This protocol is intended to be a general outline only. The physician reserves the right to either advance or delay this protocol as deemed necessary. If so, this should be done by direct communication with the therapist, or in writing on the therapy referral form given to the patient on the day of surgery.
General Guidelines for Crutches and TROM Brace
- Bilateral axillary crutches to be used immediately post-op, NWB’ing x 2 weeks. At 2 weeks post op, begin PWB’ing in TROM and progress to full weight bearing by 6 weeks.
- TROM brace to be worn for all ADL’s except sleeping, bathing, and exercises.
- At Week 6, patient can gradually initiate weightbearing with TROM brace unlocked once able to perform SLR independently and good quad control is achieved. Discharge TROM once patient has a normal gait pattern.
- No prone knee flexion ROM until 8 weeks post-op.
Guidelines for Wound Care
- Place occlusive dressing over steri-strips at wound sites at first visit. Change occlusive dressing every other day, leaving steri-strips on unless they come off easily. Cover old steri-strips with new ones if needed.
- Keep wound sites covered with occlusive dressing until stitches are removed. After that, cover with standard adhesive bandages (wrapping knee in plastic wrap for showers) until wounds are fully healed.
Frequency of Physical Therapy Visits
Schedule physical therapy at Day One Post-Op.
Schedule 1x/week for the first four weeks.
Increase to 2-3x/week to begin more aggressive PROM knee flexion at Week 4.
Day 1 Post-Op
- Remove bulky dressings. Leave steri-strips on; place occlusive dressing over all portals and incisions.
- Discard post-op immobilizer if used. Issue TROM brace.
- Provide patient with home e-stim unit to be used while doing quad sets and SLR’s
- Initiate heel prop knee ext stretch to encourage full knee extension if needed.
- Quad sets, SLR’s, open-chain hip and core strengthening.
- Ankle pumps / elastic band ankle exercises.
- Frequent icing using “Game Ready” machine or Cryocuff for first 2-7 days.
Week 1-6: Patient to be seen 1x/week
PROM Goal: 90 degrees flexion @ Week 4, 110 degrees flexion @ Week 6.
Unlock TROM at Week 6 if quad control adequate.
- Continue above exercises
- Perform electric stimulation to the quadriceps for muscle recruitment
- Add side-lying hip abduction and extension exercises
- Teach home self-ROM with foot on the wall or over EOB within protocol restrictions.
- PROM initially to 45 degrees flexion for Week 1.
- Increase range of motion by 15-20 degrees each week.
- Progress to standing weight shifts, heel raises, soleus reaches, and standing resisted TKE’s with band.
Week 7-12: Patient to be seen as needed
PROM Goal – Full ROM by 8 weeks.
- Unlock, then D/C TROM when quad strength is sufficient.
- Use of ERMI Flexionator as needed in clinic and/or at home
- Place patient in Breg PTO Brace for all weightbearing activities once TROM is D/C’d
- Add resistance to above exercises as tolerated
- Stationary bike for ROM without resistance
- When patient has good quad recruitment, add small-range closed-chain flexion linebackers (0-45°), mini-squats (0-30°), etc.
- Single leg stance with reaching activities, ball toss, etc.
- Lateral lunges to non-operative side.
- RDLs, progress to single leg RDLs.
Week 12 – 16
- Add forward lunges and lunges to operative side, progressing to lunge walking with dumbbells
- Add shuffles, progressing to crossover (karaoke) shuffles
- Progress to bilateral and unilateral leg exercises on unstable surfaces (Airex pad, BOSU ball etc.) as tolerated
- Add step-ups (forward and lateral), resisted sidestepping using pulley around waist or elastic band around thighs
- Add leg press from 10-60° of flexion with bilateral legs
- Initiate Proprio machine training, Pilates Reformer, shuttle, etc.
Week 16 and Beyond
- Unilateral leg press, single leg squats
- Perform Proprio Test and baseline sport-specific tests (Y Balance, etc.).
- Begin jogging and then progress to running drills if patient has good control and endurance with above exercises.
- Progress to bilateral and unilateral hopping drills.
- At 4-6 Months Post-Op: Patient seen on as-needed basis for Phase IV training and HEP progression as appropriate once cleared by MD and therapist (see below).
Return to Play
- Assess for return to sport-specific training using the FMS/Move2Perform program or other standardized testing. Tests may include Single Hop Test, the Triple Hop Test (Goal = within 90% of non-operative LE), Y Balance Test, and Quad Girth within one inch of non-operative LE.
- Once patient has excellent eccentric control of LE, progress to the following: • Bilateral and unilateral hopping drills • Running, cutting, and pivoting. • Begin sport-specific drills using soccer ball, basketball, etc.
- Contact Sports: Prior to return to sports, patient should complete standard Proprio Test, showing good leg control and side-to-side symmetry. Begin non-competitive or competitive play once physician and therapist are satisfied with sport-specific functional drill performance.
Return to Sport Guidelines
Running: Begin independent jogging at 4 months post-op, increasing running time by 5-minute increments to tolerance. Begin more strenuous running programs incorporating various terrain and inclines at 6 months post-op.
Revised 9.27.15 TJB