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ACL Reconstruction Rehabilitation Protocol

 

Meniscus Repair RehabilitationRehabilitation following Anterior Cruciate Ligament Reconstruction (ACL) continues to be a exciting and popular topic in orthopedics and sports medicine.  Just pick up any journal and you are bound to find at least one article on the ACL in each issue!

Over the past decade, Kevin Wilk, James Andrews, and I have continuously adapted and expanded our preferred treatment guidelines following ACL reconstruction.  Kevin has published many classic manuscripts on the topic and we collectively have presented our treatment program several times in journal articles the last decade.

Since these publications, Kevin and I have continued to advance our rehabilitation protocol.

I am pleased to announce that we have officially just released our latest protocol for Accelerated Rehabilitation Following ACL Reconstruction with our latest protocols at RehabilitationProtocols.com.

But because our ACL reconstruction rehabilitation protocol is one of our most popular, we simple want to give it away for free!

But first, take a quick look at this video to see the building our our ACL protocols.  I share an inside look at our Rehabilitation Protocols:

 

 

 

 

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

There continues to be great debate over the most appropriate rehabilitation progression following rotator cuff repair.  We’ve done a great job improving our strategies for shoulder impingement treatment, however, rotator cuff injuries do continue to progress to full thickness tears.

Although our surgical techniques have gradually progressed from full open repairs, to smaller mini-open repairs, to the current standard all-arthroscopic repairs, many clinicians continue to utilize the same rehabilitation guidelines from past invasive procedures.

And more confusing is the lack of consensus among surgeons regarding the optimal postoperative rehabilitation protocol following arthroscopic rotator cuff repair.  Protocols can vary as drastically as beginning gentle passive range of motion and isometric exercises post-operative week 1 to delaying 12 weeks for the initiation of similar exercises.

I want to share the postoperative protocol that I have developed with Kevin Wilk and James Andrews.

It details the postoperative guidelines that we have used since the shift to arthroscopic rotator cuff repairs several years ago. While there is still a lack of efficacy studies, these guidelines have proven to us to be both safe and effective in the rehab of 1000’s of patients at our clinics.

Before downloading the protocol, I want to explain the goals of rehabilitation and what I believe are the 3 keys to rehabilitation. These principles are the cornerstone behind the protocol you are about to download.

Goals of Rehabilitation Following Rotator Cuff Repair

When rehabilitating after an arthroscopic rotator cuff repair surgery, the main goals of the rehabilitation protocol should be:

  • Protect the integrity of the rotator cuff repair
  • Minimize postoperative pain and inflammation
  • Restore passive range of motion
  • Restore strength and dynamic stability of the shoulder
  • Restore active range of motion
  • Return to functional activities

Pretty simple, right?  When you lay it out like that, we simply combine those goals with what we know about the basic science of healing tissue and you can fill in the gaps and individualize a program based on the patient and your treatment preferences.

The 3 Most Important Keys to Rotator Cuff Repair Rehabilitation

Now that you understand the goals, I want to share what I consider the 3 most important keys to rotator cuff repair rehabilitation.  Follow the goals above and focus on these 3 keys and you’ll be well on your way to full functional recovery:

  1. shoulder-shrug-signRestore full passive ROM quickly. It is extremely easy to lose motion following surgery. In my opinion this is caused by scarring in the subacromial space as well as loss of the redundancy of the glenohumeral capsule with immobilization. This is one of the common “rookie mistakes” I see with students and new graduates. Passive range of motion should be initiated immediately following surgery in a gradual and cautious fashion. Studies have shown that passive range of motion into flexion and external rotation actually decreases strain in the rotator cuff repair (still need to be cautious with adduction, extension, and internal rotation).
  2. Restore dynamic humeral head control. This is likely the most important goal of postoperative rehabilitation, other than maintaining the integrity of the repair. What this means is to restore the rotator cuff’s ability to center the humeral head within the glenoid fossa. Have you ever seen a patient following repair that had a shoulder “shrug” sign? That is caused by the inability of the cuff to compress the humeral head and the resultant superior humeral head migration. This is why it is imperative to begin gentle isometrics, rhythmic stabilization drills, and other drills to re-educate the rotator cuff.
  3. Maximize external rotation strength. I often refer to external rotation as the key to the shoulder. Weakness of ER is common in almost every pathology and strengthening of the area is extremely important to balance the anterior and posterior balance of cuff. Several studies have shown that ER strength takes the longest amount of time to restore after rotator cuff repair. The longer this area is weak, the more difficult it will be to stabilize the joint.

