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Phase I – Maximum Protection (Weeks 0 to 4):

0 to 1 Week:

  • Brace locked in full extension for 4 weeks
  • Use crutches for 7 to 10 days to reduce inflammation, then weight bearing as tolerated
  • Ice and modalities to reduce inflammation and pain

    • Range of Motion

    • 0° of knee extension
    • 90° of knee flexion for 4 weeks

    Exercises

    • Patella mobility in all planes
    • Passive/active knee range of motion with 90° flexion limit
    • Quadriceps setting emphasize VMO function
    • Multi-plane straight leg raising
    • Gait training

Weeks 1 to 4:

  • Continue with program as outlined in weeks 0 to 1
  • Range of Motion
    • -0° to 90° limitation

    Exercises

    • Initiate open kinetic chain multi-plane hip strengthening; progress to closed kinetic chain as swelling and pain permit
    • Begin pool program working on ROM and light strengthening once incisions are healed
    • Begin proprioceptive training, avoiding rotation
    • Manual PNF hip and ankle strengthening

Phase II – Progressive Stretching and Early Strengthening (Weeks 4 to 6):

Weeks 4 to 6:

  • Continue with modalities to control pain and inflammation
  • Open brace 0° to 90° for 2 weeks

    • Range of Motion

    • Full knee extension/hyperextension
    • Gradual progression to full knee flexion

    Exercises

    • Continue with phase I program
    • Continue to emphasize patella mobility and quality VMO function
    • Begin bilateral closed kinetic chain strengthening, gradually progressing to unilateral as swelling, pain, and neuromuscular function allow
    • Begin stationary cycle- low resistance emphasizing endurance
    • Gait training- normalize gait pattern
    • Advance proprioception program

Phase III – Advanced Strengthening and Proprioceptive Phase (Weeks 6 to 12):

Weeks 6 to 8:

  • Continue with exercises in phase I and II
  • Wean out of brace over a 7 to 10 day period

    • Range of Motion

    • Full knee range of motion

    Exercises

    • Patella mobility
    • Terminal stretching in flexion and extension
    • Advance stationary biking program (increase intensity), introduce treadmill walking and elliptical trainer
    • Advance pool program, higher intensity strengthening

Weeks 8 to 12:

  • Continue with program as outlined in weeks 6 to 8

    • Range of Motion

    • Full knee ROM

    Exercises

    • Advance unilateral closed kinetic chain program
    • Advance pool program
    • Begin multi-directional functional cord program avoiding rotation (carioca)
    • Increase intensity on stationary bike, elliptical trainer, and treadmill walking program, may begin interval programs
    • Begin gym strengthening; squats, leg press, partial walk lunge, hamstring curls, ab/adduction,
    • calf raises, and leg extensions (30° to 0° gradually increasing to full range of motion as patello-
    • femoral arthrokinematics normalize

Phase IV – Advanced Strengthening and Plyometric Drills (Weeks 12 to 16):

Weeks 12 to 16:

  • Begin pool running program, no bounding or jumping
  • Continue to advance overall strength and conditioning program, emphasize unilateral work with gym program

Phase V – Return to Sport Phase (Weeks 16 to 24):

Weeks 16 to 20:

  • Begin straight plane running; emphasize distance and endurance

Weeks 20 to 24:

  • Begin sprinting program
  • Begin multi-directional drills
  • Plyometric drills from bilateral to unilateral
  • Follow-up examination with the physician
  • Sports test for return to play

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