ACL Hamstring Graft Protocol

Immediate Post-Operative Phase (1-4 Days):

• DO NOT remove steri-strips.
• Change surgical dressing 2-3 days postoperatively and replace with 4x4 gauze if drainage is present. (If you are a patient of Dr. Zahn, wait until your first physical therapy session for the therapist to change the dressing for you).
• Perform sponge baths or shower with saran wrap covering surgical site. (If you are a patient of Dr. Zahn, sponge baths only. No showers until follow up with him at 1 week after surgery)
• Avoid resisted knee extension to protect graft.
• 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 postoperative brace on involved lower extremity.
• 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.
• 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, 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).
• Active Knee extension 90-40 degrees.

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 and hamstring 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 (4-7 weeks):

• Continue to progress above exercises.
• At 4 weeks begin active range of motion knee flexion and hip extension.
• Begin resisted knee extension from 90-40 degrees.
• 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.
• At 6 weeks post-operatively begin resisted knee flexion and hip extension.
• 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 postoperative brace at that time.

Return to Activity Phase (8-11 weeks):

• Continue to progress above exercises with emphasis on single leg strengthening for all resistive strengthening.
• Perform 8 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, double-leg agility work, and dynamic flexibility programming.
• All plyometrics, jogging, and agility should be performed with the functional ACL brace on.

Activities Progression Phase (12-15 weeks):

• Continue to progress above exercises.
• 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 single leg uniplanar and double leg multiplanar plyometrics, and progress ladder work accordingly.
• 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.

Return to Prior Level of Recreational Activities (16-20 weeks):

• Continue to progress resistive and endurance exercises.
• Perform 16 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.
• Return to sports when released by physician.