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 ACL Tear Nonoperative Rehabilitation

PHASE I - IMMEDIATE INJURY PHASE (Day 1 to Day 7)

 

Goals:    

Restore full passive knee extension

Diminish joint swelling and pain

Restore patellar mobility

Gradually improve knee flexion

Re-establish quadriceps control

Restore independent ambulation

 

Post-Injury Day 1- 3

 

Brace: Brace/Immobilizer applied to knee, locked in full extension during ambulation as directed by physician

 

Weight Bearing: Two crutches, weight bearing as tolerated

 

Exercises: 

*Ankle pumps

*Overpressure into full, passive knee extension

*Active and Passive knee flexion (90 degree by day 5)

*Straight leg raises (Flexion, Abduction, Adduction)

*Quadriceps isometric setting

*Hamstring stretches/ calf stretches

*Closed kinetic chain exercises:  mini squats, weight shifts        

 

Muscle Stimulation:              Use muscle stimulation during active muscle exercises (4-6 hours per day)

                 

Ice and Elevation:                  Ice 20 minutes out of every hour and elevate with knee in full extension, may

                                                      use e-stim for edema control             

Post-Injury Day 3 to 7

 

                  Brace:  Locked at zero degrees extension for ambulation and unlocked for sitting

 

                  Weight Bearing: Two crutches weight bearing as tolerated

                 

                  Range of Motion: Remove brace to perform range of motion exercises 4-6 times per day, knee flexion 90 degrees by day 5,     approximately 100 degrees by day 7

 

Exercises:                                 

*Multi-angle isometrics at 90 and 60 degrees (knee extension)

*Knee Extension 90-40 degrees

*Overpressure into extension

*Patellar mobilization

*Ankle pumps

*Straight leg raises (3 directions)

*Mini squats and weight shifts

*Standing Hamstring curls

*Quadriceps isometric setting

*Proprioception and balance activities

*Continue Hamstring and calf stretching

 

                 

Muscle Stimulation:              Electrical muscle stimulation (continue 6 hours daily)

 

Ice and Elevation:                  Ice 20 minutes of every hour and elevate leg with knee full extension

 

 

PHASE II - INTERMEDIATE REHABILIATION PHASE (Week 2-4)

Criteria to Progress to Phase II

 

  1. Quad Control (ability to perform good quad set and SLR)

  2. Full passive knee extension

  3. PROM 0-90 degrees

  4. Good patellar mobility

  5. Minimal joint effusion

  6. Independent ambulation

 

Goals:     Maintain full passive knee extension (at least 0 to 5-7 hyperextension)

Gradually increase knee flexion

Diminish swelling and pain

Muscle training

Restore proprioception

Patellar mobility

Week Two

 

Brace:                                         Discontinue brace or immobilizer at 2 to 3 weeks per physician

 

Weight Bearing:                     As tolerated (goal is to discontinue crutches 10-14 days post injury)

 

Range of Motion:                   Self-ROM stretching (4-5 times daily), emphasis on maintaining full, passive range of motion progress flexion as tolerated

 

Exercises:                                    *Muscle stimulation to quadriceps exercises

                                                      *Isometric quadriceps sets

                                                      *Straight Leg raises (4 planes)

                                                      *Leg Press (0-60 degrees)

                                                      *Knee extension 90-40 degrees

                                                      *Half squats (0-40)

                                                      *Weight shifts

                                                      *Gait training with cones                                       

                                                      *Front and side lunges

                                                      *Hamstring Curls                                    

                                                      *Bicycle

                                                      *Proprioception training

                                                      *Tilt board squats

                                                      *Dip walking

                                                      *Overpressure into extension

                                                      *Passive range of motion from 0 to 50 degrees

                                                      *Patellar mobilization

                                                      *Well leg exercises

                                                      *Progressive resistance extension program – start with 1 lb., progress 1 lb. per week

                                                      *Continue stretching program

 

Swelling control:                     Ice, compression, elevation, e-stim

Week Three

 

Brace:                                         Discontinue

 

Range of Motion:                   PROM should be full or near full ROM

 

Passive Range of Motion:   Continue range of motion stretching and overpressure into extension

 

Exercises:                                  *Continue all exercises as in week two

                                                      *Passive Range of Motion as tolerated

                                                      *Bicycle for range of motion stimulus and endurance

                                                                        *Pool walking program (if incision is closed)

