Physical Therapy Protocols

Post-operative rehabilitation protocol for anterior shoulder instability

The physical therapy rehabilitation for anterior shoulder instability will vary in length depending on factors such as:

1. Degree of shoulder instability/laxity
2. Acute vs. chronic condition
3. Length of time immobilized
4. Strength/ROM status
5. Performance/activity demands

The rehabilitation program is outlined in three phases.  It is possible to overlap phases (Phase I – II, Phase II – III) depending on the progress of each individual.

Phase I

In all exercises during Phase I and Phase II, caution must be applied in an effort to prevent undue stress on the anterior joint capsule as dynamic joint stability is restored.

• Apply modalities as needed (ice, heat, electrotherapy, etc.)
• Perform range of motion exercises (passive, active-assist): avoid abduction, extension, and external rotation
  • Rope and pulley exercises
  • Finger walk exercises
  • Wand exercises
• Manual stretching: avoiding stretching the anterior capsule
• Posterior cuff stretch in supine position (cross arm adduction)
• Functional behind the back stretch (IR towel stretch) if needed
• Mobilization of posterior cuff if needed
• Elastic resistance for IR/ER with arm at side and elbow at 90 degrees
• Scapular strengthening (shrugs, rows, etc.)
• UBE
• DB
  • Supraspinatus: full and empty can in the scapular plane below shoulder level
  • Shoulder flexion
  • Shoulder abduction (pain free)
  • Shoulder extension in prone position: do not move the shoulder past the plane of the body
  • Shoulder rows in prone position
  • Shoulder shrugs in seated position
  • Serratus punch in supine position (push-up plus program)
• Forearm/elbow strengthening
• Rhythmic stabilization exercises: begin in the supine position and progress to functional planes of motion
• PNF patterns with gentle manual resistance: progress by working in the dysfunctional plane of motion

Phase II

In all exercises during Phase I and Phase II, caution must be applied in an effort to prevent undue stress on the anterior joint capsule as dynamic joint stability is restored.

• Continue posterior cuff stretching
• Continue strengthening exercises with free weights and elastic resistance: may progress planes of motion to the 90/90 position and emphasize eccentric work on the rotator cuff
• Add lower trap pull downs with pulley system if available
• Progress prone DB program by adding the following
  • Horizontal abduction
  • Retraction with ER
  • Extension with palm forward
• Plyotoss chest pass: progress to overhead and single arm
• Progress push-up program
  • Wall push-ups
  • Modified floor push-ups
  • Floor push-ups
• Begin progressive throwing program as advised
• Begin total body conditioning including a well-organized core stability program for overhead athletes
• Begin skill development at a low intensity level
• Continue with rhythmic stabilization exercises with resistance in the functional planes of motion
• Continue PNF patterns

Phase III

Phase III focuses on progressing exercises in preparation for returning to the prior activity level (sports, work, recreational activity, etc.).

• Continue flexibility/mobility exercises
• Continue strengthening exercises
• Continue UBE
• Continue progressive throwing program
• Continue total body conditioning
• Add overhead strengthening (military press)
• Progress to bench program
  • Regular
  • Incline
  • Decline
• Progress skill development at higher intensity
• Begin sport-specific skill development (work hardening)

Post-operative rehabilitation protocol for arthroscopic rotator cuff repair

This post-operative protocol is designed for SMALL rotator cuff tears that are repaired by arthroscopic methods. Larger rotator cuff tears often require a longer initial period of sling immobilization prior to initiation of ROM exercises. If a longer initial period of immobilization is warranted, this will be indicated.

Days 0-7

• Patient remains immobilized in a sling
• No passive, active-assist, or active ROM

Weeks 2-3

• Begin passive ROM (flexion, abduction, IR, IR)
  • Begin rotation with the arm at the side and elbow flexed to 90°
  • Progress to scapular plane and then to a 90°/90° position as tolerated
• Begin shoulder shrugs and ball squeezes

Weeks 3-6

• Use modalities as needed (ice, heat, electrotherapy, etc.)
• Continue passive ROM exercises as tolerated
• Add joint mobilization as needed
• Begin submaximal pain-free isometrics with arm at the side
• Begin active-assist exercises (pendulums, pulley, wand, IR towel stretch)
• Begin active ROM exercises for shoulder internal/external rotation (arms positioned at the side with elbows extended)

