• Patient: Parshvnath Sudhakar Balol, 49M
• Diagnosis: PCL complete tear + medial meniscus posterior horn Grade II signal with avulsion + Grade III popliteo-fibular ligament tear + Grade I LCL signal + OA changes
• Surgery: PCL reconstruction + partial medial meniscectomy (arthroscopic), done ~11/04/2026
• Current status: POD 40, swelling, pain, ROM limited to 70° flexion

Post-Operative Rehabilitation Protocol

PCL Reconstruction + Partial Medial Meniscectomy, Right Knee

Patient: Parshvnath Balol, 49M | POD 40 | Starting Status: Swelling +, ROM 0-70°

Understanding This Patient's Complexity

• Complete PCL tear (surgically reconstructed)
• Grade II posterior horn medial meniscus - avulsion at root + pseudo-extrusion (partial meniscectomy done)
• Grade III popliteo-fibular ligament (PFL) tear - this is a posterolateral corner (PLC) structure
• Grade I LCL signal involvement
• OA changes: medial > lateral joint space narrowing, chondromalacia patella Grade 1, synovitis

Critical Precautions for This Case:

1. No open-chain hamstring exercises - these apply posterior tibial translation force directly onto the PCL graft. Avoid until at least 4 months post-op (Miller's Review of Orthopaedics, 9th Ed.)
2. No varus stress - Grade III PFL tear means posterolateral corner is vulnerable
3. No hyperextension of the knee at any stage
4. OA + synovitis means this patient is likely to swell more than a young athlete - progress conservatively

Weight Bearing Progression

Note on brace: The PCL-specific dynamic brace (anteriorly directed tibial pad) should be used through at least 6 months for any community ambulation, per multiligament reconstruction protocols. At week 6 (current status), transition from locked brace to dynamic PCL brace when swelling allows.

Phase-Wise Rehabilitation Protocol

PHASE I - PROTECTION & ACTIVATION (POD 40 = Where Patient Is Now)

• Reduce swelling and pain
• Regain ROM from 70° toward 90-100°
• Achieve SLR without extension lag
• Initiate quadriceps activation
• Protect PCL graft integrity

• RICE principle - Rest, Ice (15-20 min, 3-4x/day), Compression (tubigrip/elastic bandage), Elevation above heart level
• Retrograde lymphatic massage from distal to proximal
• Electrical stimulation (TENS or IFC at 80-100 Hz, 20 min) for pain
• Neuromuscular electrical stimulation (NMES) to quadriceps - 2500 Hz, 75 burst/sec with quad sets (evidence: MGH protocol, 2024)
• Cryotherapy immediately after exercise

• Prone passive ROM - lying prone, gravity-assisted knee flexion (gravity-assisted, no active hamstring pull). Progress to 90° by end of week 8
• Heel slides (supine) - slide foot toward buttocks, hold 5 sec, return. 3 sets x 15 reps. Avoid active hamstring pull.
• Gravity-assisted flexion - seated at edge of table, let gravity flex the knee with opposite foot assist. Do NOT let hamstrings contract actively
• Terminal knee extension (TKE) - standing with resistive band behind knee, push into full extension. 3 sets x 15 reps - this is the single most important exercise for quad activation at this stage
• Passive extension stretching - prone knee extension with pillow under ankle (avoid prone hang that loads hamstrings)

• Quad sets (isometric) - knee straight, press back of knee into bed, hold 10 sec. 3 sets x 20 reps. Key for quad activation.
• Straight leg raises (SLR) - with brace locked in full extension. 3 sets x 20 reps. Goal: no extension lag
• Hip abduction - sidelying, 3 sets x 20 reps
• Hip extension - prone, 3 sets x 20 reps
• Calf raises (bilateral) - seated or standing, 3 sets x 20 reps
• Ankle pumps - for DVT prophylaxis and swelling, 3 sets x 30 reps

• Open-chain hamstring curls
• Active knee flexion against gravity
• Any posterior tibial translation force
• Deep squats beyond 70°

PHASE II - EARLY STRENGTHENING & ROM RESTORATION

• SLR without extension lag
• Knee flexion >90°
• Swelling minimal (modified stroke test negative)
• Full passive knee extension

• ROM: 0-120° by end of phase
• Progress to full weight bearing
• Initiate closed-chain exercises
• Neuromuscular control in early stance

• Continue heel slides, add wall slides (standing with back to wall, slide down)
• Stationary bicycle - start with seat high (minimal ROM), pedal in circular motion. Begin around week 9-10 when flexion reaches 100°. Progress resistance weekly.
• Pool therapy / hydrotherapy - walking in chest-high water reduces effective body weight by ~70%. Excellent for this patient's OA + swelling.

