Rehabilitation protocols

Week 0-1 – exercise twice a day

• Lift your leg above the heart level as often as possible
• Apply cold poultice 3-5x a day for 15 minutes
• An elastic bandage is compulsory for the first 24h, for the 7 days after that, only when walking
• Foot flexion inwards and outwards (to prevent thrombosis in the shin area) 20 reps, 5x a day
• Static exercises for thigh muscles with a focus on the quadriceps muscle 5×20 sec
• Range of motion exercises for the knee (bending of the knee on a surface)
• Bending of the knee while lying on your stomach
• Leg lifts
• Back leg lifts while lying on your stomach
• Leg alphabet while holding your leg straight

Week 1-2 – exercises once a day, exercise bike twice a day

• Exercise bike on the lowest resistance setting 2×15 min
• Put a towel under the knee and push downwards – focus on the quadriceps, straighten leg as much as possible 10×20 sec
• Leg lifts with a focus on the quadriceps 3×10 reps
• Rotate the leg outwards at the hip, keep in position for leg lifts with a focus on the quadriceps 3×10 reps
• Lay on your healthy side; side leg lifts (with the operated leg) 3×10 reps
• Lay on your operated side, put your healthy leg over the operated one; inner thigh lifts (with the operated leg) 3×10 reps
• Lay on your stomach; back leg lifts 3×10 reps
• Leg bends at the knee with a weight around your ankle while lying on your stomach 3×10 reps
• Leg extensions from the knee in a sitting position with a weight on the ankles
• Hip raises (focus on the gluteus) 3×10 reps
• Bridge exercise (extended legs, focus on the hamstrings) 3×10 reps
• Start doing proprioception exercises (balance board, balance on one foot, …)

Week 2-3 – keep doing all exercises from week 2 once a day

• Exercise bike on a higher resistance setting 2×20 min
• Longer walking distances
• Advanced proprioception exercises

Week 3-4

• Increase activity (squats – not deep, functional exercises, bicycle)
• Exercise bike on a higher resistance setting 30min a day

Full activity and range of motion are expected 2 weeks to a month after surgery.

It is advised to walk on crutches for 7 days while bearing about 50% of the weight on the operated leg

Walking on crutches:

• Walking on straight surfaces and down the stairs: 1. crutches, 2. operated leg, 3. healthy leg
• Walking up the stairs: 1. crutches, 2. healthy leg, 3. operated leg
• If the patient doesn’t require crutches: walk on stairs with your leg straight

Week 0-2 – exercise twice a day

• Circulatory exercises 5x a day, 50 reps (foot flexions, leg alphabet)
• Pendulum exercise (relax the operated leg and move it forward and backwards while keeping the healthy leg on a stair)
• Circumduction (move your leg in a circular motion from the hip clockwise and counter clockwise)
• Isometric exercises for glutes, quadriceps, hamstrings, abductors, adductors, external and internal hip rotators 5×20 sec
• Leg bends at the knee (passive/active, put a towel as support under the knee)
• Leg extensions from the knee in a sitting position with a weight on the ankles 3×10 reps
• Exercise bike with a high seat position and lowest resistance setting 2×10 min (first week), 2×15 min (second week)

Week 2-4 – old exercises + new exercises twice a day

• Activation of internal and external hip rotators (30-degree angle) on the side 3×10 reps
• Leg extensions from the knee in a sitting position with a weight on the ankles while lying on your stomach 3×10 reps
• Exercise bike on the lowest resistance setting 2×20 min

Week 4-6 – exercise once a day (remove all exercises from weeks 0-4 except for leg extensions from the knee and leg bends on your stomach)

• Hip raises (focus on the gluteus) 3×10 reps
• Bridge exercise (extended legs, focus on the hamstrings) 3×10 reps
• Leg lifts with a focus on the quadriceps, lay on your back 3×10 reps
• Adductor strength – place a ball between your legs bent at the knee and squeeze 3×10 reps
• Activation of internal and external hip rotators (30-degree angle) on the side with resistance bands 3×10 reps
• Bird dog exercise (do not lift leg above body) 10 reps on each side
• Exercise bike 2×15 min (increase to 20 min) with light resistance

