Dr. Mitchell W. Larsen MD
Director of Education
Central Utah Sports Medicine
1055 N 500 W Bld C Ste 121
Provo, UT 84604
(801)373-7350

PLC & PCL/ACL RECONSTRUCTION PROTOCOL

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GENERAL GUIDELINES

• No open chain hamstring work

• Assume 12 weeks graft to bone healing time

• Caution against posterior tibial translation (gravity, muscle action)

• No CPM

• PCL with posterolateral corner or LCL repair follows different post-op care, i.e. crutches x 3 months

• Resistance for Hip PRE’s placed above knee for hip abduction, adduction. Resistance may be distal for hip flexion.

• Supervised physical therapy takes place for approximately 3-5 months post-op

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

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

• Bathing/Showering without brace (surgical incisions should be healed before immersion in water) – 1 week post-op

• Sleep without brace - 8 weeks post-op

• Driving: 6-8 weeks post-op

• Full weightbearing without assistive devices – 8 weeks post-op (with physician’s clearance)

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:

Phase I (0-1 month): 2 visit/week

Phase II (1-3 months): 2-3 visits/week

Phase III (3-9 months): 2 visits/month

Phase IV (9-12 months): 1 visit/month

REHABILITATION PROGRESSION

The following is a general guideline for progression of rehabilitation following PCL or PCL/ACL Reconstruction. Progress through each phase should take into account patient status (e.g. healing, function) and physician advisement. Please consult the physician if there is any uncertainty concerning advancement of a patient to the next phase of rehabilitation.

PHASE I:

Begins immediately following surgery and lasts approximately one month

Goals:

• Protect healing bony and soft tissue structures

• Minimize the effects of immobilization through:

• Early protected range of motion (protect against posterior tibial sagging)

• PRE’s for quadriceps, hip and calf with an emphasis on limiting patellofemoral joint compression and posterior tibial translation

• Patient education for a clear understanding of limitations and expectations of the rehabilitation process

Brace:

• Locked at 0° for 1 week

• At one week post-op the brace is unlocked for passive range of motion performed by a physical therapist or athletic trainer.

• Technique for PT/AT assisted ROM is as follows:

• PT/AT Assisted knee flexion ROM: Patient supine for PCL patients: maintain anterior pressure on proximal tibia as knee is flexed. For combined PCL/ACL patients, maintain neutral position of proximal tibia as knee is flexed. It is important to prevent posterior tibial sagging at all times.

• Patients will be instructed in self administered PROM with the brace on with emphasis on supporting the proximal tibia

Weightbearing Status

• WBAT with crutches, brace is locked

Special Considerations:

• Pillow under proximal posterior tibia at rest to prevent posterior sag

Therapeutic Exercises:

Instructed in hospital

• Quad Sets

• SLR

• Hip AB/AD

• Hip alphabet

• Ankle Pumps

Add at first post-op visit:

• Hamstring and Calf stretching

• Calf press with Theraband progressing to standing calf raises with full extension

• Standing hip extension from neutral

• Continue exercises as above

• *Note Functional Electrical Stimulation may be used for trace to poor quad contraction

PHASE II:

Begins approximately 1 month post-op, and extends to the 12 ^th post-op week. Expectations for advancement to Phase II:

• Good quad control (Good quad set, no lag with SLR)

• Approximately 60° of knee flexion

• Full knee extension

• No signs of active inflammation

Goals:

• Increase range of motion (flexion)

• Restore normal gait

• Continue quadriceps strengthening and hamstring flexibility

Brace:

• 4-6 weeks: Brace is unlocked for controlled gait training only (patient may

ambulate with brace unlocked while attending physical therapy

or when at home)

• 6-8 weeks: Brace is unlocked for all activities

• 8 weeks: Discontinue brace as allowed by physician. Unless posterior

lateral corner and/or LCL repair

Weightbearing Status:

• 4-8 weeks: WBAT with crutches

• 8 weeks: May D/C crutches if patient exhibits: (unless PLC or LCL then 3 months)

• No quad lag with SLR

• Full knee extension

• Knee flexion 90-100°

• Normal gait pattern (Pt. May utilize one crutch or cane until normal gait is achieved)

Therapeutic Exercises:

• 4-8 weeks: When patient exhibits independent quad control, may begin open chain extension

• Wall slides (0-45°), begin isometric, progress to active against body weight. Progress to mini-squats etc.

• Eagle 4-way hip for flexion, AB, AD, Ext from neutral with knee fully extended.

• Ambulation in pool (work on restoration of normal heel-toe gait pattern in chest deep water

• 8-12 weeks:

• Stationary Bike: Foot is placed forward on the pedal without use of toe clips to minimize hamstring activity. Seat slightly higher than normal

• Closed kinetic chain terminal knee extension utilizing resisted band or weight machine. Use caution to place point of resistance to minimize tibial displacement.

• Stairmaster

• Balance and Proprioception activities (e.g. single leg stance)

• Seated calf raises

• Leg press. Knee flexion should be limited to 90° during exercises.

PHASE III:

Begins approximately three months post-op, and extends to nine months post-op. Expectations for advancement to Phase III:

• Full, pain free range of motion. Note that it is not unusal for flexion to be lacking 10-15° for up to 5 months post-op.

• Normal gait.

• Good to normal quadriceps strength

• No patellofemoral complaints

• Clearance by physician to begin more concentrated closed kinetic chain progression

Goals:

• Restore any residual loss of motion that may prevent functional progression

• Progress functionally and prevent patellofemoral irritation.

• Improve functional strength and proprioception utilizing closed kinetic chain exercises

• Continue to maintain quadriceps strength and hamstring flexibility

Therapeutic Exercises:

• Continue closed kinetic chain exercise progression

• Treadmill walking

• Jogging in pool with wet vest or belt

• Swimming – no breaststroke

PHASE IV:

Begins approximately 9 months post-op and extends until the patient has returned to work or desired activity. Expectations for advancement to Phase IV:

• Release by physician to resume full or partial activity

• No significant patellofemoral or soft tissue irritation

• Presence of the necessary joint range of motion, muscle strength and endurance, and proprioception to safely return to work or athletic participation

Goals:

• Safe and gradual return to work or athletic participation

• This may involve sports specific training, work hardening or job restructuring as needed

• Patient education is essential to provide the patient with a clear understanding of their possible limitations

• Maintenance of strength, endurance and function

• Cross-country ski machine

• Sports specific functional progression which may include but not be limited to:

• Slide Board

• Jog/Run progression

• Figure 8, Carioca, Backward running, cutting

• Jumping (plyometrics)

• Work hardening program as directed by physician prescription