Brigham & Women's Hospital - Knee Rehabilitation PT Protocols

8/8/2019 Brigham & Women's Hospital - Knee Rehabilitation PT Protocols

1/27

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 ones clinical decision making

regarding the progression of a patients post-operative course based on their physicalexam/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 graftfixation (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 beremoved for bathing/showering.

Sleep with brace locked in extension for 1 week or as directed by PT/MD formaintenance 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 normalgait mechanics and good quad control as defined by absence of quadriceps lag.

Return to work as directed by PT/MD based on work demands.

1


2/27



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 fullextension.

Brace locked in extension for ambulation until patient demonstrates full extensionwith 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

Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates normalgait 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 toprevent 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

2


3/27



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 astolerated

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 Protect graft and graft fixation 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 legbiking

Continue to progress proprioceptive activities ball toss, balance beam, mini-trampbalance

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 8weeks.

3


4/27



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. Minimal swelling/inflammation

Goals:

Full range of motion

Improve strength, endurance and proprioception of the lower extremity to prepare forsport 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

4


5/27



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 drillsSingle 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 individualneeds and deficits.

Initiate plyometric program as appropriate for patients athletic goals Agility progression including, but not limited to:

Side stepsCrossovers

Figure 8 runningShuttle running

One leg and two leg jumping

CuttingAcceleration/deceleration/sprints

Agility ladder drills

Continue progression of running distance based on patient needs. Initiate sport-specific drills as appropriate for patient

5


6/27



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 activityGoals:

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 anindividual basis.

Formatted: Mike Cowell Reviewers: Reg Wilcox III

Marie-Josee Paris4/2006

6


7/27

Department of Rehabilitation ServicesPhysical Therapy

ACL Hamstring Tendon Autograft Reconstruction Protocol

The intent of this protocol is to provide the clinician with a guideline for the post-operativerehabilitation course of a patient that has undergone an ACL hamstring tendon autograftreconstruction. It is no means intended to be a substitute for ones clinical decision making

regarding the progression of a patients post-operative course based on their physical

exam/findings, individual progress, and/or the presence of post-operative complications. If aclinician 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 graftfixation (8 12 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 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 beremoved for bathing/showering.

Sleep with brace locked in extension for 1 week or as directed by PT/MD formaintenance of full extension

Driving: 1 week for automatic cars, left leg surgery2-4 weeks for standard cars, or right leg surgery

Post-op brace locked in full extension (0-1 week) for ambulation & sleeping1-3 weeks- unlock brace (


8/27

ACL Hamstring Tendon Autograft Reconstruction ProtocolCopyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All

rights reserved.

2


PHASE I: Immediately post-operatively to week 4

Goals: Protect graft and graft fixation with use of brace and specific exercises Minimize effects of immobilization Control inflammation and swelling Full active and passive extension/hyperextension range of motion. Caution: avoid

hyperextension greater than 10o

Educate patient on rehabilitation progression Flexion to 90o only in order to protect graft fixation Restore normal gait on level surfaces

Brace:

0-1 weekpost-op brace locked in full extension for ambulation and sleeping 1-3 weeks- unlock brace (


9/27


rights reserved.

3



Full extension/hyperextension Good quad set, SLR without extension lag Flexion to 90o Minimal swelling/inflammation Normal gait on level surfaces

Goals:

Restore normal gait with stairclimbing Maintain full extension, progress toward full flexion range of motion Protect graft and graft fixation 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 chainhamstring exercises at week 12)

Continue hamstring, Gastroc/Soleus stretches Stairmaster (begin with short steps, avoid hyperextension) 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 at10-12 weeks


10/27


rights reserved.

4

Phase III: Post-operative weeks 12 to 18-20 (4 -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) Minimal swelling/inflammation

Goals:

Full range of motion Improve strength, endurance, and proprioception of the lower extremity to prepare for

sport activities

Avoid overstressing the graft. Progressively increase resistance for hamstringstrengthening

Protect the patellofemoral joint 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


11/27


rights reserved.

5

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


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 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 individualneeds and deficits

Initiate plyometric program as appropriate for patients athletic goals Agility progression including, but not limited to:

Side steps

CrossoversFigure 8 running

Shuttle running

One leg and two leg jumping

CuttingAcceleration/deceleration/springs

Agility ladder drills

Continue progression of running distance based on patient needs Initiate sport-specific drills as appropriate for patient


12/27


rights reserved.

6

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 towork 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 anindividual basis

Formatted: Mike Cowell Reviewers: Reg Wilcox III

Marie-Josee Paris4/2006


13/27

ACL Allograft Reconstruction ProtocolCopyright 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved

1

ACL Allograft 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 allograft reconstruction. It is no

means intended to be a substitute for ones clinical decision making regarding the progression of

a patients 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 arecontinued for 6 weeks.

CPM not commonly used 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 ofbrace and crutches may be extended by the physician.

