression of a patient’s post-operative course based on their physical
exam/findings, individual progress, and/or the presence of post-operative complications. If a
clinician requires assistance in the progression of a post-operative patient they should consult
with the referring Surgeon.
GENERAL GUIDELINES
• Focus on protection of graft during primary re-vascularization (8 weeks) and graft
fixation (8 –12 weeks)
• For ACL reconstruction performed with meniscal repair or transplant, defer to ROM
and weightbearing precautions outlined in the meniscal repair/transplant protocol.
• The physician may alter time frames for use of brace and crutches
• Supervised physical therapy takes place for 4-7 months
• Use caution with hamstring stretching/strengthening based on donor site morbidity

• No bathing/showering (sponge bath only) until after suture removal. Brace may be
removed for bathing/showering.
• Sleep with brace locked in extension for 1 week or as directed by PT/MD for
maintenance of full extension
• Post-op brace locked in full extension (0-1 week) for ambulation & sleeping
1-3 weeks- unlock brace (<90o) as quad control allows
3-4 weeks- wean from brace as patient demonstrates good quad control and normal
gait mechanics
• Use of crutches/brace for ambulation for 4 weeks with adequate quad function
• Weight bearing (0-1 week)- PWB with crutches and brace
• Return to work as directed by PT/MD based on work demands

Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All
rights reserved.
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PHASE I: Immediately post-operatively to week 4
Goals:
• Protect graft and graft fixation with use of brace and specific exercises
• Control inflammation and swelling
• Full active and passive extension/hyperextension range of motion. Caution: avoid
hyperextension greater than 10o
• Flexion to 90o only in order to protect graft fixation
• Restore normal gait on level surfaces
Brace:
• 0-1 week- post-op brace locked in full extension for ambulation and sleeping
• 1-3 weeks- unlock brace (<90o) as quad control allows
• 3-4 weeks- wean from brace as patient demonstrates good quad control and normal
gait mechanics
• 4-8 weeks- patient should only use brace in vulnerable situations (e.g. crowds, uneven
terrain, etc)
Weightbearing Status:
• 0-1 week- partial weightbearing with two crutches to assist with balance
• 1-4 weeks- partial weightbearing progressing to full weight bearing with normal gait
mechanics
gait mechanics and good quad control as defined as lack of quadricpes lag
Exercises:
• Active-assisted leg curls 0-1 week. Progress to active as tolerated after 1 week. Delay
strengthening for 12 weeks.
• Heel slides (limit to 90o)
• Quad sets (consider NMES for poor quad sets)
• Gastroc/Soleus stretching
• Very gentle hamstring stretching at 1 week
• SLR, all planes, with brace in full extension until quadriceps strength is sufficient to
prevent extension lag- add weight as tolerated to hip abduction, adduction and
extension.
• Quadriceps isometrics at 60o and 90o
• If available, aquatic therapy (once sutures removed) for normalizing gait,
weightbearing strengthening, deep-water aquajogging for ROM and swelling

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• Full extension/hyperextension
• Flexion to 90o
• Normal gait on level surfaces
Goals:
• Restore normal gait with stairclimbing
• Maintain full extension, progress toward full flexion range of motion
• Increase hip, quadriceps, and calf strength
• Increase proprioception
Brace/Weightbearing Status:
• If necessary, continue to wean from crutches and brace.
Exercises:
• Continue with range of motion/flexibility exercises as appropriate for the patient
• Initiate CKC quad strengthening and progress as tolerated (wall sits, step-ups, mini-
squats, Leg Press 90o-30o, lunges)
• Progressive hip, hamstring, calf strengthening (gradually add resistance to open chain
hamstring exercises at week 12)
• Continue hamstring, Gastroc/Soleus stretches
• Nordic Trac, Elliptical machine for conditioning
• Stationary Biking (progressive time and resistance)
• Single leg balance/proprioception work (ball toss, balance beam, mini-tramp balance
work)
• If available, begin running in the pool (waist deep) or on an unweighted treadmill at
10-12 weeks

