Phase 1 Preoperative

Therapeutic aim during preoperative phase

▫ Prevent / limit quadriceps / hamstring deficit and atrophy

▫ Become familiar with, and gain an understanding of, postoperative rehabilitation

(remedial therapy), particularly neuromuscular and proprioceptive training

▫ Gain an understanding of positions and movements that lead to stress

▫ Maintain/improve general condition through cardiovascular training (biking /

rowing)

▫ Schedule of adjustments for temporary reduced mobility inside and outside the

home

▫ The aforementioned aims should be achieved within the patient’s capacities (no

pain or swelling)

Phase2 0 to 6 weeks postoperative

Background

Wound healing, graft repair (cell attachment, inflammation and proliferation)

Therapeutic aims during phase 2

▫ Protection of the healing tissue against shearing and compression forces

(neuromuscular and proprioceptive training)

▫ Decrease of pain and swelling

▫ Restoration of complete passive flexion in the knee

▫ Gradual improvement of active flexion in the knee

▫ Gain control over quadriceps

Rehabilitation in hospital

Immediately after surgery: slight elevation of the leg during the first 5 days

Day 1 Dorsal – plantar flexion of the ankle

Training with quadriceps in extension

Continuous Passive Motion (CPM) up to a maximum of 10º for 3 hours per

day (half hour CPM, half hour rest, half hour CPM, ……)

Days 2 - 5 Same exercises as on day 1

If no swelling occurs, extend CPM by 5° - 10° / day

Increase CPM to 4x 1 hour

Provide instructions for ‘mini-heel slide’ exercises (up to maximum flexion

permitted= 20°)

Range of motion (ROM) Suggestion for save regaining ROM

Weeks 0 – 2, 0 - 20º active flexion, passive extension

Weeks 2 – 4, 0 - 75º active flexion, active extension up to 45°, passive between 45°-0°

Weeks 4 – 6, 0 - 110º act. flexion, active extension up to 45°, passive between 45°-0°

Weeks > 6, Full range active flexion, active extension up to 45°, and passive between 45°-0°

Procedures

▫ Immediately after surgery – complete passive extension

▫ Start CPM on first day after surgery

▫ Extend CPM by 5° - 10°/day if permitted by patient

▫ Movement exercises during the day, seated

▫ PROM 4 – 6 times per day

▫ Patella mobilisation by Quadriceps settings (in extension position)

Load

Days 0 - 3 Do not load (activities of daily living (ADL) with 2 crutches), Keep leg

actively in extension

Day 3 week 2 Continue with 2 crutches and support to full weight bearing is allowed, noextension lag exists during straight leg raise test (good Quadriceps control in extension) up to 4 times a day for 1 hour

Weeks > 2 Increase progressively gait with full weight bearing with leg in extension

Week 3 -6 Gait exercise with accent on full knee extension on heel contact and

passive/active knee flexion before/during the swing phase of operated leg are advised (stride length depending on ROM allowed). If stride length is normal reduce use of crutches and normalise gait if load training infra reached full weight bearing

Strength and function

Weeks 0 – 2 Isometric exercises (no pain) in various knee positions Myofeedback for muscle rehabilitation

Weeks 2 – 4 Closed and open chain exercises within load limitations

Weight movement (isometric)

Proprioceptive training and neuromotor control

Improvement of general condition using exercises in swimming pool and/or cardiovascular training of upper limbs

Weeks 4 – 6 Begin with biking and/or rowing ergometry for a total of 1 hour per day, accent on active flexion during cycling not on ‘pushing foot downwards

Bilateral closed chain exercises with limited load, such as rowing, ‘leg press’, ‘squats’ with objective balance measurement

Depending on the size and location of the defect, unilateral closed chain

exercises can be started within limited angles (see load in table above)

Criteria for passage to phase 3

▫ Completion of phase 2

▫ Active flexion up to 110°

▫ Minimal pain and swelling

▫ Complete passive flexion if no swelling

▫ Voluntary quadriceps activity

Phase 3 4 to 12 weeks postoperative

Background

Acquisition of strength in repaired tissue (cell differentiation and maturation phase)

Therapeutic aims during phase 3

▫ Complete ROM as from 6 weeks after surgery

▫ Improve quadriceps strength and endurance

▫ Improve functional activities

▫ Extend load according to defined aims

▫ Maintain homeostasis (pain, swelling)

▫ Aim for a good walking pattern and prevent ‘anterior knee pain’ (from reduced

active stability) _ neuromuscular training

Range of motion

From week 6 Progress to full active ROM from full range active flexion, active extension up to 45°, and passive extension, to 0° to active-assisted extension, to 0°

to active extension (without resistance in open chain)

Procedures

▫ Maintain complete passive extension

▫ Patella mobilisation by quadricpes settings

▫ Daily stretching program, paying attention to joint kinematics

▫ Extend active knee flexion, paying attention to the repaired zone

Load

Weeks 6 – 10 If walking pattern and propriocepsis are normal and swelling and pain are minimal, the use of crutches can be gradually reduced (starting in the morning for a few days, with gradual extension to full days) Starting in week 6, begin control exercises without brace within loadbearing range (week 4 load bearing guidelines to progress, see table)

Starting in week 10 Prevent overload by doing stairs or downhill walking!