• Mini-squats - bilateral, 0-45° range, at wall for support. 3 sets x 15 reps
• Leg press (bilateral, 0-60° arc) - start low weight, high reps. Increase ROM to 90° by week 12
• Knee extension (closed chain) - terminal knee extension with band, not open chain
• Step-ups (forward) - begin with 5 cm step, progress to 10-15 cm. 3 sets x 15 reps
• Calf raises bilateral progressing to unilateral
• Hip strengthening continues - side-lying hip abduction with resistance, standing hip extension
• SLR - progress to adding ankle weight (0.5 kg, progress weekly)
• Balance / proprioception - bilateral stance on unstable surface (foam pad), progress to eyes closed

• Ultrasound therapy to the knee joint (1 MHz, continuous 1.0-1.5 W/cm², 5 min) for joint capsule stiffness
• TENS for pain management
• Manual therapy - patellar mobilization, soft tissue massage
• Ice post-exercise, 15-20 min

PHASE III - PROGRESSIVE LOADING

• ROM 0-120° or greater
• Full weight bearing with normalized gait
• SLR without lag, adequate quad activation
• No post-exercise swelling

• ROM: 0-130° to full (135-140°) by end of phase
• Unilateral closed-chain loading
• Progressive resistance
• Begin cardiovascular conditioning

• Squats - progress depth gradually from 0-60° toward 0-90° (beyond 70° of knee flexion loading may be introduced after 4 months per PCL protocol)
• Leg press (single limb) - begin unilateral loading. Start 60° arc, progress to 90°
• Hamstring strengthening - start submaximal around weeks 13-16. Begin with prone hip extension (not lying hamstring curl), then Swiss ball hamstring curl (bilateral)
• Step-ups and step-downs - increase step height progressively
• Elliptical trainer - begin at 12-14 weeks
• Stair climber / stepper - begin at 14-16 weeks
• Swimming (flutter kick - avoid breaststroke) - begin at 12 weeks
• Proprioception progression - single-leg stance on foam, eyes closed, perturbation training
• Balance board/wobble board training

• Joint mobilization (Grade III/IV) for ROM deficits
• Soft tissue release of gastrocnemius, hamstrings, IT band
• Scar tissue management at portal sites

• Neuromuscular electrical stimulation (NMES) for quadriceps hypertrophy
• Aquatic exercise preferred - significantly reduces joint load
• Avoid high-impact activities

PHASE IV - FUNCTIONAL STRENGTHENING

• ROM 0-130° minimum
• Quad strength >60% of contralateral side (isokinetic or HHD)
• No swelling with activity
• Single-leg squat to 60° without pain

• Quadriceps index >80% symmetry
• Begin low-intensity plyometrics (at 16 weeks per PCL protocol)
• Activity-specific conditioning

• Open-chain hamstring curls - may now be cautiously introduced at 4 months+ (submaximal, progress gradually)
• Nordic hamstring - delay until last (kneeling position, high activation)
• Single-leg leg press
• Lateral step-ups / lateral lunges (avoid varus stress on the PFL-injured side)
• Low-intensity plyometrics (double-leg jumps, jump rope) - begin at 16-18 weeks
• Forward lunges (avoid deep forward lunge until 5 months)
• Bilateral jump landing mechanics training

PHASE V - RETURN TO ACTIVITY

• Quad index >90% (HHD or isokinetic testing at 60°/sec)
• Hamstring index >90%
• Single-leg hop test >90% of contralateral side
• KOOS or Lysholm score appropriate for desired activity level
• No swelling, full ROM

• Return to community-level activities (walking, low-demand ADLs): ~4-5 months
• Return to occupation (depending on type): 4-6 months
• Recreational sports: 9-12 months minimum given PFL injury and OA
• High-demand sport: not advisable given Grade III PFL + OA changes