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Phase III: Post-operative weeks 12 to 18-20 (4 ½-5 months)
Criteria to advance to Phase III include:

• No patellofemoral pain
• Minimum of 120 degrees of flexion
• Sufficient strength and proprioception to initiate running (unweighted or in pool)
Goals:
• Improve strength, endurance, and proprioception of the lower extremity to prepare for
sport activities
• Avoid overstressing the graft. Progressively increase resistance for hamstring
strengthening
• Normalize running mechanics
• Strength approximately 70% of the uninvolved lower extremity per isokinetic
evaluation
Exercises:
• Continue flexibility and ROM exercises as appropriate for patient
• Initiate open kinetic chain leg extension (90o-30o), progress to eccentrics as tolerated
• Isokinetics (with anti-shear device)- begin with mid range speeds (120o/sec-240o/sec)
• Progress toward full weightbearing running at about 16 weeks
• Begin swimming if desired
• Recommend isokinetic test with anti-shear device at 14-16 weeks to guide continued
strengthening
• Progressive hip, quad, hamstring, calf strengthening
• Cardiovascular/endurance training via stairmaster, elliptical, bike
• Advance proprioceptive activities

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Phase IV: Post-operative months 4 ½ or 5 through 6-7

• No significant swelling/inflammation
• Strength approximately 70% of uninvolved lower extremity per isokinetic evaluation
• Sufficient strength and proprioception to initiate agility activities
• Normal running gait
Goals:
• Symmetric performance of basic and sport specific agility drills
• Single hop and three hop tests 85% of uninvolved leg
• Quadriceps and hamstring strength at least 85% of uninvolved lower extremity per
isokinetic strength test
Exercises:
• Continue and progress flexibility and strengthening program based on individual
needs and deficits
• Initiate plyometric program as appropriate for patient’s athletic goals
• Agility progression including, but not limited to:
Side steps
Crossovers
Figure 8 running
Shuttle running
One leg and two leg jumping
Cutting
Acceleration/deceleration/springs
Agility ladder drills
• Continue progression of running distance based on patient needs
• Initiate sport-specific drills as appropriate for patient

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Phase V: Begins at post-operative months 6 or 7

• No patellofemoral or soft tissue complaints
• Necessary joint ROM, strength, endurance, and proprioception to safely return to
work or athletics
Goals:
• Safe return to athletics/work
Exercises:
• Gradual return to sports participation
• Maintenance program for strength, endurance
Bracing:
• Functional brace generally not used, but may be recommended by the physician on an
individual basis
Formatted: Mike Cowell Reviewers: Reg Wilcox III

Marie-Josee Paris
4/2006

rights reserved.
6
BRIGHAM AND WOMEN’S HOSPITAL
Physical Therapy
ACL Allograft Reconstruction Protocol
rehabilitation course of a patient that has undergone an ACL allograft reconstruction. It is no
means intended to be a substitute for one’s clinical decision making regarding the progression of
a patient’s post-operative course based on their physical exam/findings, individual progress,
and/or the presence of post-operative complications. If a clinician requires assistance in the
progression of a post-operative patient they should consult with the referring Surgeon.
GENERAL GUIDELINES
• Allograft revascularization is slower than for autografts. Therefore, crutches and brace are
continued for 6 weeks.
• ACL reconstruction performed with meniscal repair or transplant: follow the ACL protocol
with avoidance of open kinetic hamstring strengthening for 6 weeks. Time frames for use of
brace and crutches may be extended by the physician.
• Supervised physical therapy takes place for 3-9 months.

