Rehabilitation of Posterior Cruciate Ligament and Posterolateral Reconstructive Procedures

Clinical Concepts

A paucity of information exists in the literature regarding rehabilitation for injuries to the posterior cruciate ligament (PCL) and posterolateral structures. The posterolateral structures comprise the fibular collateral ligament and popliteus muscle-tendon-ligament unit, including the popliteofibular ligament and posterolateral capsule. A recent systematic review failed to find high-level evidence studies of rehabilitation protocols for either conservative or operative treatment of these injuries. The rehabilitation protocols described in this chapter consist of a careful incorporation of exercise concepts supported by biomechanic and clinical data and over 3 decades of patient experience. The goal is to progress a patient at a rate that takes into account the condition of the articular surfaces and menisci, return of muscle function and lower limb control, postoperative graft healing and remodeling, and athletic and occupational goals. Modifications to the postoperative exercise program may be required if noteworthy articular cartilage deterioration is found during surgery.

The protocol for PCL reconstruction was developed for high-strength quadriceps tendon-patellar bone (QT-PB) autografts or Achilles tendon-bone allografts with interference screw fixation of the bone and soft tissue portions (and additional suture fixation of the tendon portion over a suture post; see Chapter 16 ). The protocol for posterolateral reconstruction may be used after the various operative options described in detail in Chapter 17 , including anatomic reconstructions, femoral-fibular reconstructions, and proximal advancement techniques of the posterolateral structures.

The supervised rehabilitation programs are always supplemented with home exercises performed daily. The therapist must routinely examine the patient in the clinic to implement and progress the appropriate protocol. Therapeutic procedures and modalities are used as required for successful rehabilitation. For the majority of patients, a range of 11 to 21 postoperative physical therapy visits is expected to produce a desirable result. A few more visits may be required between the sixth and twelfth postoperative months for certain patients who desire to return to strenuous activities for advanced training.

For all patients, joint swelling, pain, gait pattern, knee motion, patellar mobility, muscle strength, and flexibility are continually monitored postoperatively.

Patients are warned to avoid any exercises or activities that place high posterior shear forces on the tibia such as walking down inclines or squatting for the first 6 postoperative months. In addition, patients are cautioned that an early return to strenuous activities postoperatively carries a risk of a repeat injury or the potential of compounding the original injury. These risks cannot always be scientifically predicted, and patients are cautioned to avoid strenuous activities for 9 to 12 postoperative months and to avoid activities that produce pain, swelling, or a feeling of instability. These patients are monitored after surgery with posterior drawer testing and stress radiography if an increase in posterior tibial displacement is detected.

Patients with posterolateral reconstruction are warned specifically at the fourth to eighth postoperative weeks when weight bearing and weaning of crutches occur to avoid hyperextension, varus, or internal tibial rotation positions that could place high tensile forces on the posterolateral structures. It is important that the patient demonstrates good lower extremity control with suitable muscle strength to maintain tibiofemoral compression and avoid a lift-off of the lateral tibiofemoral joint that would disrupt the posterolateral reconstruction.

PCL Clinical Biomechanics

Many studies have demonstrated that posterior tibial subluxation occurs in PCL-deficient knees during activities of daily living in high knee flexion positions, but not usually at low flexion positions where smaller posterior shear forces are present. In activities such as sudden stopping, deceleration, or walking down a ramp, a posterior subluxation of the tibia is expected to occur.

Using knee models created from magnetic resonance imaging (MRI) and dual fluoroscopy, several recent investigations found significant differences in knee kinematics at higher knee flexion angles during a single-leg lunge between PCL-deficient and contralateral normal knees. For instance, Gill and colleagues reported PCL-deficient knees had significantly increased posterior tibial translation between 60 degrees and 120 degrees of flexion compared with normal knees (mean difference, 3.5 ± 1.1 mm, P < .05). Significant decreases in patellar rotation and tilt were also observed between PCL-deficient knees and normal knees between 75 degrees and 120 degrees of knee flexion.

Using lateral radiographs, Castle and colleagues measured posterior tibial subluxation during a static double-legged squat in patients with PCL-deficient knees. The results revealed a statistically significant mean increase of 5.9 mm in posterior tibial translation ( P < .05) of the injured knee compared with the contralateral knee at high knee flexion angles. At low flexion angles, the magnitude of increase in mean posterior tibial translation was only 2.1 mm. Tibiofemoral shear forces were small compared with tibiofemoral joint compression forces.

