This protocol should be modified and adapted to the rehabilitation of SPECIFIC ACL AND COMBINED LESIONS. All post-op patients require early active mobilization so that full extension and flexion are achieved rapidly. The range of motion should be achieved actively by the patient. It is our feeling that the literature has been confusing in this regard. Many patients have been unnecessarily restricted in their range of motion activities because of the notion that active extension causes stretching of the ACL graft. This is true if resisted exercises are used or if the graft is improperly placed and not isometric! However, our experience has shown that the graft that is isometric can tolerate early active ROM without stretching out. Further, it has been our experience that contractures have occurred in which initiation of range of motion activity is delayed.

ACUTE ACL TEARS, WHEN ASSOCIATED WITH: I) significant MCL tears, 2) repair of meniscal lesions, 3) osteochondral fracture of articular surfaces, require early mobilization to prevent flexion contracture and promote chondral healing.

We have found that in patients OVER 30 YEARS OF AGE, whether they be acute or chronic reconstructions, tend to develop stiffness if not mobilized early.

CHRONIC ACL RECONSTRUCTIONS frequently have had previous surgery and are associated with degenerative joint disease. These knees occasionally require spongializing arthroplasty which demands early motion.

With the exception of repaired meniscal tears, and ACL reconstructions combined with PCL reconstructions, we start active mobilization at two to three weeks post operative. After splint and suture removal, a hinged-adjustable rehabilitative brace is applied and locked at 40 degrees for a few days. We have found that long range stability has been maintained using this brace-mobilization technique.

It should be emphasized that this rehabilitation program has been modified and revised many times since its inception in 1979. We have based our experiences on over 750 ACL repairs, augmentations and reconstructions. We have emphasized a conservative approach and as our results improve without degradation, we hope to become more aggressive where possible.

PHASE I: 1-2 weeks

You should contact the office after leaving the hospital to make an appointment to have your stitches removed. Elevation of your leg 50% of the day is essential. This means having your foot higher than your head. DO NOT TAKE THE SPLINTS OFF!! USE YOUR CRUTCHES - NO WEIGHTBEARING ON YOUR LEG.

1. Draw the alphabet using capital letters with your big toe - a minimum of five times per day.

PHASE II: 3-4 weeks

Your brace will be applied at this time. This is a soft, hinged brace. It will be in the locked position for a few days. The brace should be adjusted to permit 20 degrees of extension. NO MORE THAN 20 DEGREES OF EXTENSION SHOULD BE PERMITTED. The flexion stop will be adjusted when you are able to obtain the available flexion permitted in the brace. It is important that you work diligently to achieve the range of motion you have in your brace. There is no limit to the amount of flexion you may gain in your brace. After the brace's application, partial weight-bearing is allowed with crutches. At three weeks, full weight-bearing is allowed and you may discontinue the use of crutches provided you feel safe and comfortable without them. Your exercise program is vital to your rehabilitation, so follow it faithfully! Call to arrange an appointment with physical therapy.

Begin manual resisted exercises to hip abductors and extensors, three sets of ten repetitions per day.

1. Begin a limited number of straight leg raises, so that you are able to lift your leg.

2. Whirlpool is begun, 20 minutes duration in a warm whirlpool. BENDING AND STRAIGHTENING are encouraged in the whirlpool.

3. WORK ON BENDING AND STRAIGHTENING YOUR KNEE 10 - l5 MINUTES EACH HOUR, within the limits of the brace.

PHASE III: 5 - 6 weeks

You may take your brace off to sleep and bathe. You must wear it at all other times.

1. Continue with previously prescribed exercises.

2. Walking progressing to running in pool, you must be chest-deep in water.

PHASE IV: 7 - 9 weeks

Your brace will be removed at this time. The stationary bicycle will be started in this phase. To make sure your knee does not straighten too far when riding the bike, keep your seat as low as possible. Use the toe clips on the pedals so that you can push up rather than push down on the pedals.

1. Stationary bicycle.

2. Isotonic hamstring strengthening on N/K table, three sets of ten repetitions. Be careful not to let the knee straighten too far.

3. Continue manually resisted exercises to hip abductors and extensors.

4. Regular swimming workouts. Run in the pool.

5. WORK ON BENDING AND STRAIGHTENING OF YOUR KNEE 10 - l5 MINUTES OF EACH HOUR.

6. Nautilus, hip and back extension, three sets of ten repetitions.

PHASE V: 10 - 15 weeks

You will begin isotonic quadricep strengthening. Continue to work on motion. Begin isokinetic Fitron work. Begin step-ups.

1. Isotonic quadricep strengthening on the N/K table 90 degrees to 45 degrees. DO NOT GO HIGHER THAN 45 DEGREES!!! Ten pound maximum this phase. LET THE WEIGHT DOWN VERY SLOWLY!

2. Begin isokinetic Fitron, increase intensity and duration according to tolerance.

3. Begin step-ups on a footstool or step, three sets of thirty-second bouts.

4. Stationary bicycle.

5. Continue with isotonic hamstring exercises.

6. CONTINUE WORK ON BENDING AND STRAIGHTENING THE KNEE.

PHASE VI: 16 - 23 weeks

Walk at a brisk pace for exercise, preliminary to running will be started. DO NOT RUN. Avoid going up and down hills. Increase stationary bicycle riding for range of motion. Begin Nordic Track with a low resistance initially, increase resistance according to tolerance. No lifting of objects heavier than a sack of groceries.

1. Continue quadricep strengthening, 90 degrees to 45 degrees only!! Work up to 30 pounds this phase. LET THE WEIGHT DOWN VERY SLOWLY!

2. Begin Nordic Track, low resistance. Increase intensity and duration according to tolerance.

3. Begin Isokinetic Cybex or Orthotron exercises, for hamstrings. DO NOT PUSH UP, PULL DOWN ONLY.

4. CONTINUE TO WORK ON BENDING AND STRAIGHTENING.

5. Continue with isotonic hamstring exercises.

6. Continue step-ups

PHASE VII: (will depend on individual progression)

You may begin straight ahead running. Run in grass or soft surfaces. Level only. No up or down hills. Continue with stationary bicycle and Fitron. Time or distance according to ability.

1. Begin quadricep strengthening, full range of motion. Increase weights according to tolerance. LET THE WEIGHT DOWN VERY SLOWLY!

2. Continue with isotonic hamstring exercises.

3. Continue with isokinetic Cybex or Orthotron hamstring exercises.

4. Walk up stadium steps, take the ramp down, or walk down slowly.

5. Run straight once for 30 yards, increase to ten times.

6. Begin leg press-limited range only, 90 degrees to 45 degrees.

PHASE VIII: (will depend on individual progression)

1. Continue quadricep strengthening exercises.

2. Continue with isotonic hamstring exercises.

3. Run stadium steps. Run up, walk down. Work up to ten stadiums per day.

4. Begin work on isokinetics, Cybex or Orthotron, high speed (quadriceps and hamstrings).

5. Back pedal. Once for 30 yards, increase to ten times.

6. Circles. Ten yards diameter, ten per day. Continue to increase speed and decrease diameter of the circle. Run clockwise and counter-clockwise.

7. Zig-zag. Forty-five zig-zags, five yards each. Once for 30 yards, increase to ten times at 30 yards.

8. Figure eights. Twenty yards long, ten yards wide. Build to ten times. Decrease size of "8" and increase speed.

9. Cybex evaluation.

10. KT-l000 evaluation.