Week 1 – ACL Program (BTB Reconstruction)

1. Use your crutches until you can walk comfortably & safely. 2. It is OK to go to the gym and lift with your upper body. 3. Use ice for 10-20 minutes, or until the knee is numb to touch, to help control knee pain and

swelling. Keep the sutures dry. 4. You will be in your brace for 4 weeks. You may remove the brace to perform the following

exercises:

A. Extension (straightening knee)

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Lie on the bed with your ankle on a pillow. Let your knee relax down to stretch your knee straight. Avoid tightening your thigh muscle. Hold 5-10 minutes, 4-5 times per day.

Lie on your stomach with your knee and lower leg hanging over the edge of the bed to stretch your knee straight. Hold 5-10 minutes, 4-5 times per day.

B. Flexion (bending knee)

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Lie on your bed witha loop of towel under your foot. Bend your knee by sliding your heel toward your buttocks. Sustain the stretch for 3-5 seconds. Do 25 reps 4-5 times per day.

Week 1 continued:

Flexion: Knee bending can also be accomplished by sitting in a chair. Slide your foot backwards with the help of your other foot. Hold 10 seconds Repeat 25 times 4-5 times daily

C. Calf Stretch: Lie on your bed with your leg out straight and a towel looped under the ball of your foot. Gently pull your toes toward your nose. Hold for 1 minutes. Do 4-5 times per day.

D. Quad Sets: When you are able to stretch your knee completely straight you can do this exercise. With your knee completely straight, tighten your front thigh muscle (quad). Hold for 3-5 seconds, repeat 10-20 times, 4-5 times per day.

E. Supported Weight Shifting – In the brace Stand facing the kitchen counter with your brace on. Slowly shift your weight to your right and left foot. Also shift your weight onto the balls of your feet then onto your heels. Focus on contracting/controlling the muscles around the knee

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Week 2 – ACL Program (BTB Reconstruction) Pt has recheck with Orthopedics Department

1. Stationary Bike – mild tension, seated rocking for motion, 15 minutes, 2-3x per day. Once you can ride without compensations and with full revolutions for 10-15 minutes, then it is OK to add tension and gradually increase your riding time to 15-20 minutes. 2. Strength Progression

• 5-10 repetitions, 1-2x per day unless otherwise specified • Add 1-2 repetitions every 2 days • Goal: 30 repetitions • Then add/increase weight and repeat the above progression • NOTE: Stop any exercise that causes sharp, shooting pain in the knee joint. It is

normal to experience muscle soreness, fatigue, and minimal swelling after exercising. Use ice as needed to control these responses.

Straight Leg Raise – Brace On When you are able to stretch your knee completely straight you can do this exercise: With your knee completely straight and the brace on and with your other knee bent, lift the operated leg up as high as your other knee. Hold for 2-3 seconds, repeat 10-20 times, 4-5 times per day.

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Single Leg Balance in Brace Start with eyes open. Progress to: eyes closed, then on a pillow. Goal is 90 seconds.

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Heel Raises Stand in the brace with the balls of your feet on a 1-2 inch ledge. Raise up onto your toes. Follow strength progression as above

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Week 2 exercises continued:

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Hip Workout: Extension Secure a loop of theraband in a door. Stand in the bracewith the band around your ankle. Extend your leg backwards. Follow strength progression as above. Repeat with opposite leg.

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Hip Workout: Abduction: Secure a loop of theraband in a door. Stand in the brace with the band around your ankle. Lift your leg out to the side. Follow strength progression as above. Repeat with opposite leg.

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Hip Workout: Adduction: Secure a loop of theraband in a door. Stand in the bracewith the band around your ankle. Pull band across yourbody by crossing your leg. Follow strength progression as above. Repeat with opposite leg.

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Mini Squats: Out of brace only if ok with your therapist: Standwith your feet shoulder width apart while holding onto a table or countertop. Bend your knees until your knees are directly over your toes. Hold 5 seconds then return to the starting position. Follow strength progression as above.

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Week 3 – ACL Program (BTB Reconstruction)

In addition to the exercises of the previous weeks, add the following. (Follow the strength progression rules outlined in the week 2 handout.)

VMO Isometrics: Sit with your knee with at least 70 degrees of bend in it. Squeeze a small ball or rolled towel between your knees while pushing your feet into the floor. Hold 5-10 seconds and repeat 10 times, 1-2 times daily.

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Hamstring Curls: Lie on your stomach with your knees hanging off the end of the bed. Curl your lower leg up. You can use your other leg to help the operated leg back to the starting position. Hold 5 seconds and repeat 10 times, 1-2 times daily.

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Week 4 – ACL Program (BTB Reconstruction) Patient has recheck with Physician

1. Discontinue Brace. You may need to return to using an assistive device for walking if you

limp or do not have adequate strength/balance. Your therapist will determine what you need to do.

Single Leg Balance – Brace Off: Start on level floor then progress to standing on a pillow. Progress from using your arms for support to no arm use. Try with eyes open then progress to eyes closed if you have good control and are safe.