Two- and 3-dimensional biomechanic models have been used to predict forces generated during exercises and on standing at different knee flexion angles. Kaufman and coworkers used a 3-dimensional biomechanic model to predict dynamic patellofemoral and tibiofemoral forces generated during isokinetic exercises at 60 degrees/sec and 180 degrees/sec. During isokinetic extension, posterior shear forces were detected at knee flexion angles of 40 degrees and greater. The maximum posterior shear force occurred at 70 to 80 degrees of knee flexion and measured 0.5 ± 0.1 body weight at 60 degrees/sec and 0.6 ± 0.1 body weight at 180 degrees/sec. A posterior shear force occurred throughout the entire flexion exercise at all knee flexion angles, reaching a peak at 75 degrees of knee flexion of 1.7 ± 0.8 body weight (60 degrees/sec) to 1.4 ± 0.5 body weight (180 degrees/sec). The authors concluded that isokinetic exercise exerted moderate posterior shear forces and should be used cautiously after PCL rupture and reconstruction.

Ohkoshi and associates used a 2-dimensional model to calculate shear force exerted on the tibia during standing at various knee flexion angles in 21 healthy subjects. Posterior shear forces were found in the upright position of the trunk and at knee flexion angles of 15 to 90 degrees ( Fig. 18-1 ). At 30 degrees and 60 degrees, the posterior drawer force was significantly increased by anterior flexion of the trunk.

Berchuck and coworkers calculated large posterior shear forces during gait analysis for the activities of jogging, ascending stairs, and descending stairs ( Fig. 18-2 ) in five normal subjects. Lutz and associates evaluated tibiofemoral joint shear and compressive shear forces using a 2-dimensional biomechanic model and electromyographic (EMG) of hamstrings and quadriceps muscle activity during a closed kinetic chain (CKC) leg press exercise, an isometric open kinetic chain (OKC) extension exercise, and an OKC flexion exercise. Measurements of maximum muscle contractions were obtained at 30, 60, and 90 degrees of knee flexion. The OKC isometric flexion exercise produced posterior shear forces at all knee flexion angles ( Fig. 18-3 ), ranging from –939 ± 174 N at 30 degrees of knee flexion to a maximum of –1780 ± 699 N at 90 degrees of knee flexion. The CKC exercises produced significantly lower posterior shear forces at 60 degrees and 90 degrees of flexion (–538 N, P < .05). These findings were similar to those reported by Smidt during isometric knee extension and flexion exercises ( Fig. 18-4 ). Maximum hamstrings EMG activity was detected during the OKC exercise at 90 degrees of flexion (82% ± 15% of maximum contraction). The antagonistic muscle activity was minimal during this exercise at all knee flexion angles. In contrast, cocontraction of the quadriceps and hamstrings was observed during the CKC exercise, which was greatest at 30 degrees and 60 degrees of flexion. The authors concluded that CKC exercise produced significantly lower tibiofemoral shear forces compared with OKC exercise ( P < .05).

Wilk and colleagues evaluated tibiofemoral shear forces and EMG activity of the quadriceps, hamstrings, and gastrocnemius muscles during OKC extension and CKC leg press and squat exercises. Both CKC exercises produced posterior shear forces. However, during the squat, these forces were relatively low (245 to 565 N) from 0 to 45 degrees of knee flexion. A rapid increase in posterior shear forces was detected from 45 to 72 degrees of flexion. In addition, cocontraction of the quadriceps and hamstrings occurred from 0 to 30 degrees of flexion.

Wilk and colleagues also found that the knee extension exercise produced posterior shear forces from 60 to 100 degrees of knee flexion; however, these forces were lower than those measured during both CKC exercises. The leg press induced minimal hamstring muscle activity.

Hoher and coworkers reported that the in situ forces in the PCL significantly increased with knee flexion in response to an isolated hamstrings load, reaching a maximum at 90 degrees of flexion. These findings were in agreement with other authors who also reported increased strain in the PCL with knee flexion. The addition of a 200-N quadriceps load (simulating cocontraction of the quadriceps and hamstrings) reduced the in situ forces in the PCL.

Toutoungi and associates combined noninvasive experimental measurements with geometric modeling of the lower extremity to calculate ligament forces during isometric, isokinetic, and squat exercises. The data indicated that isokinetic extension at knee flexion angles less than 70 degrees should be safe in the early postoperative period following PCL reconstruction. However, isokinetic flexion and deep squats should be avoided. During isokinetic flexion, only the PCL is loaded and peak forces may reach over four times the patient's body weight at 90 degrees of knee flexion. During squatting, PCL forces may reach 3.5 times body weight at high knee flexion angles. Shallow squats with knee flexion angles kept below 50 degrees may be considered.

