Knee-multi-lig-MBergin

REHABILITATION GUIDELINES AFTER
MULTIPLE LIGAMENT KNEE RECONSTRUCTION
Mark A. Bergin, MD
St Clair Orthopaedics & Sports Medicine
(586) 773-1300
Please send progress notes
The intent of this protocol is to provide the physical therapist with guidelines of the post-
operative rehabilitation course after multi-ligament reconstruction surgery. It should not 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. The physical therapist should consult the referring physician
with any questions or concerns.
INDIVIDUAL CONSIDERATIONS:
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GENERAL CONSIDERATIONS
• WBAT for PCL/or ACL/PCL injuries

• NWB for combined MCL reconstruction for 5 weeks, then PWB for 1 week, then
FWB at 6 weeks
• NWB for combined PLC reconstruction or repair for 6 weeks, then PWB for 6
weeks, then FWB at 12 weeks postop.
• No active hamstring activity for 8 weeks after PLC reconstruction
• No hamstring strengthening for 16 weeks after PLC reconstruction
PHASE I (0-2 weeks)

Goals
• Control inflammation and pain
• Full active extension
• Achieve quadriceps control
Brace
• Locked in extension for ambulation for 4 weeks for ACL/PCL and/or MCL
reconstructions, then unlocked for ambulation for 2-4 weeks until normal gait is
established.
1
• Locked in extension for ambulation for 12 weeks for PLC reconstruction
• May remove for ROM exercises
• Keep brace locked in extension for SLRs for 6 weeks to prevent posterior sag,
may remove when quad control is good enough to prevent extension lag
Weight-Bearing Status
• WBAT with crutches for ACL/PCL
• NWB for 5 weeks, PWB for 1 weeks, then FWB for MCL
• NWB for 6 weeks, PWB for 6 weeks, then FWB for PLC
• NWB for all ambulatory activities and use a long leg brace locked in full
extension at all times.
• Allowed to bear weight equally on both legs when standing stationary.
• Begin PWB gait of approximately 20% of body weight and increase
incrementally by 20% each week.
Therapeutic Exercises
• SLR in all planes (with brace locked in extension)
• Calf pumps, quadriceps sets
• Electrical stimulation
• Patellar mobilization
• Cryotherapy,elevation,TENS/NMES, ankle pumps and elevation
• Balancing activities on a stable platform with eyes open and closed
PHASE II (2- 6 weeks)
Criteria
• Good quad set and SLR with brace
• Full extension
• No active inflammation
Goals
• Achieve 90 degrees of flexion
• Protect graft fixation
Brace/Weight-bearing status
• As above in Phase I
• Starting at 5 weeks, long leg brace is opened for full flexion for ROM
exercises and patient is encouraged to begin passive or active-assisted flexion
WITHOUT active hamstring activity. Brace can be discontinued at night.
Stationary bicycling permitted.
• Begin ROM
• Prone passive knee flexion to 90 degrees with care to avoid posterior tibial sag
2
• Wall slides then progress to mini-squats (0-45 degrees) when quad control is good
o AVOID if PLC reconstruction was performed for 8 weeks
• Pool walking to restore normal gait pattern
• Toe raises
• Gastroc stretches
• Ankle strengthening with sports tubing (Theraband)
• Continue quadriceps strengthening and patellar mobilization.
• Starting at 5 weeks, can begin short and long arc quadriceps strengthening.
Hip strengthening can be initiated but should avoid motions that promote
increased knee varus or valgus stress depending on involved structures.
PHASE III (6-12 weeks)
Criteria
• Knee flexion to 90 degrees
• No active inflammation
• Good quadriceps control
Goals
• Achieve full flexion
• Establish normal gait
• Progress with strengthening and endurance
Brace/Weight-Bearing Status
• FWB with brace unlocked, may discontinue brace when normal gait is established
for ACL/PCL and/or MCL reconstructions
• PWB with brace locked in extension for PLC reconstruction
• Starting at week 10, long-leg brace is discontinued and patient is fitted for a
functional brace for ADL that may stress the reconstruction.
Therapeutic Exercise
• Begin active knee flexion at 6 weeks for ACL/PCL and/or MCL and at 8 weeks
for PLC reconstruction
• Begin the following at 6 weeks for ACL/PCL and/or MCL and at 8 weeks for
PLC reconstruction
o Stationary bike (low resistance, high seat, with no toe clips---so as to
prevent hamstring contraction)
o Mini-squats to 45 degrees
o Leg press to 60 degrees
o Stairmaster
o Elliptical trainer
o Proper gait mechanics
o Proprioception
! Mini-tramp standing
! Unstable platform (BAPS) with eyes open and closed
3
! Standing ball throwing and catching
Postop weeks 10-16.