Special Considerations for This Patient

1. OA + Chondromalacia Patella Grade 1

• Avoid deep knee flexion loading (>90°) until strength is adequate
• Prefer aquatic therapy and cycling over land-based impact
• Consider glucosamine sulfate 1500 mg/day and omega-3 supplementation (evidence: Grade B)
• NSAIDs or topical diclofenac gel for pain management during rehab (surgeon approval)

2. Grade III Popliteo-Fibular Ligament (PFL) Tear

• Avoid active hip abduction and varus knee stress for 6 months
• No lateral step-overs, side shuffles until Phase III
• Weight bear in slight knee extension (avoid stance in flexion initially)

3. Synovitis + Effusion

• Significant knee effusion causes quadriceps inhibition - even small effusions (20-30 mL) can inhibit quad activation by 50% (arthrogenic muscle inhibition)
• This is likely why the patient struggles with ROM at POD 40
• Aspiration may be considered by the surgeon if effusion is large and inhibiting progress
• NMES is mandatory to overcome arthrogenic inhibition

4. Age 49 + Reduced Bone Mineralization (per MRI)

• Monitor vitamin D levels - deficiency common in India
• Vitamin D 60,000 IU weekly x 8 weeks + calcium 500 mg BD supplementation (after physician prescription)
• Avoid high-impact loading until bone quality confirmed

Weekly Milestone Summary

Evidence Base

Key Dos and Don'ts Summary Card

Disclaimer: This protocol is for use by qualified physiotherapists and should be adapted in consultation with the operating surgeon (Dr. Satishkumar Patil). Progression through phases must be criterion-based, not purely time-based. Any increase in swelling, pain >4/10 post-exercise, or graft instability symptoms requires regression of loading and surgical team review.Here is the complete, evidence-based protocol. Let me highlight the most critical points for your clinical practice:

Quick Summary for Clinical Use

1. Swelling first - The 70° ROM limitation is almost certainly arthrogenic muscle inhibition from effusion. Aggressive swelling control (ice, compression, elevation, NMES) unlocks ROM faster than any exercise.
2. Quad activation is the cornerstone - Quad sets, SLR, TKE with band, NMES. The PCL graft is protected when quadriceps dominate; hamstrings must be kept inactive.
3. Weight bearing is currently correct at ~50-70% - Progress to full WB by weeks 9-10 with the PCL dynamic brace (Ossur Rebound-type). Keep brace on for 6 months of ambulation.
4. ROM target: 90° by week 8, 120° by week 12 via prone/gravity-assisted flexion only (no active hamstring pull).

Post-Operative Rehabilitation Protocol

PCL Reconstruction + Partial Medial Meniscectomy, Right Knee

Patient: Parshvnath Balol, 49M | POD 40 | Starting Status: Swelling +, ROM 0-70°

Understanding This Patient's Complexity

• Complete PCL tear (surgically reconstructed)
• Grade II posterior horn medial meniscus - avulsion at root + pseudo-extrusion (partial meniscectomy done)
• Grade III popliteo-fibular ligament (PFL) tear - posterolateral corner (PLC) structure
• Grade I LCL signal involvement
• OA changes: medial > lateral joint space narrowing, chondromalacia patella Grade 1, synovitis

WEIGHT BEARING PROGRESSION TABLE

Critical brace note: The PCL-specific dynamic brace (with anteriorly directed tibial pad) must be worn for all ambulation through 6 months. At week 6 (now), transition from locked hinged brace to dynamic PCL brace when swelling allows.

GLOBAL PRECAUTIONS - APPLY THROUGHOUT ALL PHASES

1. NO open-chain hamstring exercises until at least 4 months post-op. Hamstring contraction drives posterior tibial translation = direct force on PCL graft. (Miller's Review of Orthopaedics 9th Ed.; Cruz PCL Protocol 2024; Bradley Smith Multiligament Protocol)
2. NO hyperextension of knee at any stage
3. NO varus stress - Grade III PFL tear makes the posterolateral corner vulnerable
4. NO prone knee hangs - activate hamstrings passively via gravity and damage graft
5. NO active knee flexion against gravity (no sitting leg curls)
6. All ROM work is passive or gravity-assisted only in Phase I and II
7. Progress weight bearing by symptoms + quad control, not by time alone

PHASE I - PROTECTION, PAIN CONTROL & QUAD ACTIVATION

Week 6 through Week 8 (POD 40-56) - THIS IS WHERE PATIENT IS NOW

• Reduce swelling aggressively
• Regain ROM from 70° to 90-100°
• Achieve SLR without extension lag
• Activate quadriceps
• Maintain full passive extension
• Patient education

