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.

General Progression of Activities of Daily Living

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.

Rehabilitation Progression

Phase I: Immediately post-operatively to week 4

Goals:

• Protect healing bony and soft tissue structures.
• Minimize the effects of immobilization:
  • Early protected range of motion (protect against posterior tibial sagging).
  • 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:
  • Patient supine; therapist maintains anterior pressure on proximal tibia as knee is flexed (force on tibia is from posterior to anterior).
  • 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.
  • 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).

Phase II: Post-operative weeks 4 to 12

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.

*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:
  • No quadriceps lag with SLR.
  • Full knee extension.
  • Knee flexion 90-100 degrees.
  • 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:
  • Wall slides/mini-squats (0-45 degrees).
  • Leg press (0-60 degrees).
  • Standing 4-way hip exercise for flexion, extension, abduction, adduction (from neutral, knee fully extended).
  • Ambulation in pool (work on restoration of normal heel-toe gait pattern in chest-deep water).
• 8-12 weeks:
  • Stationary bike (foot placed forward on pedal without use of toe clips to minimize hamstring activity; seat set slightly higher than normal).
  • Closed kinetic chain terminal knee extension using resisted band or weight machine. Note: important to place point of resistance to minimize tibial displacement.
  • Stairmaster.
  • Elliptical trainer.
  • Balance and proprioception exercises.
  • Seated calf raises.
  • 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.

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 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.
  • Full, painfree ROM.
  • Satisfactory clinical examination.
  • Quadriceps strength 85% of uninvolved leg.
  • Functional testing 85% of uninvolved leg.
  • No change in laxity testing.

Goals:

• Safe and gradual return to work or athletic participation.
  • This may involve sport-specific training, work hardening, or job restructuring as needed.
  • 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:
  • Slide board.
  • Jog/Run progression.
  • Figure 8, carioca, backward running, cutting.
  • 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.