Phase 1: weeks 0-2

Goals

Protect graft fixation

Minimize effects of immobilization

Control inflammation

No CPM

Achieve full extension, 90* knee flexion

Educate patient about rehabilitation process

Brace

Locked in extension for ambulation and sleeping

Weight-bearing

Weight-bearing as tolerated with two crutches

Discontinue crutches as tolerated after 7 days (with demonstrated good quadriceps control)

Therapeutic exercises

Heel/wall slides

Quadriceps sets, hamstring sets

Patellar mobilization

Non-weight-bearing gastrocsoleus, hamstring stretches

Sitting assisted flexion hangs

Prone leg hangs for extension

Straight leg raises all planes with brace in full extension until quadriceps strength is sufficient to prevent extension lag

Aerobic conditioning

Upper extremity ergometer

Well-leg bicycle

Active/passive joint positioning

Balancing activities

Stable platform, eyes open

Stable platform, eyes closed

Seated ball throwing and catching

Phase 2: weeks 2-4

Criteria for progression to phase 2

Good quad set, SLR without extension lag

Approximately 90* knee flexion

Full extension

No signs of inflammation

Goals

Restore normal gait

Restore full ROM

Protect graft fixation

Improve strength, endurance, and proprioception to prepare for functional activities

Weight-bearing

Patellar tendon graft - continue ambulation with brace lacked in extension, may unlock brace for sitting and sleeping, may remove brace for ROM exercises

Hamstring graft and allograft - may discontinue brace use when normal gait pattern and quadriceps control are achieved

Therapeutic exercises

Mini squats 0-30*

Stationary bike

Closed-chain extension (leg press 0-30*)

Toe raises

Continue hamstring stretches, progress to weight-bearing gastrosoleus stretches

Continue prone leg hangs with progressively heavier ankle weights until full extension is achieved

Aerobic conditioning

Advance to two-leg bicycle 

Continue upper extremity ergometry

Muscle training

Stair walking

Up/down, forward/backward

Aquatherapy

Pool walking

Pool jogging (deep water running)

Proprioception

Balancing activities

Unstable platform with eyes open/closed

Mini-tramp standing

Standing ball throwing and catching

Phase 3: week 6- month 4

Criteria for progression to phase 3

Normal gait

Full ROM

Sufficient strength and proprioception to initiate functional activities

Stable graft on Lachman and KT 1000 testing

Goals

Improve confidence in the knee

Avoid overstressing graft fixation

Protect the patellofemoral joint

Progress strength, power, and proprioception to prepare for functional activities

Therapeutic exercises

Continue flexibility exercises as appropriate for patient

Advance closed-kinetic chain strengthening (one-leg squats, leg press 0-60*)

Elliptical stepper, stair stepper

Cross country skiing machine

Aerobic conditioning (weeks 6-12)

Continue bicycling/UBE

Pool running/swimming

Stair stepper/elliptical stepper

Cross-country skiing machine

Plyometrics (weeks 6-12)

Stair jogging

Box jumps

6-12 inch heights

Running (weeks 6-12)

Straight ahead jogging, progressing to running

Figure 8 pattern

Large circles, walking or slow jogging

Proprioception (weeks 6-12)

Mini-tramp bouncing

Pogoball balancing

Lateral slide board

Ball throwing and catching on unstable surface

Aerobic conditioning (weeks 12+)

Continue as above

Agility (weeks 12+)

Start at slow speed, advance slowly

Shuttle run 

Lateral slides

Carioca cross-overs

Proprioception (weeks 12+)

Continue as above

Add sport-specific activities (1/4 to ½ speed)

Running (weeks 12+)

Figure 8 pattern

Small circles, running

Plyometrics (weeks 12+)

Stair running

Box jumps (1 - 2 ft height)

Phase 4: month 4

Criteria for progression to phase 4

Full, painless ROM 

No evidence of patellofemoral joint irritation

Sufficient strength and proprioception to progress functional activities

Physical clearance to initiate advanced closed-kinetic chain exercises and functional progression

Stable graft on Lachman and KT 1000 testing

Goal

Return to unrestricted activity

Therapeutic exercises

Continue and progress flexibility and strengthening programs

Aerobic conditioning

Continue as above

Agility

Continue as above

Cutting drills

Proprioception

Reaction drills

Advanced sport-specific drills (full speed)

Running

Continue as above

Plyometrics

Advance heights

Phase 5: Return to sports

Criteria for progression to phase 5

No patellofemoral joint or soft tissue complaints

All criteria met for return to sports

Physician clearance to resume full activity

Goals

Safe return to athletics

Maintenance of strength, endurance, and proprioception

Patient education concerning any possible limitations

Brace

Functional brace may be recommended by physician for use during sports for the first 1-2 years after surgery for psychological confidence

Therapeutic exercise

Gradual return to sports participation 

Maintenance program for strength and endurance

Agility and sport-specific drills progressed