| Important note: Rehabilitation is function-based, not time based. Individual patients will progress through this program at different rates. |
| Stage I: Initial 4 to 6 weeks after injury |
| Basic care and protection: |
- PRICE-M (Protection with brace, Rest, Ice, Compression with elastic wrap, Elevation, Medication [analgesics] as needed)
- PCL brace worn at all times including sleep (minimum 12 weeks)
|
| Goals: |
- Protect injured knee
- Minimize strength and mobility loss
- Decrease effusion and soft tissue swelling
- Gradually increase knee range of motion
|
| Guidelines: |
- Avoid knee hyperextension (12 weeks)
- Prevent posterior tibial translation (12 weeks)
- No isolated hamstring exercises
- Partial weight bearing with crutches as necessary (2 weeks)
|
| Exercises: |
- Gentle range of motion (ROM) exercises
- Includes ankle pumps: Active dorsiflexion and plantar flexion of ankles to alleviate lower extremity edema
- Prone passive knee motion; gradually increase to 90 degrees over first 2 to 3 weeks, then gradually progress to full ROM
- Patellar mobilizations
- Quadriceps activation
- Begins with quad sets: Active, isometric contraction of quadriceps while thigh rests on a surface
- Advance to straight leg raises (SLR) once quadriceps can maintain knee in terminal extension without posterior lag
- Gastrocnemius stretching
- Hip abduction/adduction exercises
- Calf raises and single leg balance when weaned from crutches
- Maintain upper body and core strength using non-weightbearing exercises that do not place stress on injured knee
- Stationary bike with zero resistance when knee ROM >120 degrees
|
| Criteria for advancing to Stage II: |
- Achieve active ROM of knee of 0 to ≥120 degrees; no posterior lag during repeated SLR (3 sets x 10 repetitions); no or minimal swelling or effusion
|
| Stage II: Generally weeks 6 to 12 after injury |
| Goals: |
- Achieve full knee ROM
- Improve endurance of supporting musculature
|
| Guidelines: |
- Prevent posterior tibial translation
- Avoid knee hyperextension
- Limit leg strength exercises to no more than 70 degrees of knee flexion
- PCL brace worn at all times
- Use set and repetition scheme emphasizing endurance for all strength exercises: 3 x 20
|
| Exercises: |
- Gastrocnemius stretching and light hamstring stretching
- Leg press
- Squat progression (squat; squat with calf raise; squat with weight shift - slowly transfer weight from side to side while maintaining half-squat position)
- Static lunge (assume lunge position and hold for time; build to 3 sets of 45 second holds)
- Hamstring bridges on ball with knees extended
- Single leg dead lift with knee extended
- Proprioceptive and balance exercises (use static exercises [eg, "Stork stance"] and dynamic exercises [eg, playing catch while on one leg]; gradually advance from stable to unstable surface [eg, foam pad])
- Stationary bike: Gradually increase resistance
- Light kicking in pool
- Incline treadmill walking (gradually increase incline from 7 to 12 degrees)
|
| Criteria for advancing to Stage III: |
- Full knee ROM; quadriceps strength 85 percent of uninjured, contralateral leg; no gait abnormalities; proper lower extremity mechanics; minimal to no pain with activities
|
| Stage III: 13 to 18 weeks after injury |
| Goals: |
- Improve strength and mobility
- Prepare athlete for sport-specific activity
|
| Guidelines: |
- Discontinue PCL brace
- Use set and repetition scheme emphasizing strength development for all strength exercises: 3 x 8 to 10
- Gradually increase weight used for strength exercises
- Gradually increase knee flexion during strength exercises to >70 degrees
- Isolated hamstring exercises may begin after week 12
|
| Exercises: |
- Double leg press; advance to single leg press
- Single leg knee bends
- Balance squats
- Single leg dead lift
- Single leg bridges
- Single leg balancing exercises, gradually incorporating unstable surfaces (eg, foam pads, wobble boards, balance balls)
- Continue stationary bike and treadmill walking
|
| Running permitted when patient demonstrates sufficient strength and stability with functional exercises, and quadriceps girth ≥90 percent of contralateral, uninjured thigh |
| Running program: |
- Week 1: 4 minute walk; 1 minute jog for 15 to 20 minutes
- Week 2: 3 minute walk; 2 minute jog for 20 minutes
- Week 3: 2 minute walk; 3 minute jog for 20 minutes
- Week 4: 1 minute walk; 4 minute jog for 20 minutes
Once running progression completed, gradually progress to multi-planar agility exercises |
| Criteria for advancing to Stage IV: |
- Normal clinical examination; proper performance of rehabilitation exercises; clinician judgment about patient preparedness for next stage; patient/family preferences and goals
|
| Stage IV: Approximately 19 weeks after injury; varies depending on evidence of healing and performance of functional exercises during Stage III |
| Goals: |
- Return to full activity
- Content and duration of this stage depends heavily on patient/family preferences and goals
|
| Guidelines: |
- Use set and repetition scheme emphasizing power development for strength exercises: 3 x 4 to 8
|
| Exercises: |
- Continue strength and balance exercises from Stage III
- Add sport-specific agility exercises
|
| Athlete may return to full contact sport when meets following criteria: |
- Full active knee ROM
- No evidence of knee instability
- Single leg balance can be maintained, with hip level, for 30 seconds
- Quadriceps strength >85 to 90 percent of uninjured extremity
- Function of injured knee approximately 90 percent of uninjured knee with sport-specific testing
- Athlete mentally prepared for return to sport; no fear of re-injury
|
