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Discharge Instructions & Physical Therapy Protocol for ACL Reconstruction BPTB

Recovery after knee surgery entails controlling swelling and discomfort, healing, return of range-of-motion of the knee joint, regaining strength in the muscles around the knee joint, and a gradual return to activities. The following instructions are intended as a guide to help you achieve these individual goals and recover as quickly as possible after your knee surgery.

Comfort

  • Elevation - Elevate your knee and ankle above the level of your heart. The best position is lying down with two pillows lengthwise under your entire leg. This should be done for the first several days after surgery
  • Swelling - A cooling device may be provided to control swelling and discomfort by slowing the circulation in your knee. Initially, this can be used continuously for the first 3 days, (while the initial post-op dressing is on). After 3 days, the cooling device should be applied 3 times a day for 10-minute intervals. If a cooling device is not provided at the time of surgery, place crushed ice in a plastic bag over your knee for no more than 20 minutes, three (3) times a day
  • Pain Medication - Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication
  • Antibiotic Medication - If an antibiotic has been prescribed, start taking the day of your surgery. The first dose should be around dinnertime. Continue taking until the prescription is finished
  • Driving - Driving is NOT permitted for six weeks following right knee surgery

Activities

  • Range-of-Motion - Move your knee through range of motion as tolerated. This must be done while sitting or lying down
  • Locking Knee Brace - The brace is to be worn for up to 4 - 6 weeks following surgery. It will be locked straight until bone healing and good knee strength have been achieved (usually 6 weeks after surgery). At that time your doctor will determine if your leg has enough strength to allow your brace to be unlocked. You may unlock the brace while sitting but lock the brace before standing. Sleep with the brace on until directed by Dr. Forsythe
  • Exercises - These help prevent complications such as blood clotting in your legs. Point and flex your foot and wiggle your toes. Thigh muscle tightening exercises should begin the day of surgery and should be done for 10 to 15 minutes, 3 times a day, for the first few weeks after surgery
  • CPM - (Continuous Passive Motion Machine) - A Continuous Passive Motion (CPM) machine should be started the day after your surgery. This machine will be set at 30°. Motion on the machine should be increased at 10-15° per day or as much as tolerated, to a maximum of 110° in one week. The machine should be used 6 hours per day (i.e. 2 hours in the morning, 2 hours in the afternoon and 2 hours in the evening). Use of the machine will continue for 1-2 weeks, or until maximum flexion of the machine is reached (110°). DO NOT WEAR LEG BRACE OR COOLING DEVICE WHILE USING CPM MACHINE
  • Weightbearing Status - You are allowed to put all of your weight on your operative leg using your brace in the locked straight position. Do this within the limits of pain. Two crutches should be used until directed to discontinue by Dr. Forsythe
  • Physical Therapy - PT should be started 3-5 days after surgery. You should call the physical therapist of your choice for an appointment as soon as possible after surgery. A prescription for physical therapy, along with physical therapy instructions (included in this packet) must be taken to the therapist at your first visit
  • Athletic Activities - Athletic activities, such as swimming, bicycling, jogging, running and stop-and-go sports, should be avoided until allowed by your doctor
  • Return to Work - Return to work as soon as possible. Your ability to work depends on a number of factors - your level of discomfort and how much demand your job puts on your knees. If you have any questions, please call your doctor

Wound Care

  • Tub bathing, swimming, and soaking of the knee should be avoided until allowed by your doctor - Usually 2-3 weeks after your surgery. Keep the dressing on, clean and dry for the first 3 days after surgery
  • Remove the dressing 3 days after surgery. The steri-strips (small white tape that is directly on the incision areas) should be left on until the first office visit. You may apply band-aids to the small incisions around your knee
  • You may shower 5 days after surgery with band-aids on. Apply new band-aids after showering

Eating

  • Your first few meals, after surgery, should include light, easily digestible foods and plenty of liquids, since some people experience slight nausea as a temporary reaction to anesthesia

Call your physician if

  • Pain in your knee persists or worsens in the first few days after surgery
  • Excessive redness or drainage of cloudy or bloody material from the wounds (Clear red tinted fluid and some mild drainage should be expected). Drainage of any kind 5 days after surgery should be reported to the doctor
  • You have a temperature elevation greater than 101°
  • You have pain, swelling or redness in your calf
  • You have numbness or weakness in your leg or foot

Return to the office

  • Your first return to our office should be within the first 1 - 2 weeks after your surgery. Call your physician’s office to make an appointment for this first post-operative visit

Rehabilitation Program Following Anterior Cruciate Ligament Reconstruction Using the Bone-Patellar Tendon Autograft

INTRODUCTION

The anterior cruciate ligament (ACL) is one of the main stabilizing ligaments of the knee. Loss of this ligament can lead to functional instability during work or sports and can also lead to the development of knee arthrosis. These guidelines were developed for patients after ACL surgery using the bone-patellar tendon autograft.