Supervised physical therapy takes place for 3-9 months.GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVINGPatients may begin the following activities at the dates indicated (unless otherwise specified by the

physician):

Bathing/Showering without brace: refer to your surgeons post-operative instructions Sleep with brace locked in extension for 1 week Driving: 1 week for automatic cars, left leg surgery

4-6 weeks for standard cars, or right leg surgery

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 postoperativelythrough approximately week 6

Goals:

Protect graft fixation Minimize effects of immobilization Control inflammation Full extension range of motion Educate patient on rehabilitation progression Flexion to 90-degrees Normalize gait mechanics in pool (if available).

BRIGHAM AND WOMENS HOSPITAL


Physical Therapy


14/27


2

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 optionalWeightbearing 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 stretchingPHASE II: Postoperative weeks 6 to 8


Good quad set, SLR without extension lag 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 fullextension and can SLR without extension lag.


15/27


3

Patient may exhibit antalgic gait pattern. Consider using single crutch or cane until gait isnormalized.

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:

Full range of motion Improve strength, endurance and proprioception of the lower extremity to prepare for

functional activities

Avoid overstressing the graft Protect the patellofemoral joint


Continue and progress previous flexibility and strengthening activities Stairmaster (begin with short steps, avoid hyperextension) 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


Full, pain-free ROM No evidence of patellofemoral joint irritation 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.


16/27


4


Continue and progress previous flexibility and strengthening activities Functional progression including:

Walk/Jog progression Forward, backward running, , , 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

Physician clearance to resume partial or full activityGoals:

Initiate cutting and jumping activities Completion of appropriate functional progression Maintenance of strength, endurance, proprioception Patient education with regards to any possible limitations


Functional progression including, but not limited to: Walk/jog progression Forward/backward running, , , full speed Cutting, crossover, caricoa, etc. Plyometric activities as appropriate to patients 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

Marie-Josee Paris, PT

April, 2006

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

April, 2008 Mike Cowell, PT

Deleted:


17/27


Physical Therapy

This protocol has been adopted from Brotzman & Wilk, which has been published in

Brotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: MosbyInc; 2003:315-319. The Department of Rehabilitation Services at Brigham & WomensHospital 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 nomeans intended to be a substitute for ones clinical decision making regarding the

progression of a patients post-operative course based on their physical exam/findings,

individual progress, and/or the presence of post-operative complications. If a clinicianrequires 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 ProtocolCopyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All

rights reserved.

1


18/27


rights reserved.

2

o Motion is limited for the first 7-21 days, depending on the development ofscar 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 isometricso 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 degreesStage 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


19/27


rights reserved.

3

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 4/54) Independent with home program

5) Normal age appropriate balance and proprioception6) Resolved palpable edema


20/27

Department of Rehabilitation ServicesPhysical Therapy

This protocol has been modified from Brotzman & Wilk, which has been published inBrotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby

Inc; 2003:315-319. The Department of Rehabilitation Services at Brigham & WomensHospital has accepted this protocol as our standard protocol for the management ofpatients 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

ones clinical decision making regarding the progression of a patients post-operative

course based on their physical exam/findings, individual progress, and/or the presence ofpost-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 duringSLR)

Educate the patient regarding precautions, activity progression and therehabilitation process

Weight bearing:

Weight bearing as tolerated. Use two crutches initially progressing to weaningcrutches as swelling and quadriceps status dictates.

Arthroscopic partial medial or lateral meniscectomy, loose body removal or

debridement protocol:Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All

rights reserved.

1


21/27



rights reserved.

2

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 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


22/27



rights reserved.

3

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 drillsCriteria for discharge from skilled therapy:1) Non-antalgic gait

2) Pain free /full ROM

3) LE strength at least 4+/54) Independent with home program

5) Normal age appropriate balance and proprioception

6) Resolved palpable edema

Authors: Reviewers:

Colleen Coyne Jeff CarlsonAmy Butler 12/04 Joel Fallano 12/04

Reviewed

Ethan Jerome 4/06


23/27


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/ACLreconstruction. It is by no means intended to be a substitute for ones clinical decision-

making regarding the progression of a patients post-operative course based on their

exam findings, individual progress, and/or presence of post-operative complications. If aclinician 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 PREs should be placed above the knee for hip abduction andadduction; 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 weekpost-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 surgeons

clearance based on structural integrity of repair). The exception is PCL with

posterior lateral corner (PLC) or LCL repair, as above.


Copyright 2007 The Brigham and Women's Hospital, Inc. Department of

Rehabilitation Services. All rights reserved.

1


24/27




2


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 PREs 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 therehabilitation 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 physicaltherapist or PT assistant. Technique for passive ROM is as follows:

o Patient supine; therapist maintains anterior pressure on proximal tibia asknee is flexed (force on tibia is from posterior to anterior).

o For patients with combined PCL/ACL reconstructions, the abovetechnique 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 tibialsag.

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.


25/27




3

Functional electrical stimulation (as needed for trace to poor quadricepscontraction).


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.Therapeutic Exercises:

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 inchest-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).


26/27




4

o Closed kinetic chain terminal knee extension using resisted band or weightmachine. 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 10-15degrees 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.Therapeutic exercises:

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 towork, 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.


27/27


Copyright 2007 The Brigham and Women's Hospital, Inc. Department of5

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.Therapeutic exercises:

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 surgeonrecommendation. 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

Documents

Brigham & Women's Hospital - Knee Rehabilitation PT Protocols