Orthopedics Specialists - Knee Rehabilitation Physical Therapy Protocols

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

AUTOLOGOUS CHONDROCYTE IMPLANTATION (FEMORAL CONDYLE ONLY) REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

0-2 weeks: non-

0-2 weeks: locked in

0-4 weeks:

0-2 weeks: Quad sets, SLR,

0 - 12 weeks

weight bearing

full extension (removed

CPM: use in

hamstring isometrics - complete

for CPM and exercise)

2 hour in-

exercises in brace if quad control

2-4 weeks: partial

2-4 weeks: Gradually

crements for

is inadequate

weight bearing -

open brace 20 at a

6 - 8 hours

2-6 weeks: Begin progressive

(30 - 40 lbs)

time as quad control

per day at 1

closed chain exercises*

4-6 weeks:

is gained - discontinue

cycle/minute -

6-10 weeks: Progress bilateral

progress to use

use of brace when quads

begin at 0-30

closed chain strengthening, begin

of one crutch

can control SLR without

increasing

opened chain knee strengthening

6-12 weeks:

an extension lag

5-10 daily per

10-12 weeks: Progress closed

progress to full

patient comfort -

chain exercises using resistance

weight-bearing

patient should

less than patient's body weight,

gain at least 90

progress to unilateral closed

by week 4 and

chain exercises, begin balance

120-130

activities

by

week 6

PHASE II

Full with a

Full active

Advance bilateral and unilateral

12 weeks 6 months

normalized

range of

closed chain exercises with

gait pattern

motion

emphasis on concentric/eccentric

None

control, continue with biking, stairmaster and treadmill, progress balance activities

PHASE III

Full with a

6 - 9 months

normalized

None

Full and

Advance strength training, initiate

pain-free

light plyometrics and jogging - start with

gait pattern

2 minute walk/2 minute jog, emphasize sport-specific training

PHASE IV

Full with a

9 - 18 months

normalized

None

Full and

Continue strength training - emphasize

pain-free

single leg loading, begin a progressive

gait pattern

running and agility program - high impact activities (basketball, tennis, etc.) may begin at 16 months if pain-free

*Respect chondrocyte graft site with closed chain activities: If anterior - avoid loading in full extension If posterior - avoid loading in flexion >45 **If pain or swelling occurs with any activities, they must be modified to decrease symptoms

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

AUTOLOGOUS CHONDROCYTE IMPLANTATION (TROCHLEA/PATELLA)* REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

0-6 weeks: non-

0-2 weeks: locked in

0-4 weeks:

1-4 weeks: Quad sets, SLR,

0 - 12 weeks

weight bearing

full extension (removed

CPM: use in

hamstring isometrics - complete

for CPM and exercise)

2 hour in-

exercises in brace if quad control

2-4 weeks: Locked

crements for

is inadequate

at 0 for ambulating

6 - 8 hours

4-10 weeks: begin isometric

per day - begin

closed chain exercises - at 6-10

6-8 weeks:

4-6 weeks: Begin to

at 0-30 - 1

weeks, may begin weight shifting

advance to

open 20 to 30 with

cycle/minute -

activities with involved leg extended

partial weight bear

ambulation - discontinue

after week 3,

if full weight bearing - at 8 weeks begin

status - progress

use after 6 weeks

increase

balance activities and stationary bike

to use of one

flexion by 5 -

with light resistance

crutch

10 daily

10-12 weeks: hamstring

8-12 weeks:

6-8 weeks:

strengthening, theraband 0-30

progress to full

gain 0-90

resistance, light open chain

weight bearing and

8 weeks:

knee isometrics

discard crutches

gain 0-120

PHASE II

Full with a

12 weeks 6 months

normalized

None

Full range

Begin treadmill walking at a slow

of motion

to moderate pace, progress

gait pattern

balance/proprioceptive activities, initiate sport cord lateral drills

PHASE III

Full with a

6 - 9 months

normalized

None

Full and

Advance closed chain strengthening,

pain-free

initiate unilateral closed chain exercises,

gait pattern

progress to fast walking and backward walking on treadmill (initiate incline at 8-10 months), initiate light plyometric activity

