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
ACL HAMSTRING TENDON AUTOGRAFT RECONSTRUCTION PROTOCOL
GENERAL GUIDELINES
• Focus on protection of graft during primary re-vascularization (8 weeks) and graft fixation (8 –12 weeks)
• CPM not commonly used
• For ACL reconstruction performed with meniscal repair or transplant, defer to ROM and weightbearing precautions outlined in the meniscal repair/transplant protocol.
• The physician may alter time frames for use of brace and crutches
• Supervised physical therapy takes place for 4-7 months
• Use caution with hamstring stretching/strengthening based on donor site morbidity
GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING
• No bathing (sponge bath only) until after suture removal. Brace may be removed for bathing/showering.
• May shower after three days
• Sleep with brace locked in extension for 1 week
• Driving: no driving on narcotics
• 1 week for automatic cars, left leg surgery
• 2-4 weeks for standard cars, or right leg surgery
• Post-op brace locked in full extension (0-1 week) for sleeping
0-3 weeks- wean from brace as patient demonstrates good quad control and normal gait mechanics
• Use of crutches/brace as needed for ambulation for 4 weeks with adequate quad function
• Weight bearing (0-1 week)- Adv to WBAT with crutches and brace
• Return to work as directed by PT/MD based on work demands
REHABILITATION PROGRESSION:
Frequency of physical therapy visits should be determined based on individual patient status and progression.
The following is a general guideline for progression of rehabilitation following ACL hamstring tendon autograft reconstruction. Progression 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 post-op through approximately 4 weeks.
Goals:
• Protect graft and graft fixation
• Minimize effects of immobilization
• Control inflammation and swelling patient use of ice/polar care machine
• Full active and passive extension/hyperextension range of motion. Caution: avoid hyperextension greater than 10 o
• Educate patient on rehabilitation progression
• Restore normal gait on level surfaces
Brace:
• 0- week- post-op brace locked in full extension for sleeping
• 1-3 weeks- unlock brace (<90 o ) as quad control allows
• 1-3 weeks- wean from brace as patient demonstrates good quad control and normal gait mechanics
• 1-3 weeks- patient should only use brace in vulnerable situations (e.g. crowds, uneven terrain, etc)
Weightbearing Status:
• 0-2 weeks- partial weightbearing progressing to full weight bearing with normal gait mechanics
• Wean from crutches/brace for ambulation by 2 weeks as patient demonstrates normal gait mechanics and good quad control.
Exercises:
• Active-assisted leg curls 0-1 week. Progress to active and resistance as tolerated after 1 week.
• Heel slides
• Quad sets (consider NMES for poor quad sets)
• Gastroc/Soleus stretching
• Gentle hamstring stretching at 1 week
• SLR, all planes, with brace in full extension until quadriceps strength is sufficient to prevent extension lag- add weight as tolerated to hip abduction, adduction and extension.
• Quadriceps isometrics at 60 o and 90 o
• Aquatic therapy (once sutures removed) for normalizing gait, weightbearing strengthening, deep-water aquajogging for ROM and swelling.
PHASE II:
Begins approximately 2 weeks post-op and extends to approximately 10 weeks. Criteria for advancement to Phase II:
• Full extension/hyperextension
• Good quad set, SLR without extension lag
• Flexion 90% of contralateral side
• Minimal swelling/inflammation
• Normal gait on level surfaces
Goals:
• Restore normal gait with stairclimbing
• Maintain full extension, progress toward full flexion range of motion
• Protect graft and graft fixation
• Increase hip, quadriceps, hamstring, and calf strength
• Increase proprioception
Exercises:
• Continue with range of motion/flexibility exercises as appropriate for the patient
• Initiate CKC quad strengthening and progress as tolerated (wall sits, step-ups, mini-squats, Leg Press 90 o -30 o , lunges)
• Progressive hip, hamstring, calf strengthening (gradually add resistance to open chain hamstring exercises)
• Continue hamstring, Gastroc/Soleus stretches
• Stairmaster (begin with short steps, avoid hyperextension)
• Nordic Trac, Elliptical machine for conditioning
• Stationary Biking (progressive time and resistance)
• Single leg balance/proprioception work (ball toss, balance beam, mini-tramp balance work)
• Bicycle in pool at 3-4 weeks
• Hamstring Ball
• Lateral wobble board
Phase III:
Begins at approximately 10-12 weeks and extends through approximately 18-20 weeks (4 ½- 5 months). Criteria to advance to Phase III include:
• No patellofemoral pain
• Minimum of 120 degrees of flexion
• Sufficient strength and proprioception to initiate running (unweighted or in pool)
• Minimal swelling/inflammation
Goals:
• Full range of motion
• Improve strength, endurance, and proprioception of the lower extremity to prepare for sport activities
• Avoid overstressing the graft
• Protect the patellofemoral joint
• Normalize running mechanics
• Strength approximately 70% of the uninvolved lower extremity per isokinetic evaluation
Exercises:
• Continue flexibility and ROM exercises as appropriate for patient
• Closed chain full range
• Initiate open kinetic chain leg extension (90 o -30 o ), progress to eccentrics as tolerated
• Isokinetics (with anti-shear device)- begin with mid range speeds (120 o /sec-240 o /sec)
• Start to progress to full weightbearing running at 10 - 12 weeks
• Begin swimming if desired
• Recommend isokinetic test with anti-shear device at 14-16 weeks to guide continued strengthening
• Progressive hip, quad, hamstring, calf strengthening
• Cardiovascular/endurance training via stairmaster, elliptical, bike
• Advance proprioceptive activities
• Begin running in the pool (waist deep) when incisions healed. or on an unweighted treadmill at 10-12 weeks
Phase IV: Bridge to Sporting Activities
Begins at approximately 4 1/2 -5 months and extends through 6-7 months post-op. Criteria for advancement to Phase IV:
• No significant swelling/inflammation
• Full, pain-free ROM
• No evidence of patellofemoral joint irritation
• Strength approximately 70% of uninvolved lower extremity per isokinetic evaluation
• Sufficient strength and proprioception to initiate agility activities
• Normal running gait
Goals:
• Symmetric performance of basic and sport specific agility drills
• Single hop and three hop tests 85% of uninvolved leg
• Quadriceps and hamstring strength at least 85% of uninvolved lower extremity per isokinetic strength test
Exercises:
• Continue and progress flexibility and strengthening program based on individual needs and deficits
• Dynamic proprioception exercises
• Initiate plyometric program as appropriate for patient’s athletic goals
• Agility progression including, but not limited to:
Side steps
Crossovers
Figure 8 running
Shuttle running
One leg and two leg jumping
Cutting
Acceleration/deceleration/springs
Agility ladder drills
• Continue progression of running distance based on patient needs
• Initiate sport-specific drills as appropriate for patient
Phase V:
Begins at 6 months post-op. Criteria for advancement to Phase V:
• No patellofemoral or soft tissue complaints
• Necessary joint ROM, strength, endurance, and proprioception to safely return to work or athletics
• Physician clearance to resume partial or full activity
Goals:
• Safe return to athletics/work
• Maintenance of strength, endurance, proprioception
• Patient education with regards to any possible limitations
Exercises:
• Gradual return to sports participation
• Maintenance program for strength, endurance
Bracing:
• Functional brace generally not used, but may be recommended by the physician on an individual basis