Physiotherapy Rehabilitation Protocol

Post-Op ACL Reconstruction + Meniscus Repair + MCL Injury

MRI Summary - Surgical Context

Current Status: POD 25 (Week 3-4) - Still in Phase 1

PHASE 1: Maximum Protection (Weeks 1-6)

Goals

• Control swelling and pain
• Achieve full passive extension (0°)
• Achieve 90° flexion by Week 4, 120° by Week 6
• Restore quadriceps activation
• Protect meniscus repair and MCL healing
• Partial weight bearing progressing to full by Week 4-6

WEEK 3-4 (Current Week - POD 21-28)

• Cryotherapy - Ice pack over compression bandage, 15-20 min, 4-6 times/day. Never direct ice on skin.
• Elevation - Leg elevated above heart level when resting, minimum 3-4 hrs/day
• Compression bandage - Tubigrip or crepe bandage throughout the day
• Electrical stimulation (IFT / NMES) - 20 min per session, helps with both pain and oedema absorption
• Soft tissue massage - Gentle effleurage strokes distal to proximal, 10 min

1. Heel slides (supine) - Slide heel toward buttocks slowly, hold 5 sec, extend. Target: 0-90°
2. Seated gravity-assisted flexion - Sit at edge of bed/chair, let gravity assist gentle flexion. Hold 10 sec at end range.
3. Prone knee flexion - Lying prone, flex knee slowly. Gravity-assisted extension with prone hang.
4. Passive extension stretch - Heel prop with towel roll under ankle, gravity stretches knee into full extension. 10-15 min hold, 3×/day
5. Ankle pumps - 20 reps × 3 sets × 3 times/day (DVT prophylaxis + venous return)
6. Patellar mobilizations - Mediolateral and superior-inferior glides, 5-10 min daily. Critical for preventing patellar adhesions post MPFL injury.

1. Quad sets (isometric) - Tighten quads, press knee flat, hold 5-10 sec. 20 reps × 3 sets, 3×/day
2. Straight leg raises (SLR) - Brace on, knee locked in extension, lift to 45°, hold 2 sec, lower. Start without weight. 3 × 10-15 reps.
3. Hip abduction SLR - Lying on side, raise leg 30-45°, hold 2 sec. 3 × 10-15 reps. No resistance below knee; no hip abduction with leg - avoid valgus stress.
4. Gluteal sets - Lying, squeeze glutes, hold 5 sec. 3 × 20 reps.
5. Hamstring sets (isometric) - Press heel into bed, hold 5 sec. 3 × 20 reps.
6. Calf raises - Standing with support, bilateral. 3 × 15-20 reps.

WEEK 5-6 (POD 29-42)

• Continue icing post-exercise session (15-20 min)
• NMES / EMS on quads - 20 min, help reduce disuse atrophy and effusion
• Ultrasound therapy (pulsed, 1 MHz, 1.0 W/cm²) over suprapatellar bursa for bursitis - 5-7 min

1. Stationary bike (no resistance) - Begin Week 4 post-op. Seat height raised so only partial ROM required initially. 10-15 min. Progressively lower seat to increase flexion range. As ROM improves, lower seat height.
2. Wall slides - Standing, back to wall, slide down 0-60°. Hold 5 sec. 3 × 10 reps.
3. Seated knee extension - No resistance; active range only from 0-90°. 3 × 15 reps. No open chain resistance (isotonic weights) until Week 12.

1. SLR with 0.5-1 lb ankle weight from Week 5
2. Mini wall squats (0-45° only) - both legs, with support. 3 × 10-15 reps
3. Double-leg bridges - Supine, knees 45°, lift hips. Hold 3-5 sec. 3 × 15 reps
4. Step-ups (small step, 4-inch) - Forward step-up. 3 × 10 reps
5. Terminal knee extension with resistance band (standing) - last 20° of extension. 3 × 15 reps

1. Double-leg standing balance on foam pad - 30-60 sec × 3 sets
2. Weight shifting side to side - supported, 2 min

PHASE 2: Controlled Motion & Early Strengthening (Weeks 7-12)

Goals

• Full ROM (0-130°+)
• Normal gait pattern without crutches
• Discontinue brace (surgeon's clearance; usually 8-10 weeks)
• No joint effusion
• Progress closed chain strengthening
• Begin proprioception and balance training

WEEK 7-8 (POD 43-56)

• Continue icing post-session (10-15 min)
• US therapy on MCL region (pulsed, 1 MHz) if still sore - 5 min
• Begin moist heat before sessions (10-15 min)