PHASE IV

Full with a

9 - 18 months

normalized

None

Full and

Continue strength training - emphasize

pain-free

single leg loading, begin a progressive

gait pattern

running and agility program - high impact activities may begin at 16 months if pain-free

*Most trochlear/patellar defect repairs are performed in combination with a distal realignment procedure, and thus weight bearing is restricted for the first 4-6 weeks to protect the bony portion of the distal realignment during healing **May consider patellofemoral taping or stabilizing brace if improper patella tracking stresses implantation ***If pain or swelling occurs with any activities, they must be modified to decrease symptoms

NOTE: Post-operative stiffness in flexion following trochlear/patellar implantation is not uncommon and patients are encouraged to achieve 90 of flexion at least 3x/day out of the brace after their first post-op visit (day 7-10)

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

ACL RECONSTRUCTION (PATELLA TENDON GRAFT)* WITH AUTOLOGOUS CHONDROCYTE IMPLANTATION (FEMORAL CONDYLE) REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

PHASE I

0-2 weeks: non-

0-2 weeks: locked in

0-4 weeks:

1-2 weeks: active/passive ROM,

0 - 12 weeks

weight bearing

full extension (removed

CPM: use in

active knee extension 90-60 ,

for CPM and exercise)

2 hour incre-

quad/hamstring sets, SLR, begin

2-4 weeks: partial

2-6 weeks: gradually

ments for 6 -

active hamstring strengthening

weight bearing

open 20 at a time

8 hours per

2-6 weeks: progress exercises in

(30 - 40 lbs) with

as patient gains quad

day, begin at

phase I, add resistance above the knee,

crutches

control - discontinue

0-30 , 1

begin closed chain exercises keeping

4-6 weeks:

use of brace when

cycle/minute -

weight bearing restrictions in mind

progress to one

patient has good

after week 3,

6-10 weeks: weight shifting

crutch

quad control, but no

increase flexion

activities, progress closed chain

6-12 weeks:

sooner than 6 weeks

by 5-10 daily

and hamstring strengthening,

progress to full

forward/backward treadmill walking,

weight bearing

begin Stairmaster

without crutches

10-12 weeks: progress closed chain activities using resistance less than patient's body weight, open chain knee extension 90-30 , continue hamstring strengthening, balance activities

PHASE II

Full with a

Maintain full

Advance closed chain exercises,

12 weeks 6 months

normalized

active/passive

begin full ROM active knee extension*,

gait pattern

range

progress treadmill - initiate light jog

PHASE III

Full with a

Full and

Initiate slight incline with treadmill jog,

6 - 12 months

normalized

pain-free

emphasize single leg loading, begin

gait pattern

None

None

progressive running and agility programincluding sport-specific activities

*Monitor for signs of patella femoral irritation

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

ACL ALLOGRAFT RECONSTRUCTION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

PHASE I

As tolerated with

0-2 weeks: locked in

As tolerated

Heel slides, quad/hamstring sets,

0 - 2 weeks

crutches*

full extension for

patellar mobs, prone hangs,

ambulation and sleeping

gastroc/soleus stretch***, SLR with brace in full extension until quad strength prevents extension lag

PHASE II

Discontinue

Discontinue use

Maintain full

Progress to weight bearing

2 - 6 weeks

crutch use

when patient has full

extension and

gastroc/soleus stretch, begin toe

extension and no

progressive

raises, closed chain extension,

extension lag

flexion

balance exercises, hamstring curls, and stationary bike

PHASE III

Full, without use

6 weeks 4 months

of crutches and

None

Gain full and

Advance closed chain

pain-free

strengthening, progress

with a normalized

proprioception activities, begin

gait pattern

Stairmaster/Nordic Trac and running straight ahead at 12 weeks

PHASE IV

Full

None

4 - 6 months

Full and

Progress flexibility/strengthening,

pain-free

progression of function: forward/ backward running, cutting, grapevine, etc., initiate plyometric program and sport-specific drills May add open chain quad exercises

PHASE V

Full

None

6 months and beyond

Full and

Gradual return to sports participation,

pain-free

maintenance program for strength and endurance At patient's discression, a functional ACL brace may be used from 6 mo to 1 yr post-op