A. SWELLING & PAIN MANAGEMENT (Priority #1)

• Ice pack application 15-20 minutes, 4-5 times/day
• Mandatory after every exercise session
• Use compression wrap (tubigrip/crepe bandage) between sessions

• Elevate limb above heart level when resting - pillows under heel (NOT under knee)
• Avoid pillows under the knee as it promotes flexion contracture

• TENS (80-100 Hz, 30-40 min) for pain relief, 1-2x daily
• IFC (interferential current) for deeper tissue pain - 80 Hz, 20 min
• NMES (Neuromuscular Electrical Stimulation) to quadriceps: 2500 Hz, 75 bursts/sec, paired with quad sets. Critical for overcoming arthrogenic muscle inhibition from effusion. 15-20 min sessions.

• Gentle retrograde effleurage (distal to proximal) for lymphatic drainage
• Patellar mobilization - superior/inferior/medial/lateral glides (Grade I-II) to prevent patellar stiffness

B. ROM EXERCISES (Phase I)

• Lie prone on bed, let gravity flex the knee
• Use opposite foot to gently assist flexion if needed
• Hold at comfortable end range 10 seconds
• 3 sets x 15 reps, 2x/day
• Target: reach 90° by end of week 7
• Why prone: gravity assists flexion WITHOUT any hamstring contraction

• Lie on back, slide heel toward buttocks using a plastic bag under foot (reduces friction)
• Use a towel/rope around foot to assist - pull with arms, not hamstrings
• Hold end range 5 seconds, slowly return
• 3 sets x 15 reps, 2x/day
• DO NOT let the knee muscle behind the thigh (hamstring) contract

• Sit at edge of treatment table, let gravity flex the knee slowly
• Use opposite foot to support and control descent
• Hold at 5-10° beyond current comfortable range, 10-15 seconds
• Return using opposite foot support
• 3 sets x 10 reps
• Start at 70°, aim to reach 90° by week 7-8

• Lie supine, pillow under ankle (NOT under knee)
• Let gravity achieve full extension passively
• Hold 5-10 minutes per session
• This prevents flexion contracture - a common complication

• Pump ankle up and down continuously
• 3 sets x 30 reps
• Purpose: DVT prophylaxis and distal swelling reduction

C. STRENGTHENING EXERCISES (Phase I)

• Lie on back, knee straight
• Press back of knee firmly into bed surface
• Feel thigh muscle tighten and kneecap move upward
• Hold 10 seconds, relax
• 3 sets x 20 reps, multiple times daily
• This is THE most important exercise at this stage

• Brace locked in full extension
• Lie on back, tighten quad first (quad set), then lift leg to 45°
• Hold 3 seconds at top, lower slowly (5 seconds)
• 3 sets x 20 reps, 2x/day
• Goal: perform 30 consecutive SLR without extension lag before progressing
• If extension lag present: NMES + more quad sets before attempting SLR

• Stand with elastic band looped behind the knee, attached to fixed point in front
• Start with knee slightly bent (20-30°)
• Straighten knee fully against band resistance
• Hold 2 seconds, return
• 3 sets x 15 reps
• One of the best closed-chain quad activation exercises

• Lie on unaffected side
• Lift operated leg to 45°, hold 2 seconds, lower slowly
• 3 sets x 20 reps
• Protects the PFL/posterolateral corner by strengthening hip abductors

• Lie prone, keep knee straight
• Lift entire leg from hip by 10-15°, hold 3 seconds
• 3 sets x 15 reps
• Activates gluteus maximus without hamstring isolation

• Seated or standing bilateral
• Rise onto toes fully, hold 2 seconds, lower slowly
• 3 sets x 20 reps

D. WEIGHT BEARING & GAIT (Phase I, Week 6-8)

• Walk with both crutches initially, progressing to one crutch (on opposite side) by end of week 7 if tolerated
• Step pattern: crutch and operated leg move forward together
• Dynamic PCL brace should be fitted now (week 6) if not already done
• Short walking distances only (within home/clinic) - avoid prolonged standing
• Monitor for increased swelling after each session - if swelling worsens, reduce weight bearing

PHASE II - EARLY STRENGTHENING & ROM RESTORATION

Weeks 9-12 (POD 57-84)