Weeks 6-8

• Patient may discontinue sling
• Continue joint mobilizations, isometrics, passive, active-assist, and active ROM as tolerated and needed
  • Begin active shoulder abduction to 90°
  • Begin active shoulder flexion through available ROM
  • Begin active shoulder extension in prone position (preventing arm movement beyond the plane of the body)
  • Begin active horizontal adduction (supine) as tolerated
• Begin isotonic strengthening exercises as outlined
  • Begin IR/ER strengthening using Thera-band with the arm at the side
  • Begin light dumbbell strengthening for rotation (external rotation in side or prone position with the arm abducted at 90°, internal rotation supine with the arm at the side and elbow flexed at 90°)
• Begin scapular stabilization exercises (rows, shrugs, serratus punch)

Weeks 8-12

• Continue joint mobilizations, isometrics, and ROM exercises as needed
  • Patient should have full PROM at 8 weeks and full AROM by 12 weeks
• Continue active isotonic exercises with emphasis on strengthening the rotator cuff
  • Progress active horizontal abduction beyond 90°(prone)
  • Begin supraspinatus strengthening exercise at 12 weeks if pain free and adequate ROM (0°-70°)
    • Start in the scapular plane and progress from a “full can” to “empty can” (thumb up to thumb down) as pain allows
• Upper extremity PNF (D2) patterns may be added

Weeks 12-18

• Continue to progress isotonic strengthening exercises
  • Gradually progress from 0° to 45° to 90° of shoulder abduction as tolerated for internal rotation and external rotation strengthening
• Begin isokinetic strengthening and endurance training (arm at side) for internal and external rotation (speeds 200 plus d/s)
• Add military press

Weeks 18-24

• As strength improves, continue to increase weight resistance and high speed training with isotonic and isokinetic exercises
  • Emphasize the eccentric phase in strengthening the rotator cuff
  • Perform isokinetic test at 180, 240, 300 speeds (the shoulder should be pain free and have no significant swelling)
• Add total conditioning program including flexibility, strength, endurance, and core stabilization

Month 6+

• Continue strengthening program and add sport-specific exercises
  • Isokinetic test results for the shoulder should demonstrate at least 80% strength and endurance (compared to the other side) before proceeding to sport-specific activities
• Continue total body conditioning program with emphasis on the shoulder
• Throwing athletes may begin progressive throwing program
• Begin practicing skills specific to the activity (work, recreational activity, sport, etc.)

Post-operative rehabilitation protocol for arthroscopic posterior shoulder stabilization

Weeks 0-3

• Patient is immobilized in a S.C.O.I. brace for the first 3 weeks post-operatively
• The brace should be worn 24 hours/day for the first 3 days post-operatively
• Beginning on POD #4, the patient may remove the brace for approximately 30 minutes per day to shower; otherwise, the brace should be worn at all times
• Begin ball squeezes

Weeks 3-6

• Patient no longer required to wear the brace
• Use modalities as needed (ice, heat, electrotherapy, etc.)
• Begin gentle passive ROM exercises in all directions
  • Gentle with internal rotation; NO cross body adduction
• Begin isometric internal and external rotation exercises with arm at side and elbow flexed to 90 degrees as patient’s pain tolerance allows; isometric flexion and extension may be added as needed
• Add active-assist ROM exercises (wand exercises); ROM limited by pain
  • Gentle with internal rotation; NO cross body adduction
• Add gentle joint mobilization as needed
• Add shoulder shrug exercises

Weeks 6-9

• Continue passive and active-assist ROM exercises
  • May begin gentle cross-body adduction
  • May add wall climbs for shoulder flexion/abduction
• Continue isometric exercises as above
• Begin IR/ER strengthening exercises with adducted arm (arm at side) using rubber tubing (Thera-band)
• Begin active IR strengthening with free weights with adducted arm and elbow flexed to 90 degrees
• Begin UBE comfortably at 60 rpm
• Add supraspinatous exercise if movement is pain-free and adequate ROM exists (0-90 degrees)
• o Shoulder is positioned in the scapular plane approximately 20-30 degrees forward in the coronal plane
• Add active shoulder flexion through pain-free ROM
• Add active shoulder abduction to 90 degrees as tolerated
• Continue shoulder shrugs and scapular strengthening

Weeks 9-12

• Continue active and passive ROM exercises
  • Try to regain full active and passive ROM by 12 weeks post-operatively
• Continue isotonic strengthening exercises with emphasis on the rotator cuff and posterior deltoid
• Proprioceptive neuromuscular facilitation (PNF) may be added as needed
  • Emphasis on the flexion/abduction/ER diagonal; start ¼ of the way in the diagonal in an effort to protect the posterior capsule from excessive stress

