ACL Rehab Protocol. NPTE Study Guide: Master the NPTE

Tibiofemoral joint

Joint between the convex femur and concave tibia

Anterior cruciate ligament (ACL)

Ligament that resists anterior translation and medial rotation of the tibia on the femur, often injured by hyperextension of the knee.

ACL Reconstruction

Surgical procedure to repair a torn anterior cruciate ligament in the knee. Uses a tendon graft most times

Preoperative exercises

Begin immediately on day 1., but w/ caution. Restore full knee ROM (especially ext). Prevent atrophy & weakness. Address hip & ankle strength & flexibility

How long does it take until the tendon graft starts to heal?

Tendon graft goes through necrotizing process in the first 2–3 weeks before revascularization

Precautions for ACL Reconstruction

Knee flexor strengthening for hamstring tendon. 

Knee extensor strengthening for patellar tendon.

Avoid shear forces & stress on new ACL: No OKC knee ext in short sitting! Stay within 90-45°. CKC is preferred for rehab safety .

Avoid CKC quadriceps strengthening between 60-90° of FLX

Contraindication for ACL reconstruction

Lack of skeletal maturity

Bracing

A hinged orthosis w/ a locking mechanism to keep knee extended, worn for 1 or 6 wks based on surgeon. Able to unlock w/ exercises when ROM is prescribed. Locked w/ ambulation

Functional bracing

For advanced rehabilitation (11–24 wk). For participation in high-demand sports. Reduces anterior translation, especially at low external loads.

How many phases of postoperative rehabilitation are there?

Phase 1: Maximum Protection Phase (1–4 wk)

Phase 2: Moderate Protection Phase (4–10 wk)

Phase 3: Minimum Protection Phase (11–24 wk)

Patient presentation during Phase 1

Pt presents w/ pain, decreased ROM, decreased voluntary quadriceps activation, Ambs w/ crutches, protective bracing (if prescribed)

What do Weeks 0–2 of rehab look like?

PRICE (bracing). Gait training w/ crutches; PWB to WBAT. At wk 1 WBAT w/ ROM as tolerated is ideal. PROM to AAROM. Prevent EXT lag (reflex inhibition). Grades I & II patellar mobilizations. Muscle setting, isometrics. Can use ES or biofeedback. Assisted SLR test (4-way)

What do Weeks 2–4 of rehab look like?

Progress to FWB. If active full knee ext & pain-free = adequate quad strength. CKC exercises (mini-squats, heel & toe raises). OKC knee EXT (90-45° only). Trunk & pelvis stabilization. Aerobic conditioning: stationary bike (3 wk

Goals of phase 1?

Protect healing tissues. Prevent reflex inhibition of mm. Prevent vascular complications (DVT). Decrease jt effusion. ROM 0-110°. WB 75% to WBAT. Establish HEP

What must be done to move to phase 2?

To move on to next phase: 60% of strength of knee muscle compared to C/L side

Patient presentation during Phase 2

Pt presents w/ pain & edema controlled, MMT 3+/5 to 4/5, Ind Amb, close to full ROM

What do Weeks 5–7 of rehab look like?

Multi-angle isometrics. CKC strengthening & PRE w/ OKC PRE (resistance above knee until stable). Endurance training (bike, pool, elliptical). SLS: balance training. Band walks, elastic band exercises.

What do Weeks 7–10 of rehab look like?

Advanced strengthening, PNF. High-speed step drills, unstable surfaces, balance beam. Initiate walking & then jogging program. 

Goals of phase 2?

Full pain-free ROM (0-125°). 4/5 MMT. Dynamic knee control. Improve kinesthetic awareness. Normalize gait pattern & ADL function. Focus on gaining terminal knee EXT in CKC by strengthening quadriceps & hamstrings.

What must be done to move to phase 3?

75% of strength of knee muscle compared to C/L side.

Patient presentation during Phase 3

Pt presents w/ no jt instability, knee function 75% of C/L LE

What do Weeks 11–24 of rehab look like?

Advanced PRE, CKC strengthening; Emphasize eccentric contractions. Initiate plyometrics. Progress agility drills. Simulated work &/or sports training. Full-speed jogging, sprints, running & cutting.

Goals of phase 3?

Increase mm strength, endurance, & power: Improve neuromuscular control, dynamic stability, & balance. Regain ability to function at highest desired level. Reduce risk of re-injury. Return to sport: 6mo to 1year post-surgery.

Excessive genu-valgus requires strengthening of what?

Gluteus medius, not the VMO.