-long leg brace discontinued and patient fitted for a functional
brace for ACL that may stress the reconstruction.
• Starting at week 10, closed chain exercises initiated in a 0-60 degrees
range. ROM exercises are continued and patient should be able to flex to
110 degrees or greater by the end of postop month 4.
PHASE IV (3-6 months)
Criteria
• Full, pain-free active range of motion
• No patellofemoral irritation
• Sufficient strength and proprioception to progress to functional activities
• Normal gait
Goals
• Improve strength and proprioception
• Maintain FROM
• Progress with flexibility and closed-chain strengthening program
• Swimming (no breast stroke)
• Stationary bike (may increase resistance)
• Box steps (6 and 12 inches)
• Jogging, straight ahead, may be started around 4-5 months when quad strength is
90% of contralateral side
• Isolated hamstring strengthening against gravity without weight is initiated
at end of postop month 5 and resistive hamstrings can be introduced at end
of postop month 6. ROM of 120 degrees is desirable at t his point. A 10-15
degree terminal flexion deficit is typical.
• Aggressive quadriceps strengthening is implemented. Can begin low-
intensity plyometric program at the end of postop month 5. In addition low-
intensity sport-specific activities.
PHASE V (6-9 months)

Criteria
• Full, pain-free motion
• No effusion
• Sufficient hamstring and quadriceps strength to progress to agility exercises
4
Goals
• Return to all recreational and sporting activities by 9 months
• Maintain full, painless motion
• Progress with strengthening, agility, and endurance
• Symmetrical strength and proprioception before returning to unrestricted activity
• Progress with closed chain quadriceps and hamstring strengthening
• Plyometrics
o Stair jogging
o Box jumps (6 to 12-inch heights)
• Proprioception
o Mini-tramp bouncing
o Lateral slide board
o Ball throwing and catching on unstable surface
• Functional Training
o Running
! Figure-of-eight pattern
• Agility
o Start at slow speed
o Shuttle run, lateral slides, Carioca cross-overs
o Plyometrics
o Stair running
o Box jumps (1-2 foot heights)
o At 8 months, may start
! Sports specific training (start at 25% speed and increase as
tolerated)
! Incorporate cutting
! Increase heights for plyometric conditioning
Months 6-12
- Continue with above program for anticipated return to
sports or very heavy labor.
Criteria for Return to Sports

• Usually occurs at 9-12 months post-op
• Full, painless range of motion
• No effusion
• Quadriceps and hamstring strength 90% of contralateral side
• No apprehension with all sports specific drills
• Functional bracing is used for sports or work activities that put the reconstruction
at risk until the patient reaches 18 months postop.
• Cleared by doctor.

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REHABILITATION GUIDELINES AFTER

MULTIPLE LIGAMENT KNEE RECONSTRUCTION

Please send progress notes

• WBAT for PCL/or ACL/PCL injuries

PHASE I (0-2 weeks)

PHASE II (2- 6 weeks)

PHASE III (6-12 weeks)

Postop weeks 10-16.

PHASE IV (3-6 months)

PHASE V (6-9 months)

Criteria for Return to Sports

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