Knee Post-Operative Rehabilitation Protocols

8/8/2019 Knee Post-Operative Rehabilitation Protocols

1/16

Postoperative Rehabilitation Protocolfor 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 domini squats

Assume 12 weeks graft to bone healing time

Wit h hamstrings or Allograft flexion is rest ricted t o 90 degreesfor f irst 4 w eeks to r educe st ress 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 LIVI NG

Patients may begin the following activities at the dates indicated (unlessotherwise specified by the physician):

Showering once dressing removed; no immersion untilstitches/staples removed and wounds healed, if brace is present mayremove for shower.

If patient has a brace may sleep without brace after comfortable(usually a few days) unless there is cartilage repair or lateral sidesurgery then same for WB restrictions.

Driving: when safely able to operate the controls of the vehicle. Anytime for left knee surgery (assuming automatic transmission), andlonger for right leg surgery.

Full weight bearing without crutches usually by 2 weeks or astolerated, however for meniscus repair toe touch for about 4 weeks,and 8 weeks when any lateral side surgery also performed.

PHYS ICAL THERAP Y ATTENDAN CEThe 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


2/16

PHASE I:Begins immediately following surgery and lasts approximately one month.

Patient is to perform ROM exercises and hip, knee and ankle strengthening asdirected 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, patellamobilizations and flexion limit dependent on graft choice, meniscusrepair and other concurrent surgery (i.e., lateral side)

PREs 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.


3/16

PHASE II:

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

Goals:

Increase range of motion for all patients/all grafts progress to fullflexion

Progress in weight bearing for all patients/all grafts according toprevious precautions (i.e., lateral side surgery 6-8 weeks ofcrutch/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 extremityand the patient as a whole in preparation for return to activity or sports


4/16

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 yetPHASE 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 isimportant not to go any faster even if the patient seems able, since the mostimportant consideration is graft protection. Please have physician contacted ifthere 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 its all about You at your Peak Performance

www.performanceorthopedics.com


5/16

Postoperative Rehabilitation Protocolfor Carticel Im plantation 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 LI VINGPatients may begin the following activities at the dates indicated (unless otherwise specified bythe physician):

Showering once dressing removed; no immersion until stitches/staples removedand wounds healed, if brace is present may remove for shower.

Driving: when safely able to operate the controls of the vehicle. Any time for leftknee surgery (assuming automatic transmission), and longer for right leg surgery.

Return to work/school will depend on the individual needsPHYSICAL THERAPY ATTENDANCEThe 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-bearingactivities. 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 body weight) 6 weeks: May progress to weight bear as tolerated


6/16

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 /dayo May continue CPM 6-8 hours/day for 4-6 weeks

Motion guidelines on CPMo 1-2 weeks: Knee flexion 90o 3-4 weeks: Knee flexion 105o 5-6 weeks: Knee flexion 120

Stretch hamstrings and calf daily Begin patellar mobilization and soft tissue mobilizationStrengthening: 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 I I: Transition Phase:Begins 6 weeks post-op, and extends to the 12th post-op week. Discontinue post-operativebrace 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 125-135o Maintain full extension

Continue patellar mobilization and soft tissue mobilization Continue stretching program (hip, knee, and ankle)


7/16

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. Thepatient may also begin gradually increasing standing and walking. Increase biking andswimming activities.

Criteria to Progress: Full ROM Acceptable Strength (estimated by manual effort)

o Hamstrings within 10-20% of other lego 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 flexionStrengthening: 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)


8/16

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 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 notto go any faster even if the patient seems able, since the most important consideration is graftprotection. Please have physician contacted if there are questions or concerns

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



248-988-8085 Phone / 248-988-8565 Fax




9/16

Postoperative Rehabilitation Protocolfor 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 LI VINGPatients may begin the following activities at the dates indicated (unless otherwise specified bythe physician):

Showering once dressing removed; no immersion until stitches/staples removedand wounds healed, if brace is present may remove for shower.

Driving: when safely able to operate the controls of the vehicle. Any time for leftknee surgery (assuming automatic transmission), and longer for right leg surgery.

Return to work/school will depend on the individual needsPHYSICAL THERAPY ATTENDANCEThe 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-bearingactivities. 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**


10/16

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 /dayo 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 mobilizationStrengthening: 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 I I: Transition Phase:Begins 6 weeks post-op, and extends to the 12th post-op week. Discontinue post-operativebrace 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


11/16

Therapeutic Exercises:ROM: Gradually increase ROM

o Knee flexion to 120-125by week 8o Maintain full extension

Continue patellar mobilization and soft tissue mobilization Continue stretching programStrengthening: 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 mayalso begin gradually increasing standing and walking.

Criteria to Progress: Full ROM Acceptable Strength

o Hamstrings within 10-20% of other lego 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 flexionStrengthening: 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


12/16

Functional Activities:As patient improves, increase walking (distance, cadence, incline, etc). Light running can beinitiated 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 notto go any faster even if the patient seems able, since the most important consideration is graftprotection. Please have physician contacted if there are questions or concerns




248-988-8085 Phone / 248-988-8565 Fax




13/16

Postoperative Rehabilitation Protocol forPCL 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-opcare, i.e. crutches x 8 weeks and brace to avoid varus stress

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVI NGPatients may begin the following activities at the dates indicated (unlessotherwise specified by the physician):

Showering once dressing removed; no immersion untilstitches/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.

PHYS ICAL THERAP Y ATTENDAN CEThe 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.


14/16

Goals: Protect healing bony and soft tissue structures Minimize the effects of immobilization through:

Early protected range of motion (protect against posterior tibialsagging)

PREs for quadriceps, hip and calf with an emphasis on limitingpatellofemoral joint compression and posterior tibial translation

Patient education for a clear understanding of limitations andexpectations 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 translationWeight bearing Status

TTWB with crutches, brace is locked at full extension.Special Considerations:

Pillow under proximal posterior tibia at rest to prevent posterior sagTherapeutic 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 kneeextension to prevent posterior tibial translation

PHASE II:Begins at 1 month post-op, and extends to the 12 th 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 isremoved during PT for strengthening and stretching. Avoid varusstress during this phase if concomitant posterolateral corner

reconstruction.


15/16

At 6 weeks for PCL, or PCL/ACL brace is removed, for any lateral orposterolateral 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 inextension only, progress to active knee extension as tolerated frompoint 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 requirethe brace, therapy can be liberalized and proceed on a more astolerated basis. Stationary Bike: Foot is placed forward on the pedal without use of

toe clips to minimize hamstring activity. Seat slightly higher thannormal

Closed kinetic chain terminal knee extension utilizing resisted bandwhile standing or weight machine. For leg press, knee flexionshould be limited to 90 during exercises.

Stairmaster and/or elliptical machines can be used for cardio andleg 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 maystretch 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/oropen kinetic chain exercises


16/16

Continue to work on restoration of functional progression of theextremity 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 guideli ne s. Before 3

months it is important not to go any faster even if the patient seemsable, since the m ost important consideration is graft protection. Please

have physician con tacted if there are questions or concerns.




248-988-8085 Phone / 248-988-8565 Fax



Documents

Knee Post-Operative Rehabilitation Protocols