Arthroscopic LOA, and/or Open posterior capsular release, and/or AIR (anterior interval release) requires aggressive encouragement of regaining ROM flexion and extension as quickly as possible. Time is crucial and it may be necessary to see the patient daily until ROM is trending positively.
General time frames for each phase are listed below but these are variable and may be accelerated per Dr. Borque
Phase 1 (week 0-2):
Emphasis on motion return, swelling, inflammation and pain control
Ensure patient is compliant with post-operative medicine protocol (prednisone, losartan, etc)
WB: WBAT, No brace
ROM:
- Obtain full extension, symmetric to contra-lateral side ASAP
- Steady progression of knee flexion to full as tolerated ASAP
- CPM should be utilized minimum 6-8 hours daily
Therapeutic Exercises:
- Patellar mobilizations: Use gentle soft tissue techniques for areas such as anterior interval/fat pad, quadriceps, hamstrings, and scar management
- Swelling control (Including GameReady and patient ed)
- Prone hangs, heel slides, and calf stretches
- Prolonged duration low load stretching
- Use modalities/IM dry needling as needed
- Gait training: emphasize TKE at heel strike and in stance phase, emphasize flexion throughout swing phase
- Static balance
Strengthening: not prioritized
Isometric hip abduction and adduction exercises
Maintenance of quad tone:
- -E-stim
- -Quad sets ensuring proper form
- -Straight leg raises with calf taps, ensuring constant quad contraction and minimizing lag
- -mini squats, chair squats, step ups, hip machine, bridges, total gym
- - Stationary biking: must be > 110° knee flexion
D/C crutches: when have full, symmetric hyperextension, minimal swelling, and can ambulate without a limp
Phase 2 (weeks 2-4):
WBAT
ROM: Must always focus on maintenance of full motion, once obtained, to prevent regression
Gentle passive stretching at end ranges
Therapeutic Exercises:
- Core exercises, TKEs, calf raises, static balance, chair squats, step ups, static lunge, HS curls, hip machine (abduction), bridges
- Squat progressions as follows: DL leg press, DL mini squats, DL chair squats, DL body weight squats
- May begin stationary bike
- Advance hip abduction & glut strength: band walks, lateral lunge, reverse lunge
- Core exercises: planks, side planks, v-ups, Russian twist, superman
Phase 3 (week 4-6):
- Maintenance of full symmetric ROM
- Continue stretching at terminal limits of flexion and extension
- Return to running preparation
Therapeutic Exercises:
- Can begin single leg (SL) squats POW 4 as long as patient demonstrates good glute and quad activation and good form with 90 degree (DL) body weight squats and has minimal effusion
- SL Squat progressions: SL leg press, SL step ups, Static lunge split squat, SL step downs, SL squats, SL split squat with elevated back leg, walking lunges, SL sit to stands, SL slide outs
Focus on strengthening and preparation for jogging and in-line running
- Leg press, step ups, step downs, RDLs, lunges, Bulgarian squats, wall sits
- Continue stationary bike and begin rowing machine
- Balance training: foam pad, balance board
- Instruct on dynamic warm-ups: frankenstein kicks, leg swings, knee hugs, heel sweeps, heel/toe walks, oil rigs, lateral lunge, hip rotation, inch worm, speed squats
- Swimming: straight kick, no flip turns
Phase 4 (Weeks 6+):
Initiation of running, agility and plyo’s
Running prep exercises:
- focus on the deceleration phase such as DL speed squats, DL drop squats, DL “bounce bounce bounce squat”, then progress to alternating SL drop squats.
Initiate jogging and progress to in-line running:
- Begin on treadmill with 2- 3 days per week. Begin with 1:1 or 2:1 walk to jog ratios, (ie. 1 min walk to 1 min jog or 2 min walk to 1 min jog). Then progress each week by 1 min jog until 12-15 min of jogging is achieved.
Agility and DL Plyos:
- Ladder drills, footwork agility drills, cone drills
- Double leg plyos: jump rope, line jumps, cone jumps, depth jumps, box jumps
- High intensity predictable patterned movements, incorporate sport specific drills
Therapeutic Exercises:
- May begin progressive advancement of gym training (barbell squats, deadlifts, Olympic lifts)
- SL strengthening: SL squats, sit to stands, ball slams, step ups/downs
- Dynamic core exercises: mountain climbers, planks, pikes, pale off press
- Integrate interval strength circuits & work/rest timed intervals
- Intermittently increase the tempo of regular strengthening exercises to align with the timing requirements of jogging and jumping