ACL Reconstruction - Accelerated Rehabilitation Program
            (Quadrupled Hamstring or Allograft Protocol)

General:
1. Hamstring or allograft rehab is generally easier because extensor mechanism is not violated.
2. Graft integration into bone takes longer (10-12 weeks vs. 6 weeks for BTB).
3. Preoperative program is the same regardless of graft choice.
4. Ultimate outcome appears equal in double-blind prospective studies using autograft tissue and secure fixation techniques.

Philosophy:
Program is modeled after the Shelbourne protocol for bone-patellar-bone rehab. (The Physician and Sports Medicine. Vol 28(1), 31-44, January 2000). Consists of five phases:

1. Preoperative phase.
2. Early Postoperative Phase (Week 1).
3. Ambulation and Protection Phase (Weeks 2-3).
4. Concentrated Rehabilitation (Weeks 4-12).
5. Sport Specific Rehabilitation (Weeks 13-24 or more).

1. Preoperative Phase.
Initial goals of rehab are to reduce swelling, return knee range-of-motion, restore normal gait pattern, re-establish quadriceps control/strength (may take 2 weeks to 2 months) and educate the patient on post-operative rehab program.

Goals

Exercise or Modalities
Reduce Swelling. Cold compression cuff.
Return knee range-of-motion Heel-slice exercise.
Regain hyperextension. Heel-prop and prone hang exercise.
Restore normal gait pattern. Gait training, heel to toe crutch.
Restore quad control Quad sets, SLRs, multiple angle co-contractions.
Educate patient. Review post-op program.

 

2. Early Postoperative Phase (Week 1).
Goals are to minimize hemarthrosis and swelling, promote wound healing, obtain full extension, regain quad control, and achieve at least 90 degree flexion. Patient is discharged with cryocuff, crutches and knee immobilizer in extension for walking with WBAT to bathroom and a home CPM unit set to move from 0-30 degrees.

He/She will be seen on POD #1 by physician for dressing change, drain removal, operative explanation and confirmation of full extension, good quad set and SLR. Patient is allowed to bear weight as tolerated with crutches, but is encouraged to be up and about only for bathroom privileges and meals. During the remainder of this time, the patient is to rest, limit walking and elevate the surgically repaired extremity.

Follow-up with physical therapist is at POD #4-5 to monitor the patient’s progress and aid in achieving the above goals. CPM unit is returned after one week unless range-of-motion is poor.

Goals

Exercise or Modalities
Eliminate hemarthrosis and pain. CPM (0-30) and cold compression cuff.
Achieve hyperextension and flexion of > 90 degrees Heel prop (10 minutes every waking hour)
CPM (flexion exercises 6 times daily)
Heel-slide exercises.
Re-establish leg control. Quad contraction exercises, E-stim if needed, WB as tolerated, Crutch use as needed.

 

3. Ambulation and Protection Phase (week 2 and 3).
Goals are to establish good leg control, maintain full hyperextension and increase flexion, evolve to a normal gait pattern, start to regain proprioceptive awareness and continue to minimize swelling. Patient will see physician POD #7-8 for suture removal and wound check. Rehab progress will be observed and communication with the physical therapist will be based on clinical findings. Patient will follow-up with physical therapist at POD #14.

Goals

Exercise or Modalities
Minimize swelling. Cold compression cuff and Ace wrap.
Quad sets 25-50 times per hour.
Maintain hyperextension and increase flexion. Heel prop and prone hand exercises, heel-slide to 100-110 degrees, AA flexion.
Achieve good leg control. SLRs, multi-angle isometrics,
closed chain mini-squats.
Progress to normal gait. Wean off immobilizer and crutches as leg control normalizes (by the end of week 3).

 

4. Concentrated Rehabilitation Phase (Week 4-12).
Patient progresses to linear physiologic exercise program to build leg strength and coordination while putting minimal stress on the graft. Evaluated by physician on POD #21 and physical therapist at POD #28. Maintain hyperextension and progress to 130 degrees of flexion. Reduce activity if swelling returns. Increase closed-chain activities. Re-evaluation by physician at end of week 6 and therapist at end of week 8.

Goals

Exercise or Modalities
Maintain hyperextension and regain flexion. Heel prop and prone hang exercises.
Control swelling. Reduce activity if swelling returns
Increase flexion. Heel-slide and towel-pull exercises
Increase quadriceps, hamstring and hip strength, and coordination. Stairmaster, calf raises, hip joint exercises, forward lunges. Start stationary biking and stair climb.

 

5. Sport Specific Activities (week 13-24 and greater).
Goals are to increase activity levels while avoiding undue stress on the graft. Biking is increased. Rope jumping and straight ahead running can begin at week 16. Initiate lateral shuffles, agility drills, controlled run and cut after 20 weeks. Enrollment in Sports Dynamics ACL Prevention program is encouraged before return to competitive sports. After 24 weeks, the patient may return to full sports participation when demonstrates full range-of-motion, no effusion, good knee stability and has completed a running or ACL Prevention program. Expect three months to be competitive.

 

Physician/ PA Visits

PT Visits
  POD #1

 
  POD #7-8 POD #4-5
  3 weeks POD #14
  6 weeks 4 weeks
  12 weeks 8 weeks
  5 months 16 weeks
  9 months 6 months
  12 months  


Following these instructions will lead to a speedy recovery.

The most important factor in your recovery… is You!

 

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3/1/2006

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