Postoperative Rehabilitation Protocol

for ACL Reconstruction

GENERAL GUIDELINES
• Program is designed to protect the ACL and the patella, and get full
extension early
• Even with addition of meniscus repair no significant changes made in
rehab
• Patellofemoral protection is important; no wall slides or lunges, only do
mini squats
• Assume 12 weeks graft to bone healing time
• With hamstrings or Allograft flexion is restricted to 90 degrees
for first 4 weeks to reduce stress on graft
• ACL with posterolateral corner or LCL repair follows different post-op
care, i.e. crutches x 8 weeks and brace to avoid varus stress

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated (unless
otherwise specified by the physician):
• Showering – once dressing removed; no immersion until
stitches/staples removed and wounds healed, if brace is present may
remove for shower.
• If patient has a brace may sleep without brace after comfortable
(usually a few days) unless there is cartilage repair or lateral side
surgery then same for WB restrictions.
• Driving: when safely able to operate the controls of the vehicle. Any
time for left knee surgery (assuming automatic transmission), and
longer for right leg surgery.
• Full weight bearing without crutches usually by 2 weeks or as
tolerated, however for meniscus repair toe touch for about 4 weeks,
and 8 weeks when any lateral side surgery also performed.

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:
• Formal PT begins after 1st post-op visit usually about 2 weeks
• 3 times per week is optimal
• Home exercises daily as instructed by the therapist
• Supervised physical therapy takes place for approximately 3-5 months
post-op
PHASE I:
Begins immediately following surgery and lasts approximately one month.
Patient is to perform ROM exercises and hip, knee and ankle strengthening as
directed daily.

Goals:
• Protect healing bony and soft tissue structures
• Minimize quadriceps atrophy and joint stiffness through:
• Early range of motion with emphasis on full extension, patella
mobilizations and flexion limit dependent on graft choice, meniscus
repair and other concurrent surgery (i.e., lateral side)
• PRE’s for quadriceps, hip and calf
• Patient education for a clear understanding of limitations and
expectations of the rehabilitation process

Weight bearing Status: (Unless with meniscal repair*)

• 0-1 weeks: Partial weight bearing with two crutches to assist with
balance
• 1-2 weeks: Partial weight bearing with normal gait mechanics
• After 2 weeks, full weight bearing allowed based on quad function
* With meniscal repair weight bearing may be kept toe-touch for one-
month post-op, lateral side surgery 6-8 weeks.

Therapeutic Exercises:
0-2 weeks
• Hip flexion, extension, abduction and adduction as able
• Straight leg raises and quad sets for quads tone
• Ankle Pumps
• Patella mobilizations
• Passive full extension
• Active flexion to 90 if possible
Add at first post-op visit 2 weeks out through week 4:
• Standing toe raises for calf muscle tone
• For bone-tendon-bone may begin AAROM for full ROM, begin exercise
bike, mini-squats, balance training
• For hamstrings or Allograft same exercises as above but limit flexion to
90 (i.e., mini-squats, balance, bike is OK)
• After sutures out at 2 weeks if pool available may begin aquatics (walk
in pool, mini-squats). Pool is helpful but not essential.
PHASE II:
Begins at 1 month post-op, and extends to the 12th post-op week

Goals:
• Increase range of motion for all patients/all grafts progress to full
flexion
• Progress in weight bearing for all patients/all grafts according to
previous precautions (i.e., lateral side surgery 6-8 weeks of
crutch/brace)
• Continue lower extremity muscle toning
• Begin functional restoration of leg function for balance and ADL
• Begin total patient reconditioning with non-impact cardiovascular
exercise
• Continue to protect graft(s)

Therapeutic Exercises:

4-12 weeks: Once patient is full weight bearing and does not require the brace,
therapy can be liberalized and proceed on a more “as tolerated” basis.
• Begin isometric quads and co-contraction of quads/hams
• Progress to mini-squats when able to be full weight bearing, graduated step
ups OK
• May continue hip flexion/extension/Abduction/Adduction
• Closed kinetic chain for knee extension utilizing resisted band while standing
and weight machines as follows. Leg press is OK, active open chain knee
flexion is OK.
• Stationary bike, XC ski machine, Stairmaster and/or elliptical machines can be
used for cardio and leg conditioning
• Balance and Proprioception activities (e.g. single leg stance or mini-
trampoline)