• SLR with zero extension lag
• ROM at least 90° or more
• Swelling minimal or absent after activity
• Pain <3/10 with weight bearing

• ROM: reach 0-120° by end of week 12
• Full weight bearing with normalized gait pattern
• Initiate closed-chain strengthening
• Begin stationary cycling
• Neuromuscular/proprioception training

Weight Bearing (Phase II)

• Week 9: 90% WB, single crutch
• Week 10: Full WB, dynamic PCL brace, no crutch on flat surface
• Crutches only for stairs or uneven terrain initially

ROM Exercises (Phase II)

• Begin when flexion reaches 100° (approximately week 9-10)
• Seat height HIGH initially - just enough to complete full revolution
• Resistance: very light (resistance level 1-2)
• Duration: 10 minutes, build to 20-30 minutes by week 12
• No clipless pedals - use flat platform pedals
• Gradually lower seat height as ROM improves (each reduction requires ~5° more flexion)
• Goal: achieve full pedal revolution indicates ~110° of usable flexion

• Stand with back against wall
• Slide down to 45° squat, hold 5 seconds, slide back up
• Progresses ROM and begins closed chain loading
• 3 sets x 15 reps
• Progress depth by 5° per week

• Continue from Phase I, progress toward 120°

Strengthening Exercises (Phase II)

• Stand with feet shoulder-width, back straight
• Bend both knees to 30-45° only
• Hold 3 seconds, return to standing
• 3 sets x 15 reps
• Add resistance (body weight first, then light dumbbells)
• Progress: 45° to 60° by end of Phase II
• NOT beyond 70° at this stage

• Foot plate position: feet hip-width
• ROM: 0-60° initially, progress to 0-90° by week 12
• Start with light weight (25-30% of estimated 1RM)
• 3 sets x 15 reps
• Focus on slow eccentric (lowering) phase - 3 seconds down, 1 second up
• Increase weight 5-10% per week if no swelling

• Start with 5 cm step height
• Step up with operated leg first, stand fully, step down
• 3 sets x 15 reps each leg
• Progress step height to 10 cm, then 15 cm by week 12

• Increase band resistance
• Add isometric hold at full extension 5 seconds
• Progress to single-leg TKE by week 10-11

• Standing, band around ankles
• Step sideways 10-15 steps each direction
• 3 sets x 15 reps each direction
• Critical for PFL/PLC rehabilitation

• Stand on operated leg (slight knee bend 10-15°)
• Eyes open: hold 30 seconds
• Progress to eyes closed
• Progress to unstable surface (foam pad)
• 3 sets x 30 seconds each

• Begin bilateral week 9
• Progress to single-leg calf raise by week 11-12
• 3 sets x 20 reps

Modalities (Phase II)

• Ultrasound therapy to posterior joint capsule (1 MHz, 1.0-1.5 W/cm², continuous, 5 min) for capsular stiffness
• Grade III-IV patellar mobilization for ROM
• Soft tissue massage to gastrocnemius, calf, quadriceps
• Ice 15-20 min post-session
• NMES continues if quad lag persists

PHASE III - PROGRESSIVE LOADING & FUNCTIONAL CONDITIONING

Weeks 13-20 (POD 85-140)

• ROM 0-120° minimum
• Full weight bearing with normalized, non-antalgic gait
• No post-exercise swelling
• Adequate quad activation - no extension lag
• Single-leg stance 30 seconds eyes closed on flat surface

• ROM: 0-130° to full (135°) by end
• Unilateral closed-chain loading begins
• Cardiovascular conditioning
• Begin submaximal hamstring work (after 13-14 weeks)
• Proprioception progression

Strengthening Exercises (Phase III)

• Weeks 13-16: Bilateral squats 0-70°
• After week 16: Begin progressing toward 0-90°
• Add resistance bands or light barbell by week 16
• Focus on form - knees tracking over toes, no valgus collapse

• Single-leg leg press, 0-60° arc initially
• Progress to 0-90° by week 16-18
• 3 sets x 12-15 reps

• Start with prone hip extension with knee bent - this activates gluteus more than hamstring
• Progress to Swiss ball hamstring bridge (bilateral): lie on back, feet on ball, lift hips and curl ball toward buttocks
• Week 16-18: Prone hamstring curl on machine (submaximal weight, 50-60% max)
• Nordic hamstring curl - delay until last (after week 20) due to high activation in kneeling position
• Open-chain lying hamstring curls: introduce cautiously after 4 months