Patients may begin the following activities at the dates indicated (unless otherwise specified by the
physician):
• Bathing/Showering without brace: refer to your surgeon’s post-operative instructions
• Sleep with brace locked in extension for 1 week
• Brace locked in extension for 1 week for ambulation
• Use of crutches, brace for ambulation for 6 weeks
PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:
Phase I (0-6 weeks): 1-2 visit/week
Phase II (6-8 weeks): 2-3 visits/week
Phase III (2-6 months): 2-3 visits/week
Phase IV, V (6 months +): Discharge after completion of appropriate functional
progression
PHASE I: Immediately postoperatively through approximately week 6

Goals:
• Protect graft fixation
• Control inflammation
• Full extension range of motion
• Flexion to 90-degrees
• Normalize gait mechanics in pool (if available).
ACL Allograft Reconstruction Protocol 1

Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
Brace:
• Post op brace 0-6 weeks
• 1st week: Locked in full extension for ambulation and sleeping
• 1-6 weeks: Brace remove for rehab and sleeping
• 6-12 weeks: To be worn in situations where patient may be at risk for fall (crowds, walking
on uneven surfaces)
• After 12 weeks brace is optional
Weightbearing Status
• 0-2 weeks: Touch down weight bearing with two crutches
• 2-4 weeks: Partial weight bearing
• 4-6 weeks: Weight bearing as tolerated
Therapeutic Exercises: {Reminder: ACL reconstruction performed with meniscal repair or transplant:
follow the ACL protocol with avoidance of open kinetic hamstring strengthening for 6 weeks}
• Initiate active-assisted leg curls; progress to active range of motion when pain free
• Heel slides
• Quad sets
• Patellar mobilization
• Non-weight bearing gastroc/soleus stretching, begin hamstring stretches at 2 weeks
• SLR, all planes, with brace in full extension until quadriceps strength is sufficient to prevent
extension lag. Quadriceps isometrics at 60-degrees and 90-degrees
• Pool after 2-3 weeks (once incisions have healed), to work on underwater treadmill
• At 4-weeks post-op add biking, deep well pool running with aqua vest (if pool available), leg
press, quadriceps stretching.
• Partial weight bearing closed chain knee extension 0-45-degrees
• Theraband
• Leg press
• Pool mini-squats
• Gentle hamstring stretching
PHASE II: Postoperative weeks 6 to 8

• Approximately 90° of flexion
• Full active knee extension in sitting
• No signs of active inflammation
Goals:
• Initiate closed kinetic chain exercises
• Restore normal gait
• Protect graft fixation
Brace/Weightbearing status:
• Discontinue use of brace and crutches as allowed by physician when the patient has full
extension and can SLR without extension lag.

• Patient may exhibit antalgic gait pattern. Consider using single crutch or cane until gait is
normalized.
Therapeutic Exercises:
• Wall slides 0-45-degrees, progressing to mini-squats
• 4-way hip
• Stationary bike (begin with high seat, low tension to promote ROM, progress to single leg)
• Closed chain terminal extension with resistive tubing or weight machine
• Toe raises
• Balance exercises (e.g. single-leg balance, KAT)
• Hamstring curls
• Aquatic therapy with emphasis on normalization or gait
• Continue hamstring stretches, progress to weight-bearing gastroc/soleus stretches
PHASE III: Postoperative week 8 to 6 months
Goals:
• Improve strength, endurance and proprioception of the lower extremity to prepare for
functional activities
• Avoid overstressing the graft
• Continue and progress previous flexibility and strengthening activities
• Nordic Trac, Elliptical
• Knee extensions 90°-45°, progress to eccentrics
• Advance closed kinetic chain activities (leg press, one-leg mini squats 0-45° of flexion, step-
ups begin at 2” progress to 8”, etc.)
• Progress proprioception activities (slide board, use of ball, racquet with balance activities,
etc.)
• Progress aquatic program to include pool running, swimming (no breaststroke)
PHASE IV: Postoperative months 6 to 9

• Strength and proprioception approximately 70% of uninvolved
• Physician clearance to initiate advanced closed kinetic chain exercises and functional
progression
Goal:
• Progress strength, power, and proprioception to prepare for return to functional activities.