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

physical therapy rehabilitation protocolsIf you are interested in using the protocols that I have helped develop with Kevin Wilk and Dr. James Andrews, we have recently revised and expanded all of our protocols and made them completely online and downloadable.  Our physical therapy rehabilitation protocols have been published in several journals over the years and based on our decades of research, scientific evidence, and experience.

They are the most widely used and respected rehabilitation protocols today.

Want to see what our protocols include?  You can download our 3 most popular protocols for FREE:

  • Accelerated rehabilitation following ACL reconstruction using a patellar tendon autograft
  • Rehabilitation following arthroscopic rotator cuff repair for a type II medium-large sized tear
  • Thrower’s ten exercise program

physical therapy rehabilitation protocols online accessOur entire collection includes over 175 nonoperative, preoperative, postoperative protocols for shoulder, elbow, hip, knee, foot, and ankle.  There are several variations of many protocols to account for many specific procedures and concomitant surgeries.  Plus, we have several of our exercise handouts and interval return to sport programs.

If you work in an outpatient orthopedic or sports medicine clinic, these protocols are an invaluable resource to help guide your treatment approach.

Is it Time to Finally Ditch Using Rehabilitation Protocols?

The use of rehabilitation protocols in physical therapy continues to be common practice.  I recently performed a quick survey of my readers and they mostly agree.  The majority still follow protocols:

do you still use rehabilitation protocols

 

However, a recent trend on social media has been to criticize these guidelines and those that follow them.  Students are even coming out of college shunning the use of protocols.  I’ve heard so many complaints over the years, like:

  • We need to use our brains, not follow a piece of paper
  • Physical therapists shouldn’t follow a cookbook
  • Physical therapy isn’t black and white
  • We need individualize our treatment approach

I completely understand and agree, to an extent at least.  As a physical therapist (or other rehabilitation specialist), we’ve spent a lot of time and energy learning how the human body functions.  We’ve spent countless hours (and dollars…) becoming a physical therapist and mastering our craft.  We’ve spent years refining our skills based on our experiences and patient outcomes.

We should be using our brains and individualizing programs based on each person.

But rehabilitation protocols can help us do this better if used properly.  To highlight this, it helps to break down exactly what rehabilitation protocols are, and are not, in physical therapy to best understand how we should be using them in our practices.

 

Rehabilitation Protocols Are Not Cookbooks

physical therapy cookbookLet’s get this point out of the way first – rehabilitation protocols are not designed to be complete cookbooks.  This is where a physical therapist can often become paralyzed by the protocols, thinking that they can’t do anything that isn’t specifically listed in the protocol.

Realistically, the purpose of a good rehabilitation protocol is to clearly define the goals, precautions, and timelines to gradually apply load to healing tissue.  These are designed based on our understanding of the basic science of the healing process.

There is a still a huge gray area between what you definitely SHOULD be doing and what you definitely SHOULD NOT be doing.

Think of this as your opportunity to customize your recipe and make your own sandwich.  You need to put bread on both sides, but what meat, cheese, and condiments you put between the slices of bread will depend on the patient, your training, and your experience.  You may have your own preferences, as will I.

I often do things that are not specifically listed in a protocol with my patients that I know are in alignment with the goals and precautions of the protocol.  A good example is working the soft tissue of the traps after rotator cuff repair or including core training in the early phases of ACL rehabilitation.  Just because they are not specifically included in the protocol, doesn’t mean you can’t perform them.

Rehabilitation protocols are the foundation of your program, which should be adjusted based on:

  • The unique goals of each person
  • The specific injury or surgery
  • Any concomitant injuries, which are common

 

Rehabilitation Protocols Are Guidelines Following Injury

A common misconception regarding protocols is that they are concrete rules, instead of guidelines.  All of the nonoperative rehabilitation protocols that we have produced over the years are intended to be a way of guiding you through the steps of returning a patient from an injury.