*Modified with concomitantly performed meniscus repair/transplantation or articular cartilage procedure ***This exercise is to be completed in a non-weight bearing position

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

ACL PATELLAR TENDON AUTOGRAFT RECONSTRUCTION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

As tolerated with

0-2 weeks: locked in

As tolerated

Heel slides, quad/hamstring sets,

crutches*

full extension for

patellar mobs, prone hangs, gastroc/soleus

ambulation and sleeping

stretch***, SLR with brace in full

2-4 weeks: unlocked

extension until quad strength

for ambulation, remove

prevents extension lag

PHASE I 0 - 4 weeks

for sleeping**

PHASE II 4 - 6 weeks

Gradually

Discontinue use when

Maintain full

Progress to weight bearing

discontinue

patient has full

extension and

gastroc/soleus stretch, begin toe

crutch use

extension and no

progressive

raises, closed chain extension,

extension lag

flexion

balance exercises, hamstring curls, and stationary bike

PHASE III 6 weeks 4 months

Full, without use

None

of crutches and

Gain full and

Advance closed chain

pain-free

strengthening, progress

with a normalized

proprioception activities, begin

gait pattern

Stairmaster/Nordic Trac and running straight ahead at 12 weeks

PHASE IV 4 - 6 months

Full

None

Full and

Progress flexibility/strengthening,

pain-free

progression of function: forward/ backward running, cutting, grapevine, etc., initiate plyometric program and sport-specific drills May add open chain quad exercises

PHASE V 6 months and beyond

Full

None

Full and

Gradual return to sports participation,

pain-free

maintenance program for strength and endurance At patient's discression, a functional ACL brace may be used for sports

*Modified with concomitantly performed meniscus repair/transplantation or articular cartilage procedure from 6 mo to 1 year post-op ***This exercise is to be completed in a non-weight bearing position

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

ACL HAMSTRING AUTOGRAFT RECONSTRUCTION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

As tolerated

0-2 week: locked in

As tolerated

Heel slides, quad sets, patellar mobs

0 - 4 weeks

with crutches*

full extension for

gastroc/soleus stretch***, SLR with

ambulation and sleeping

brace in full extension until quad strength prevents extension lag****

PHASE II

Gradually

Discontinue use when

Maintain full

Progress to weight bearing

4 - 6 weeks

discontinue

patient has full

extension and

gastroc/soleus stretch and closed

crutch use

extension and no

progressive

chain activities, begin hamstring

extension lag

flexion

stretching

None

Gain full and

Begin hamstring strengthening, advance

pain-free

closed chain strengthening, progress

PHASE III

Full, without use

6 weeks 4 months

of crutches and with a normalized

proprioception activities, begin

gait pattern

Stairmaster/Nordic Trac, begin running straight ahead at 12 weeks

PHASE IV

Full

None

4 - 6 months

Full and

Progress flexibility/strengthening,

pain-free

progression of function: forward/ backward running, cutting, grapevine, etc., initiate plyometric program and sport-specific drills

PHASE V

Full

None

6 months and beyond

Full and

Gradual return to sports participation,

pain-free

maintenance program for strength and endurance At patient's discression, a functional ACL brace can be used from 6 mo to 1 yr post-op

*Modified with concomitantly performed meniscus repair/transplantation or articular cartilage procedure **Avoid open chain quadriceps strengthening for first 4 months ***This exercise is to be completed in a non-weight bearing position ****NO hamstring stretching until 4 weeks post-operative

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

HIGH TIBIAL OSTEOTOMY - OPENING WEDGE REHABILITATION PROTOCOL

PHASE I 0 - 6 weeks

WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES**

0-6 Weeks: Non-

Locked in full extension

As tolerated -

Heel slides 0 - 90 , quad sets,

weight bearing with

for all activities (including

CPM* for 2

ankle pumps, calf/hamstring

crutches

sleeping) - remove for

hours, twice

stretches***, SLR with brace

exercise and CPM use (if

daily, from

locked in full extension, resisted

applicable)