PHASE III:
Begins approximately three months post-op, and extends to 4-5 months post-op.
Expectations for advancement to Phase III:

Goals:
• Restore any residual loss of motion that may prevent functional progression
• Improve functional strength and proprioception utilizing closed and/or open
kinetic chain exercises
• Continue to work on restoration of functional progression of the extremity
and the patient as a whole in preparation for return to activity or sports
Therapeutic Exercises:
• Continue lower extremity exercise progression with emphasis on quads tone
and strength
• Treadmill walking progress to running as tolerated
• Stairmaster/elliptical trainer, swimming is OK (no breast stroke)
• May progress to out door biking, walking and ultimately running
• May play golf or bowling if able
• No twisting turning or jumping activities yet

PHASE IV:
Return to sport at approximately 5-6 months

Goals:
• Safe and gradual return to work or athletic participation
• This may involve sports specific training, work hardening or job
restrictions as needed
• Maintenance of strength, endurance and function
• Running progression
• Figure 8 progression, Carioca, Backward running, cutting
• Jumping (plyometrics) if needed for sport (i.e., volleyball or basketball)

***These instructions are to be used as general guidelines. Before 3 months it is

important not to go any faster even if the patient seems able, since the most
important consideration is graft protection. Please have physician contacted if
there are questions or concerns

Kenneth A. Jurist, M.D., Joseph H. Guettler, M.D.

24255 Thirteen Mile Road, Suite 100
Bingham Farms, MI 48025
248-988-8085 Phone / 248-988-8565 Fax
“At Performance Orthopedics it’s all about You at your Peak Performance”
www.performanceorthopedics.com
 Postoperative Rehabilitation Protocol
for Carticel Implantation for Femoral Condyle

GENERAL GUIDELINES
• Program is designed to protect the Carticel Implantation, minimize stress on the
grafted area, preserve joint motion, and rehabilitate the extremities

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated (unless otherwise specified by
the physician):
• Showering – once dressing removed; no immersion until stitches/staples removed
and wounds healed, if brace is present may remove for shower.
• Driving: when safely able to operate the controls of the vehicle. Any time for left
knee surgery (assuming automatic transmission), and longer for right leg surgery.
• Return to work/school will depend on the individual needs

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:
• Aquatic exercises if available for first month
• Formal PT begins after patient is able to begin to bear weight usually 4-6 weeks
• 3 times per week is optimal
• Home exercises daily as instructed by the therapist
• Supervised physical therapy takes place for approximately 3-5 months post-op

PHASE I: Protection Phase:

Begins immediately following surgery and lasts approximately six weeks. Patient is to
protect the healing tissue from load and shear forces. Brace locked at 0° during weight-bearing
activities. Sleep in the locked brace for 2-4 weeks.

Goals:
• Protect healing bony and soft tissue structures
• Decrease pain and effusion
• Gradually improve knee flexion
• Restore full passive knee extension
• Regain quadriceps control

Weight bearing Status:

• 1-2 weeks: Non weight bearing, may begin toe-touch weight bearing per physician
orders
• 2-3 weeks: Toe touch weight bearing allowed based on quad function
(approximately 20-30 lbs)
• 4-5 weeks: Partial weight bearing (approximately ¼ body weight)
• 6 weeks: May progress to weight bear as tolerated
Therapeutic Exercises:
ROM:
• Begin Exercises 6-8 hours after surgery
• Gain full passive knee extension ASAP
• 1-3 weeks: Initiate Continuous Passive Motion (CPM) day 1: 8-12 hours/day
o Progress 5°-10° /day
o May continue CPM 6-8 hours/day for 4-6 weeks
• Motion guidelines on CPM
o 1-2 weeks: Knee flexion 90°
o 3-4 weeks: Knee flexion 105°
o 5-6 weeks: Knee flexion 120°
• Stretch hamstrings and calf daily
• Begin patellar mobilization and soft tissue mobilization
Strengthening:
• Ankle pumps using rubber tubing
• Quad sets
• Isometrics of the quad and hamstrings (co-contraction in brace)
• Straight leg raises
• 4-6 weeks: Begin GAIT training in pool (chest deep water)

