ACL Hamstring Graft Protocol

Immediate Postoperative Phase (1-4 Days):

• Wait until your first physical therapy session for the therapist to change the surgical dressing for you.
• Perform sponge baths or shower with saran wrap covering surgical site.
• Avoid resisted knee extension to protect graft.
• Avoid active knee flexion and hip extension until 4 weeks post-op.
• Avoid resisted knee flexion and hip extension until 6 weeks post-op.
• If you experience malaise, fever, or chills- contact your physician immediately.
• Perform home exercise program issued at pre-op from Hamilton Orthopedics Physical Therapy Department.
• Control acute inflammation with the use of Cryocuff, 15-20 minutes hourly, rest, elevation, and prescribed medications.
• Ambulation: weight bearing as tolerated with the use of bilateral crutches or walker, a post-operative brace on involved lower extremity locked in full extension for 1 day. Unlock brace the day after surgery.
• If a meniscus repair was involved, restrict weight bearing to 25% for 4 weeks. At 4 weeks, full weight bearing as tolerated.
• Primary goal is to achieve terminal knee extension and good quad control.

Acute Phase (5 days - 2 weeks):

• Begin Physical Therapy 5 days postoperatively for 3 sessions per week.
• Continue to ambulate with post-op brace, needs to be worn for all weight bearing activity for 6 weeks.
• Continue to avoid resisted knee extension.
• Continue to avoid active and resisted knee flexion and hip extension.
• Steri –strips should remain intact for approximately 2 weeks post –op.
• Ambulation/Gait training: begin with stance shifts to regain good quad control and advance to single crutch, then no assistive device by 2 weeks.
• Patella mobilization.
• Ankle pumps.
• Isometric quad sets.
• Active and passive terminal knee extension.
• Straight leg raises, adding resistance as tolerated (hip flexion, abduction).
• Flexibility of hamstring (gentle), gastroc-soleus, quadriceps, hip adductors.
• AAROM: wall-slides, heel-slides, and knee flexion in chair.
• Standing calf lifts.
• Partial wall squats (<45 degrees of flexion).
• Closed chain resisted terminal knee extension (i.e ball squeeze at wall).

Acute Phase Continued (14 days - 4 weeks)

• Continue to progress above exercises.
• Range of motion: 0-120 degrees.
• Continue patella mobilization as needed.
• Proprioceptive and single leg balance activities (if able to fully weight bear through involved lower extremity).
• Stationary lunge.
• Partial wall squats (<60 degrees of flexion).
• Stationary bike (when able to achieve 110 degrees of flexion).
• Leg press (0-90 degrees).
• Sub maximal quad isometrics at 45 degrees of knee flexion.
• Stairmaster, Nordic Track.
• Forward/ lateral step-ups (4-8 inches).
• Continue to control edema and discomfort.

Subacute Phase (4-11 Weeks)

• Continue to progress above exercises.
• Begin resisted knee extension from 90-40 degrees with care not to irritate the graft site.
• Begin active knee flexion and prone hip extension at 4 week post-op.
• Begin resisted knee flexion and hip extension at 6 weeks post-op.
• Begin squats (machine based only, No free weight squats x 6 mos.)
• Begin eccentric quad strengthening.
• Range of motion: 0-135 degrees/full.
• Emphasize closed kinetic chain therapeutic exercise.
• Walking lunges at 6 weeks post op.
• Aerobic stepping (Reebok step program) forward and lateral at 6 weeks post op.
• Fitting for sports specific functional ACL brace at Hamilton Orthopaedics at 6 weeks. Discontinue post-operative brace at that time.

Return to Activity Phase (12-15 Weeks)

• Continue to progress above exercises with emphasis on single leg strengthening for all resistive strengthening.
• Perform 12 week functional test with forms provided by Hamilton Orthopaedics. Fax results to Surgeon, (315) 824-8961.
• If patient successfully completes the test, they may begin interval jogging, uniplanar double leg plyometrics, and dynamic flexibility program.
• All plyometrics and jogging should be performed with the functional ACL brace on.

Activities Progression Phase (16-19 Weeks):

• Continue to progress above exercises.
• Perform 16 week functional test with forms provided forms provided by Hamilton Orthopaedics. Fax results to Surgeon, (315) 824-8961.
• If patient successfully completes the test, they may begin single leg uniplanar, double leg multiplanar plyometrics, and agility work.
• Continue jogging program, progressing to tolerance.
• Begin sport specific training as indicated.
• All plyometrics, jogging, and sports specific training should be performed with the ACL brace on.

Pre-Return to Prior Level of Recreational Activities (4-9 Months):

• Continue to progress resistive and endurance exercises
• Perform 20 week functional test with forms provided by Hamilton Orthopaedics. Fax results to Surgeon, (315) 824-8961.
• Prior to discharge, perform sports related drills implementing directional changes and sprinting.
• Discharge formal PT and continue gym program to progress strength, jogging, plyometrics, and sports related drills.
• Return to sports when released by physician at 9 months post-op.