0 - 90 of

plantarflexion

flexion out of brace

PHASE II

As tolerated with

Unlocked for ambulation -

Discontinue

Progress exercises in phase I,

6 - 8 weeks

crutches - begin to

removed for sleeping

CPM if knee

SLR without brace if able to

advance to a

flexion is at

maintain full extension, initiate

normalized gait

least 90

stationary bike with low resistance

pattern without crutches

PHASE III

Full, without use

Discontinue use - per

Gain full and

Mini-squats 0-45 - progressing

8 weeks 3 months

of crutches and

physician

pain-free

to step-ups, leg press 0-60

, closed

with a normalized

chain terminal knee extensions, toe

gait pattern

raises, balance activities, hamstring curls, increase to moderate resistance on bike

PHASE IV

Full

None

3 - 9 months

Full and

Progress closed chain activities,

pain-free

begin treadmill walking, swimming, and sport-specific activities

**No closed chain exercises until 6 weeks post-op ***This exercise is to be completed in a non-weight bearing position

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

ARTHROSCOPIC LATERAL RELEASE REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

PHASE I

As tolerated with

None

As tolerated

Heel slides, quad/hamstring sets,

0 - 2 weeks

crutches

patellar mobilization in all quadrants, prone hangs, gastroc/soleus stretch*, Straight leg raising, edema control

PHASE II

Gradually

2 - 6 weeks

None

Maintain full

Progress to normal gait pattern,

discontinue

extension and

gastroc/soleus stretch, begin toe

crutch use

progressive

raises, closed chain extension,

flexion

balance exercises, hamstring curls, and stationary bike

PHASE III

Full, without use

6 weeks 3 months

of crutches and

None

Gain full and

Advance closed chain

pain-free

strengthening, progress

with a normalized

proprioception activities, begin

gait pattern

Stairmaster/Nordic Trac and running straight ahead

PHASE IV 3 months and beyond

Full

None

Full and

Progress flexibility/strengthening,

pain-free

progression of function: forward/ backward running, cutting, grapevine, etc., initiate plyometric program and sport-specific drills Gradual return to sports participation, maintenance program for strength and endurance

* This exercise is to be performed in a non-weight bearing position

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

MENISCAL ALLOGRAFT TRANSPLANTATION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE**

PHASE I

0-2 weeks: partial

0-1 week: locked in

0-2 weeks:

0-2 weeks: Heel slides, quad sets,

0 - 8 weeks

weight bearing -

full extension for

non-weight

patellar mobs, SLR, SAQ

(up to 50%)

sleeping*

bearing 0-90

2-8 weeks: addition of heel

2-6 weeks: as

0-2 weeks: locked in

2-8 weeks:

raises, total gym (closed chain),

tolerated with

extension for all

as tolerated,

and terminal knee extensions -

crutches -

weight bearing

non-weight

activities with brace until 6 weeks,

discontinue use

activities

bearing

then without brace to tolerance

of crutches at 4

2-6 weeks: Locked

NOTE: No weight bearing with

weeks when

0 - 90 - discontinue

flexion >90

gait normalizes

brace after 6 weeks

PHASE II

Full, without

None

8 - 12 weeks

crutches

during phase I

Full active

Progress closed chain activities, begin

range of

hamstring work, lunges 0-90 of flexion,

motion

proprioception exercises, leg press 0-90 - flexion only, begin stationary bike

PHASE III

Full with a

12 - 16 weeks

normalized

None

gait pattern

Full and

Progress phase II exercises and

pain-free

functional activities such as: single leg hops, jogging to running progression, plyometrics, slideboard, and sport-specific drills

*Brace may be removed for sleeping after first post-operative visit (day 7-10) **Avoid any tibial rotation for 8 weeks to protect meniscus

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

MICROFRACTURE - FEMORAL CONDYLE REHABILITATION PROTOCOL

WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

Touchdown

None

Use of a CPM for

Passive stretching/exercise

0 - 6 weeks

weight bearing

6-8 hours/day - set

for the first 6 - 8 weeks, quad/hamstring

(20-30%) for the

at a rate of 1 cycle/

isometrics

first 6 weeks.

minute, advancing 10 daily - begin at a level of flexion that is comfortable for the patient - advance to full flexion as tolerated