1. Stationary bike with resistance - 15-20 min, light resistance
2. Double-leg press (leg press machine, 0-80° arc only, no >90°) - 3 × 15 reps
3. Wall squats (0-60°) - progress from two legs to one-leg assist
4. Double-leg bridges + single-leg bridges (3 × 10-15 reps)
5. Step-ups (6-inch step) - forward and lateral step-ups. 3 × 15 reps
6. Hamstring curls (prone, no resistance first, then light resistance) - 3 × 15 reps
7. Hip abduction/adduction (sidelying, then cable or band at Week 8) - 3 × 15 reps
8. Calf raises (bilateral → unilateral progression) - 3 × 20 reps
9. SLR with 1-2 lb weight - 3 × 15 reps

1. Single-leg stance on firm surface - 30-60 sec × 3 sets (begin with eyes open, progress to eyes closed)
2. BOSU ball double-leg balance - 60 sec × 3 sets
3. Wobble board - bilateral, then unilateral - 2-3 min sets

WEEK 9-12 (POD 57-84)

1. Leg press (increase weight progressively, 0-90°) - 3 × 15-20 reps
2. Goblet squat or supported squat (0-90°) - 3 × 12-15 reps
3. Romanian deadlift (bilateral) - 3 × 12 reps
4. Step-down program (8-inch step eccentrics) - 3 × 15 reps. Important functional test milestone.
5. Lunges (forward, lateral) - 3 × 12 reps each side
6. Hip strengthening - clam shells, lateral band walks (mini-band around ankles) - 3 × 15 reps
7. Seated calf press on leg press - 3 × 20 reps
8. Core strengthening - planks (30-60 sec), dead bugs, bird-dog - 3 sets each

1. Single-leg BOSU balance - 30-60 sec × 3 sets
2. Tandem walking (heel to toe)
3. Lateral band walks - 3 × 15 steps each direction
4. Perturbation training - therapist applies random perturbations while patient stands single-leg

• Stationary bike 20-30 min, moderate resistance
• Pool walking (if available from Week 8): 20 min

PHASE 3: Progressive Strengthening & Neuromuscular Control (Weeks 12-18)

Goals

• Strength symmetry > 70% compared to contralateral limb
• Full pain-free ROM
• Advanced proprioception
• Begin running program (treadmill) at Week 12+ when 8-inch step-down satisfactory
• No open chain isotonic knee extension until cleared (surgeon/physio dependent)

WEEK 12-16

• Full ROM
• No effusion
• 8-inch step-down with controlled alignment
• Single-leg stance > 30 sec

1. Forward treadmill walking - incline 7%, 20-30 min. Transition to jogging when gait symmetrical.
2. Leg press single-leg - 3 × 12-15 reps (60-70% 1RM)
3. Bulgarian split squat - 3 × 10-12 reps
4. Nordic hamstring curls (eccentric) - 3 × 8-10 reps (begin bilateral)
5. Box step-downs (8-12 inch) - eccentrics, 3 × 15 reps
6. Core + hip complex - Copenhagen adductor exercise, Pallof press, lateral sled walks
7. Knee extension isotonic (if surgeon cleared, 90°-40° only, closed chain preferred)

1. Perturbation training on tilt board - 5-10 min
2. Reactive balance drills - catch and release, mini-trampoline
3. Single-leg squat (partial depth, mirror feedback for alignment)

WEEK 16-22 (Power + Plyometrics)

1. Double-leg box jumps - 3 × 10 reps
2. Lateral hops over line (bilateral to unilateral)
3. Skipping, bounding drills
4. Agility ladder drills
5. Running program - progress to 50% speed then 75%, straight lines only initially

WEEK 22-30+ (Return to Sport)

• Sport-specific drills (cutting, pivoting) with MD clearance
• Functional Sports Assessment / hop tests
• Return to full sport approximately 9-12 months post-op (ACL graft maturation)

Brace Protocol Summary

Swelling Monitoring Protocol (Priority - POD 25)

• Circumference measurement (mid-patella, 5 cm above, 5 cm below)
• Joint line tenderness
• End-range pain on ROM

• Sudden increase in swelling
• Fever, increased warmth, skin redness (infection)
• Sharp pain with passive extension beyond 0°
• Effusion not decreasing by Week 6-8

1. RICE protocol strictly - elevate limb whenever seated or supine
2. IFT (Interferential Therapy) - 80-120 Hz, 20 min, 2x/day
3. NMES to quads - reduces disuse atrophy which worsens effusion
4. Grade 1-2 joint mobilization of tibiofemoral joint for effusion management
5. Patellar glides daily (patellofemoral effusion from suprapatellar bursitis)
6. Ensure no excessive activity between sessions

Key Precautions Throughout Rehabilitation

Exercise Dose Reference Table