Swelling Control:
• Ice, elevation and compression

Criteria to Progress
• Full passive knee extension
• Knee flexion to 120°
• Minimal pain and swelling
• Good quadriceps control

PHASE II: Transition Phase:

Begins 6 weeks post-op, and extends to the 12th post-op week. Discontinue post-operative
brace at 6th week. Consider using an interim brace such as a short-runner or un-loader type.

Goals:
• Gradually increase ROM
• Gradually improve quadriceps strength and endurance
• Gradual increase to functional activities

Weight-bearing Status:
• Progress weight-bearing as tolerated
• 8-9 weeks: Progress to full weight-bearing
• 8-9 weeks: Discontinue crutches

Therapeutic Exercises:
ROM:
• Gradually increase ROM
o Knee flexion to 125°-135°
o Maintain full extension
• Continue patellar mobilization and soft tissue mobilization
• Continue stretching program (hip, knee, and ankle)
 Strengthening:
• Progress to mini-squats (0°-45°) when able to be full weight bearing
• May continue hip flexion/extension/Abduction/Adduction
• Open chain knee flexion is OK
• Closed kinetic chain for knee extension utilizing resisted band while standing and weight
machines as follows. Leg press is OK, active open chain knee flexion is OK.
• Stationary bike and/or elliptical machines can be used for cardio and leg conditioning;
low resistance and gradually increase time
• Balance and Proprioception activities (e.g. single leg stance or mini-trampoline)
• Initiate front and lateral step-ups
• Continue use of pool for GAIT training and exercise until able to walk without limp, full
weight bearing, and go up stairs without pain

Functional Activities:
As pain and swelling decrease, the patient may gradually increase functional activities. The
patient may also begin gradually increasing standing and walking. Increase biking and
swimming activities.

Criteria to Progress:
• Full ROM
• Acceptable Strength (estimated by manual effort)
o Hamstrings within 10-20% of other leg
o Quadriceps within 20-30% of other leg
• Balance testing within 30% of other leg
• Patient is able to walk 1-2 miles or bike 30 minutes

PHASE III: Maturation Phase:

Begins approximately 12 weeks post-op, and extends to 26 weeks post-op.

Goals:
• Improve functional strength and proprioception utilizing closed and/or open kinetic chain
exercises
• Increase functional activities

Therapeutic Exercises:
ROM:
• Patient should maintain 125°-135° flexion
Strengthening:
• Continue lower extremity exercise progression with emphasis on quads tone and
strength
• Bilateral squats (0°-60°)
• Treadmill progressive walking program as tolerated
• Stairmaster/elliptical trainer, swimming is OK

Functional Activities:
As patient improves, increase walking (distance, cadence, incline, etc)
Criteria to Progress:
• Full non-painful ROM
• Strength within 80-90% of other leg
• Balance and stability within 75% of other leg
• Rehabilitation and functional activities do not cause pain, inflammation and swelling

PHASE IV: Functional Activities Phase:

Return to sport at approximately 26-52 weeks

Goals:
• Safe and gradual return to work or athletic participation
• This may involve sports specific tra ining, work hardening or job restrictions as needed
• Maintenance of strength, endurance and function
• Running progression
• Figure 8 progression, Carioca, Backward running, cutting
• Jumping (plyometrics) if needed for sport (i.e., volleyball or basketball)

***These instructions are to be used as general guidelines. Before 3 months it is important not
to go any faster even if the patient seems able, since the most important consideration is graft
protection. Please have physician contacted if there are questions or concerns

Kenneth A. Jurist, M.D. and Joseph H. Guettler, M.D.

