ACL-PCL Protocol

ANTERIOR CRUCIATE LIGAMENT AND POSTERIOR
CRUCIATE LIGAMENT COMBINED RECONSTRUCTION

SURGERY REHABILITATION PROGRAM
I. IMMEDIATE POSTOPERATIVE PHASE (Day 1 - 13)
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
POSTOPERATIVE DAY 1 - 4
Brace:
Drop lock brace locked at zero degrees extension with compression wrap
Sleep in brace
Weightbearing:
Two crutches as tolerated (less than 50%)
Range of Motion:
Range of motion 0 – 45/50°
CPM 0 - 60° as tolerated
Exercises:
Ankle pumps
Quad sets
Straight leg raising – flexion, abduction, adduction in brace
Muscle stimulation to quadriceps (4 hours per day) during quad sets & straight leg raises
Patellar mobilizations 5-6x daily
Ice and elevation every 20 minutes of each hour with knee in extension
POSTOPERATIVE DAY 5 – 13
Brace:
Continue use of drop lock brace locked at zero degrees extension during ambulation & sleep
Weightbearing:
Two crutches: gradually increase WB to 50% by day 7; 75% by day 12
Range of motion:
Day 5: 0 - 65°
Day 7: 0 - 75°
Day 10: 0 - 85/90°
Day 13: 0 - 90°
Gradually increase CPM ROM 0 - 70° day 7; 0 - 90° day 12
Exercises:
Continue previous exercises
Initiate knee extension 60 - 0°
Continue use of muscle stimulation
Continue use of ice, elevation, and compression

Page 2 of 5
II. MAXIMUM PROTECTION PHASE (Week 2 to 6)
Criteria to Enter Phase II:

1) Good 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
Goals: Control deleterious forces to protect grafts

Nourish articular cartilage
Decrease swelling
Decreased fibrosis
Prevent quad atrophy
Initiate proprioceptive exercises
WEEK 2
Brace:
Continue use of brace locked at zero degrees of extension
Weightbearing:
As tolerated; approximately 75% body weight
Range of Motion:
Continue to perform passive ROM 5-6x daily
Day 14: 0 - 90°
Exercises:
Continue quad sets & straight leg raises
Continue knee extension 60 - 0°
Multi-angle isometrics at 80°, 60° and 40°
Well leg bicycle
Weight shifts
Mini-squats (0 - 45°)
Continue use of muscle stimulation
Continue ice, elevation, and compression
WEEK 3
Continue above mentioned exercises
ROM: 0 - 90°
Continue use of 2 crutches - 75-80% body weight
WEEK 4
Brace:
Continue use of brace locked at zero degrees extension
Discontinue sleeping in brace
Weightbearing:
Progress to weight bearing as tolerated with 1 crutch
Range of Motion:
AAROM, PROM: 0 – 90/100°
Exercises:
Weight shifts
Mini-squats (0 - 45°)
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Page 3 of 5
Knee extension 90 - 40° (therapist discretion)
Light pool exercises and walking

Initiate bicycle for ROM & endurance
Begin leg press 60 - 0° (light weight)
Proprioception/balance drills
KT-2000 testing performed – 20 pound (at 25° and 70°)
WEEK 5 – 6
Discontinue use of crutches week 5 – 6

Unlock brace for ambulation week 6
Fit for functional ACL/PCL brace
Range of Motion week 5: 0 - 105°; week 6: 0 - 115°
Continue pool exercises
Initiate lateral lunges
Hip abduction and adduction
KT-2000 testing performed – 30 pounds at week 6
III. MODERATE PROTECTION PHASE (Week 7 – 12)
Criteria to Enter Phase III:

1) PROM 0 – 115 degrees
2) Full weightbearing
3) Quadriceps strength > 60% contralateral side (isometric test at 60°)
4) Unchanged KT test (+1 or less)
5) Minimal to no full joint effusion
6) No joint line or patellofemoral pain
Goals: Control forces during ambulation

Progress knee range of motion
Improve lower extremity strength
Enhance proprioception, balance, and neuromuscular control
Improve muscular endurance
Restore limb confidence and function
Brace:
Continue use of unlocked brace for ambulation – discharge week 7 – 8
Range of Motion:
AAROM/PROM 0 - 125°
Exercises:
Initiate swimming
Initiate lateral and front step-ups (2” step, gradually increase)
Progress closed kinetic chain exercises (squats 0 - 60°, leg press 90 - 0°)
May begin light hamstring isotonics week 8
Progress proprioceptive training
KT-2000 test: 20 & 30 pounds at week 6 & 8

Page 4 of 5
IV. CONTROLLED ACTIVITY PHASE (Week 13 – 16)
Criteria to Enter Phase IV:

1) AROM 0 - 125°
2) Quadriceps strength > 60-70 contralateral side (isokinetic test)
3) No change in KT scores (+2 or less)
4) Minimal effusion
5) No patellofemoral complaints
6) Satisfactory clinical exam
Goals: Protect healing grafts