Weeks 12-16

• Patient may resume upper body workouts in gym; start at very easy/low intensity level and gradually progress to more intense work-outs
  • Gradually progress in exercises that stress the posterior capsule (flat bench press, military press, push-ups)
• Continue to progress strengthening as tolerated
  • Emphasis on eccentric phase of contraction of the rotator cuff
• Begin active horizontal adduction
• Add total body conditioning program

Weeks 16-24

• Should have full ROM in all directions
• Continue total body conditioning program
• Begin sport-specific activity and skills
  • Throwing athletes may begin the throwing program

Return to Sports

Throwing Sports

May begin progressive shoulder throwing program at 4 months post-op if patient has achieved full ROM and approximately 80% strength

Contact Sports

No contact sports (such as tackle football, snow skiing, water skiing, wrestling, martial arts) until 6 months post-op and greater than 90% strength and endurance

Post-operative rehabilitation protocol for arthroscopic anterior shoulder stabilization

Weeks 0-3

• Patient remains in a sling for at least 3 weeks post-operatively
• Patient comes out of sling daily to perform rehabilitation exercises
• Patient may discontinue sling once good muscular control of shoulder is achieved (usually between 4-6 weeks post-operatively)
• Caution patient to avoid abducted, externally rotated, and extended position
• Begin passive exercises: pendulums, rope and pulley exercises (flexion only), wand exercises (flexion only)
  • Limit passive external rotation to 45 degrees; internal rotation as tolerated
• Begin isometric exercises: abduction, external rotation, biceps, triceps (avoid biceps if concomitant SLAP repair)
• Patient may begin the following active assist exercises: supine forward elevation assisted with normal arm; ROM limited by pain
• Patient may begin the following active exercises: elbow flexion and extension (no active elbow flexion if concomitant SLAP repair)
• Putty for grip strengthening

Weeks 3-6

• Continue active exercises as in weeks 0-3
• Continue active assist exercises as in weeks 0-3
• Continue isometric exercises as in weeks 0-3
• Continue passive exercises as in weeks 0-3
  • Do NOT allow external rotation beyond 60 degrees with the arm in the adducted position (arm at side); do not push beyond pain tolerance
  • Continue to avoid externally rotated and abducted position

Weeks 6-9

• Continue active exercises as above
• Continue active assist exercises as above
• Continue isometric exercises as above
• Continue passive exercises as above
  • Continue to avoid externally rotated and abducted position
  • ROM goals to achieve by 9 weeks post-operatively: 150 degrees flexion, 60 degrees external rotation, 80 degrees internal rotation
• Begin IR/ER strengthening exercises with adducted arm (arm at side) using rubber tubing (Thera-band)
• Begin the following strengthening exercises with 1-2 pound weights: forward flexion, prone extension (do not allow arm to pass behind plane of body during prone extension), empty can, deceleration
• Begin scapular strengthening: seated rows, shrugs, wall push-offs
• May institute contract-relax techniques, mobilization techniques, etc. if required to meet ROM goals
• UBE (cable column)
  • Biceps (gently progress if concomitant SLAP repair), triceps, lat pull down (narrow hand grip, pull down in front)

Weeks 9-12

• Continue active and passive ROM
  • Try to regain full ROM in flexion, extension, IR, ER (with arm by side), and adduction by 12 weeks post-operatively
  • Avoid abducted, extended, externally rotated stretch
• Progress strengthening program with addition of the following:
  • UBE (cable column): seated rows, punches, biceps, triceps, horizontal
  • Push up program: start with kneeling push-ups, then progress to regular push-ups (avoid push-ups with elbow flexion past 90 degrees and extension past neutral; “stop push-up halfway down”)
  • Begin plyoball routine emphasizing chest passes; progress gradually to single arm throws without “cocking”
  • Standing stabilization exercises with tubing, arm elevated in diagonal pattern

Weeks 12-24

• Patient may resume upper body workouts in gym; start at very easy/low intensity level and gradually progress to more intense work-outs
  • Avoid the abducted/extended/externally rotated position (during bench press, incline press, and military press)
• Continue strengthening program
• May begin progressive throwing program when adequate strength achieved (OK to put arm in “cocked” position for throwing)
• Add total body conditioning program

Return to Sports

Throwing Sports

May begin progressive shoulder throwing program at 3 months post-op if patient has achieved full ROM and approximately 80% strength