Markolf and colleagues studied the effects of muscle loads on cruciate force levels when the knee was subjected to external forces and moments. Load cells were installed into cadaveric knees to record forces in the ACL and PCL under five loading conditions. These force measurements were repeated with a 100-N load applied to the quadriceps tendon and with a combined 50-N load applied to both the biceps and semimembranosus-semitendinosus tendons.

With no applied tibial force, application of hamstrings load significantly increased mean PCL force from 15 to 120 degrees of knee flexion ( Fig. 18-5 ). With the application of a 100-N posterior tibial force, the addition of hamstrings load significantly increased mean PCL force between 30 degrees and 105 degrees of flexion ( Fig. 18-6 ). When a 5 N-m external tibial torque was applied, the addition of hamstrings load significantly increased mean PCL force beyond 75 degrees of knee flexion ( P < .05). Under a 5 N-m internal tibial torque, application of hamstrings load also significantly increased mean PCL force between 60 degrees and 100 degrees of flexion ( P < .05). The authors concluded that, in general, the hamstrings were more effective in producing changes in cruciate force levels. Application of tibial torque in either an anterior or posterior direction when the knee was flexed greater than 60 degrees increased PCL force, and isolated hamstrings activity (with tibial torque) further increased PCL force.

Protocol for Partial or Acute Isolated PCL Ruptures

This program does not apply to PCL avulsions in which surgery may be indicated, and partial PCL tears with 5 mm or less of increased posterior tibial translation. The goal with complete PCL disruptions (8-10 mm of increased posterior tibial translation at 90 degrees of flexion) is to allow PCL healing and reduce abnormal posterior tibial translation. Importantly, this includes maintaining normal tibiofemoral contact at full knee extension or with knee flexion. An anterior drawer produced by the therapist during motion in the early phases of rehabilitation will allow for protection of healing PCL fibers. This protective program for acute PCL ruptures has been used by us for over 20 years. The rules to treat partial or acute isolated PCL tears are as follows:

• 1.

  Patient is within 14 days of the injury.

• 2.

  Protect for 6 weeks in full knee extension with a brace and posterior calf pad ( Fig. 18-7 ) or bivalved cylinder cast to maintain tibiofemoral reduction. Use quadriceps isometrics, electrical muscle stimulation (EMS), leg raises, and 25% weight bearing.

  

• 3.

  Obtain a lateral radiograph to verify no posterior tibial subluxation exists, which can occur in up to 50% of knees.

• 4.

  At 2 weeks, the therapist initiates 0 to 90 degrees of motion, maintaining anterior tibial translation load during knee motion exercises. The patient must sleep in the brace and is not allowed unsupervised knee motion. Only passive flexion with the therapist is permitted.

• 5.

  At 4 weeks, the patient is allowed to perform active quadriceps extension without the brace, use 50% weight bearing with crutch support, and continue brace protection.

• 6.

  At 5 to 6 weeks, the patient is weaned from the brace and crutch support and the rehabilitation protocol (described later) is begun. It should be noted that some centers use a Jack PCL Brace (Albrecht, Germany) to provide added protection against posterior tibial subluxation, which may be considered if insomnia issues are resolved.

• 7.

  At 6 months, a posterior stress radiograph determines the amount of posterior tibial translation compared with the opposite knee.

PCL Reconstruction Rehabilitation Protocol

Immediate Postoperative Management

Patients are instructed in the rehabilitation program preoperatively. They present to physical therapy the first day after surgery on bilateral axillary crutches in a postoperative dressing with a long-leg brace locked in full extension with a posterior calf pad ( Table 18-1 ). The postoperative bandage and dressing are changed to allow the application of thigh-high compression stockings and a compression bandage. Early control of postoperative effusion is essential for pain management and early quadriceps reeducation. In addition to compression, cryotherapy is important in this time period.