Protect patellofemoral joint articular cartilage
Normalize lower extremity strength
Enhance muscular power and endurance
Improve neuromuscular control
Exercises:
Emphasis on eccentric quadriceps strengthening
Continue closed kinetic chain mini-squats, step-ups, step-downs, lateral lunges, leg press
Continue knee extension 90 - 40°
Hip abduction & adduction
Initiate front lunges
Calf raises (gastroc and soleus strengthening)
Bicycle and stairmaster for endurance
Initiate pool running (side shuffle, backward, forward)
Initiate walking program
Initiate isokinetic exercise 100 - 40° (120-240 °/s spectrum)
KT-2000 test at week 12

Isokinetic testing at week 12 (180° and 300°/s)
V. LIGHT ACTIVITY PHASE (Month 4 – 6)
Criteria to enter Phase V:

1) AROM > 125 degrees
2) Quadriceps strength 70% of contralateral side; flexion/extension ratio 70-79%
3) No change in KT scores (+2 or less)
4) Minimal joint effusion
Goals: Enhancement of strength, power, and endurance

Initiate functional and/or sport-specific activity
Prepare for return to functional activities
Exercises:
Continue strengthening exercises – emphasize quadriceps & co-contraction
Initiate plyometric program month 4-5
Initiate running program month 4-6
If appropriate
Initiate agility drills month 5-6
Initiate sport-specific training and drills month 5-6
Isokinetic strength test at week 16 & week 18

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Criteria to initiate running program:

Acute reconstruction may begin at 4 – 5 months
Chronic reconstruction may begin at 5 – 6 months
Satisfactory clinical exam
Unchanged KT test
Satisfactory isokinetic test
Quadriceps bilateral comparison (80% or greater)
Hamstring bilateral comparison (110% or greater)
Quadriceps torque/body weight ratio (55% or greater)
Hamstrings/Quadriceps ratio (70% or greater)
Proprioception testing 100% of contralateral side
Functional hop test > 75% of contralateral leg
VI. RETURN TO ACTIVITY PHASE (Month 6 – 9)
Criteria to return to activities:

2) Unchanged KT test
3) Satisfactory isokinetic test
4) Proprioception testing 100% of contralateral side
5) Functional hop test > 80% of contralateral leg
Goals: Gradual return to full-unrestricted sports

Achieve maximal strength and endurance
Normalize neuromuscular control
Progress skill training
Exercises:
Continue strengthening programs
Continue proprioception & neuromuscular control drills
Continue plyometric program
Continue running and agility program
Progress sport specific training and drills
CLINICAL FOLLOW-UPS AT 6, 12, & 24 MONTHS POSTOPERATIVE:
KT-2000 testing
Isokinetic testing
Functional testing
Clinical exam


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ANTERIOR CRUCIATE LIGAMENT AND POSTERIOR

CRUCIATE LIGAMENT COMBINED RECONSTRUCTION

I. IMMEDIATE POSTOPERATIVE PHASE (Day 1 - 13)

Goals: Restore full passive knee extension

Continue use of ice, elevation, and compression

II. MAXIMUM PROTECTION PHASE (Week 2 to 6)

Criteria to Enter Phase II:

Goals: Control deleterious forces to protect grafts

Continue ice, elevation, and compression

Copyright © 2004-2010 by the Advanced Continuing Education Institute, LLC. www.AdvancedCEU.com.

Knee extension 90 - 40° (therapist discretion)

Light pool exercises and walking

KT-2000 testing performed – 20 pound (at 25° and 70°)

Discontinue use of crutches week 5 – 6

KT-2000 testing performed – 30 pounds at week 6

III. MODERATE PROTECTION PHASE (Week 7 – 12)

Criteria to Enter Phase III:

Goals: Control forces during ambulation

KT-2000 test: 20 & 30 pounds at week 6 & 8

Copyright © 2004-2010 by the Advanced Continuing Education Institute, LLC. www.AdvancedCEU.com.

IV. CONTROLLED ACTIVITY PHASE (Week 13 – 16)

Criteria to Enter Phase IV:

Goals: Protect healing grafts

KT-2000 test at week 12

V. LIGHT ACTIVITY PHASE (Month 4 – 6)

Criteria to enter Phase V:

Goals: Enhancement of strength, power, and endurance

Isokinetic strength test at week 16 & week 18

Copyright © 2004-2010 by the Advanced Continuing Education Institute, LLC. www.AdvancedCEU.com.

Criteria to initiate running program:

VI. RETURN TO ACTIVITY PHASE (Month 6 – 9)

Criteria to return to activities:

Goals: Gradual return to full-unrestricted sports

CLINICAL FOLLOW-UPS AT 6, 12, & 24 MONTHS POSTOPERATIVE:

Copyright © 2004-2010 by the Advanced Continuing Education Institute, LLC. www.AdvancedCEU.com.

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