Contact Sports

No contact sports (such as tackle football, snow skiing, water skiing, wrestling, martial arts) until 6 months post-op and greater than 90% strength and endurance

Post-operative rehabilitation protocol for debridement and/or labral repair of hip

Phase I weeks 1-4

Goal is to protect and minimize pain and inflammation, initiate early motion
Weight bearing precautions:

• Debridement:  WB as tolerated
• Labral repair or osteoplasty:  TTWB for 3 weeks (may be up to 6 weeks if specified by MD)
• **Symmetrical gait pattern is important.  D/C of crutches is based on symmetrical gait pattern NOT PAIN LEVEL

ROM Precautions:

• ROM:  Flex 90° (10 days -2 weeks)
• Ext. 10° (10 days -2 weeks)—for labral repair only
• Abd. 25°  (10 days -2 weeks)—for labral repair only
• ER and IR: Gentle for 3 weeks

Limit sitting at 90 degrees or more due to anterior impingement
Lie prone 1 to 2 hours a day  (work up to this amount)

• Passive supine hip roll into IR: weeks 1-2
• Isometrics gluts, quads, HS, TrA: weeks 1-4
• Bike no resistance high seat: weeks 1-4
• PROM emphasize prone lying, IR, circumduction: weeks 1-4
• Heel slides: week 1-4
• Piriformis stretch: weeks 1-6
• Uninvolved knee to chest: weeks 1-4
• Grade 1 hip jt. Mobs: weeks 1-4
• Manual long axis traction: weeks 2-6
• C-R stretch for IR/ER: weeks 2-6
• Water walking with flotation (if no pain): weeks 2-6
• 3 way leg raises (abd, etc, add): weeks 3-6
• Water jogging with flotation device (if no pain): weeks 3-6

Phase 2 weeks 5-7 transitioning to strength

To move from phase 1 to 2: ROM must be 75% or equal to that of the other side. Must be able to perform hip abduction for Glut. Medius without TFL or Quadratus lumborum compensation.

• Double 1/3 knee bends (partial squats): weeks 5-6
• Bike with resistance: weeks 5-7
• Manual A/P mobilizations: weeks 5-7
• Hip flexor stretch (off bed, with chair, or kneeling; kneeling preferred): weeks 5-7
• Involved knee to chest, adductor stretch: weeks 5-7
• Seated resisted IR/ER (in less than 90 degrees flexion): weeks 5-7
• Leg press: weeks 5-7
• Double leg bridge: weeks 5-7
• Single leg bridge: weeks 5-9
• Freestyle swimming (non-competitive): weeks 5-7
• Wall sits with abductor band: weeks 6-7
• Elliptical/stair climber: weeks 6-9
• Side stepping with abductor band: weeks 7-9

Phase 3 weeks 8-12

To transition to this phase no trendelenburg gait present and full ROM with minimal complaints of pain. If not full ROM (symmetrical to other side) by 10 weeks then terminal stretches allowed with moderate pain is acceptable. Patients with labral repair may take 4 months to get full ER and IR.

• Standing resisted hip ER: weeks 7-9
• Lunges with lunges with trunk rotation: weeks 7-9
• Core ball stabilization progression: weeks 7-9
• Forward/backward/sideways with walking cord: weeks 7-9
• Golf progression (not for 3 months with repair): weeks 7-9
• Water bounding/plyometrics: week 9
• Initial agility drills – single plane (eccentric control and shock absorption is important to instruct patient): week 9

Phase 4 weeks 12+ sport-specific training

Need good psoas and piriformis flexibility and no trendelenburg sign

Can run at 4 months

• Z-cuts/W-cuts: weeks 9-25
• Cariocas/Ghiradelli’s: weeks 9-25
• Sports-specific drills: weeks 9-25
• Functional testing – sportcord test: weeks 17-25

Hip Rehab is important because the surgery corrects the mechanical deficits but the functional deficits are corrected in therapy.

Good form with exercises and core stabilization are key to a good outcome. Glut. Medius and maximus must function without compensation from hip flexors or quadratus lumborum to avoid anterior impingement

Pre-operative

• Stretch hip flexors
• Strengthen glut. Medius and maximus
• Core stabilization and transverse strengthening
• Stretch hip into ER and IR

Post-operative rehabilitation protocol for osteochondral autograft

This rehabilitation protocol has been developed for the patient with an osteochondral autograft (carticel) procedure.  It is of the utmost importance to protect this patient against high weight bearing forces during the early postoperative period to avoid shearing or disruption of the graft tissues.  Early passive range of motion within the allowed range is highly beneficial to enhance the cartilage and the remodeling process.  The protocol is divided into phases.  Each phase is adaptable based on the individual patient and special circumstances.

