Reconstructive ACL and meniscus repair physical therapy weeks 9-12 (month 3)

Posted on March 15, 2012

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Rather than continue posting one week at a time, I decided I would post a few weeks in conjunction with one another. Weeks 9-12 mark the third month of rehab.

Overall, other than consistently needing to achieve full knee extension the first 6 weeks or so, this has been a pretty smooth process. I’ve barely had any pain and things have stayed according to plan.

I still have some fluid sporadically in my knee. Like on days where I work for 10 hours. I think because of this (the fluid) I have had some issues with patellar pain. It’s not really so much pain as it is an annoyance. If I’m a little stiff I’ll have some sensation at the patella during single leg stuff. Most probably wouldn’t consider it much but I do have a history of anterior knee pain on my right leg, (the surgery leg, which is shorter than my left, giving me some predisposition) so I’m hyper aware of anything going on in that area.

The most difficult part has been regaining my hamstring strength. The first day I did hamstring curls trying to lift 10lbs was seriously close to maximal effort. It didn’t hurt, but damn it was hard.

However, it’s supposed to be hard. The hamstring strength typically doesn’t return to normal levels til at least the 6 month mark. So while it’s hard, it’s just like lifting weights in any other scenario, but the amount of weight I can lift has been reduced. Not like I’m writhing in pain or hating life.

Other than that, which is really minimal, I’ve actually been a little surprised by how smooth this has gone. Like I said, I can stand on my legs for 10 hours and have no issues. In fact, I barely think about it anymore. This is obviously good in the sense I’m healing well, but it can be a deterrent in the sense I have to make sure I don’t accidentally jog somewhere or go up the stairs in twos. I’ve had to stop myself on multiple occasions.

For example, I was crossing the street with a friend and we wanted to beat the light so all of a sudden I took a jogging step without thinking about it. It took me a couple seconds to go, “Oh shit, I’m not supposed to do that.” But it didn’t hurt.

The end of month 3 marks the hopeful half-way point of this rehab. Projecting me to be back at full sports at the end of 6 months.

Here’s the details:

 

Week 9 (Days 57-63)

Routine schedule:

Day 57: Massage, ROM, Proprioception, Strength,

Day 58: Massage, ROM, Conditioning, Proprioception

Day 59: Massage, ROM, Upper body

Day 60: Massage, ROM, Proprioception, Strength

Day 61: Massage, ROM, Conditioning, Proprioception

Day 62: Massage, ROM, Upper body

Day 63: Massage, ROM

 

Massage Work

Foam Rolling / Tennis Ball: Adductors, Glutes, Quads, Calves, Peroneals, TFL,

 

Range of motion exercises (15 reps of each exercise. Should be done often enough throughout day to accomplish goals! There is no magic number.)

-Extension: To 0 degrees or 5-7 degrees of hyperextension.

-Passive knee extension with quad squeezes

-Flexion: Full flexion allowed as tolerated.  Resisted flexion now allowed.

-Patellar mobilizations

-Sitting hamstring stretch

-Tibial rotations. Palpate hamstrings and tibia to make sure these are moving and movement is not only occurring at the ankle.

-Clamshells

-Straight leg raise

-Plantar flexion / dorisflexion

-Hip flexion

-Hip adduction / abduction

-Lying down knee extension 90-0 degrees

 

Strengthening (Barefoot)

Day 57:

A1) Squatting to 90 degrees 2 x6-8r (25lbs)

A2) Glute Bridges weighted 3 x6-8r (25lbs)

B1) RESS to 90 or as tolerated  3 x10-12r(BW X6r)

B2) Single Leg Hamstring curls (10lbs)

B3) Single leg calves

Day 60:

A1) Squatting to 90 degrees 2 x6-8r (Day off from this, patella was acting up)

A2) Glute Bridges weighted 3 x6-8r (45lbs)

B1) Side to side to 90 or as tolerated  3 x10-12r (Day off from this too)

B2) Single Leg Hamstring curls 3 x10-12r (10lbs)

B3) Single leg calves

 

> So we have some pretty big differences with the transition to week 9.

Basically all knee bending is improved from 60 degrees to 90.

Glute bridges are now weighted. This is primarily because week 9 marks the point where it is ok to load the knee at 90 degrees. Doing glute bridges without the knees bent to at least 90 degrees is pretty cumbersome, hence me waiting to load the movement til this point.

Because of that, resisted knee flexion –or hamstring curls- are also introduced. These were HARD. 10 pounds was seriously like maxing out for me. I also had to pay attention to how much active flexion I was generating. 90 degrees was about the max point where I would feel some tension on the graft site. So I never pushed this.

With that said, each time I do them they get easier, illustrating the strength of my hamstring is coming back quickly.

