ACL Rehab Protocol. NPTE Study Guide: Master the NPTE

Tibiofemoral jt: Convex femur and concave tibia. W/ excessive genu-valgus, strengthen the gluteus medius, not the VMO.

Anterior cruciate ligament (ACL): Resists anterior translation and medial rotation of tibia on femur. Often injured by hyperextension of the knee

ACL Reconstruction: Think safety & rehab progression. 

-Preoperative exercises: Restore full knee ROM (especially ext). Prevent atrophy & weakness. Address hip & ankle strength & flexibility. Lack of skeletal maturity can be a contraindication to surgery. Begin postoperative exercises immediately on first day. Tendon graft goes through necrotizing process in the first 2–3 weeks before revascularization; Progress exercises cautiously during this phase! Bone-to-bone healing is faster than soft-tissue–to–bone healing. Bone–patellar tendon–bone technique vs hamstring tendon technique (weaker). Continuous passive motion (CPM) may be used—but is not very beneficial.

-Precautions: 

  1. Knee flexor strengthening for hamstring tendon. 

  2. Knee extensor strengthening for patellar tendon.

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

  4. Avoid CKC quadriceps strengthening between 60-90° of FLX

-Bracing: A hinged orthosis w/ locking mechanism is used that locks knee in ext. Worn up to 6 weeks (Note: This is an older thought. Recent clinical practice allows ROM as tolerated after 1 week). Able to unlock w/ exercises when ROM is prescribed. Locked w/ ambulation.

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

Phases of postoperative rehabilitation:

Phase 1: Maximum Protection Phase (1–4 wk): Pt presents w/ pain, decreased ROM, decreased voluntary quadriceps activation, Ambs w/ crutches, protective bracing (if prescribed).

  1. Weeks 0–2: 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). 

  2. Weeks 2–4: 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).

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

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

Phase 2: Moderate Protection Phase (4–10 wk): Pt presents w/ pain & edema controlled, MMT 3+/5 to 4/5, Ind Amb, close to full ROM.

  1. Weeks 5–6: 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.

  2. Weeks 7–10: Advanced strengthening, PNF. High-speed step drills, unstable surfaces, balance beam. Initiate walking & then jogging program. 

  3. Goals: 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.

  4. To move on to next phase: 75% of strength of knee muscle compared to C/L side.

Phase 3: Minimum Protection Phase (11–24 wk): Pt presents w/ no jt instability, knee function 75% of C/L LE. 

  1. Weeks 11–24: • Advanced PRE, CKC strengthening; Emphasize eccentric contractions. Initiate plyometrics. Progress agility drills. Simulated work &/or sports training. Full-speed jogging, sprints, running & cutting.

  2. Goals: 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.