The overall goals of the surgical procedure and rehabilitation are to:

• Control pain, swelling, and hemarthrosis
• Regain normal knee range of motion
• Regain a normal gait pattern and neuromuscular stability fro ambulation
• Regain normal lower extremity strength
• Regain normal proprioception, balance, and coordination for daily activities
• Achieve the level of function based on the orthopedic and patient goals

The physical therapy should be initiated within 3 to 5 days post-op.  It is extremely important for the supervised rehabilitation to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility.  Important post-op signs to monitor:

• Swelling of the knee or surrounding soft tissue
• Abnormal pain response, hypersensitive
• Abnormal gait pattern, with or without assistive device
• Limited range of motion
• Weakness in the lower extremity musculature (quadriceps, hamstring)
• Insufficient lower extremity flexibility

Return to activity requires both time and clinical evaluation.  To safely and most efficiently return to normal or high level functional activity, the patient requires adequate strength, flexibility, and endurance.  Isokinetic testing and functional evaluation are both methods of evaluating a patient’s readiness to return to activity.  Return to intense activities following a carticel procedure may increase the risk of repeat injury or the potential of compounding the original injury.  Symptoms such as pain, swelling, or instability should be closely monitored by the patient.

Phase 1: weeks 1-8

Goals of phase

• ROM 0-120°
• NWB to PWB with one crutch
• Control pain, inflammation, and effusion
• Adequate quad/VMO contraction

Exercises by type

• ROM-Passive: Goal 0-90° (week 4), 0-107° (week 5), 0-120° (week 8)
  • Femoral condyle defect: 0-45°
  • Trochlear defect: 0-30°
  • Range of motion to increase to reach goals based on area of defect as noted by Dr. Lowe
  • Gastroc/Soleus stretch
  • Hamstring/ITB stretch
  • hell/wall slides to reach goal
  • Patella mobs
  • Ankle pumps
• Strength
  • Quad/Hamstring/Gluteal sets
  • Multi-angle isometric (0-60°) (week 4)
  • Multi-angle isometric (90-30°) (week 6-8)
  • SLR in all 4 planes as tolerated
  • Hip flexion
  • Selective ROM activity-depending on defect site as noted by Dr. Lowe
  • Trochlear repair- only isometric training with quads, NO active motion through range
• Weight-bearing: Goal NWB to PWB (week 6-8)
  • NWB with crutches
• Brace
  • Locked at 0° extension for protection
• Modalities
  • E-stim/biofeedback as needed
  • Ice 15-20 minutes

Phase 2: weeks 8-36

Goals of phase

• PWB to FWB with quad control
• ROM 0-135°
• Increase lower extremity strength and endurance
• Control pain and inflammation
• Enhance proprioception, balance, and coordination

Exercises by type

• ROM: Goal 0-135°
  • Passive, 0-135°
  • Patella mobs
  • Gastoc/Soleus stretch
  • Hamstring/ITB stretch
  • Heel/Wall slides to reach goal
• Strength
  • SLR in 4 planes with ankle wt/tubing
  • Mini-squats (0-30°)
  • Wall squats
  • Initiate 3-6” lateral/forward step-up/downs
  • Leg press (0-60°)/Total Gym
  • Knee extension (90-30°)
  • Hamstring curls (0-90°)
  • Multi-hip machine in 4 planes
  • Heel raise/Toe raise
• Balance training
  • Weight shift (side-to-side, fwd/bkwd)
  • Initiate single leg balance work
  • Progress to wobble board, ½ foam roller
  • Single leg balance with plyotoss
  • Sportscord balance work
• Weight-bearing: Goal FWB (week 8) and D/C (week 6-8)
  • NWB to PWB to FWB with quad control
• Brace
  • Discharge by week 8 or as noted by Dr. Lowe
• Aerobic conditioning
  • Bicycle when 110° flexion is reached
  • EFX for endurance
  • Treadmill with 2-3% incline to reduce joint loads
  • Swimming (as noted by Dr. Lowe)
• Modalities
  • Ice 15-20 minutes

Phase 3: weeks 36-52

Goals of phase

• Maintain full range of motion
• Maximize lower extremity strength and endurance
• Initiate sport specific activity
• Initiate functional activity