PHASE II

Gradual return

6 - 12 weeks

to full weight

None

Gain full and

Progressive active strengthening

pain-free

bearing

PHASE III 12 weeks and beyond

Full

None

Full and pain-free

Return to full activities, including cutting, turning, and jumping

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

MICROFRACTURE - TROCHLEAR/PATELLAR DEFECT REHABILITATION PROTOCOL

WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

Weight bearing

Locked 0 - 30

Use of a CPM for

Passive stretching/exercise

0 - 6 weeks

as tolerated

of flexion for

6-8 hours/day - begin

for the first 6 - 8 weeks, quad/hamstring

in brace

weight bearing

at a rate of 1 cycle/

isometrics

Unlocked when non-

minute, ranging from

weight bearing

0 - 50, advance 10 degrees daily - advance to full flexion as tolerated

PHASE II

Full

None

6 - 12 weeks

PHASE III 12 weeks and beyond

Full

None

Gain full and

Begin closed chain activities,

pain-free

emphasizing a patellofemoral program

Full and pain-free

Return to full activities, including cutting, turning, and jumping

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

MENISCAL ALLOGRAFT TRANSPLANTATION WITH AUTOLOGOUS CHONDROCYTE IMPLANTATION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

0-4 weeks: non-

0-2 weeks: locked in

10 days - 4

0-2 weeks: Quad sets, SLR,

0 - 12 weeks

weight bearing

full extension (removed

weeks: CPM -

hamstring isometrics - complete

for CPM and exercise)

use in 2 hour

exercises in brace if quad control

4-6 weeks: partial

2-4 weeks: Gradually

increments for

is inadequate

weight bearing -

open brace 20 at a

6 - 8 hours

2-6 weeks: Begin progressive

(30 - 40 lbs)

time as quad control

per day- begin

closed chain exercises*

is gained - discontinue

at 0-40

6-10 weeks: Progress bilateral

6-12 weeks:

use of brace when

increase by

closed chain strengthening, begin

progress to full

quads can control SLR

5-10 daily, as

opened chain knee strengthening

weight bearing

without extension lag.

tolerated -

10-12 weeks: Progress closed

patient should

chain exercises using resistance

gain full ROM

less than patient's body weight,

by 12 weeks

progress to unilateral closed chain

and

exercises, begin balance activities

PHASE II

Full with a

12 weeks 6 months

None

Full active

Advance bilateral and unilateral closed

normalized

range of

chain exercises with emphasis on

gait pattern

motion

concentric/eccentric control, continue with biking, Stairmaster, and treadmill, progress balance activities

PHASE III

Full with a

6 - 9 months

normalized

None

Full and

Advance strength training, initiate

pain-free

light plyometrics and jogging - start with

gait pattern

a 2 minute walk/2 minute jog, emphasize sport-specific training

PHASE IV

Full with a

9 - 18 months

normalized

None

Full and

Continue strength training - emphasize

pain-free

single leg loading, begin a progressive

gait pattern

running and agility program - high impact activities (basketball, tennis, etc.) may begin at 16 months if pain-free

*Respect chondrocyte graft site with closed chain activities: If anterior - avoid loading in full extension If posterior - avoid loading in flexion >45 **If pain or swelling occurs with any activities, they must be modified to decrease symptoms

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

MULTI-LIGAMENT RECONSTRUCTION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

Non - weight

Locked in full extension

None

Quad sets, ankle pumps, SLR, hip ab/

PHASE I 0 - 3 weeks

bearing

adduction, hamstring/calf stretch, calf press with theraband, patellar mobilization

3 - 6 weeks

Non - weight

3 - 6 weeks: locked in full

passive only**

Add chair slides, passive ROM in prone

bearing

extension for ambulation -

to tolerance

position

removed for exercise

0 to 70 degrees

Weeks 6 - 10:

6-10 weeks: unlocked for

Maintain full

6-8 weeks: gait training, wall slides,

Progress 25% per

all activities

extension and

mini-squats, resisted hip exercises in

week until full

10 weeks - 4 mo: Varus

progressive

standing***

weight bearing at 10

unloader brace

flexion

8-12 weeks: stationary bike with light

PHASE II 6 - 12 weeks

weeks

resistance (to begin) and seat higher than normal, closed chain terminal knee extensions, Stairmaster, balance and propriception activities, leg press (limiting knee flexion to 90 )