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W

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Stool Scoot: Sit on a stool or chair with rollers. Pull yourself forward along on a hard floor. Do for 2-5 minutes. Then reverse directions and push yourself backwards for 2-5 minutes (watch where you’re going!).

alking Exercise: Start Forward WALKING on flat surface/treadmill • Start with ¼ mile on a treadmill, track, or flat road • Add ¼ mile every 4 times you walk. • Stop if you have sharp, shooting pain in the knee joint

tationary Bike: OK to continue increasing the tension on your stationary bike. Biking must be painfree. Limit your bike workout to 15-20 minutes.

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Week 4 continued:

Step/Dip Exercises: Forward and Sideways • Start with operated leg on a 2 inch step • 5-10 repetitions • Add 1-2 repetitions every 2 days • Goal = 30 reps • Then increase height another 2 inches • Repeat the progression • Ultimate goal = 6-8 inch step, 50 repetitions

STEPUPS

DIPS

Side Step Ups: step up sideways with the operated leg, then step back down onto your good leg.

Forward Dips: Operated leg on step. Just touch opposite heel to floor in front of the step then come right back up

Forward Step Ups: step up forward with the operated leg, then step back down onto your good leg.

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Sideways Dips: Operated leg on step. Just touch opposite heel to floor then come right back up

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Week 6-7 – ACL Program (BTB Reconstruction) Pt has recheck with Orthopedics Department

1. You should have close to full range of motion. 2. You may now use the stair stepper, pool, and/or your street bicycle for fitness. 3. You may go to the gym and lift with your legs:

• PAIN FREE • Follow the strengthening progression • Calf machine – sit/stand • Multi-hip machine • Leg press – both legs, knees over toes • Hamstring curls – sit or on stomach • Squats – knee over toes

• Alternate your cardiovascular fitness days with your weightlifting days • Avoid the quadriceps leg extension machine as it places too much stress on the knee

Wall slides with theraband: Lean up against a wall with a theraband around your knees. Put tension on the band by moving your knees apart. Make sure that your knees end up directly over your toes. As you slide down the wall, don’t allow your knees to bend more than 90 degrees.

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Wall slides with ball: Lean up against a wall with a ball between your knees. Squeeze the ball with your knees making sure that your knees end up directly over your toes. Maintain the squeeze while sliding down the wall. Don’t allow your knees to bend more than 90 degrees.

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Lunges – body erect, knees over toes ↔

Advanced walking exercises • Backward • Hills or inclines on treadmill • Side-step on ground • Theraband/Sports cord for resistance: side stepping and diagonal stepping

Theraband Sidestep Theraband diagonal forward and backward step

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Week 8-9 – ACL Program (BTB Reconstruction)

Start low level plyometrics if 4-inch lateral dip test (15 seconds) is at least 50% on the uninvolved leg

1. Gentle sliding side to side from one leg to the other 2. Gentle rocking back and forth.

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3. Gentle diagonal rocking back and forth. Switch legs.

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4. Rapid one leg ¼ squats ↔

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12 o’clock 8 o’clock 4 o’clock6 o’clock

5. Foot clocks: Balance on your operated leg while touching the toes of your other foot forward, backward, and diagonally. Alternate between 12 & 6 o’clock, 4 & 8 o’clock and 2 & 10 o’clock (not pictured). Progress to low stool (below) as control improves. Progress reps as outlined in strength progression handout week 2.

Foot Clocks on Stool: Stand on stool with your operated leg while alternately touching your toes of your other leg forward, backward, and diagonally as outlined above.

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3 Months – ACL Program Pt has recheck with Orthopedics Department

1. Start the jogging progression on flat surfaces, track, or treadmill.

• Start with ¼ mile • Add ¼ mile every 4 times you jog • Stop if you have any sharp, shooting pain in the knee joint

2. May start sport specific drills once your 4-inch lateral dip tests are 70% of the uninvolved leg, for example dribble ball, shoot baskets, kick ball in controlled environment.

3. May progress plyometrics once your 4-inch lateral dip tests are 70% of the uninvolved leg

• 2 leg jumping for control • Multidirectional 2 leg jumping for control

• Side to side • Forward and backward • Diagonal

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2 Legged Jump Sideways

2 Legged Jump Diagonal Forward and Backward

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Progress to 2 legged jumping onto 6 inch curb: side to side and forward and backward

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2 Legged Jump Up to the Right then back to the starting position

2 Legged Jump Up to the Left then back to the starting position

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2 Legged Jump Up Forward then back to the starting position

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4 Months – ACL Program 1. Figure eight running – Work from large to small loops 2. Unilateral plyometrics – If the 4-inch lateral dip tests are 90% of the uninvolved leg.

Single Leg Stance Hopping: Stand on your operated leg and hop from side to side. ↔

Single Leg Stance Clock Hopping: Stand on your operated leg and hop forward to the 12 o clock position then back to the starting position. Then to 2 o clock and back. Continue in a clockwise direction to 4, 6, 8, and 10 o clock positions.

