DAY ONE - Initial Evaluation

1. Evaluate knee and patient tolerance to PROM (evaluate for possible CPM necessity). If CPM - Home rental, 6/8 hours a day to tolerence working to MAXIMUM flexion-
2. Open brace 0-120. Therapist may remove brace to do exercises.
3. Evaluate for muscle stimulation (Home Rental).
4. Take circumferential measurements.
5. Patients seen 4 times for the first 2 weeks postop to achieve ROK 0 degree extension, 110/115 degree flexion.
6. Icing 3/4 times a day with exercises. Use ice unit continuously for fu'st week.
7. Patella mobilization.
8. Quad sets.
9. Straight Leg Raises (SLR) with leg at 0 degrees - to complete extension.

Day One - Exercises through week One

1. Initiate Quad setting exercises (hold 5 sec. rest 3 sec.)..repeat throughout day 3/4 times a day 50/60 reps each time..
2. Straight Leg Raise exercises at 0 deg; initiate 10/15 reps working to sets of 50 reps 3/ 4 times a day.
3. Side leg raises, ADductors.
4. Side leg raises, ABductors.

   (2, 3, 4 eliminate assistance when patient able to perform independently.)

5. Ankle pumping throughout the day.
6. Patellar mobilization - medial, lateral, superior, infenor
7. Self PROM knee flexion sitting in chair, foot flat, sliding in and out of flexion to tolerance.
8. Passive Extension, long sit position, fold towel under knee, can do quad setting. Active hamstring stretching by reaching out to toes with knee straight Hamstring g for 5 - 10 minutes every 2 hours.
9. Partial Weight Bearing (PWB) with crutches started second day, should progress to Full Weight Bearing (FWB) by two weeks. Important to instructon heel > toe strike with knee extended.
10. Prone leg hand, 3 - 4 times daily 10 - 15 minutes.

Must maintain full extension always!!! Evaluate patients ability to maintain full extension actively and passively.

WEEK ONE - Initiate Exercise

1. Hip Abduction
2. Hip ADduction (unless associated with MCL repair).
3. Hip extension
4. NO HAMSTRING STRENGTHENING.
5. Bicycle when AROM permits complete cycle (minimal resistance 150 kpn/min).
6. Mini squats, wall slides 3 sets 15 reps daily.

Week Two

1. Continue as in week one increasing active assisted ROM and PROM.
2. PROM 0 - 130/140 at least by end of second week.
3. BICYCLE lowering seat height to help with flexion (NO TENSION).
4. THERAPIST MAY NEED TO PUSH KNEE THROUGH SCAR TISSUE USUALLY DONE IN PRONE POSITION. (PAINFUL TO PATIENT BUT SOMETIMES NECESSARY. BE SOMEWHAT AGGRESSIVE WITH PROM).
5. Always maintain full extension PROM and AROM emphasizing full extension.
6. Use modalities as necessary Icee, muscle stimulation, ultrasound. (BE AWARE OF FIXATION SCREWS AND STAPLES.)
7. Icing at end of treatments.
8. Continue SLR at 0 deg flexion, 3 sets 30 reps, wall slides, mini squats and set ups and add isometric quads at 600 and 900.
9. Crutch full weight bearing.

Week Three

1. Patient continues at home with SLR at 0 deg, 60 deg and 90 deg, begin putting weights above knee for resistance to tolerance 50 reps 3/4 times a day all planes adduction, abduction.
2. Continue to push all reconstructions to 0 deg individual tolerance.
3. Start toe raises, 1/4 squats, 4 " step ups, on and flexion to tolerance (full flexion).
4. Patient should continue with all home exercises stretching and strengthening.
5. NO HAMSTRING STRENGTHENING.
6. Prevent hyperextension.
7. Full Weight Bearing WITHOUT crutches (must have full extension with heel strike, no limp with gait or flexion contracture or extensor lag). TWO CRUTCHES UNTIL PATIENT IS ABLE TO WALK NORMALLY.