24255 Thirteen Mile Road, Suite 100
Bingham Farms, MI 48025
248-988-8085 Phone / 248-988-8565 Fax

“At Performance Orthopedics it’s all about You at your Peak Performance”
www.performanceorthopedics.com
 Postoperative Rehabilitation Protocol
for Carticel Implantation for Trochlea/ Patella

GENERAL GUIDELINES
• Program is designed to protect the Carticel Implantation, minimize stress on the
grafted area, preserve joint motion, and rehabilitate the extremities

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated (unless otherwise specified by
the physician):
• Showering – once dressing removed; no immersion until stitches/staples removed
and wounds healed, if brace is present may remove for shower.
• Driving: when safely able to operate the controls of the vehicle. Any time for left
knee surgery (assuming automatic transmission), and longer for right leg surgery.
• Return to work/school will depend on the individual needs

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:
• Aquatic exercises if available for first month
• Formal PT begins after patient is able to begin to bear weight usually 4-6 weeks
• 3 times per week is optimal
• Home exercises daily as instructed by the therapist
• Supervised physical therapy takes place for approximately 3-5 months post-op

PHASE I: Protection Phase:

Begins immediately following surgery and lasts approximately six weeks. Patient is to
protect the healing tissue from load and shear forces. Brace locked at 0° during weight-bearing
activities. Sleep in the locked brace for 2-4 weeks. Extended standing should be avoided.

Goals:
• Protect healing bony and soft tissue structures
• Decrease pain and effusion
• Gradually improve knee flexion
• Restore full passive knee extension
• Regain quadriceps control

Weight bearing Status:

• Immediate partial weight bearing in full extension as tolerated
• 25% body weight with brace locked
• 50% body weight by week 2 in brace
• 75% body weight by weeks 3-4 in brace
**If combined with tibia l tubercle transfer, then non-weight bearing for 6 weeks**
Therapeutic Exercises:
ROM:
• Immediate motion exercises days 1-2
• Gain full passive knee extension ASAP
• 1-3 weeks: Initiate Continuous Passive Motion (CPM) day 1: 8-12 hours/day
o Progress 5°-10° /day
o May continue CPM 6-8 hours/day for up to 6 weeks
• Motion guidelines for CPM Guidelines if tibial tubercle transplant
• 2-3 weeks: Knee flexion 90° • 0-2 weeks: 0°
• 3-4 weeks: Knee flexion 105° • 2-4 weeks: 0-30°
• 5-6 weeks: Knee flexion 120° • 4-6 weeks: 30-60°
• 6-8 weeks: 60-90°
• Stretch hamstrings and calf daily
• Begin patellar mobilization and soft tissue mobilization
Strengthening:
• Ankle pumps using rubber tubing
• Quad sets and Straight Leg Raises
• Isometrics of the quad and hamstrings
• Straight leg raises
• Toe and Calf Raises
• 4 weeks: Begin GAIT training in pool

Swelling Control:
• Ice, elevation and compression

Criteria to Progress
• Full passive knee extension
• Knee flexion to 120°
• Minimal pain and swelling
• Good quadriceps control

PHASE II: Transition Phase:

Begins 6 weeks post-op, and extends to the 12th post-op week. Discontinue post-operative
brace at 6th week.

Goals:
• Gradually increase ROM
• Gradually improve quadriceps strength and endurance
• Gradual increase to functional activities

Weight-bearing Status:
• Progress weight-bearing as tolerated
• 6-8 weeks: Progress to full weight-bearing
• 6-8 weeks: Discontinue crutches
Therapeutic Exercises:
ROM:
• Gradually increase ROM
o Knee flexion to 120°-125°by week 8
o Maintain full extension
• Continue patellar mobilization and soft tissue mobilization
• Continue stretching program
Strengthening:
• Progress to mini-squats (0°-45°) when able to be full weight bearing
• May continue hip flexion/extension/Abduction/Adduction
• Open kinetic chain OK
• Closed kinetic chain for knee extension utilizing resisted band while standing.
• Stationary bike and/or elliptical machines can be used for cardio and leg conditioning;
low resistance and gradually increase time
• Balance and Proprioception activities (e.g. single leg stance or mini-trampoline)
• Initiate front and lateral step-ups
• Continue toe and calf raises
• Continue use of pool for GAIT training and exercise

Functional Activities:
As pain and decrease, the patient may gradually increase functional activities. The patient may
also begin gradually increasing standing and walking.