Allow going up stairs normally, only if full weight bearing is reached

during exercises.

Strength and function

Weeks 4 – 6 Begin with biking and/or rowing ergometry for a total of 1 hour per day. Bilateral closed chain exercises with limited load, such as rowing, ‘leg

press’, ‘squats’ with objective balance measurement. Depending on the size and location of the repair (see load table supra), unilateral closed chain exercises can be started within limited angles (see table phase 2)

Weeks 6 – 12 Progression of proprioceptive exercises within the load limitations

Prevent or correct ‘knee in-in’ position by relieving the medial

Compartment.

Increase of knee load during functional activities by means of biking

and/or rowing ergometry for a total of 1 hour per day

Criteria for passage to phase 4

▫ Completion of phase 3

▫ Minimal pain and swelling

▫ Full active ROM

▫ No reactive knee (increase of pain and swelling) after strength exercises

▫ Able to walk 1.6 – 3.2 km or bike and/or row 30 minutes on an ergometer

Phase 4 10 to 26 weeks postoperative

Background

Continued remodelling of the tissue into a more organised structure

Therapeutic aims during phase 4

▫ Improve muscle strength within safety margin

▫ Improve endurance through ‘low impact’ activities or exercises in upper limbs

▫ Extend functional activities

Range of motion

Patient must be able to perform his/her full active ROM

Procedure

Active ROM exercises with mild resistance within the safety zones

Load

Patient should be fully loaded, except during eccentric quadriceps control suc as

downhill, downstairs. Exercise in shorts sets, increase load and number of reps

slowly.

Strength and function

3 – 6 months Steps within range of motion

Biking and/or rowing with mild resistance (max. peak load 1x body

weight)

Cardiovascular training in upper limbs

Few repetitions with bipedal landing on a “soft” surface (e.g. minitrampoline

or mattress)

Build up specific force within safe zone (e.g. through triple repetitions)

Criteria for passage to phase 5

▫ Completion of phase 4

▫ No pain or swelling during ‘low impact’ exercises

▫ Full active, painless ROM

▫ Strength within 75-80% of contra lateral leg

▫ Balance and stability within 75 - 80% of contra lateral leg

Phase 5 5 to 9 months postoperative

Background

Tissue reaches full formation, maturation starts

Therapeutic aims during phase 5

▫ Muscle control within loaded zone

▫ Extend functional activities

▫ The moments of force and functionality can be evaluated at around the 9th month, provided such evaluation is clinically justified (patient experiences no pain or swelling)

Range of motion

Full active and passive ROM

Load

Full load, prevent overload during activities of daily living (no downhill, down stairs running or lengthy walking)

Strength and function

6 - 9 months Gradual increase of resistance through increased repetitions and decrease of number of sets

Start more intensive jogging, meaning low average speed, rapid

movement frequency for short distances, more sets (namely, dynamic,

ensure that the landing of the front of the foot is secure when beginning

jogging)

Muscle control in loaded zone, with ‘high load’ isometric control

Eccentric training in legs, with full ROM during ‘low impact’ and only

within safe zone for ‘high impact’ exercises such as skipping

Criteria for passage to phase 6

▫ Completion of phase 5

▫ No pain or swelling during or after ‘low impact’ or ‘high impact’

exercises

Phase 6 9 to 12 months postoperative

Background

Tissue maturation

Therapeutic aims during phase 6

▫ Sport-specific training, ‘low impact’ sports

▫ The moments of force and functionality can be evaluated at around

the 9th month, provided such evaluation is clinically justified (patient

experiences no pain or swelling)

Range of motion

Full active and passive ROM

Load

Full load

Strength and function

Sport-specific training for ‘low impact’ sports (no pivoting sports and sports characterised by open skills)

Sport-specific training for ‘high impact’ sports not allowed, increase of strength training

Criteria for passage to phase 7

▫ Completion of phase 6

▫ No pain or swelling during ‘low impact’ sport

Phase 7 > 12 months postoperative

Background

Tissue reaches full maturation

Therapeutic aims during phase 7

▫ Sport-specific training, ‘high impact’ sports

▫ Return to ‘low impact’ sports

Range of motion

Full active and passive ROM

Load

Full load

Strength and function

After month 12 Maximum muscle force exercises during complete ROM movements and slow progression in plyometric load forms in the repaired zone

Increase resistance training during ‘moderate impact’ activities

Sport-specific training for ‘high impact’ sports

‘Low impact’ sports allowed, provided joint homeostasis is maintained (no

pain or swelling)

Return to sport situation depending on: the type of sport, the patient’s

level and medical guidelines

Activities such as football, basketball, etc. can be started after 16 months

or earlier if the patient has no pain and there is no swelling