• Continue and progress previous flexibility and strengthening activities
• Functional progression including:
• Walk/Jog progression
• Forward, backward running, ½, ¾, full speed
PHASE V: Postoperative month 9 +

• No patellofemoral or soft tissue complaint
• Necessary joint ROM, strength, endurance, and proprioception to safely return to work or
athletics
Goals:
• Initiate cutting and jumping activities
• Completion of appropriate functional progression
• Functional progression including, but not limited to:
• Walk/jog progression
• Forward/backward running, ½, ¾, full speed
• Cutting, crossover, caricoa, etc.
• Plyometric activities as appropriate to patient’s goals
• Sports-specific drills
• Safe, gradual return to sports after successful completion of functional progression
• Maintenance program for strength and endurance
Bracing:
Functional brace may be recommended by the physician for use during sports for the first 1-2 years after
surgery.
Authors: Mike Cowell, PT Reviewers: Joel Fallano, PT Deleted: ¶

Marie-Josee Paris, PT
April, 2006
Revised: Marie-Josee Paris Reviewers: Joel Fallano, PT

April, 2008 Mike Cowell, PT

Physical Therapy
This protocol has been adopted from Brotzman & Wilk, which has been published in
Brotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby
Inc; 2003:315-319. The Department of Rehabilitation Services at Brigham & Women’s
Hospital has accepted this protocol as our standard protocol for the management of
patients s/p meniscal repair.
Meniscal Repair:
The intent of this protocol is to provide the clinician with a guideline of the post-
operative rehabilitation course of a patient that has undergone a meniscal repair. It is no
means intended to be a substitute for one’s clinical decision making regarding the
progression of a patient’s post-operative course based on their physical exam/findings,
individual progress, and/or the presence of post-operative complications. If a clinician
requires assistance in the progression of a post-operative patient they should consult with
the referring Surgeon.
Progression to the next phase based on Clinical Criteria and/or Time Frames as
Appropriate.
Key Factors in determining progression of rehabilitation after Meniscal repair include:

• Anatomic site of tear
• Suture fixation (failure can be caused by too vigorous rehabilitation)
• Location of tear (anterior or posterior)
• Other pathology (ligamentous injury)
Phase I –Maximum Protection- Weeks 1-6:

Goals:
• Diminish inflammation and swelling
• Restore ROM
• Reestablish quadriceps muscle activity
Stage 1: Immediate Postoperative Day 1- Week 3

• Ice, compression, elevation
• Electrical muscle stimulation
• Brace locked at 0 degrees
• ROM 0-90
Mensical Repair Protocol

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o Motion is limited for the first 7-21 days, depending on the development of
scar tissue around the repair site. Gradual increase in flexion ROM is
based on assessment of pain and site of repair (0-90 degrees).
• Patellar mobilization
• Scar tissue mobilization
• Passive ROM
• Exercises
o Quadriceps isometrics
o Hamstring isometrics (if posterior horn repair, no hamstring exercises for
6 weeks)
o Hip abduction and adduction
• Weight-bearing as tolerated with crutches and brace locked at 0 degrees
• Proprioception training with brace locked at 0 degrees
Stage 2: Weeks 4-6

• Progressive resistance exercises (PREs) 1-5 pounds.
• Limited range knee extension (in range less likely to impinge or pull on repair)
• Toe raises
• Mini-squats less (than 90 degrees flexion)
• Cycling (no resistance)
• PNF with resistance
• Unloaded flexibility exercises
Phase II: Moderate Protection- Weeks 6-10
Criteria for progression to phase II:

• ROM 0-90 degrees
• No change in pain or effusion
• Quadriceps control (MMT 4/5)
Goals:
• Increased strength, power, endurance
• Normalize ROM of knee
• Prepare patients for advanced exercises
Exercises:
• Strength- PRE progression
• Flexibility exercises
• Lateral step-ups
• Mini-squats

