This protocol is intended to be a general guideline. The physician staff may advance, delay, or alter this protocol based on individual patient status. If so, this should be done by direct communication with the therapist, or in writing on the therapy referral form pro-vided to the patient or therapist.
Guidelines for Pre-Op Physical Therapy
- Patient will receive instruction from Dr. Chams or one of his physician extenders on post-operative expectations, post-op Day One exercises, and use of crutches or an-other assistive device. If deemed necessary at that time, the patient may be referred for one pre-op PT visit to receive gait training, review post-op exercises, and discuss post-op expectations.
- If seen pre-op in PT clinic, patient should be instructed in edema control and post-op exercises (quad set, SLR, ankle pumps) and the importance of resting knee in full knee ext to avoid flexion contracture.
Guidelines for Post-Op Physical Therapy
- Therapy beings on Day One post-op in the outpatient clinic.
- Patient is typically seen in clinic 2x/week for 12 to 20 weeks post-operatively (or more, depending on patient status and ADL demands).
Guidelines for MD Follow-Up Visits (including telehealth)
- At two weeks post-op, patient will be seen in clinic for removal of stitches and follow up.
- At six weeks post-op, patient may be seen by physician extender through telehealth video communication during an in-clinic PT session to connect with patient and treat-ing therapist about current ROM and strength status.
Additional follow-ups with MD staff will be scheduled as needed.
Guidelines for Wound Care
- Original steri-strips should be left in place until stitch removal. They can be reinforced with more if needed.
- On Day One post-op, remove post-op cotton wrapping. Place 2×2 gauze and occlu-sive dressing over wound sites. Change dressings as needed and do not allow wounds to become wet.
- Instruct patient to wrap knee in “press and seal” plastic wrap for showering until 3-5 days after stitches are removed (make sure wounds are fully healed before being ex-posed to water).
Guidelines for Ambulation and Hinged Knee Brace
- Unless otherwise specified, patient will be TDWB (foot flat) for four weeks post-op.
- Hinged (TROM) knee brace will be issued at surgical center. Brace to be worn and locked at 0 degrees extension with all ADL’s for first 4 weeks (includes sleep-ing). Brace may removed for bathing and unlocked or removed for exercises.
- At 4 weeks post-op, begin WBAT with brace locked in extension for an additional 2 weeks unless otherwise instructed by physician staff.
- At 6 weeks post-op, allow FWB gait without brace or with hinge unlocked, depending on quad control.
- Continue to use brace in crowds or on unstable surfaces for first 12 weeks post-op.
Meniscal Repair Precautions
- No closed-chain knee flexion for first eight weeks.
- No resisted hamstring exercises (open or closed chain) for first three weeks.
- PROM restricted to 90 degrees for first 4-6 weeks (based on surgeon instruction)
- After above PROM restrictions are lifted, flexion ROM performed in supine or prone to tolerance is allowed.
Day One Post-Op
- Review post-op exercises and edema control (ice/elevation): quad set, SLR, full knee ext (heel prop if necessary).
- Adjust hinged knee brace to leg for proper fit in clinic and instruct patient on how to don/doff brace.
- Initiate NMES for quad recruitment if patient has difficulty with quad setting. Consider home unit if appropriate.
- PROM knee flex (around 0-45 degrees) and instruction in self-AAROM (any position) for ROM progression
Week 1- Week 6
ROM Goal: 90 degrees flexion by Week 4
- Optional: Add in-clinic personalized blood flow restriction if appropriate.
- NWB’ing hip exercises: S/L hip abd, prone hip extension and abduction
- Ankle strengthening with elastic resistance (avoid torque on knee)
- Core strengthening (crunches, UE resistance, neutral spine stabilization)
- Use of in-clinic personalized Blood Flow Restriction and/or NMES for muscle re-edu-cation in NWB’ing
- Issue home NMES unit if needed for NWB’ing quad recruitment.
- At Week 4, begin WB’ing exercises in TROM (or without TROM in clinic), avoiding all closed-chain knee flexion.
- Heel raises, weight shifting, ski jumpers, calf stretches, SLS on stable surfaces.
Week 6 – 8
- Progress flexion ROM as tolerated, weaning from TROM as able
- Standing terminal knee extension with resistance
- Gait training for normalization of gait pattern
- Advanced gait (backwards, tandem, hurdles)
- Initiate stationery bike for ROM (no resistance)
Precaution: Squats and lunge instruction should emphasize no forward transla-tion of the knee to avoid patellofemoral stress.
Goal: Full knee flexion by Week 12.
- Patient may begin swimming (flutter kick) and elliptical machine. May add resistance to stationery bike.
- Closed-chain knee flexion strength progression: step ups, squats, single leg squats, and RDL’s.
- Lateral lunges, progressing to forward lunges (avoid ant translation of knee)
- Incorporate machines if desired, avoiding seated knee ext machine long-term.
- Step downs with progressive depth
- Balance drills, progress to unstable surfaces (tilt board, BOSU ball, foam, etc.) and perturbations as tolerated
- Agility ladder drills (no plyo)
Week 16 to Discharge
- Perform Phase IV and sport-specific exercises when appropriate: jogging starting at Week 16, then progress to running, cutting, pivoting, and perturbation training.
- Advance to progressive plyometric activity:
- Lateral shuffles
- Advanced ladder agility drills
- Begin double-leg jumping in place. Then add distance, height and rotational chal-lenges.
- Progress to single leg hopping in place. Then add distance, height, rotational, and proprioceptive challenges.
- Discharge when patient has achieved full ROM, is independent with ongoing HEP for strength/ROM/coordination/flexibility, and has ability to perform all ADLs and work du-ties.