Exercises by type

• ROM
  • Continue all stretching activities from previous phases
• Strength
  • Continue all strengthening activities from previous phases increasing weight and repetition
  • Reverse/Lateral lunges
  • Straight leg dead lift
  • Stool crawl
• Balance training
  • Advance to dynamic balance work with different surfaces
• Running/conditioning program
  • Initiate running on minitramp, progress to treadmill as tolerated in a straight plane
  • Initiate jump rope for endurance and impact
  • Initiate walking program for endurance
  • Swimming (kicking)
  • Bicycle for endurance
  • Continue to increase time and resistance on the above
• Functional training
  • Initiate light plyometric work
  • Initiate lateral movement (shuffle, slide board)
  • Initiate sport specific/functional drills at month 6
  • Progress into sport training at month 9
• Modalities
  • Ice 15-20 minutes as needed

Post-operative rehabilitation protocol for patellofemoral joint dysfunction

The physical therapy rehabilitation for patellofemoral joint dysfunction varies in length depending on factors such as:

1. Structure(s) involved: patellar tendon, patellar cartilage, plica, PF tracking
2. Acute vs. chronic condition
3. Muscle strength and endurance
4. Lower extremity biomechanics: pronated foot, leg length discrepancy, etc.
5. Performance or activity demands

The rehabilitation program is outlined in three phases.  It is possible to overlap phases (Phase I-II, Phase II-III), depending on the progress of each individual.

Phase I

1. Identify the problem as patellar tendonitis, chondromalacia, plica formation, patellar subluxation, patellar dislocation, patellar tracking, or other extensor mechanism disorders
2. Decrease and localize the area of pain
3. Establish appropriate stretching and strengthening exercises
4. Modify activity level

• Apply modalities as needed (ice, heat, phonophoresis, etc.)
• Perform range of motion exercises for knee flexion and extension
• Add isometric strengthening exercises: hip adduction, quadriceps sets, hamstring sets (note: no open chain full ROM isotonic exercises yet)
• Electrical stimulation to vastus medialis oblique (VMO)/quadriceps (as needed)
• Flexibility exercises: calf, achilles, groin, hamstring, ilio-tibial band, quadriceps, hip flexor, hip rotators (as needed); Very Important
• Add calf strengthening (i.e., toe raises)
• Add straight leg raises as tolerated
• Mobilization (patellar mobilization techniques as needed)
• Asses lower extremity biomechanics during standing and walking (as needed)
• Modify activity level (as needed)
• Apply ice after exercise session
• Bike: low resistance, seat high
• OK to begin closed chain strengthening (i.e. leg press, total gym, shuttle, etc.) at light resistance when pain free
• Active hip adduction
• Hamstrings curls

Phase II

Progressive strengthening and stretching exercises are continued as needed along with isokinetic training and endurance activities (e.g. biking) as tolerated

• Continue modalities, mobilization, and flexibility exercises as needed
• Continue electrical stimulation to VMO/quad (as needed)
• OK to progress closed chain strengthening to eccentric loading as pain allows
• Start knee extensions in pain free ROM, progress to weights only through the same pain free ROM – gradually try to increase range of motion as pain allows
• Isokinetic training: isokinetic strengthening and endurance exercises (starting at high speeds) for knee flexion/extension may be added; the knee joint should be pain-free and have no significant amount of swelling
• Continue to use ice after each workout session
• Multi angle isometrics with knee extension
• For the athletic population, OK to begin walk/jog program and slowly progress to running as pain and swelling allow; DO NOT run to the point of persistent swelling; progress gradually to treadmill and then track

NOTE:  The knee flexion angle and/or foot position (e.g. pronation/supination) may be adjusted to allow a pain-free muscle contraction to occur. If there is pain with active movements, active-assist exercises may be substituted (electrical stimulation, use of uninvolved extremity, etc.).

Phase III

A running program and agility drills are integrated in preparation for return to the prior activity level (work, recreational activity, sports, etc.)

• Continue stretching and strengthening exercises
• Proceed with running program as tolerated
• Add eccentric training for quadriceps strengthening*
• Progress with open and closed chain strengthening through pain free range of motion*
• Biking – increase intensity/duration level
• Add total body conditioning program with emphasis on strength and endurance
• Agility drills may be added; running distance should be approximately one and a half to two miles without knee pain or discomfort; drills may include – backward running, carioca step, high knees drills, sprinting, figure eight drill
• Practice drills specific to the activity or sport

NOTE: The initial weight is determined by the amount the patient is able to lift in the last 30° of extension.  Movement is performed slowly through the full range of extension.