Hello!

Rehabilitation Goals:

• Protect graft
• Reduce swelling, minimize pain
• Restore patellar mobility
• Restore full-extension, gradually improve flexion
• Minimize arthrogenic muscle inhibition, re-establish quad control, regain full active extension
• Patient education
  • Keep your knee straight and elevated when sitting or laying down. Do not rest with a towel placed under the knee
  • Do not actively kick your knee out straight; support your surgical side when performing transfers (Ie. sitting to laying down)
  • Do not pivot on your surgical side

Weight Bearing

• Walking
  • Initially, brace unlocked, crutches
  • May start walking without crutches as long as there is no increased pain
    • Allograft and hamstring autograft continue weight-bearing as tolerated with crutches for 2 weeks unless otherwise instructed by physician
  • May unlock brace once able to perform straight leg raise without lag
  • May discontinue use of brace after 2 weeks and once adequate quad control is achieved
  • When climbing stairs, make sure you are leading with the non-surgical side when going up the stairs, make sure you are leading with the crutches and surgical side when going down the stairs

Intervention

• Swelling Management
  • Ice, compression, elevation
  • Retrograde massage
  • Ankle pumps
• Range of motion/Mobility
  • Patellar mobilizations: superior/inferior and medial/lateral
    • **Patellar mobilizations are heavily emphasized in the early post-operative phase following patella tendon autograft**
  • Seated assisted knee flexion-extension and heel slides with towel
  • Low intensity, long duration extension stretches: prone hang, heel prop
  • Standing gastroc stretch and soleus stretch
  • Supine active hamstring stretch and supine passive hamstring stretch
• Strengthening
  • Calf raises
  • Quad sets
  • Straight leg raise
    • **Do not perform straight leg raise if you have a knee extension lag
  • Hip abduction
  • Multi-angle isometrics 90 and 60 deg knee extension

Criteria to Progress

• Knee Extension ROM 0 degrees
• Quad contraction with superior patella glide and full active extension
• Able to perform straight leg raise without lag

Rehabilitation Goals

• Continue to protect graft
• Maintain full-extension, restore full flexion (contralateral side)
• Normalize gait

Additional Intervention

• Range of Motion/Mobility
  • Stationary bicycle
  • Gentle stretching all muscle groups: prone quad stretch, standing quad stretch, kneeling hip flexor stretch
• Strengthening
  • Prone hamstring curls
  • Step-ups and step-ups with march
  • Partial squat exercise
  • Ball squats, wall slides, mini squats from 0-60 deg
  • Lumbopelvic strengthening: bridge & unilateral bridge, side lying hip external rotation-clamshell, bridges on physioball, bridge on physioball with roll-in, bridge on physioball alternating, hip hike
• Balance/proprioception
  • Single leg standing balance (knee slightly flexed) static progressed to dynamic and level progressed to unsteady surface
  • Lateral step-overs
  • Joint position re-training

Criteria to Progress

• No swelling (Modified Stroke Test)
• Flexion ROM within 10 deg contralateral side
• Extension ROM equal to contralateral side

Rehabilitation Goals

• Continue to protect graft site
• Maintain full ROM
• Safely progress strengthening
• Promote proper movement patterns
• Avoid post-exercise pain/swelling
• Avoid activities that produce pain at graft donor site

Additional Intervention

• Range of motion/Mobility
  • Rotational tibial mobilizations if limited ROM
• Cardio
  • Elliptical, stair climber, flutter kick swimming, pool jogging
• Strengthening
  • Gym equipment: leg press machine, seated hamstring curl machine, hamstring curl machine,  hip abductor and adductor machine, hip extension machine, roman chair, seated calf machine
    • Hamstring autograft can begin resisted hamstring strengthening at 12 weeks
  • Progress intensity (strength) and duration (endurance) of exercises
  • **The following exercises to focus on proper control with emphasis on good proximal stability
    • Squat to chair
    • Lateral lunges
    • Romanian deadlift
    • Single leg progression: partial weight-bearing single leg press, slide board lunges: retro and lateral, step-ups and step-ups with march, lateral step-ups, step-downs, single-leg squats, single-leg wall slides
    • Knee Exercises for additional exercises and descriptions
• Balance/proprioception
  • Progress single-limb balance including perturbation training

Criteria to Progress

• No swelling/pain after exercise
• Normal gait
• ROM equal to contralateral side
• Joint position sense symmetrical (<5 degree margin of error)
• Quadriceps index ≥80%; HHD mean preferred (isokinetic testing if available)

Rehabilitation Goals

• Maintain full ROM
• Safely progress strengthening
• Promote proper movement patterns
• Avoid post-exercise pain/swelling
• Avoid activities that produce pain at graft donor site

Additional Interventions

• Begin sub-max sport-specific training in the sagittal plane
• Bilateral PWB plyometrics progressed to FWB plyometrics

Criteria to Progress

• No episodes of instability
• Maintain quad strength
• 10 repetitions single leg squat proper form through at least 60 deg knee flexion
• Drop vertical jump with good control
• Functional Assessment
  • Quadriceps index >80%; HHD mean preferred (isokinetic testing if available)
  • Hamstring, glute med, glute max index ≥80%; HHD mean preferred (isokinetic testing for HS if available)
  • Single leg hop test ≥75% compared to contralateral side (earliest 12 wks)
• Return-to-sport testing can be performed if necessary

Rehabilitation Goals

• Safely progress strengthening
• Safely initiate sport-specific training program
• Promote proper movement patterns
• Avoid post-exercise pain/swelling
• Avoid activities that produce pain at graft donor site

Additional Intervention

• Interval running program
  • Return to Running Program
• Progress to plyometric and agility program (with functional brace if prescribed)
  • Agility and Plyometric Program

Criteria to Progress

• Clearance from Dr. Lis and ALL milestone criteria below have been met
• Completion jog/run program without pain /swelling
• Functional Assessment
  • Quad/HS/glut index ≥ 90%; HHD mean preferred (isokinetic testing if available)
  • Hamstring/Quad ratio ≥ 70%; HHD mean preferred (isokinetic testing if available)
  • Hop Testing ≥ 90% compared to contralateral side

Rehabilitation Goals

• Continue strengthening and proprioceptive exercises
• Symmetrical performance with sport-specific drills
• Safely progress to full sport

Additional Intervention

• Multi-plane sport-specific plyometrics program
• Multi-plane sport-specific agility program
• Include hard cutting and pivoting depending on the individuals’ goals (~7 mo)
• Non-contact practice → Full practice → Full play

Criteria to Progress

• Last stage, no additional criteria