TABLE 18-1

Rehabilitation Protocol After Posterior Cruciate Ligament Reconstruction

	POSTOPERATIVE WEEKS					POSTOPERATIVE MONTHS
	1-2	3-4	5-6	7-8	9-12	4	5	6	7-12
Hinged long-leg postoperative brace	X	X	X
Patellar knee sleeve				X	X	X	X
Functional brace								X	X
Range of motion minimum goals (degrees):
0-90	X
0-110		X
0-120			X	X
0-135					X
Weight bearing:
25% body weight	X
50% body weight		X
Full			X
Patellar mobilization	X	X	X	X
Modalities:
EMS	X	X	X	X	X
Pain/edema management (cryotherapy)	X	X	X	X	X	X	X	X	X
Stretching: hamstring, gastrocnemius-soleus, iliotibial band, quadriceps	X	X	X	X	X	X	X	X	X
Strengthening:
Quadriceps isometrics, straight-leg raises, active knee extension	X	X	X	X	X
Closed-chain: gait retraining, toe raises, wall-sits, minisquats			X	X	X	X	X	X
Knee flexion hamstring curls *						X	X	X	X
Knee extension quads *		X	X	X	X	X	X	X	X
Hip abduction-adduction, multihip					X	X	X	X	X
Leg press (70-10 degrees)				X	X	X	X	X	X
Balance/proprioceptive training:
Weight-shifting, cup walking, BBS			X	X
BBS, BAPS, perturbation training, balance board, minitrampoline				X	X	X	X	X	X
Conditioning:
UBC	X	X	X	X	X
Bike (stationary)			X	X	X	X	X	X	X
Aquatic program						X	X	X	X
Swimming (kicking)						X	X	X	X
Walking					X	X	X	X	X
Stair-climbing machine						X	X	X	X
Ski machine						X	X	X	X
Elliptical cross-trainer						X	X	X	X
Running: straight								X	X
Cutting: lateral carioca, figure 8s									X
Plyometric training									X
Full sports							X	X	X

PHASE 1: WEEKS 1-2 (VISITS 2-4)
General Observation	Toe-touch to 25% weight bearing Brace
Evaluation (Goal)	Pain (controlled) Hemarthrosis (mild) Patellar mobility (good) ROM minimum (0-90 degrees) Quadriceps contraction and patella migration (good) Soft tissue contracture (none)
Goals	ROM 0-90 degrees Adequate quadriceps contraction Control inflammation, effusion Prevent soft tissue contracture Protect ligament reconstruction at insertion sites

	Frequency	Duration
ROM	3-4 ×/day, 10 min
0-90 degrees (active extension/passive flexion with 10-lb anterior drawer)		20 cycles
Patellar mobilization		10 reps, 30 sec
Ankle pumps (plantar flexion with resistance band)
Hamstring, gastrocnemius-soleus stretches		5 reps, 30 sec
Strengthening	3 ×/day, 15 min
Straight-leg raises (flexion, 0- to 5-lb ankle weight)		3 sets × 10 reps
Active quadriceps isometrics		1 set × 10 reps
Knee extension (active assisted, 90-30 degrees)		3 sets × 10 reps
Aerobic Conditioning	1-2 ×/day, 10 min
UBC
Modalities	As required
EMS		20 min
Cryotherapy		20 min
ADLs
Knee brace to avoid sudden knee flexion while asleep

PHASE 2: WEEKS 3-4 (VISITS 2-4)
General Observation	50% weight bearing with one crutch when: Pain is controlled Hemarthrosis is controlled Muscle control throughout ROM Brace
Evaluation (Goal)	Pain (controlled) Effusion (minimal) Patellar mobility (good) ROM minimum (0-110 degrees) Quadriceps contraction and patella migration (good) Soft tissue contracture (none)
Goals	ROM 0-110 degrees Control inflammation, effusion Muscle control Prevent soft tissue contracture Protect ligament reconstruction at insertion sites

	Frequency	Duration
ROM	3-4 ×/day, 10 min
Passive (0-110 degrees, 10-lb anterior drawer)		20 cycles
Patella mobilization		10 reps, 30 sec
Ankle pumps (plantar flexion with resistance band)
Hamstring, gastrocnemius-soleus stretches		5 reps, 30 sec
Strengthening	2-3 ×/day, 20 min
Straight-leg raises (flexion, adduction, abduction)		3 sets × 10 reps
Isometric training: multiangle (0, 60 degrees)		1 set × 10 reps
Knee extension (active assisted, 90-0 degrees, 0- to 7.5-lb weight)		3 sets × 10 reps
Aerobic Conditioning	2 ×/day, 10 min
UBC
Water walking
Stationary bicycling (patellofemoral precautions)
Modalities	As required
EMS		20 min
Cryotherapy		20 min
ADLs
Knee brace to avoid sudden knee flexion while asleep