Criteria to Progress:
• Full ROM
• Acceptable Strength
o Hamstrings within 10-20% of other leg
o Quadriceps within 20-30% of other leg
• Balance testing within 30% of other leg
• Patient is able to walk 1-2 miles or bike 30 minutes

PHASE III: Maturation Phase:

Begins approximately 13 weeks post-op, and extends to 32 weeks post-op.

Goals:
• Improve functional strength and proprioception utilizing closed and/or open kinetic chain
exercises
• Increase functional activities

Therapeutic Exercises:
ROM:
• Patient should maintain 125°-135° flexion
Strengthening:
• Continue lower extremity exercise progression with emphasis on quads tone and
strength
• Bilateral squats (0°-60°)
• Treadmill progressive walking program as tolerated
• Stairmaster/elliptical trainer, swimming is OK
Functional Activities:
As patient improves, increase walking (distance, cadence, incline, etc). Light running can be
initiated toward end of phase per physician.

Criteria to Progress:
• Full non-painful ROM
• Strength within 80-90% of other leg
• Balance and stability within 75% of other leg
• Rehabilitation and functional activities do not cause pain, inflammation and swelling

PHASE IV: Functional Activities Phase:

Return to sport at approximately 8 to 15 months

Goals:
• Safe and gradual return to work or athletic participation
• This may involve sports specific training, work hardening or job restrictions as needed
• Maintenance of strength, endurance and function
• Running progression
• Figure 8 progression, Carioca, Backward running, cutting
• NO Jumping (plyometrics) until 12 months and then gradual progression if needed for
sport (i.e., volleyball or basketball)
• Continue maintenance 3-4 times/week

***These instructions are to be used as general guidelines. Before 3 months it is important not
to go any faster even if the patient seems able, since the most important consideration is graft
protection. Please have physician contacted if there are questions or concerns

Kenneth A. Jurist, M.D., Joseph H. Guettler, M.D.

24255 Thirteen Mile Road, Suite 100
Bingham Farms, MI 48025
248-988-8085 Phone / 248-988-8565 Fax
“At Performance Orthopedics it’s all about You at your Peak Performance”
www.performanceorthopedics.com
 Postoperative Rehabilitation Protocol for
PCL Reconstruction
PCL/ACL Reconstruction
Posterolateral Corner Surgery

GENERAL GUIDELINES
• Program is designed to protect the PCL
• Even with addition of ACL no changes made in rehab
• No active hamstring work
• Assume 12 weeks graft to bone healing time
• Caution against posterior tibial translation (gravity, muscle action)
• PCL with posterolateral corner or LCL repair follows different post-op
care, i.e. crutches x 8 weeks and brace to avoid varus stress

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated (unless
otherwise specified by the physician):
• Showering – once dressing removed; no immersion until
stitches/staples removed and wounds healed
• Sleep without brace - 8 weeks post-op
• Driving: when safely able to operate the controls of the vehicle. Any
time for left knee surgery (assuming automatic transmission), and
longer for right leg surgery.
• Full weight bearing without assistive devices – 6 weeks for just PCL,
but need 8 weeks when any lateral side surgery also performed.

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:
• Formal PT begins one month post-op
• 3 times per week is optimal
• Home exercises daily as instructed by the therapist
• Supervised physical therapy takes place for approximately 3-5 months
post-op

PHASE I:
Begins immediately following surgery and lasts approximately one month.
Patient is to perform ROM exercises and hip, knee and ankle strengthening as
directed daily.
Goals:
• Protect healing bony and soft tissue structures
• Minimize the effects of immobilization through:
• Early protected range of motion (protect against posterior tibial
sagging)
• PRE’s for quadriceps, hip and calf with an emphasis on limiting
patellofemoral joint compression and posterior tibial translation
• Patient education for a clear understanding of limitations and
expectations of the rehabilitation process
Brace:
• 0-2 weeks brace on at all times except to shower fixed at 0 degrees.
• 2-4 weeks post-op the brace is unlocked for passive range of motion to
60 degrees with patients instructed in passive flexion and active knee
extension to prevent posterior tibial translation
Weight bearing Status
• TTWB with crutches, brace is locked at full extension.
Special Considerations:
• Pillow under proximal posterior tibia at rest to prevent posterior sag
Therapeutic Exercises:
0-2 weeks
• Hip flexion, extension, abduction and adduction as able
• Straight leg raises for quads
• Ankle Pumps
Add at first post-op visit 2 weeks out:
• Calf press with Theraband
• 2-4 weeks post-op the brace is unlocked for passive range of motion to
60 degrees with patients instructed in passive flexion and active knee
extension to prevent posterior tibial translation

