KNEE REPLACEMENT REHAB PROTOCOL

With the client recovering from knee surgery, I will first check with the physician to make sure that the exercises are appropriate and also get the physician’s target for the client’s current condition. The physician normally releases patients in the post protection phase. That’s about from day 3 post-op. The program will be back to training assuming the client is an athlete or a back to functional ADL if the client is not an athlete. For athletes, the programmed will be tailored for their sports specific conditioning. After screening the client, I will inform him that it is necessary to dedicate 24 weeks that is around six months depending on how he will be progressing with the program so as to get him back to his optimal functional state. I will be consulting with the physician if signs and symptoms of infection on the wound are present also make sure that the client uses assistive devices as indicated by the physician. I will be keeping an eye for increased edema and use cryotherapy as needed.

PHASE 1 (0-2 Weeks)

Goals:The main goals will be to control pain, inflammation and protect the healing graft. Restoration of range of motion will begin aiming at total knee extension and establishing good quadriceps activation.

Contraindications: Weight-bearing as tolerated with assistive device for the knee and partial weight-bearing with assistive device for the muscle group the graft was taken from. The knee brace locked in extension with ambulation and sleeping Bledsoe Brace unlocked 0-900 when non-weight bearing.

Therapeutic exercises include:

Range of Motion 3- 5 times a day

  1. Heel Slides 2 Sets of 20 Repetitions.
  2. Assisted Knee Flexion/Extension in Sitting 2 Sets of 20 Repetitions Heel Prop (passive extension)
  3. Rolled towel under the heel seated leg extension (with permission) 5 to 10 s x 3.
  4. Band Stretch (Calf and Hamstring stretch) Hold for 30 Seconds 3-5 Repetitions.
  5. Ankle Pumps without resistance at least 2 Sets of 20

Strength Training once daily

  1. Quad Sets 2-3 Sets of 20 Repetitions
  2. SLR *(no Lag)* 2-3 Sets of 10-20 Repetitions
  3. Hip Abd/Add/Extension (against gravity) 2-3 Sets of 10-20 Repetitions
  4. Standing or Prone
  5. Hamstring Curls (contraindicated for Hamstring Graft) 2-3 Sets of 10-20 Repetitions T-Band on the ankle.
  6. Ankle Pumps 2-3 Sets of 20-25 Repetitions
  7. Stationary bike repetitions cycle with minimal resistance 10-15 Minutes Daily if possible.

PHASE 2 (Week 3- Week 5)

The goal is to progress ROM as tolerated without restriction. Protect the healing tissue. Progress weight-bearing as tolerated to full weight-bearing. Wean the client off crutches when good quad control is demonstrated. Introduce strengthening especially quadriceps.

Therapeutic Exercises will include:

Range of Motion

  1. Continue with ROM exercises from phase 1.
  2. Stationary bike 15 Min daily if possible. No resistance with unoperated knee doing all the work.
  3. Patella mobilization is active and passive.
  4. Figure 4 Hamstring stretch with a band on the operated leg. Hold for 5s to 10s three times

Strengthening once a day, 2 sets of 15-20 reps

  1. Continue Quad Sets (as needed for VMO activation)
  2. Continue 4 way SLR program (add ankle weight as needed)
  3. Hamstring Curls (Patellar Tendon and Allograft Only)
  4. Standing Terminal Knee Extension
  5. Leg Press
  6. Heel Raises
  7. Leg Stance Standing hip abduction. Both limbs to activate the hip musculature. Use a broomstick for support.

PHASE 3 (Week 6- Week 12)

The main goals of this phase are achieving AROM of 0-110’ progressing knee flexion as tolerated, having good voluntary quadriceps control (develop a strong base), normalize the gait of the client to achieve independent ambulation community distances (>/= 800 feet) without the walker with minimal; antalgia, pain, and inflammation as well as introduce balance and proprioception exercises.