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Endurance Program:
• Swimming (no frog kick), pool running- if available
• Cycling
• Stair machine
Coordination Program:
• Balance board
• Pool sprinting- if pool available
• Backward walking
• Plyometrics
Phase III: Advanced Phase- Weeks 11-15
Criteria for progression to phase III:

• Full, pain free ROM
• No pain or tenderness
• Satisfactory clinical examination
• SLR without lag
• Gait without device, brace unlocked
Goals:
• Increase power and endurance
• Emphasize return to skill activities
• Prepare for return to full unrestricted activities
Exercises:
• Continue all exercises
• Increase plyometrics, pool program
• Initiate running program
Return to Activity: Criteria

• Full, pain free ROM
• Satisfactory clinical examination
Criteria for discharge from skilled therapy:

1) Non-antalgic gait
2) Pain free /full ROM
3) LE strength at least 4/5
4) Independent with home program
5) Normal age appropriate balance and proprioception
6) Resolved palpable edema

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3
Physical Therapy
This protocol has been modified from Brotzman & Wilk, which has been published in
Brotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby
Inc; 2003:315-319. The Department of Rehabilitation Services at Brigham & Women’s
Hospital has accepted this protocol as our standard protocol for the management of
patient’s s/p arthroscopic partial medial or lateral meniscectomy.
Arthroscopic partial medial or lateral meniscectomy, loose

body removal or debridement protocol:
The intent of this protocol is to provide the clinician with a guideline of the post-
operative rehabilitation course of a patient that has undergone a partial meniscectomy,
loose body removal or debridement. It is by no means intended to be a substitute for
one’s clinical decision making regarding the progression of a patient’s post-operative
course based on their physical exam/findings, individual progress, and/or the presence of
post-operative complications. If a clinician requires assistance in the progression of a
post-operative patient they should consult with the referring Surgeon.
Rehabilitation after meniscectomy may progress aggressively because there is no

anatomic structure that requires protection.
Progression to the next phase is based on clinical criteria and meeting the
established goals for each phase.
Phase I – Acute Phase:
Goals:
• Diminish inflammation and swelling
• Restore knee range of motion (goal 0-115, minimum of 0 degrees extension to 90
degrees of flexion to progress to phase II)
• Reestablish quadriceps muscle activity/re-education (goal of no quad lag during
SLR)
• Educate the patient regarding precautions, activity progression and the
rehabilitation process
Weight bearing:
• Weight bearing as tolerated. Use two crutches initially progressing to weaning
crutches as swelling and quadriceps status dictates.
Arthroscopic partial medial or lateral meniscectomy, loose body removal or

debridement protocol:
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Modalities:
• Cryotherapy
• Electrical stimulation to quadriceps for functional retraining as appropriate
• Electrical stimulation for edema control- high volt galvanic or interferential
stimulation as needed
Therapeutic Exercise:
• Quadriceps sets
• SLR
• Hip adduction, abduction and extension
• Ankle pumps
• Gluteal sets
• Heel slides
• ½ squats
• Active-assisted ROM stretching, emphasizing full knee extension (flexion to
tolerance
• Hamstring and gastroc/ soleus and quadriceps stretches
• Use of compression wrap or brace
• Bicycle for ROM when patient has sufficient knee ROM. May begin partial
revolutions to recover motion if the patient does not have sufficient knee flexion
Phase II: Internal Phase :
Goals:
• Restore and improve muscular strength and endurance
• Reestablish full pain free ROM
• Gradual return to functional activities
• Restore normal gait without an assistive device
• Improve balance and proprioception
Weight bearing status:

Patients may progress to full weight bearing as tolerated without antalgia. Patients may
require one crutch or cane to normalize gait before ambulating without assistive device.
Therapeutic exercise:
• Continue all exercises as needed from phase one
• Toe raises- calf raises
• Hamstring curls
• Continue bike for motion and endurance
• Cardio equipment- stairmaster, elliptical trainer, treadmill and bike as above.
• Lunges- lateral and front
• Leg press
• Lateral step ups, step downs, and front step ups
2

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• Knee extension 90-40 degrees
• Closed kinetic chain exercise terminal knee extension
• Four way hip exercise in standing
• Proprioceptive and balance training
• Stretching exercises- as above, may need to add ITB and/or hip flexor stretches
Phase III – Advanced activity phase:
Goals:
• Enhance muscular strength and endurance
• Maintain full ROM
• Return to sport/functional activities/work tasks
Therapeutic Exercise:
• Continue to emphasize closed-kinetic chain exercises
• May begin plyometrics/ vertical jumping
• Begin running program and agility drills (walk-jog) progression, forward and
backward running, cutting, figure of eight and carioca program
• Sport specific drills
Criteria for discharge from skilled therapy:

1) Non-antalgic gait
2) Pain free /full ROM
3) LE strength at least 4+/5
4) Independent with home program
5) Normal age appropriate balance and proprioception
6) Resolved palpable edema
Authors: Reviewers:
Colleen Coyne Jeff Carlson
Amy Butler 12/04 Joel Fallano 12/04
Reviewed
Ethan Jerome 4/06

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Physical Therapy
PCL Reconstruction Protocol
The intent of this protocol is to provide the clinician with a guideline for the post-
operative rehabilitation course of a patient that has undergone a PCL or PCL/ACL
reconstruction. It is by no means intended to be a substitute for one’s clinical decision-
making regarding the progression of a patient’s post-operative course based on their
exam findings, individual progress, and/or presence of post-operative complications. If a
clinician requires assistance in the progression of a post-operative patient, they should
consult with the referring surgeon.
GENERAL GUIDELINES
• No open chain hamstring work.

• Typically it takes 12 weeks for graft to bone healing time.
• Caution against posterior tibial translation (gravity, muscle action).
• Typically no CPM.
• PCL with posterolateral corner or LCL repair follows different post-op care (i.e.
crutches x 3 months).
• Resistance for hip PRE’s should be placed above the knee for hip abduction and
adduction; resistance may be placed distally for hip flexion.
• Supervised physical therapy generally takes place for 3-5 months post-
operatively.
Patients may begin the following activities at the dates indicated, unless otherwise
specified by the surgeon:
• Bathing/showering without brace (sponge bath only until suture removal)- 1 week
post-op.
• Typically patients can return to driving: 6-8 weeks post-op.
• Typically begin sleeping without brace: 8 weeks post-op.
• Full weight-bearing without assistive devices: 8 weeks post-op (with surgeon’s
clearance based on structural integrity of repair). The exception is PCL with
posterior lateral corner (PLC) or LCL repair, as above.
PCL Reconstruction Protocol 1

Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
PHASE I: Immediately post-operatively to week 4
Goals:
• Protect healing bony and soft tissue structures.
• Minimize the effects of immobilization:
o Early protected range of motion (protect against posterior tibial sagging).
o PRE’s for quadriceps, hip, and calf with an emphasis on limiting
patellofemoral joint compression and posterior tibial translation.
• Patient education for a clear understanding of limitations and expectations of the
rehabilitation process, and need for supporting proximal tibia/preventing sag.
Brace:
• 0-1 week: post-op brace locked in full extension at all times.
• At 1 week post-op, brace is unlocked for passive ROM performed by a physical
therapist or PT assistant.
• Technique for passive ROM is as follows:
o Patient supine; therapist maintains anterior pressure on proximal tibia as
knee is flexed (force on tibia is from posterior to anterior).
o For patients with combined PCL/ACL reconstructions, the above
technique is modified such that a neutral position of the proximal tibia is
maintained as the knee is flexed.
o It is important to prevent posterior sagging at all times.
Weight-bearing status:
• Weight-bearing as tolerated (WBAT) with crutches, brace locked in extension.
Special considerations:
• Position pillow under proximal posterior tibia at rest to prevent posterior tibial
sag.
Therapeutic exercises:
• Patellar mobilization.
• Quadriceps sets.
• Straight leg raise (SLR).
• Hip abduction and adduction.
• Ankle pumps.
• Hamstring and calf stretching.
• Calf press with exercise bands, progressing to standing calf raise with full knee
extension.
• Standing hip extension from neutral.

