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PHASE I: Post-operative weeks 0-4

NWB for 6 wks, Brace locked in extension for ambulating and sleeping for minimum of 8 wks or until quad function returns. Focus on preventing posterior subluxation of tibia to prevent PCL reconstruction stretching.

Weeks 0-2 keep extended, no flexion – work on hip flex/ext/abduction/adduction, calf pumps, quadriceps isometrics, assisted leg lifts with knee immobilizer on.

Weeks 2-4 brace unlocked 0-60 deg for passive knee flexion and active knee extension to limit posterior tibial sag

Weeks 4-6 increase to 0-90 deg flexion

Weeks 6 and on: wbat and progressive knee flexion to obtain full flexion by 12 wks; avoid open chain exercises for 12 wks to avoid posterior tibial translation.

PHASE II: Post-operative weeks 4 to 12

Criteria for progression to Phase II:

  • Good quadriceps control (good quad set, no lag with SLR).
  • Approximately 60 degrees knee flexion.
  • Full knee extension shoulder be maintained throughout.
  • No signs of active inflammation.
  • Goals:
    Increase ROM (particularly flexion).
  • Normalize gait.
  • Continue to improve quadriceps strength and hamstring flexibility.

Brace:

  • 4-6 weeks: Brace unlocked for gait in controlled environment only (i.e. patient may walk with brace unlocked while attending PT or when at home).
  • 6-8 weeks: Brace unlocked for all activities.
  • 8 weeks: Brace discontinued, as allowed by surgeon.
    • Note, if PCL or LCL repair, continue brace until cleared by surgeon.
    • Weight-bearing status:
      • 4-8 weeks: WBAT with crutches.
      • 8 weeks: May discontinue crutches if patient demonstrates:
        • No quadriceps lag with SLR.
        • Full knee extension.
        • Knee flexion 90-100 degrees.
    • Normal gait pattern (May use 1 crutch/cane until gait normalized).
    • If PLC or LCL repair, continue crutches for 12 weeks.
    • Therapeutic Exercises:
      • 4-8 weeks:
    • Wall slides/mini-squats (0-45 degrees).
    • Leg press (0-60 degrees).
    • Standing 4-way hip exercise for flexion, extension, abduction, adduction (from neutral, knee fully extended).
    • Ambulation in pool (work on restoration of normal heel-toe gait pattern in chest-deep water).
      • 8-12 weeks:
    • Stationary bike (foot placed forward on pedal without use of toe clips to minimize hamstring activity; seat set slightly higher than normal).
    • Closed kinetic chain terminal knee extension using resisted band or weight machine. Note: important to place point of resistance to minimize tibial displacement.
    • Stairmaster.
    • Elliptical trainer.
    • Balance and proprioception exercises.
    • Seated calf raises.
    • Leg press (0-90 degrees).

PHASE III: Post-operative months 3 to 9

Criteria for progression to Phase III:

  • Full, pain-free ROM. (Note: it is not unusual for flexion to be lacking 10-15 degrees for up to 5 months post-op.)
  • Normal gait.
  • Good to normal quadriceps control.
  • No patellofemoral complaints.
  • Clearance by surgeon to begin more concentrated closed kinetic chain progression.

Goals:

  • Restore any residual loss of motion that may prevent functional progression.
  • Progress functionally and prevent patellofemoral irritation.
  • Improve functional strength and proprioception using close kinetic chain exercises.
  • Continue to maintain quadriceps strength and hamstring flexibility.

Therapeutic exercises:

  • Continue closed kinetic chain exercise progression.
  • Treadmill walking.
  • Jogging in pool with wet vest or belt.
  • Swimming (no breaststroke or “frog kick”).

PHASE IV: Post-operative Month 9 until return to full activity

Criteria for progression to Phase IV:

  • Clearance by surgeon to resume full or modified/partial activity (i.e. return to work, recreational, or athletic activity).
  • No significant patellofemoral or soft tissue irritation.
  • Presence of necessary joint ROM, muscle strength and endurance, and proprioception to safely return to athletic participation.
  • Full, painfree ROM.
  • Satisfactory clinical examination.
  • Quadriceps strength 85% of uninvolved leg.
  • Functional testing 85% of uninvolved leg.
  • No change in laxity testing.

Goals:

  • Safe and gradual return to work or athletic participation.
    • This may involve sport-specific training, work hardening, or job restructuring as needed.
    • Patient demonstrates a clear understanding of their possible limitations.
  • Maintenance of strength, endurance, and function.
  • Therapeutic exercises:
  • Continue closed kinetic chain exercise progression.
  • Cross-country ski machine.
  • Sport-specific functional progression, which may include but is not limited to:
    • Slide board.
    • Jog/Run progression.
    • Figure 8, carioca, backward running, cutting.
    • Jumping (plyometrics).

Work hardening program as indicated by physical therapist and/or surgeon recommendation. Patient will need a referral from surgeon to begin work hardening.

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