Therapeutic Exercises will include:

Range of Motion and Flexibility: To be done once a day until normal ROM is achieved:

  1. Continue ROM exercises from phase 1 if necessary
  2. Hamstring and calf stretching. PNF contract-relax-(antagonist *rectus femoris)-contract) 5 x a week. This is key for optimizing neuromuscular coordination and recovery.
  3. AA/A/PROM, graduated dynamic stretching for flexion (>90 degrees) and extension. Supine heel slides and seated Long Arc Quad (LAQ). 10 reps 2 times every day.

Cardio: To be done 3 – 5 times a week for 20 – 30 minutes.

  1. Cycle with progressive resistance
  2. Start elliptical at 8 Weeks
  3. Initiate swimming at 6-8 Week
  4. 20 Min pool walking.

Strengthening: Performed 3-5 times a week. 2-3 sets of 15-20 Reps

  1. Forward step-ups.
  2. Static forward/backward lunge.
  3. Halfway-down chair squats. Aim at 90’.
  4. Back Extension targeting isometric contraction from the quadriceps, hamstring, and glute
  5. Bilateral SLR in 4 planes (flexion, abduction, adduction, extension).
  6. Hamstring curl with ankle weights.
  7. Introduce sit to stand and chair exercises.

Proprioception

  1. Single-Leg Stance
  2. Static Balance on Bosu/Wobble Board/Foam/Etc
  3. Star Drill (single leg stance with reach)

PHASE 4 (Week 12-Week 16)

The goal for this phase will be to maximize post-operative ROM to (0-125’).  AROM without pain, or plateaued AROM based on the non-operative side. Progress with single-leg strengthening. Establish good patella-femoral mobility and generally good muscular strength in all lower body to allow jogging and plyometric training. Get comfortable with running and sprinting. Pivoting and cutting are contraindicated. Straight line running only.

Therapeutic Exercises will include:

ROM and Flexibility: Continue with daily stretching.

Cardio: To be done 3 – 5 times a week for 20 – 40 minutes.

  1. Cycle with progressive resistance
  2. Elliptical increased intensity.
  3. Swimming with increased intensity.
  4. Deepwater running.

 Strengthening: 3 times a week

  1. Dynamic Lunge 2 -3 sets, 15 – 20 reps.
  2. Lateral Lunge 2 -3 sets, 15 – 20 reps.
  3. Single leg squat, 2 -3 sets, 15 – 20 reps.
  4. Lateral and Cross overstep ups. 2 -3 sets, 15 – 20 reps.
  5. Bilateral Bridge with Isometric Adduction 10×0:03s.
  6. MVP Shuttle Hop on Uninjured Leg 3×5 
  7. MVP Shuttle Press (light load) — Injured Leg 3×5

Proprioception

  1. Dynamic single-leg swing on a Bosu ball, 10 swings x 3.
  2. Side to side swings on a Bosu ball, 10 swings x 3.

Plyometrics: With a soft landing with good eccentric control, done 2 times a week.

  1. Double leg jump rope. 5 -10 jumps 3 times.
  2. Double leg hops (forward and backward over the line) 10 -15 jumps 3 times.
  3. Box Jump (6-8 inches max) 10 -15 jumps 3 times.

PHASE 5 (Week 16- Week 24)

Goals for this phase will have the client maintain adequate ROM  and achieving more flexibility, strength, and proprioception as needed for returning to their appropriate recreational sports and activities of daily life. We will continue with progressive dynamic strengthening, proprioceptive, plyometric and introduce agility training to achieve adequate strength to begin a return to sport progressions pending physician’s clearance.

Therapeutic Exercises will include:

ROM & Flexibility: Daily lower body stretches. 30s holds of 2 to 3 reps.

  1. PNF Stretching at least two times a week.
  2. Active dynamic stretches pre-session.
  3. Static active/passive as needed post-session

Cardio: To be done 3 – 5 times a week for 20 – 40 minutes.