PHASE 3: WEEKS 5 - 6 (VISITS 1 - 2)
General Observation	Full weight bearing when: Pain is controlled without narcotics Hemarthrosis is controlled Muscle control throughout ROM Brace
Evaluation (Goal)	Pain (mild/no CRPS) Effusion (minimal) Patellar mobility (good) ROM (0-120 degrees) Muscle control (3/5) Inflammatory response (none) Joint arthrometry, 6 wk, 20 degrees at 89 N and 70 degrees at 89 N (<3 mm)
Goals	ROM 0-120 degrees Control inflammation, effusion Muscle control Recognition of complications (motion loss, CRPS, increased anteroposterior displacement)

	Frequency	Duration
ROM	3 ×/day, 10 min
Passive (0-120 degrees)
Patella mobilization
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	3 ×/day, 15 min
Straight-leg raises (flexion, abduction, adduction, ankle weight, not to exceed 10% of body weight)		3 sets × 10 reps
Isometric training: multiangle (90, 60, 30 degrees)		2 sets × 10 reps
Knee extension (active, 90-0 degrees)		3 sets × 10 reps
Closed-chain:
Heel raise/toe raise		3 sets × 20 reps
Wall-sits		5 reps
Balance Training	3 ×/day, 5 min
Weight shift side-side and forward-backward
Balance board, two legged
Cup walking
Single-leg stance
Aerobic Conditioning (Patellofemoral Precautions)	2 ×/day, 10 min
UBC
Stationary bicycling
Modalities	As required
EMS		20 min
Cryotherapy		20 min
ADLs
Knee brace to avoid sudden knee flexion while asleep

PHASE 4: WEEKS 7-8 (VISITS 1-2)
General Observation	Full weight bearing Brace
Evaluation (Goal)	Pain (mild/no CRPS) Effusion (minimal) Patellar mobility (good) ROM (0-135 degrees) Inflammatory response (none) Joint arthrometry, 8 wk, 20 degrees at 89 N and 70 degrees at 89 N (<3 mm)
Goals	Full weight bearing, normal gait Control inflammation, effusion Muscle control ROM 0-120 degrees

	Frequency	Duration
ROM	3 ×/day, 10 min
Passive (0-120 degrees)
Patellar mobilization
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	3 ×/day, 15 min
Straight-leg raises (flexion, abduction, adduction)		3 sets × 30 reps
Straight-leg raises with rubber tubing		3 sets × 30 reps
Knee extension (active, 90-0 degrees)		3 sets × 10 reps
Knee flexion (active, 0-90 degrees)		3 sets × 10 reps
Closed-chain:
Wall-sits (0-40 degrees)		5 reps
Minisquats (rubber tubing, 0-30 degrees)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Balance Training	3 ×/day, 5 min
Balance board, two legged
Single-leg stance
Aerobic Conditioning (Patellofemoral Precautions)	2 ×/day, 10-15 min
UBC
Stationary bicycling
Modalities	As required
EMS		20 min
Cryotherapy		20 min
ADLs
Knee brace to avoid sudden knee flexion while asleep

PHASE 5: WEEKS 9-12 (VISITS 1-2)
General Observation	No effusion, painless ROM, joint stability ROM 0-135 degrees Brace optional Performs ADLs, can walk 20 min without pain
Evaluation (Goal)	Pain (minimal) Manual muscle test (hamstrings, quadriceps, hip abductors/adductors/flexors/extensors) (4/5) Swelling (none) Joint arthrometry, 12 wk, 20 degrees at 134 N and 70 degrees at 89 N (3 mm) Patellar mobility (good) Crepitus (none/slight) Gait (symmetric)
Goals	Increase strength and endurance ROM 0-135 degrees Return to normal gait, ADLs

	Frequency	Duration
ROM	3 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	2 ×/day, 20 min
Straight-leg raises (add extension)		3 sets × 10 reps
Straight-leg raises with rubber tubing		3 sets × 30 reps
Knee extension with resistance (90-30 degrees)		3 sets × 10 reps
Knee flexion (active, 0-90 degrees)		3 sets × 10 reps
Closed-chain:
Wall-sits		To fatigue × 3 reps
Minisquats		3 sets × 20 reps
Lateral step-ups (2- to 4-inch block)		3 sets × 10 reps
Balance Training	2 ×/day, 5 min
Balance board, two legged
Single-leg stance
Aerobic Conditioning (Patellofemoral Precautions)	1 ×/day, 15-20 min
UBC
Stationary bicycling
Walking
Modalities	As required
EMS		20 min
Cryotherapy		20 min
ADLs
Avoid squats, walking down hills and ramps, running down stairs, sudden deceleration movements

