The protocols provided by Orthopaedic Associates of Portland are examples of those used by our physicians and may not

be appropriate for every patient. You should use these only if your treating physician has reviewed the protocol and approves of its use for your recovery. This is a general outline for you as a patient to better understand the guidelines and time frames used to progress ACL Reconstruction patients through their rehabilitation. Please keep in mind that these are general guidelines and may not be met by all patients at each specific timeline due to differences in healing and tolerance to the surgery. Progression should occur at your own pace, keeping in mind that gains should be made on a daily and weekly basis to achieve progression with the protocol. You will be evaluated at regular intervals throughout the rehabilitation process, and will be progressed appropriately by your therapist and physician. The primary goals for you to strive for early in the protocol are: 1. Regain normal motion in the knee as soon as possible.2. Increase weight bearing to minimize limping as early as possible.3. Early recognition and treatment of any problems-i.e. pain, stiffness, swelling, or severe muscle weakness.4. Return to normal activities as soon as possible with deficits. The Rehabilitation Program has been divided

into phases for your benefit:

Pre-operative Visit - the purpose of this

visit is to: 1. Introduce you to the physical therapy team that will be guiding your post-operative rehabilitation.2. Orient you to the Physical Therapy Center.3. Instruct you in the correct pre-, and post-operative home exercises.4. Familiarize you with the rehabilitation protocol and goals.

ACL Visit Progression

This is the anticipated schedule of visits for ACL reconstruction post-op therapy. This is a guideline to be followed as appropriate pending each individual patients tolerance and post-op presentation of pain, swelling, and leg control: Pre-op visit 1x prior to surgery for evaluation & review of parameters for HEP (home exercise program). Starting at: 1x visit at the 1 Week Post-op PTC (prescheduled) 1x (pre2 Weeks scheduled) 3 Weeks 3x

Phase I

Phase II

Phase III

Phase IV

Phase V

4 Weeks 3x Begin weaning to 1x/week independent workouts. 5 Weeks 2x 6 Weeks 2x 7 Weeks 2x Begin weaning to 2x/week independent workouts. 8 Weeks 1x 9 Weeks 1x 10 Weeks 1x Wean to independent program at conclusion of week 10. 1x for Cybex strength evaluation; 14 Weeks functional evaluation and review of progress 1x for advanced functional 18 Weeks agility/sport specific parameters. 1x for Cybex strength 24 Weeks evaluation & functional evaluation.

ACL Physical Therapy Protocol

TIME POST-OP # of visits Progression of program Additional if tolerated

Pre-op visit

1x

Evaluation and patient education. Instruction in Home Exercise Program (HEP) per handout. Review of crutch, brace, and ice parameters.

1Week Post- operative

1x

Re-evaluation and review of HEP. Begin weaning from crutches to increase WB.

2 Weeks post-op 3x

Re-evaluation and review of HEP for progression of exs. Rx to begin with manual therapy & modalities as appropriate. Emphasis on VMO (vastus medialis obliquus quad) control with all exs, progressing to leg press, street bike and Theraband squats. Wean from immobilizer

3 Weeks post-op

3x

Continue manual Rx. Reinforce quad leg control and timing in closed chain activities. Initiate aquatic exercise (pool or large whirlpool) if available and indicated. Advanced gait training: marching, retrowalking, side-stepping, and modalities as indicated. Add leg curl and step-down

4 Weeks post-op 3x/ week if appropriate Progression of exs to emphasize single leg workouts with increased weight as tolerated. Re-evaluate after 4 weeks to determine if the patent is appropriate for weaning to 2 PT sessions per week and 1 independent session in Fitness program. Add Smith press, stairmaster and focus on PRES with single leg work on machines.

The following criteria to be evaluated: -Ability to single leg stand 30 sec.-No antalgia (limping) on level surfaces. -Normal ascend and minimal assist descending stairs.-ROM (range of motion) 0-115 with minimal discomfort. -Minimal to no pain or swelling with current program. If the criteria are not met, continue with formal PT 3x/week. Continue with manual Rx. and modalities as needed.

5 weeks post-op

2x/week

Continue to progress Progressive Resistance Exercises (PREs). Walk-through low level functional/agility exercises-those with no impact, twisting, or turning. Examples: defensive slide (1/2 speed), sport cord weight-shifting. Progress to trunk/sport cord challenges (manual resistance to trunk with walking, side stepping etc.). Continue manual therapy as needed. Single leg stand LE reach (ground clock)

6 weeks post-op

2x/week

At 6 weeks, most patients should be decreased to 2x/wk of supervised PT unless unforeseen circumstances arise. Manual Rx. and aquatic therapy if necessary. Shallow and deep water jogging is acceptable. Low level functional/agility at low speed and impact. No cutting or twisting. Increase resistance on trunk challenges. Discontinue low level exercises and wean from HEP control exs while progressing aerobic, gym PREs, and functional/agility exs. Treadmill walking with slight incline only if tolerated.

7 weeks 1x/week Wean to 1x/week at the conclusion of 7 weeks if appropriate with patient progressing 2x/week independently. Wean from manual and aquatic therapy at therapists discretion.

8 weeks

1x At 8 weeks, the therapy team will determine whether the patient needs to be seen on a regular basis or to check in periodically (every 2 weeks) to progress program. Possible exercises to add: BAPS board in standing, Vew -Do board, medicine ball toss with balancing or uni-lateral stance. The following functional test can be used to assist in making that decision: Ability to do 4" step down. PROM (passive range of motion) 0-125 with full active extension. Low speed low level agility without pain. Ground clock 10 reps. Ability to perform current exercise program without pain or swelling. At 8 week visit, continue to progress aerobic, gym exercises. This is the earliest cut-off to start a jogging progression. Still no running. Keep in mind that some physicians prefer to have12 week Cybex test results before allowing a patient to run.

10 weeks

1x

Continue with current program progressing as

tolerated. Progress jogging program. Increase speed on low level functional/agility and progress to intermediate functional activity. Aggressive resistance with trunk challenges and sport cord. Examples of intermediate functional activity: Quick steps, two leg hopping, vertical leaps, and cariocas

12 weeks

1x

Review program and parameters. 14 weeks 1x

Cybex strength test. Patient will perform functional tests at this visit. It will consist of the following: speed carioca Unilateral squat for depth Data will be recorded. Review program and increase intensity exercises

If ROM is normal and patient is progressing with

minimal pain and trace swelling, they will not need to be seen in PT again for 4 weeks.

18 weeks 1x Review program. Increase intensity as appropriate. Instruct in advanced functional/agility: sprinting, cutting and sports specific drills as tolerated.

24 weeks Final Cybex strength test and 24 Week Functional Test. Patient returns to sports if cleared by physician.

24 Week Functional Tests:

One-legged hop for distance:Patient performs onelegged hop, which consist of recording the distance a patient travels in one hop on a single leg. Each patient is allowed one trial for each leg, then performs two hops per leg for maximum measurement.

Timed one-legged hop:

A measured distance of twenty feet is marked out, at the word "go", the patient begins a series of one legged hops from start line to finish line. The patient is timed from the start line to the finish line. Each patient is allowed to complete a slow trial and then two tests are completed on the uninvolved leg and two on the involved leg.

speed carioca: Patient is tested in their ability to perform thirty feet of carioca both directions without visible antalgia, pain, or compensation.

One legged squat for depth: Patient is tested in their ability to perform a one legged mini-squat to touch floor with opposite hand with moderate trunk flexion.