  1. Cycle with progressive resistance
  2. Elliptical with increased intensity.
  3. Swimming.

Strengthening: 3 times a week 2 to 3 sets of 15 to 20 reps.

  1. High knee skip (light)
  2. High knee run (light).
  3. Double leg jump rope.
  4. Single leg jump rope.
  5. Backward lunge walks.
  6. Standing External Rotation/Abduction with Mini-Band below Patella 20×0:02s.

Proprioception: 3 times a week.

  1. Single-Leg Balance (Eyes Closed) on Airex with Resistance into Adduction 2×0:30s each leg.
  2. Dynamic single-leg swing on a Bosu ball.
  3. Side to side swings on a Bosu ball.
  4. Single leg lunges on dynamic surfaces and lateral lunge walk
  5. 20M Forward sprints to a backpedal.
  6. Acceleration and deceleration figure 8 carioca.

Plyometrics/Jumping/Agility: 2 times a week(limited to 90-foot contact per workout). From week 16 to 17, we will do independent jumps focusing on sticking each landing with good form in frontal and sagittal planes while stressing on a soft landing with good eccentric control.

  1. Double Leg Jump (for distance)
  2. Double Leg Jump (for height)
  3. Double Leg Jump (with 900 or 1800 turn)
  4. Double Leg Lateral Jump/Lateral Box Jump (side to side) Depth Jump (6-8 inches max)
  5. Double leg hurdle hops 3×5.
  6. Single-Leg Hurdle hops (Unoperated Leg 3×5)
  7. Single-Leg Line Hop (Recovering Leg 3×5)

From week 18 to 20 we begin combination jumps, aiming at moving from jump to jump.

  1. Repetitive Double Leg Jumps (distance, height, lateral, turns) Jump for Distance into Jump for Height
  2. Box Jump to Depth Jump
  3. Depth Jump to Jump for Distance/Height

Speed/Agility Progression: Begining each workout with sprinting and backpedaling 50 meters (2 reps at 1⁄2 speed, 5 reps at full speed).

From 16 to 20: Begin forward and backward sprinting.

  1. Week 1: Sprint 50-100 meters at 1⁄2 speed 10 reps.
  2. Week 2: Sprint 50-100 meters at 1⁄2 speed 5 reps. Sprint 50-100 meters  at 3⁄4 speed 10 reps
  3. Week 3: Sprint 100 meters at 1⁄2 speed 2 reps. Sprint 100 meters at 3⁄4 speed 5 reps. Sprint 50-100 meters at full speed 5 reps. Backpedal 50 meters at 1⁄2 speed 5 reps.
  4. Week 4: Sprint 100 meters at 1⁄2 speed 1 rep. Sprint 100 meters at 3⁄4 speed 2 reps. Sprint 50 meters at full speed 5 reps and 100 meters at full speed 5 reps. Backpedal 50 meters at 3⁄4 speed 5 reps.

From week 20 to 24: Start basic change of direction beginning each workout with sprinting and backpedaling 50 meters. (2 reps at 1⁄2 speed, 5 reps at full speed)

  1. Week 5: T drill 3 reps at 1⁄2 speed, forward/backpedal shuttle 5/10/20 meter 3 reps at 1⁄2 speed
  2. Week 6: T drill 3 reps full speed, forward/backpedal shuttle 5/10/20 meters 3 reps full speed, box drill with shuffling 3 reps at 1⁄2 speed
  3. Week 7: Box drill with shuffling 3 reps at full speed, 10-meter shuttle run (quick direction change) 3 reps at full speed, Z drill 6 reps at 3⁄4 speed
  4. Week 8: Box drill with cuts 3 reps at full speed, 10-meter shuttle run (quick direction change) 3 reps at full speed, Z drill 6 reps at full speed

After 24 weeks, the client will be free to begin advanced strength and conditioning. He will start working with his personal trainer to develop sport-specific drills or perform drills needed in his typical sports practice under a strength and conditioning coach supervision.

Published by Claire MK

Sports Medicine and Rehab

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