• Stand on operated leg on step (15-20 cm)
• Slowly lower opposite foot toward floor (5-second count)
• Return to standing
• 3 sets x 10-15 reps
• Excellent eccentric quad loading and proprioception

• Begin at week 12-13
• Low resistance, forward motion only initially
• 15-20 minutes, progress to 30 minutes by week 16

• Flutter kick swimming (NOT breaststroke - valgus/varus stress)
• Pool walking (chest-high water = 70% body weight reduction)
• Pool jogging by week 14-15 if tolerated
• Aquatic therapy is especially beneficial for this patient given OA changes

• Single-leg balance on wobble board / balance board
• Mini-trampoline standing
• Perturbation training (therapist applies unexpected pushes while patient maintains single-leg stance)
• Tandem walking, lateral stepping (avoid aggressive lateral movement with PFL injury)

• Begin week 14-16
• Start with short duration (5-10 min), progress

Cardiovascular Conditioning (Phase III)

• Stationary cycling: 30-45 minutes, moderate resistance
• Pool walking/jogging
• Elliptical
• Goal: heart rate 65-75% max for 20-30 minutes by week 20

PHASE IV - FUNCTIONAL STRENGTHENING & RETURN TO ACTIVITY PREP

Weeks 20-24 (POD 140-168)

• ROM 0-130° minimum
• Quadriceps index >60-70% of contralateral side
• No pain or swelling with Phase III activities
• Single-leg squat to 60° with controlled form

• Full squat depth progression (0-120°) with resistance
• Single-leg Romanian deadlift (hip hinge)
• Lateral lunges (gentle - avoid aggressive varus/valgus)
• Lateral band walks, monster walks
• Low-intensity bilateral plyometrics: double-leg squat jumps (week 16), jump rope (week 18)
• Single-leg landing mechanics practice
• Agility ladder (bilateral patterns, no pivoting yet)
• Nordic hamstring curls (last to be introduced)

PHASE V - RETURN TO ACTIVITY/SPORT

Week 24+ (POD >168)

• Quadriceps index >90% (isokinetic or HHD)
• Hamstring index >90%
• Single-leg hop test >90% symmetry
• KOOS sport subscale >85
• Full ROM, no swelling
• Functional sports assessment (FSA) passed

WEEKLY MILESTONE SUMMARY TABLE

SPECIAL CONSIDERATIONS FOR THIS PATIENT

1. Effusion-Driven Quad Inhibition (Most Important Issue at POD 40)

2. OA + Chondromalacia Patella Grade 1

• Prefer low-impact exercise (bike, pool, elliptical) over high-impact
• Avoid deep knee flexion loading until strength is adequate
• Consider glucosamine sulfate 1500 mg/day (Grade B evidence for symptomatic OA)
• Physician-prescribed topical or oral NSAIDs during active rehab periods

3. Grade III PFL (Posterolateral Corner) Tear

• Was this addressed surgically? (Not clearly documented - confirm with surgeon)
• If not surgically repaired: extra caution with all lateral-compartment loading, no varus stress
• No hip abduction strengthening with external rotation until week 9+
• Per Mitchnik et al. 2025 (PMID 40692928): significant variation in expert protocols; conservative approach recommended with this complexity

4. Age 49 + Reduced Bone Mineralization (MRI finding)

• Check serum Vitamin D, calcium levels
• Supplement under physician supervision (commonly: Vitamin D 60,000 IU weekly x 8 weeks, then maintenance + Calcium 500 mg BD)
• Avoid impact loading until bone quality is addressed

5. Root Avulsion of Medial Meniscus

• Partial meniscectomy was performed (not repair of root)
• Per 2024 ESSKA Consensus (Grade A): after partial meniscectomy, full WB is permitted early and there is no ROM restriction
• However, with co-existing PCL reconstruction, the PCL protocol governs WB progression (more conservative)

EVIDENCE BASE

DOS AND DON'TS CARD

Disclaimer: This protocol is for use by qualified physiotherapists in liaison with the operating surgeon (Dr. Satishkumar Patil, PIOS Medilinks). All phase progressions are criterion-based. Any increase in swelling after exercise, pain >4/10, or feeling of instability requires regression of loading and prompt surgical team review.