Lastly, I added in some traditional single leg exercises with the rearfoot elevated split squat and side to side lunges. Being a taller guy, single leg exercises always help hit my legs harder than squatting and are always friendlier on my lower back. Therefore, I’ve always used them as a good barometer for where my leg strength is. The RESS will be the prime indicator comparing my leg strength post-surgery to pre-surgery. I won’t return to full sports until I hit my pre-surgery numbers.

These were also pretty tough the first day. It marked the first time I tried to achieve a significant knee bend while in a single leg position. I erred on the side of caution and didn’t do many reps.

Conditioning

Biking

-Elliptical –Forward and backwards

-Pool –Walking all directions

-Backwards and side to side running

– > The only change here is the addition of riding the bike. As mentioned, week 9 marked the first time I could load my leg past 90 degrees. Riding a bike entails about 110 degrees of knee flexion, therefore it was a no-no up until this point.

Riding the bike felt good. No problems.

 

Proprioceptive training

Weight shifts on bosu ball eyes closed.

-Single leg standing straight and bent unsupported w/ball

-Ball toss on bosu ball

-Single leg straight and bent on bosu ball w/ball

-High knee stepping sideways over cones with ball. Forward and back without ball.

-> This is a drill I’ve really derived some benefit from. It gives me the ability to practice starting and stopping in different directions in a very controlled manner. It is a really nice precursor to the sideways running I’ll be doing in week 13.

Meds

Ibuprofen (Ideally after exercise.)

Nutrition

Calories = Bodyweight x 15 + 20% on strength days.

Calories = Bodyweight x 10 on other days.

Protein always high.

Glucosamine and chondroitin, fish oil and vitamin D for supplements

Week 10 (Days 65-71)

Routine schedule:

Day 65: Massage, ROM, Proprioception, Strength,

Day 66: Massage, ROM, Conditioning, Proprioception

Day 67: Massage, ROM, Upper body,

Day 68: Massage, ROM, Proprioception, Strength,

Day 69: Massage, ROM, Conditioning, Proprioception

Day 70: Massage, ROM, Upper body

Day 71: Massage, ROM

 

Massage Work

Foam Rolling / Tennis Ball: Adductors, Glutes, Quads, Calves, Peroneals, TFL,

Range of motion exercises (15 reps of each exercise. Should be done often enough throughout day to accomplish goals! There is no magic number.)

-Passive knee extension with quad squeezes

-Flexion: Full flexion allowed as tolerated.

-Patellar mobilizations

-Tibial rotations. Palpate hamstrings and tibia to make sure these are moving and movement is not only occurring at the ankle.

-Straight leg raise

-Plantar flexion / dorisflexion

-Hip flexion

Strengthening (Barefoot)

Day 65:

A1) Squatting to 90 degrees 2 x6-8r (35lbs)

A2) Glute Bridges weighted 3 x6-8r (65lbs)

B1) RESS to 90 or as tolerated 3 x10-12r (BW x6r)

B2) Hamstring curls 3 x10-12r (10lbs)

B3) Single leg calves 3 x8-10r

Day 68:

A1) Squatting to 90 degrees 2 x6-8r (40lbs)

A2) Glute Bridges weighted 3 x6-8r (95lbs)

B1) Side to side to 90 or as tolerated 3 x10-12r (BW x10r)

B2) Hamstring curl 3 x10-12r (15lbs)

B3) Single leg calves 3 x8-10r

  

Conditioning

-Biking

-Elliptical –Forward and backwards

-Pool –Walking all directions

-Backwards and side to side running

            -Plyos; double leg; backwards and side to side

– > I started doing some light jumping with both legs, side to side and backwards in the pool. It went really well and felt really good. No problems at all. 

 

Proprioceptive training

Weight shifts on bosu ball eyes closed.

-Single leg standing straight and bent unsupported w/ball

-Ball toss on bosu ball

-Single leg straight and bent on bosu ball w/ball 

High knee stepping sideways over cones with ball. Forward and back with ball.


Meds

Ibuprofen when needed (Ideally after exercise.)

Nutrition

Calories = Bodyweight x 15 + 20% on strength days.

Calories = Bodyweight x 10 on other days.

Protein always high.

Glucosamine and chondroitin, fish oil and vitamin D for supplements

Week 11 (Days 72-78)

Routine schedule:

Day 72: Massage, ROM, Proprioception, Strength,

Day 73: Massage, ROM, Conditioning, Proprioception

Day 74: Massage, ROM, Upper body,

Day 75: Massage, ROM, Proprioception, Strength,

Day 76: Massage, ROM, Conditioning, Proprioception

Day 77: Massage, ROM, Upper body,

Day 78: Massage, ROM

Massage Work

Foam Rolling / Tennis Ball: Adductors, Glutes, Quads, Calves, Peroneals, TFL,

Range of motion exercises (15 reps of each exercise. Should be done often enough throughout day to accomplish goals! There is no magic number.)