PHASE III 12 weeks 4 months

Full, without use

Varus unloader brace

of crutches and

Gain full and

Advance closed chain strengthening,

pain-free

progress proprioception and balance

with a normalized

activities, maintain flexibility

gait pattern

4 mo - 7 mo

Full

None

Full

Treadmill walking, advance to jog Add hamstring curls for strengthening

PHASE IV 7 months

Full

None

and beyond

Full and

Maintain strength, endurance, and

pain-free

function, begin sport-specific functional progression (backward running, cutting, grapevine, etc.), progress to running, initiate a plyometric program Return to sports with PCL brace until 1 year post-op

**Maintain anterior pressure on proximal tibia as knee is flexed - prevent posterior sagging at all times ***Resistance must be proximal to knee with hip ab/adduction exercises

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

OSTEOCHONDRAL AUTOGRAFT TRANSPLANT REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

Non-weight

0-1 week: locked in

0-6 weeks:

PROM/AAROM to tolerance,

0 - 6 weeks

bearing

full extension (remove

CPM: use for

patella and tibiofibular joint mobs

for CPM and exercise)

6-8 hours

(grades I & ll), stationary bike for ROM,

2-4 weeks: gradually

per day - begin

quad, hamstring, adduction, and gluteal

open brace in 20

at 0-50 , 1

sets, hamstring stretches, hip

crements as quad control

cycle/minute -

strengthening, SLR, ankle pumps

is gained - discontinue use

increasing

of brace when quads can

5-10 daily per

control SLR without an

patient comfort -

extension lag

patient should

in-

gain 100

by

week 6

PHASE II

Progress to

Gradually

Gait training, scar and patellar mobs,

6 - 8 weeks

full weight

increase flexion-

quad/hamstring strengthening, begin

bearing

patient should

closed chain activities (wall sits, shuttle,

obtain 130 of

mini-squats, toe raises), begin unilateral

flexion

stance activities

Full and

Advance activities in phase II

PHASE III

Full with a

8 - 12 weeks

normalized gait pattern

None

None

pain-free

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

OSTEOCHONDRAL ALLOGRAFT TRANSPLANT REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISE

PHASE I

Non-weight

0-1 week: locked in

0-6 weeks:

PROM/AAROM to tolerance, patella and

0 - 6 weeks

bearing

full extension (removed

CPM: use for

tibiofibular joint mobs (grades I & II),

for CPM and exercises)

6-8 hours per

quad, hamstring, and gluteal sets,

2-4 weeks: Gradually

day - begin at

hamstring stretches, hip strengthening,

open brace in 20 in-

at 0-40 -

SLR

crements as quad control

increasing 5-10

is gained - discontinue use

daily per patient

of brace when quads can

comfort

control SLR without an

patient should

extension lag

gain 100 by week 6

PHASE II

Partial weight

6 - 8 weeks

bearing (25%)

None

Gradually

Scar and patellar mobs, quad/hamstring

increase flexion-

strengthening, stationary bike for ROM,

patient should

continue to advance lower extremity

have 130

strengthening activities

of

flexion

PHASE III

Gradually return to

8 - 12 weeks

full weight bearing

None

Progress to full

Gait training, begin closed chain activities

and pain-free

(wall sits, shuttle, mini-squats, toe raises), begin unilateral stance activities

PHASE IV

Full with a

12 weeks 6 months

normalized gait pattern

None

Full and pain-free

Advance phase III activities

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

PATELLAR REALIGNMENT W/ OSTEOTOMY FOR PATELLAR INSTABILITY - REHABILITATION PROTOCOL

PHASE I

WEIGHT BEARING

BRACE

ROM**

THERAPEUTIC EXERCISES

Non-weight bearing

0 - 2 weeks: Locked in

0 - 2 weeks:

