knee---acl-allograft-protocol.pdf

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 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.

• 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 of

brace and crutches may be extended by the physician.

• Supervised physical therapy takes place for 3-9 months.

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

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

• 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

REHABILITATION PROGRESSION

PHASE I:

Immediately postoperatively through 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 WOMEN’S HOSPITAL

Department of Rehabilitation Services

Physical Therapy

ACL Allograft Reconstruction Protocol

Brace:

• Post op brace 0-6 weeks

• 1

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

Criteria for advancement to Phase II:

• 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 full

extension and can SLR without extension lag.

ACL Allograft Reconstruction Protocol

•

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:

• 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

Therapeutic Exercises:

• 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

Criteria for advancement to Phase IV:

• 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.

ACL Allograft Reconstruction Protocol

Therapeutic Exercises:

• 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 +

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:

• Initiate cutting and jumping activities

• Completion of appropriate functional progression

• Maintenance of strength, endurance, proprioception

• Patient education with regards to any possible limitations

Therapeutic Exercises:

• 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

Marie-Josee Paris, PT

April, 2006

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

April, 2008 Mike Cowell, PT

Deleted: ¶