Week Four

1. Bicycle with resistance for stimulus only.
2. CONTINUE WITH ALL HOME EXERCISES.
3. Continue to Push all reconstructions to 0 deg passive extension and flexion to tolerance.
4. RESISTED QUAD EXERCISES IN= To RANGE 90 deg > 45 deg FLEXION. Start with I lb and add 1 lb per week
5. Leg press 20 - 90 deg flexion- with 30/40 LBS. ONLY and add resistance slowly depending on stairmaster, 3 sets 15 reps. Advance as tolerated.
6. Remove postop brace, patient is given a hinged knee sleeve with buttress.
7. Start stairmaster 2 - 3 minutes, easiest setting. Progress by 30 second intervals as tolerated, easy settings.

Week Five

1. Patient continues to wear knee sleeve with ambulation up to two/three months.
2. Continue with SIR e@ses at home progressing with weights AT THIGH.
3. Bicycle only for warm up at this time should be cycling at normal seat height now.
4. Start Isokenetics 45 deg to full flexion of machine. If able to maintain full active extension start sub max hamstrings. Isokinetics stay at high speeds until five months, then start to work to 60 deg per second for test at six months.
5. Isotonics quads, abductors and adductors, possible hamstrings if extension easy to maintain (may start leg press).
6. Continue to push all reconstructions to 0 deg PROM extension and flexion to tolerance.
7. Should have normal gait with full extension at heel and roll over to push off
8. Emphasize VMO strengthening (step ups, closed chain kinetics).
9. continue leg press, range to motion 20 deg - 90 deg. Watch amount of weight being used.
10. Watch for signs of patellar tendonitis from this point.

Week Six throuh Eight

1. Patient continues to work on strengthening. Begin hamstring strengthening open chain 45' - 90' and quad strengthening open chain 900 - 450.
2. Isotonics 450 to full flexion increasing weights to tolerance. Concentric and eccentric loading.

   NOTE: (Always be looking out for patellar tendon pain. Between 5 and 8 weeks we have seen some Patients develop tendonitis. If this occurs we continue to work on strengthening but we back off on the amount of weight being used. ice massage is usually helpful.)

3. Continue to push all reconstructions to 0' extension and flexion to tolerance.
4. Modalities for pain and swelling.
5. Monitor Gait (full extension with heel strike.
6. Patient can start sleeping without knee sleeve at six weeks postop. CONTINUE TO WEAR SLEEVE UP TO FOUR MONTHS WITH DAILY ACTIVITIES: WALKING STAIRS, ETC...
7. Continue stairmaster, wall slides, 1/2 squats, step ups.

Week Eight through Sixteen (4th month)

1. PRE at home move weights to ankle.
2. Around beginning of third month begin to move extension stops with isokinetics. Work to be at full extension strengthening at 3 mos. postop. (Watch for indications of infrapatellar tendonitis.)
3. Isotonic strengthening 30' 90' with progressive weights. No increase in weights greater than 2 1/2 lbs. Must stay at each level for at least 2 - 3 work outs.
4. Continue to push all reconstructions to 0' extension and flexion to tolerance.
5. Heiden board, Fitter, Euroglide, single leg balance.
6. Week 8 > swimming.
7. Watch for hamstring tightness as patients increase weight.% (tendency to develop an extensor lag because of quad weakness hamstrings develop faster).
8. Wobble board, proprioception work.
9. Start more functional mobility program (slide board, fitter, jogging, treadmill, two leg jump rope, trampoline hop).
10. At three months start TKE's on knee extension machine with ten pounds only for increased work on VMO. We stay at low weight high reps with this exercise.
11. Evaluate possible running at three to four months on treadmill or track. No hard surface jogging-
12. Swimming
13. Start at week 12 with easy sports specific exercises and increase as tolerated.
14. At week 12 begin to instruct patient on home program and the fact that in 4 weeks they will start working out on their own.
15. Week 16 set up home program for patient.
16. Isokinetic strength: Testing at 4 and 6 months.