Heel slides, quad/hamstring sets,

extension for sleep,

0 - 30 degrees

patellar mobilization in all quadrants, prone

ambulation, can

2 - 4 weeks:

hangs, gastroc/soleus stretch*,

unlock 0 - 30 degrees

0 - 60 degrees

Straight leg raising with brace locked in

2 - 4 weeks: Unlocked

4 - 6 weeks:

extension, edema control

0 - 60 degrees

0 - 90 degrees

0 - 6 weeks

4 - 6 weeks: Unlocked 0 - 90 degrees

PHASE II

6 - 8 weeks:

6 - 8 weeks: Unlocked

Maintain full

Progress to normal gait pattern,

6 - 12 weeks

Advance to weight

8 weeks: Discontinue use

extension and

gastroc/soleus stretch, begin toe

bearing as tolerated

progressive

raises, closed chain extension,

Discontinue crutches

flexion

balance exercises, hamstring

as tolerated

PHASE III

Full, without use

3 - 4 months

of crutches and

curls, and stationary bike

None

Gain full and

Advance closed chain

pain-free

strengthening, progress

with a normalized

proprioception activities, begin

gait pattern

Stairmaster/Nordic Trac and running straight ahead

PHASE IV 4 months and beyond

Full

None

Full and

Progress flexibility/strengthening,

pain-free

progression of function: forward/ backward running, cutting, grapevine, etc., initiate plyometric program and sport-specific drills Gradual return to sports participation, maintenance program for strength and endurance

* This exercise is to be performed in a non-weight bearing position ** In cases of realignment for patellar cartilage defects, CPM & full motion may be allowed

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

PCL RECONSTRUCTION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

Non - weight

Locked in full extension

None

Quad sets, ankle pumps, SLR, hip ab/

PHASE I 0 - 3 weeks

bearing

adduction, hamstring/calf stretch, calf press with theraband, patellar mobilization

3 - 6 weeks

Non - weight

3 - 6 weeks: locked in full

passive only**

Add chair slides, passive ROM in prone

bearing

extension for ambulation -

to tolerance

position

removed for exercise

0 to 70 degrees

Weeks 6 - 10:

6-10 weeks: unlocked for

Maintain full

6-8 weeks: gait training, wall slides,

Progress 25% per

all activities

extension and

mini-squats, resisted hip exercises in

week until full

10 weeks: discontinue use

progressive

standing***

flexion

8-12 weeks: stationary bike with light

PHASE II 6 - 12 weeks

weight bearing at 10 weeks

resistance (to begin) and seat higher than normal, closed chain terminal knee extensions, Stairmaster, balance and propriception activities, leg press (limiting knee flexion to 90 ), open chain quad ranging from 0 - 60 degrees

PHASE III 12 weeks 4 months

Full, without use

None

of crutches and

Gain full and

Advance closed chain strengthening,

pain-free

progress proprioception and balance

with a normalized

activities, maintain flexibility

gait pattern

4 mo - 7 mo

Full

None

Full

Treadmill walking, advance to jog Add hamstring curls for strengthening

PHASE IV 7 months

Full

None

and beyond

Full and

Maintain strength, endurance, and

pain-free

function, begin sport-specific functional progression (backward running, cutting, grapevine, etc.), progress to running, initiate a plyometric program Return to sports in PCL brace until 1 year post-op

**Maintain anterior pressure on proximal tibia as knee is flexed - prevent posterior sagging at all times ***Resistance must be proximal to knee with hip ab/adduction exercises

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

PCL INJURY - NON-OPERATIVE REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

Progress to weight-

Locked in full extension

Within limits of

Isometric quad sets, ankle pumps, SLR,

bearing as tolerated

when not in PT

pain, in prone

hip ab/adduction, hamstring/calf stretch,

position

No open chain hamstrings Add open chain knee extension

PHASE I 0 - 1 weeks

with crutches

2 - 3 weeks

WBAT,

Brace unlocked for flexion

Increase ROM,

can discontinue

15 degree extension stop

in prone position

crutches

for ambulation

WBAT

Fit for PCL brace, 15

Full, begin

Add closed chain exercises

degree extension stop

active ROM

stationary bike with light

PHASE II 3 - 4 weeks

resistance (to begin) and seat higher than normal, closed chain terminal knee extensions, Stairmaster, balance and propriception activities, leg press (limiting knee flexion to 90 ), open chain quad ranging from 0 - 60 degrees No open chain hamstrings