PHASE II:
Begins at 1 month post-op, and extends to the 12th post-op week

Goals:
• Increase range of motion
• Progress in weight bearing
• Continue lower extremity muscle toning (except active hamstring
work)
• Continue to protect graft(s)
Brace and Weight bearing Status:
• 4-6 weeks: Patient continues to be TTWB in brace. Brace is
removed during PT for strengthening and stretching. Avoid varus
stress during this phase if concomitant posterolateral corner
reconstruction.
 • At 6 weeks for PCL, or PCL/ACL brace is removed, for any lateral or
posterolateral surgery this is extended to 8 weeks
Therapeutic Exercises:
• 4-6 weeks: When patient exhibits independent quad control, may
begin open chain extension
• Begin isometric quads and co-contraction of quads/hams in
extension only, progress to active knee extension as tolerated from
point of maximal flexion (passively) to full extension.
• Progress to mini-squats when able to be full weight bearing
• May begin or continue hip flexion/extension/Abduction/Adduction
with knee fully extended.
• While pool therapy is not routinely prescribed, if facility has a pool
then this is allowed in the first month. Ambulation in pool (work on
restoration of normal heel-toe gait pattern in chest deep water

• 6-12 weeks: Once patient is full weight bearing and does not require
the brace, therapy can be liberalized and proceed on a more “as
tolerated” basis.
• Stationary Bike: Foot is placed forward on the pedal without use of
toe clips to minimize hamstring activity. Seat slightly higher than
normal
• Closed kinetic chain terminal knee extension utilizing resisted band
while standing or weight machine. For leg press, knee flexion
should be limited to 90° during exercises.
• Stairmaster and/or elliptical machines can be used for cardio and
leg conditioning
• Balance and Proprioception activities (e.g. single leg stance or mini-
trampoline)

*It is important to avoid open-chain hamstring activity during

this period as this may cause posterior tibial translation and may
stretch the graft

PHASE III:
Begins approximately three months post-op, and extends to nine months post-
op. Expectations for advancement to Phase III:

Goals:
• Restore any residual loss of motion that may prevent functional
progression
• Improve functional strength and proprioception utilizing closed and/or
open kinetic chain exercises
 • Continue to work on restoration of functional progression of the
extremity and the patient as a whole in preparation for return to
activity or sports

Therapeutic Exercises:
• Continue lower extremity exercise progression
• Treadmill walking progress to running as tolerated
• Stairmaster/elliptical trainer, swimming is OK (no breast stroke)
• May progress to out door biking, walking and ultimately running
• May play golf or bowling if able
• No twisting turning or jumping activities yet

PHASE IV:
Return to sport at approximately 6 months to 9 months

Goals:
• Safe and gradual return to work or athletic participation
• This may involve sports specific training, work hardening or job
restrictions as needed
• Maintenance of strength, endurance and function
• Running progression
• Figure 8, Carioca, Backward running, cutting
• Jumping (plyometrics) if needed for sport (i.e., volleyball or
basketball)

***These instructions are to be used as general guidelines. Before 3

months it is important not to go any faster even if the patient seems
able, since the most important consideration is graft protection. Please
have physician contacted if there are questions or concerns.

Kenneth A. Jurist, M.D., Joseph H. Guettler, M.D.

24255 Thirteen Mile Road, Suite 100
Bingham Farms, MI 48025
248-988-8085 Phone / 248-988-8565 Fax
“At Performance Orthopedics it’s all about You at your Peak Performance”
www.performanceorthopedics.com