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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).

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Post-Operative Rehabilitation Protocol

PCL Reconstruction + Partial Medial Meniscectomy, Right Knee

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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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°

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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

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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

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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

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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

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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

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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)

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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

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WEEKLY MILESTONE SUMMARY TABLE

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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)

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EVIDENCE BASE

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DOS AND DON'TS CARD

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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.