PHASE III 5 - 6 weeks

Full, without use

PCL brace for remainder

Gain full and

Advance closed chain strengthening,

of crutches and

of season, extension stop

pain-free

progress proprioception and balance

with a normalized

at zero

gait pattern

activities, maintain flexibility May add hamstring strengthening

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

PCL and PLC RECONSTRUCTION REHABILITATION PROTOCOL WEIGHT BEARING

BRACE

ROM

THERAPEUTIC EXERCISES

Non - weight

Locked in full extension

None

Quad sets, ankle pumps, SLR, hip ab/

PHASE I 0 - 3 weeks

bearing

adduction, hamstring/calf stretch, calf press with theraband, patellar mobilization

3 - 6 weeks

Non - weight

3 - 6 weeks: locked in full

passive only**

Add chair slides, passive ROM in prone

bearing

extension for ambulation -

to tolerance

position

removed for exercise

0 to 70 degrees

Weeks 6 - 10:

6-10 weeks: unlocked for

Maintain full

6-8 weeks: gait training, wall slides,

Progress 25% per

all activities

extension and

mini-squats, resisted hip exercises in

week until full

10 weeks - 4 mo: Varus

progressive

standing***

weight bearing at 10

unloader brace

flexion

8-12 weeks: stationary bike with light

PHASE II 6 - 12 weeks

weeks

resistance (to begin) and seat higher than normal, closed chain terminal knee extensions, Stairmaster, balance and propriception activities, leg press (limiting knee flexion to 90 )

PHASE III 12 weeks 4 months

Full, without use

Varus unloader brace

of crutches and

Gain full and

Advance closed chain strengthening,

pain-free

progress proprioception and balance

with a normalized

activities, maintain flexibility

gait pattern

4 mo - 7 mo

Full

None

Full

Treadmill walking, advance to jog Add hamstring curls for strengthening

PHASE IV 7 months

Full

None

and beyond

Full and

Maintain strength, endurance, and

pain-free

function, begin sport-specific functional progression (backward running, cutting, grapevine, etc.), progress to running, initiate a plyometric program Return to sports with PCL brace until 1 year post-op

**Maintain anterior pressure on proximal tibia as knee is flexed - prevent posterior sagging at all times ***Resistance must be proximal to knee with hip ab/adduction exercises

Kevin B. Freedman, M.D. Sports Medicine 27 South Bryn Mawr Ave Bryn Mawr, PA 19010-3470 Phone: (610) 527-2727 Fax: (610) 527-1588

TIBIAL TUBERCLE OSTEOTOMY WITH PATELLAR MICROFRACTURE REHABILITATION PROTOCOL

PHASE I

WEIGHT BEARING

BRACE

ROM**

THERAPEUTIC EXERCISES

Non-weight bearing

0 - 6 weeks: Locked in

0 - 2 weeks:

Heel slides, quad/hamstring sets,

extension for sleep,

CPM 0-50,

patellar mobilization in all quadrants, prone

ambulation, can

advance 10

hangs, gastroc/soleus stretch*,

unlock for exercise

degrees/day

Straight leg raising with brace locked in

to full

extension, edema control

0 - 6 weeks

PHASE II

6 - 8 weeks:

6 - 8 weeks: Unlocked

Maintain full

Progress to normal gait pattern,

6 - 12 weeks

Advance to weight

8 weeks: Discontinue use

extension and

gastroc/soleus stretch, begin toe

bearing as tolerated

progressive

raises, closed chain extension,

Discontinue crutches

flexion

balance exercises, hamstring

as tolerated

PHASE III

Full, without use

3 - 4 months

of crutches and

curls, and stationary bike

None

Gain full and

Advance closed chain

pain-free

strengthening, progress

with a normalized

proprioception activities, begin

gait pattern

Stairmaster/Nordic Trac and running straight ahead

PHASE IV 4 months and beyond

Full

None

Full and

Progress flexibility/strengthening,

pain-free

progression of function: forward/ backward running, cutting, grapevine, etc., initiate plyometric program and sport-specific drills Gradual return to sports participation, maintenance program for strength and endurance

* This exercise is to be performed in a non-weight bearing position