• Functional electrical stimulation (as needed for trace to poor quadriceps
contraction).
Criteria for progression to Phase II:

• Good quadriceps control (good quad set, no lag with SLR).
• Approximately 60 degrees knee flexion.
• Full knee extension.
• No signs of active inflammation.
Goals:
• Increase ROM (particularly flexion).
• Normalize gait.
• Continue to improve quadriceps strength and hamstring flexibility.
Brace:
• 4-6 weeks: Brace unlocked for gait in controlled environment only (i.e. patient
may walk with brace unlocked while attending PT or when at home).
• 6-8 weeks: Brace unlocked for all activities.
• 8 weeks: Brace discontinued, as allowed by surgeon.
o Note, if PCL or LCL repair, continue brace until cleared by surgeon.
Weight-bearing status:
• 4-8 weeks: WBAT with crutches.
• 8 weeks: May discontinue crutches if patient demonstrates:
o No quadriceps lag with SLR.
o Full knee extension.
o Knee flexion 90-100 degrees.
o Normal gait pattern (May use 1 crutch/cane until gait normalized).
• If PLC or LCL repair, continue crutches for 12 weeks.
• 4-8 weeks:
o Wall slides/mini-squats (0-45 degrees).
o Leg press (0-60 degrees).
o Standing 4-way hip exercise for flexion, extension, abduction, adduction
(from neutral, knee fully extended).
o Ambulation in pool (work on restoration of normal heel-toe gait pattern in
chest-deep water).
• 8-12 weeks:
o Stationary bike (foot placed forward on pedal without use of toe clips to
minimize hamstring activity; seat set slightly higher than normal).

o Closed kinetic chain terminal knee extension using resisted band or weight
machine. Note: important to place point of resistance to minimize tibial
displacement.
o Stairmaster.
o Elliptical trainer.
o Balance and proprioception exercises.
o Seated calf raises.
o Leg press (0-90 degrees).
PHASE III: Post-operative months 3 to 9
Criteria for progression to Phase III:

• Full, painfree ROM. (Note: it is not unusual for flexion to be lacking 10-15
degrees for up to 5 months post-op.)
• Normal gait.
• Good to normal quadriceps control.
• No patellofemoral complaints.
• Clearance by surgeon to begin more concentrated closed kinetic chain
progression.
Goals:
• Restore any residual loss of motion that may prevent functional progression.
• Progress functionally and prevent patellofemoral irritation.
• Improve functional strength and proprioception using close kinetic chain
exercises.
• Continue to maintain quadriceps strength and hamstring flexibility.
• Continue closed kinetic chain exercise progression.
• Treadmill walking.
• Jogging in pool with wet vest or belt.
• Swimming (no breaststroke or “frog kick”).
PHASE IV: Post-operative Month 9 until return to full activity
Criteria for progression to Phase IV:

• Clearance by surgeon to resume full or modified/partial activity (i.e. return to
work, recreational, or athletic activity).
• No significant patellofemoral or soft tissue irritation.
• Presence of necessary joint ROM, muscle strength and endurance, and
proprioception to safely return to athletic participation.
o Full, painfree ROM.
o Satisfactory clinical examination.
o Quadriceps strength 85% of uninvolved leg.
o Functional testing 85% of uninvolved leg.
o No change in laxity testing.
Goals:
• Safe and gradual return to work or athletic participation.
o This may involve sport-specific training, work hardening, or job
restructuring as needed.
o Patient demonstrates a clear understanding of their possible limitations.
• Maintenance of strength, endurance, and function.
• Continue closed kinetic chain exercise progression.
• Cross-country ski machine.
• Sport-specific functional progression, which may include but is not limited to:
o Slide board.
o Jog/Run progression.
o Figure 8, carioca, backward running, cutting.
o Jumping (plyometrics).
• Work hardening program as indicated by physical therapist and/or surgeon
recommendation. Patient will need a referral from surgeon to begin work
hardening.
This protocol has been modified from Brotzman and Wilk, which has been published in
Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby
Inc; 2003: 300-302.
Formatted by: Melissa Flak, PT 7/’06


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Department of Rehabilitation Services

ACL Patella Tendon Autograft Reconstruction Protocol

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

ACL Patella Tendon Autograft Reconstruction Protocol

PHASE I: Immediately postoperatively to week 4

• If available, aquatics for normalizing gait, weightbearing strengthening, deep-water

PHASE II: Post-operative weeks 4 to 10

Criteria for advancement to Phase II:

PHASE III: Post-operative weeks 10 to 16

Criteria to advance to Phase III include:

ACL Patella Tendon Autograft Reconstruction Protocol

PHASE IV: Post-operative months 4 through 6

Criteria for advancement to Phase IV:

• Agility progression including, but not limited to:

ACL Patella Tendon Autograft Reconstruction Protocol

PHASE V: Begins at approximately 6 months post-op

Criteria for advancement to Phase V:

• No patellofemoral or soft tissue complaint

Formatted: Mike Cowell Reviewers: Reg Wilcox III

ACL Patella Tendon Autograft Reconstruction Protocol

ACL Hamstring Tendon Autograft Reconstruction Protocol

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

ACL Hamstring Tendon Autograft Reconstruction Protocol

PHASE I: Immediately post-operatively to week 4

ACL Hamstring Tendon Autograft Reconstruction Protocol

Criteria for advancement to Phase II:

ACL Hamstring Tendon Autograft Reconstruction Protocol

Criteria to advance to Phase III include:

ACL Hamstring Tendon Autograft Reconstruction Protocol

Criteria for advancement to Phase IV:

ACL Hamstring Tendon Autograft Reconstruction Protocol

Criteria for advancement to Phase V:

Formatted: Mike Cowell Reviewers: Reg Wilcox III

ACL Hamstring Tendon Autograft Reconstruction Protocol

ACL Allograft Reconstruction Protocol

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

PHYSICAL THERAPY ATTENDANCE

PHASE I: Immediately postoperatively through approximately week 6

ACL Allograft Reconstruction Protocol 1

PHASE II: Postoperative weeks 6 to 8

Criteria for advancement to Phase II:

ACL Allograft Reconstruction Protocol 2

PHASE III: Postoperative week 8 to 6 months

PHASE IV: Postoperative months 6 to 9

Criteria for advancement to Phase IV:

• Full, pain-free ROM

ACL Allograft Reconstruction Protocol 3

PHASE V: Postoperative month 9 +

Authors: Mike Cowell, PT Reviewers: Joel Fallano, PT Deleted: ¶

Revised: Marie-Josee Paris Reviewers: Joel Fallano, PT

ACL Allograft Reconstruction Protocol 4

Key Factors in determining progression of rehabilitation after Meniscal repair include:

Phase I –Maximum Protection- Weeks 1-6:

Stage 1: Immediate Postoperative Day 1- Week 3

Mensical Repair Protocol

Stage 2: Weeks 4-6

Phase II: Moderate Protection- Weeks 6-10

Criteria for progression to phase II:

Mensical Repair Protocol

Phase III: Advanced Phase- Weeks 11-15

Criteria for progression to phase III:

Return to Activity: Criteria