PHASE 6: WEEKS 13-26 (VISITS 2-3)
General Observation	No effusion, painless ROM, joint stability Performs ADLs, can walk 20 min without pain ROM 0-135 degrees Brace optional
Evaluation (Goal)	Pain (minimal) Manual muscle test (5/5) Swelling (minimal) Joint arthrometry (<3 mm) Patellar mobility (good) Crepitus (none/slight) Gait (symmetric) Isometric test (% difference between quadriceps and hamstrings) (30)
Goals	Increase strength and endurance

	Frequency	Duration
ROM	2-3 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	3 ×/wk, 20-30 min
Hamstring curls with resistance (0-90 degrees)		3 sets × 10 reps
Knee extension with resistance (90-30 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Closed-chain:	3 ×/wk, opposite days (machines)
Minisquats (0-40 degrees)		3 sets × 20 reps
Wall-sits		To fatigue × 3 reps
Lateral step-ups (2- to 8-inch block)		3 sets × 10 reps
Balance Training	1-2 ×/day, 5 min
Balance board, two legged to single legged
Single-leg stance to unstable platform
Aerobic Conditioning (Patellofemoral Precautions)	1 ×/day, 20 min
Stationary bicycling
Water walking
Swimming (kicking)
Walking
Stair-climbing machine (low resistance and stroke)
Ski machine (short stride, low resistance)
Elliptical cross-trainer (low resistance)
Modalities	As required
Cryotherapy		20 min
ADLs
Avoid squats, walking down hills and ramps, running down stairs, sudden deceleration movements

PHASE 7: WEEKS 27-52 (VISITS 2-3)
General Observation	No effusion, painless ROM, joint stability Performs ADLs, can walk 20 min without pain Brace optional
Evaluation (Goal)	Isokinetic test (isometric + torque 300 degrees/sec, % difference between quadriceps and hamstrings) (10-15) Swelling (none) Joint arthrometry (3 mm) Patellar mobility (good) Crepitus (none/slight) Single-leg function tests (9 mo: hop distance, timed hop, % involved vs. uninvolved) (≤15%)
Goals	Increase function Maintain strength and endurance Return to previous activity level

	Frequency	Duration
ROM	1 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	3 ×/wk, 20-30 min
Hamstring curls with resistance (0-90 degrees)		3 sets × 10 reps
Knee extension with resistance (90-30 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Closed-chain:	3 ×/wk, opposite days (machines)
Minisquats (0-40 degrees)		3 sets × 20 reps
Wall-sits		To fatigue × 3 reps
Lateral step-ups (2- to 8-inch block)		3 sets × 10 reps
Balance Training	1 ×/day, 5 min
Balance board, two legged to single legged
Single-leg stance on unstable platform with secondary activity
Aerobic Conditioning (Patellofemoral Precautions)	3 ×/wk, 20-30 min
Stationary bicycling
Water walking
Swimming (kicking)
Walking
Stair-climbing machine (low resistance and stroke)
Ski machine (short stride, low resistance)
Elliptical cross-trainer (low resistance)
Running Program (Straight, 30% Deficit Isokinetic Test)	3 ×/wk, 15-20 min
Jog		mile
Walk		mile
Backward run		20 yards
Cutting Program (20% Deficit Isokinetic Test, 9 mo)	3 ×/wk
Lateral, carioca, figure-eights		20 yards
Functional Training	3 ×/wk
Plyometric training: box hops, level, double leg (20% deficit isokinetic test, 9 mo)		4-6 sets, 15 sec
Sport-specific drills (10%-15% deficit isokinetic test)
Modalities	As required
Cryotherapy		20 min

ADLs, Activities of daily living; BAPS, Biomechanical Ankle Platform System (Patterson Medical); BBS, Biodex Balance System; CRPS, complex regional pain syndrome; EMS, electric muscle stimulation; ITB, iliotibial band; ROM, range of motion; UBC, upper body cycle.

* For knee motion limits, see text for each phase.

Patients are instructed to keep the lower limb elevated as frequently as possible during the first week. The initial response to surgery and progression during the first 2 weeks sets the tone for the initial phases of the rehabilitation program. Common postoperative complications include excessive pain or swelling, quadriceps shutdown, and range of motion (ROM) limitations. Early recognition and treatment of these problems are critical for a successful outcome.

Patients who undergo a QT-PB autograft harvest have increased pain with knee flexion and during quadriceps contractions. They require added attention for the first 4 weeks postoperatively to ensure the rehabilitation goals are achieved.