-Passive knee extension with quad squeezes

-Flexion: Full flexion allowed as tolerated.

-Patellar mobilizations

-Tibial rotations. Palpate hamstrings and tibia to make sure these are moving and movement is not only occurring at the ankle.

-Clamshells

-Straight leg raise

-Plantar flexion / dorisflexion

-Hip flexion

Strengthening (Barefoot)

Day 72:

A1) Squatting to 90 degrees 2 x6-8r (45lbs)

A2) Glute Bridges weighted 3 x6-8r (115lbs)

B1) RESS to 90 or as tolerated 3 x10-12r (BW x8r)

B2) Hamstring curls 3 x10-12r (20lbs)

B3) Single leg calves 3 x8-10r

Day 75:

A1) Squatting to 90 degrees 2 x6-8r (40lbs)

A2) Glute Bridges weighted 3 x6-8r (115lbs)

B1) Side to side to 90 or as tolerated 3 x10-12r (BW x10r)

B2) Hamstring curl 3 x10-12r (20lbs)

B3) Single leg calves 3 x8-10r 

 

Conditioning

-Biking

-Elliptical –Forward and backwards

-Pool –Walking all directions

-Backwards and side to side running

            –Plyos both legs side to side and backwards 

 

Proprioceptive training

Weight shifts on bosu ball eyes closed.

-Single leg standing straight and bent unsupported w/ball

-Ball toss on bosu ball

-Single leg straight and bent on bosu ball w/ball

High knee stepping sideways over cones with ball. Forward and back with ball.

Meds

Ibuprofen (Ideally after exercise.)

Nutrition

Calories = Bodyweight x 15 + 20% on strength days.

Calories = Bodyweight x 10 on other days.

Protein always high.

Glucosamine and chondroitin, fish oil and vitamin D for supplements

Week 12 (Days 79-85)

Routine schedule:

Day 79: Massage, ROM, Proprioception, Strength,

Day 80: Massage, ROM, Conditioning, Proprioception

Day 81: Massage, ROM, Upper body

Day 82: Massage, ROM, Proprioception, Strength,

Day 83: Massage, ROM, Conditioning, Proprioception

Day 84: Massage, ROM, Upper body

Day 85: Massage, ROM

 

Massage Work

Foam Rolling / Tennis Ball: Adductors, Glutes, Quads, Calves, Peroneals, TFL,

Range of motion exercises (15 reps of each exercise. Should be done often enough throughout day to accomplish goals! There is no magic number.)

-Passive knee extension with quad squeezes

-Flexion: Full flexion allowed as tolerated.

-Patellar mobilizations

-Tibial rotations. Palpate hamstrings and tibia to make sure these are moving and movement is not only occurring at the ankle.

-Clamshells

-Straight leg raise

-Plantar flexion / dorisflexion

-Hip flexion

Strengthening (Barefoot)

Day 79:

A1) Squatting to 90 degrees 2 x6-8r (I did some extra balance work so I took squatting out this week)

A2) Glute Bridges weighted 3 x6-8r (115lbs)

B1) RESS to 90 or as tolerated 3 x10-12r (BW x8r)

B2) Hamstring curls 3 x10-12r (25lbs)

B3) Single leg calves 3 x8-10r

Day 82:

A1) Squatting to 90 degrees 2 x6-8r

A2) Glute Bridges weighted 3 x6-8r (115lbs)

B1) Side to side to 90 or as tolerated 3 x10-12r (BW x10r)

B2) Hamstring curl 3 x10-12r (25lbs)

B3) Single leg calves 3 x8-10r

Conditioning

-Biking

-Elliptical –Forward and backwards

-Pool –Walking all directions

-Backwards and side to side running

            –Plyos both legs side to side and backwards

            -Plyos single leg backwards and side to side

 -> This was one of the only changes in week 12, the addition of single leg jumping in the pool. I took this pretty easy. Just a slight introduction for my knee.

Proprioceptive training

Weight shifts on bosu ball eyes closed.

-Single leg standing straight and bent unsupported w/ball

-Ball toss on bosu ball

-Single leg straight and bent on bosu ball w/ball

High knee stepping sideways over cones with ball. Forward and back with ball. 

 

Meds

Ibuprofen (Ideally after exercise.)

Nutrition

Calories = Bodyweight x 15 + 20% on strength days.

Calories = Bodyweight x 10 on other days.

Protein always high.

Glucosamine and chondroitin, fish oil and vitamin D for supplements

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