In fact, many don’t even have strict timelines associated with them, but rather phases with criteria to progress.  For example, here’s what some of the goals of each phases would be when rehabilitating a baseball player that has a Tommy John injury:

  • Phase 1: Facilitate healing, restore range of motion, develop baseline strength and proprioception
  • Phase 2: Maintain range of motion, maximize strength a dynamic stability
  • Phase 3: Gradually apply load to tissue, progress to sport-specific dynamic activities
  • Phase 4: Return to sport progression

Looking at the above phases, you can use these guidelines to determine what is and what is not appropriate for each phase.  This is where your personal preferences can come into play.  I like spicy mustard on my ham and cheese, you like yellow mustard.  I won’t judge.  They are both appropriate.

Postoperative is different, and we’ll discuss that more below, but for nonoperative this is how you should use a protocol.  For nonoperative injuries there are times that you may want to limit an exercise or activity for a certain amount of time, however more often than not, nonoperative rehabilitation protocols are used to divide the rehab sequence into manageable chunks.

 

Rehabilitation Protocols Are Needed Following Surgery

knee rehabilitation protocolOne area that I feel strongly about is the definitive need for rehabilitation protocols after surgery.  Rehabilitation protocols are very important components of postoperative physical therapy.  Certain standards of care following a surgery must be set and communicated to assure patients progress appropriately after surgery.

Many of these may be surgeon specific, meaning that certain doctors will want you to go faster or slower based on their experience.  As physical therapists, we must respect these guidelines from the operating surgeon.  They know their surgery and the inside of your patient better than you do.

After surgery, protocols are used to assure we protect, facilitate healing, and gradually applied load to the injured tissues.

Simply winging it and not following a protocol will give you the least likely chance that you return the person as quickly and safely as possible.  For example, you don’t want too much or too little shoulder range of motion at 6 weeks follow an anterior labral repair, both can be disadvantageous.  A well designed postoperative rehabilitation protocol will put the patient in the best position to succeed.

As a young clinician, it’s also hard to prioritize the precautions and restrictions of complicated patients.  For example, our rehabilitation protocols have 13 variations of rotator cuff repair protocols and 16 variations of ACL reconstruction protocols.  We change the guidelines based on several factors and concomitant injuries.  This is a must.

 

 

Is it Time to Finally Ditch Using Rehabilitation Protocols?

I really don’t think so, in fact, I am a huge believer in rehab protocols when used correctly.  I think it’s very shortsighted to dismiss protocols as being bad for our profession or something that we are above using.

However, a protocol simply gives you guidelines as to what you can and can NOT do.  What you “can” do is not restricted to what is within the protocol.  Think of them as guidelines to assure that you are not going too slow or too fast.  Realistically, a protocol does not list every treatment and exercise that should be included.  This is where your skill and experience comes into play.  You must determine what other interventions you can safely perform to help the patient, while assessing if that chosen intervention fits safely within the protocol restrictions.

We should not follow a rehabilitation protocol without thought, that is not “skilled” physical therapy.  However, we must appreciate the timelines often associated with the protocols and healing tissues.

The true expert clinician realizes this and combines the guidelines of a rehabilitation protocol with their vast experience and treatment preferences.

 

Want to Use My Protocols?

physical therapy rehabilitation protocolsIf you are interested in using the protocols that I have helped develop with Kevin Wilk and Dr. James Andrews, we have recently revised and expanded all of our protocols and made them completely online and downloadable.  Our protocols have been published in several journals over the years and based on our decades of research, scientific evidence, and experience.

They are the most widely used and respected rehabilitation protocols today.

Want to see what our protocols include?  You can download our 3 most popular protocols for FREE:

  • Accelerated rehabilitation following ACL reconstruction using a patellar tendon autograft
  • Rehabilitation following arthroscopic rotator cuff repair for a type II medium-large sized tear
  • Thrower’s ten exercise program

 

physical therapy rehabilitation protocols online accessThe entire collect of Wilk, Reinold, and Andrews physical therapy rehabilitation protocols includes over 175 nonoperative, preoperative, postoperative protocols for shoulder, elbow, hip, knee, foot, and ankle.  There are several variations of many protocols to account for many specific procedures and concomitant surgeries.  Plus, we have several of our exercise handouts and interval return to sport programs.

If you work in an outpatient orthopedic or sports medicine clinic, these protocols are an invaluable resource to help guide your treatment approach.