                                                                        *Eccentric quadriceps program 40-100 (isotonic only)

                                                                        *Lateral lunges

                                                                        *Lateral step ups

                                                                        *Lateral cone step overs

                                                                        *Stair-Stepper machine

                                                                        *Progress Proprioception drills, neuromuscular control drills

                                   

PHASE III - ADVANCED STRENGTHENING/NEUROMUSCULAR CONTROL PHASE (Week 4-8)

 

Criteria to Enter Phase III

 

  1. Full ROM

  2. Quadriceps strength 60%>contralateral side (isometric test at 60 degree knee flexion)

  3. Minimal to no full joint effusion

  4. No joint line or patellofemoral pain

 

Goals:     Maintain full knee range of motion (0 to 125 degrees)

Improve lower extremity strength

Enhance proprioception, balance, and neuromuscular control

Improve muscular endurance

Restore limb confidence and function

 

Brace:                                         No immobilizer or brace, may use knee sleeve or fit for function all brace

 

Range of Motion:                   Self-ROM (4-5 times daily using the other leg to provide ROM), emphasis on

                                                      maintaining full ROM

 

            Week 4

 

Exercises                                    *Progress isometric strengthening program

                                                      *Leg Press

                                                      *Knee extension 90 to 40 degrees

                                                      *Hamstring curls

                                                      *Hip Abduction and Adduction

                                                      *Hip Flexion and Extension

*Lateral Step-Overs

                                                      *Lateral Lunges

*Lateral step ups

*Front step downs

*Wall Squats

*Vertical squats

*Toe Calf Raises

*Biodex Stability System (balance, squats, etc.)

*Proprioception drills

*Bicycle

*Stair climber machine

*Pool program (backward running, hip and leg exercises)

                  Week 6

 

Exercises:                                  *Continue all exercises

                                                      *Pool running (forward) and agility drills, jumping

                                                      *Progress to balance and tilt board throws, perturbation training

                                                      *Advanced Neuromuscular control drills:

                                                                        -CKC on unstable surfaces

                                                                        -Lunges onto foam

                                                                        -Step ups on foam

                                                                        -Perturbation training

                                                      *Wall slides/squats

                                                      *Muscular training for fast reaction times

-High speed hamstring curls

*Progress dynamic stabilization drills

-Tilt board perturbations

 

PHASE IV - ADVANCED ACTIVITY PHASE (Week 8-12)

                 
Criteria to Enter Phase IV

 

  1. Full ROM

  2. Quad strength 75% of contralateral side, knee extension flexor:extensor ratio 70% to 75%

  3. No pain or effusion

  4. Satisfactory clinical exam

  5. Satisfactory isokinetic test (values at 180 degrees)

Quadriceps bilateral comparison 75%

Hamstrings equal bilateral

Quadriceps peak torque/body weight 65% at 180o/s (males) 55% at 180o/s (females)

Hamstrings/quadriceps ratio 66% to 75%

  • Subjective knee scoring >80%

 

Goals:     Normalize lower extremity strength

                  Enhance muscular power and endurance

                  Improve neuromuscular control

                  Perform selected sport-specific drills

 

Exercises:                                  *Continue all exercises

                                                   *Advanced Neuromuscular control drills:

                                                   *Plyometric program

                                                      -Leg press plyometrics

                                                      -Box jumps

 

 

PHASE V - RETURN TO ACTIVITY PHASE (Month 12-22)

                  Criteria to Enter Phase V

 

  1. Full Range of Motion

  2. Isokinetic Test that fulfills criteria if available

  3. Quadriceps bilateral comparison (80% or greater)

  4. Hamstring bilateral comparison (110% or greater)

  5. Quadriceps torque/body weight ratio (55% or greater)

  6. Hamstrings/Quadriceps ratio (70% or greater)

  7. Proprioceptive Test (100% of contralateral leg)

  8. Functional Test (85% or greater of contralateral side)

  9. Satisfactory clinical exam

  10. Subjective knee scoring >90%

 

Goals:     Gradual return to full-unrestricted sports 8 activities

                  Achieve maximal strength and endurance

                  Normalize neuromuscular control

                  Progress skill training

 

                  Exercises:                                     *Continue strengthening exercises

                                                                        *Continue neuromuscular control drills

                                                                        *Continue plyometrics drills

                                                                        *Progress running and agility program

                                                                        *Progress sport specific training

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