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6-7 Months – ACL Program

1. Pivot or twist drills 2. Return to sports once 6-inch lateral dip tests are 80% of the uninvolved leg, isometric quad

strength testing is 80% of the uninvolved leg, and KT tests are within acceptable range. 3. Vertical hop testing 4. Discharge patient if goals achieved.

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POST-OP ACL RECONSTRUCTION (BTB) R E V I S E D 1 1 / 0 6

DO’S DON’TS

DO: GET KNEE EXTENSION WITHIN 2 WEEKS POST-OPERATIVELY

DON’T: ACTIVATE YOUR QUADRICEPS MUSCLES TO STRAIGHTEN YOUR KNEE

DO: WEAR BRACE 24 HOURS/DAY FOR FIRST 4 WEEKS (EXCEPT DURING FLEXIBILITY EXERCISES)

DON’T: LIFT YOUR LEG USING YOUR QUAD MUSCLES WITHOUT THE BRACE ON

DO: USE ICE PACK 4 – 5 TIMES DAILY FOR 20 MINUTES TO CONTROL SWELLING

DON’T: TIGHTEN THE BRACE STRAPS TOO TIGHT WHEN YOU ARE SITTING DOWN

DO: ELEVATE YOUR BRACED LEG WHEN SITTING AND WHEN USING AN ICE PACK

DON’T: SLACK OFF WITH YOUR EXERCISE

DO: EXERCISE MANY TIMES DAILY TO RECOVER YOUR KNEE FLEXIBILITY

DON’T: DRIVE WITH THE OPERATED LEG

DO: KEEP YOUR POST-OP APPOINTMENTS WITH YOUR SURGEON

DON’T: WALK WITHOUT YOUR BRACE ON

DO: KEEP YOUR PHYSICAL THERAPY RECHECK APPOINTMENTS AND ATTEND ALL YOUR ACL CLASSES

DO: UTILIZE YOUR OWN GYM ONCE DIRECTED TO DO SO, IN ADDITION TO YOUR ACL CLASSES

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PATIENT INFORMATION ===============================================================

How to Make Your Own Cold Pack

1) Pour 3 cups of water in a gallon size zip lock bag 2) Add 1 cup of isopropyl alcohol 3) Mix contents 4) Close bag and place in another bag and close the second bag 5) Place in freezer

Contents should turn into a slushy mixture. If it is too solid, add more alcohol. If it is too watery, add water.

1) Always use a thin layer of cloth (ie: pillowcase) between the ice pack and skin 2) Apply for 20 minutes at a time 3) Cold pack may be reapplied as often as needed as long as you wait 20 minutes between

applications 4) Keep leg elevated when you use the cold pack

SCAR MASSAGE A scar is one of the inevitable results of a surgery and sometimes injury or cuts. Scar tissue can hinder return of full range of motion to a joint. The skin should move easily over the muscles and tissues below it. A scar forms adhesions between the skin and those tissues, much like a seam on cloth. Stitches are generally removed or absorbed after 2 weeks. Shortly after this time your therapist may begin scar massage to break loose adhesions and facilitate range of motion improvements. Scar massage may also be performed by you, 4 weeks after surgery. To perform scar massage, gently rub your fingers over the scar in a circular motion. It may also be done by rubbing back and forth across the scar. You should check periodically to look for areas on the scar which do not move easily and concentrate on those areas. Pressure should be gentle and should not cause pain. You can massage several times a day for a few minutes at a time. Sometimes it helps if you place the scarred areas in warm water while you massage or do them after an application of heat. If there is redness, pain, or oozing from the scar, you should stop and consult with your therapist or doctor. The scar should be healed before beginning massage. Consult with your therapist if you have any questions or concerns when to perform scar massage.

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POST-OP ACL RECONSTRUCTION

HOME EXERCISE PROGRAM WEEKS 1-4

ADDITIONAL EXERCISES OF EQUAL IMPORTANCE POST-OPERATIVELY

ANKLE PUMPING AND CIRCLES: This exercise helps prevent blood clots and helps to reduce swelling by using the calf muscle to encourage better circulation throughout the operated leg. It can be done seated, with the braced leg propped up, ie while at work, or lying down with the brace on or off. Move your foot in big circles both directions up to 100 times daily. Move your foot up and down, up to 100 times daily. PATELLAR MOBILIZATION: Start when incision is healed. Since 1/3 of your patellar tendon was used to construct a new ACL ligament, and because of the unavoidable post-operative swelling around the knee, the tissues attached to the patella become stiff. This leads to restriction of the normal gliding mechanism of the patella during knee flexion and extension.

NOTE: It is VERY important to promote early movement of the patella after surgery, as the gliding mechanism must be restored in order to achieve full extension.

Sitting on the bed with your legs straight out in front of you, hold the outer edges of the patella with your thumb and index finger. Move the patella towards the inside and hold 5 seconds then to the outside and hold 5 seconds. Do sets of 10.

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