The goals of ACL reconstruction are

  • To provide functional stability to the knee
  • Return the patient to his/her previous level of activity, and
  • Prevent the development of arthrosis

Modern methods of arthroscopic reconstruction of the ACL can successfully return functional stability to the knee. The most worrisome complication following this surgery is the development of arthrofibrosis with its adherent loss of motion and weakness in the operative extremity.

The goal of ACL post reconstruction rehabilitation is to return normal motion, strength, and function to the knee while not compromising the integrity of the reconstructed ACL. Total body conditioning should be utilized throughout this protocol.

The following rehabilitation program is offered to provide consistent, efficient and goal-directed rehabilitation. The program is divided into three phases. Each phase has:

  • TIME FRAME provided for the purpose of guidance and protection. However, it is understood that all patients will vary somewhat in their speed of recover
  • GOALS, which provide the rationale behind the treatment approach
  • TREATMENT RECOMMENDATIONS are the therapeutic modalities, which can be used to safely achieve the goals for each phase
  • NOTES provide parameters for the use of braces, crutches, etc., and
  • PRECAUTIONS are offered to make the treating PT and patient aware of special problems that may arise during specific phases during the rehabilitation program

If any questions arise during the course of the ACL rehabilitation program, do not hesitate in contacting the surgeon.

PHASE I: MOBILIZATION

Early Mobilization

Time Frame

  • 0 to 2 weeks

Goals

  • Decrease pain and swelling
  • Full extension, and
  • Voluntary quad contraction

Treatment Recommendations

  • Ice
  • AROM, PROM, CPM
  • Prone lying with legs off edge of bed achieving full knee extension
  • Quad sets
  • Patellar mobilizations, especially superiorly
  • Straight leg raises
  • Full arc quads without weights
  • Multidirectional hip PREs
  • Prone knee flexion
  • Calf and hamstring stretching
  • Locking knee brace - locked at 0º for the first seven (7) days except when performing exercises, use while sleeping

NOTE: Ambulation weightbearing as tolerated is begun on post-op day #1. Crutch use is continued into Phase I, Late Mobilization.

Late Mobilization

Time Frame

  • 2 to 6 weeks

Goals

  • Good quad control
  • Normal gait, and
  • Full flexion

Treatment Recommendations

  • Continue all exercises begun in Phase I, Early Mobilization, add weights as tolerated
  • Mini-squats
  • Wall slide mini-squats
  • Partial Arc Quads, 60 to 90 degrees, with weights as tolerated
  • Toe raises with weights as tolerated
  • Step-ups, 2 inches and progress to full step
  • Locking Knee Brace when ambulating, may unlock while sitting and when performing exercises; may remove for sleeping. May unlock knee brace for ambulation when good quad control achieved (generally not before 4 weeks)

NOTE: Crutches can be discontinued when the patient demonstrates a normal gait.

PRECAUTION: Motion should be full by 6 weeks. A 10 degree or greater deficit of extension and/or less than 125 degrees of flexion is considered serious losses of motion. The physician should be contacted sooner, rather than later, if full motion appears unachievable. A change in therapy or surgery may be indicated.

PHASE II: STRENGTHENING

Early Strengthening

Time Frame

  • 6 weeks to 3 months

Goals

  • Strength 60% of opposite limb
  • Re-emphasize full ROM & normal gait

Treatment Recommendations

  • Continue with exercises from Phase I, Mobilization
  • Begin more closed-chain activities, e.g., step-ups, mini-squats, Stairmaster, bike riding, PNF, etc.
  • Continue gait training, both fast speed and slow speed, for good control and strengthening of muscles
  • Proprioceptive training, early phase plyometrics performed only with supervision
  • May begin supervised jogging
  • Discontinue Locking Knee Brace

Late Strengthening

Time Frame

  • 3 to 5 months

Goals

  • Strength 80% of opposite limb

Treatment Recommendations

  • Continue with exercises from previous phases increasing resistance as tolerate
  • Increase intensity of plyometrics
  • Increase jogging/running intensity
  • Jump rope

PHASE III: FUNCTIONAL

Time Frame

  • 5 to 9 months

Goals

  • Return to full activity, work or sport

Treatment Recommendations

  • Progressive plyometrics
  • Incline plyometrics
  • Jogging
  • Running
  • Bounding
  • Skipping
  • Hopping
  • Sport simulation

Criteria for Return to Sport Activities

  • One-leg hop test 90% of opposite leg
  • Jog without a limp
  • Full-speed run without a limp
  • Shuttle run without a limp
  • Figure 8 running without a limp
  • Single leg vertical jump 90% of opposite limb
  • Squat and rise from squat

Criteria for Return to Work Activities

  • Perform simulated work activity to 90% level