ACL Reconstruction with Meniscus Repair Post-operative Physical Therapy Protocol

General Considerations

  • It is important to recognize that all times are approximate and that progression should be based on careful monitoring of the patient's functional status.
  • Early emphasis on achieving full hyperextension equal to the opposite side.
  • Patients will be in a hinged knee brace for 4 weeks post-op locked in full extension.
  • No active knee flexion X 4 weeks.
  • Partial / toe-touch weight bearing for 3-5 days post-op, increasing to full weight bearing--important to watch for lower leg rotation or “heel whip” with ambulation to avoid stress onto the meniscus.
  • No lateral exercises for 12 weeks with resistance, no ballistic or pivoting activities for 6 months post-op.
  • Regular manual treatment should be conducted to all incisions so that they remain mobile.
  • Exercises should focus on the early recruitment of the quadriceps especially VMO.
  • No resisted leg extension machines (isotonic, isokinetic, or manual resisted) at any point.
  • Patients are given a functional assessment/sport test at 3, 6 months, 1-year post-op.
  • OK to sleep without a brace.
  • No direct palpation to surgical portals x 4 weeks; consider the edges of the bandages as the “no-touch zone” approximately 2 inches from all portals. See wound care protocol for further detail.

Week 1

  • Nurse visit day 2 post-op to change dressing and review home program.
  • Icing and elevation every 2 hours for 15-20 min sessions.

Manual

  • Effleurage for edema. Soft tissue treatments and mobilization to all associated musculature (quads, hamstrings, gastrocnemius, popliteal fossa, ITB).
  • Patellar glides all directions; avoid palpation of surgical portals x 4 weeks.
  • Passive “dangle” off edge of bed for knee flexion range of motion; allow leg to bend up to 90 degrees in pain-free range 4X/day for 5 minutes.
  • Focus knee extension range of motion equal to 0 degrees.

Exercises

  • Straight leg raise exercises (lying, seated, and standing), quadriceps/abduction/ gluteal sets; balance/proprioception exercises; well-leg stationary cycling; upper body conditioning.
  • Once or twice per day: open-chain flexion of knee to end range per patient tolerance.
  • Can start double leg standing calf raises and stretches.

Goals

  • Decrease pain, edema.
  • Brace locked in extension x 4weeks for weight wearing.
  • Touch down weight bearing x 3-5 days, progress to full weight bearing with good mechanics.
  • Passive range of motion 0-90 degrees.

Weeks 2 - 4

  • Nurse visit at 14 days for suture removal and check-up.

Manual

  • Continue with soft tissue mobilization, patellar glides, range of motion.

Exercises

  • Continue with previous exercises; increase core/gluteal strength. Balance/proprioception exercises (e.g., single-leg standing balance). Activate quads to maintain knee extension.
  • Aerobic exercises consisting of upper body ergometer, well legged stationary cycling.

Goals

  • Continue to decrease pain.
  • Brace locked in extension for weight-bearing, progress to full weight-bearing.
  • Passive range of motion 0 to 90 degrees.

Weeks 4 - 6

  • M.D. visit at 4 weeks, discontinue the use of the post-op brace.

Manual

  • Continue with soft tissue mobilization to surrounding musculature, patellar glides.
  • Light joint mobilizations and scar mobilization if portals completely closed.

Exercises

  • Can start progressive resisted leg training with weight machines without symptoms.
  • Stationary cycling, cautious introduction of stair machine.
  • Can start pool exercises and swimming without brace (can use brace for support if desired) once portals are completely closed.

Goals

  • Discontinue post-op brace. Can initiate stationary cycling.
  • Active range of motion 0-120 degrees.

Weeks 6 - 8

Manual

  • Continue with above manual as needed, increase range of motion.

Exercises

  • Increase the intensity of functional exercises (i.e stretch cord resistance, adding weight, increasing resistance of aerobic machines).
  • Road cycling as tolerated.

Goals

  • Initiate road cycling.
  • Full range of motion of knee.

Weeks 8 - 12

  • Add lateral training exercises (i.e. lateral stepping, lateral step-ups, step-overs).
  • Progress proprioceptive and balance exercises, increase dynamic challenge.
  • Begin to incorporate sport-specific training (i.e. volleyball bumping, light soccer kicks and ball skills).

Goals

  • Full knee range of motion. 5/5 muscle strength in surgical leg.
  • Initiate sport-specific training.

Weeks 12 - 16

  • Complete Sport Test 1; initiate pre-running program (see additional handout for specific details).
  • Incorporate bilateral jumping and bounding exercises, making sure to watch for compensatory patterns and any signs of increased pronation and/or valgus moment with take-offs or landings.
  • Patients should be weaned into a home program with emphasis on their particular activity.

Goals

  • Complete and pass Sports Test 1, initiate pre- running drills/plyometrics.

Weeks 16 +

  • Initiate return to running program.
  • Sagittal plane plyometric training focus on form and control.
  • Working towards single-leg plyometric training.

NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.

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