Week 6-8 – keep all exercises from previous weeks, once a day

• Back leg lifts while lying on your stomach (focus on the gluteus) reps to failure x 3 sets
• Side leg raises on healthy hip, reps to failure x 3 sets
• Bird dog exercise (do not lift leg above body) 2×10 reps on each side
• Hip raises with leg extension on Pilates ball (for hamstrings) 3×8-10 reps
• Exercise bike 30 mins with light resistance

Week 8-10 – keep all exercises from previous weeks, once a day

• Increase hip mobility in all directions (use of resistance bands is advised)
• Progression of core exercises
• Iliopsoas strength – leg lifts above 90 degrees at the hip in a sitting position, reps to failure x 3 sets
• Wall sits – 3 sets to failure
• Exercise bike with increased resistance setting 30 min

Week 10-12 – keep all exercises from previous weeks, once a day

• Progression of body-weight exercises, squats, bridge/hip raises
• Exercise bike 45 min with resistance
• Balance exercises

Note:

• Walking – 10kg weight-bearing for the first four weeks
• Walking – 30kg weight-bearing for the next four weeks
• Do not flex hip over 90 degrees for the first 8 weeks
• Avoid raising the leg from surface when lying on your stomach for the first 6 weeks
• Avoid putting considerable strain on the iliopsoas for the first 12 weeks
• Avoid considerable strains for 3 months (squats with resistance…)
• Stretch the iliopsoas every day, 3-4x for 2 minutes to avoid stiffness (lay on your back, grab your healthy leg under the knee and pull towards yourself while propping the operated leg on a table – for the first 2 weeks; after the first 2 weeks you can use a towel to upholster your hip under the operated leg and stretch in the same manner)

Strengthen arms before surgery to ease walking on crutches.

Walking on crutches:

• On a straight surface: crutches – operated leg – healthy leg
• Down the stairs: crutches – operated leg – healthy leg
• Up the stairs: crutches – healthy leg – operated leg

Week 0-1

• Knee brace 0-90 degrees
• 30kg weight-bearing (about 50% weight-bearing, or as much as you can without feeling pain)
• Keep your leg hoisted to decrease swelling
• Mobilisation of the patella
• Lymphatic drainage
• Do not stretch, but rather move to increase movement range
• Electrostimulation of the quadriceps
• Foot flexion 5x a day for 50 reps or ankle alphabet exercise (to prevent thrombosis)
• Static quads, glutes, adductor and abductor 3x a day, 20×5 sec
• Active assisted knee bend (not over 90 degrees)
• Static knee extension

Week 1-3 – keep all exercises from previous week, twice a day

• Co-contraction quadriceps/hamstrings 10×10 sec
• Leg lifts with a focus on the quadriceps 3x
• Clams 3x; after week 2 add a resistance band above the knee
• Back leg lifts while lying on your stomach (focus on the gluteus) 3×10 reps
• Strengthening of dorsal and plantar foot flexors with bended knee 3×10 reps
• Leave your leg hanging from the table at a 90-degree angle
• Balance board while sitting

Week 3-4 – remove exercises from the first week, keep exercises from weeks 1-3, twice a day

• Knee brace at 100 degrees
• Knee flexor strengthening 3×10 reps
• Seated heel raises 3×10 reps
• Core activation
• Adductor strengthening with ball squeezes 3×10 reps
• Active bending of the leg on a surface
• Leg press 3×8-10 reps
• Mini squats 3×10 reps
• Straight, side and back leg lifts with weight on ankles 3×10 reps
• Walking in water

Week 4-5 – keep all exercises from weeks 1-4, twice a day

• Knee brace at 110 degrees
• Practice walking with only one crutch
• Walking with only one crutch
• Sleeping without knee brace is allowed
• Co-contraction hamstrings/quadriceps 10×10 sec each leg
• Standing heel raises 3×10 reps
• Hip raises (focus on the gluteus) 3×8-10 reps (only once a day)
• Bridge exercise (focus on the hamstrings) 3×8-10 reps (only once a day)
• Bending movements up to 110 degrees
• Exercise bike with no resistance setting 10 mins twice a day

Week 5-6 – keep all exercises from weeks 1-5, twice a day except bridge and hip raises

• Walking without crutches
• Backwards walking
• Standing co-contraction hamstrings/quadriceps
• Exercise bike with no resistance setting 20 mins twice a day

Week 6-8 – beginning of athletic rehabilitation, exercise once a day

• Knee brace is removed
• Walking correction
• Walking on treadmill
• Bending movements up to 125 degrees
• Advanced co-contraction exercises
• Balance board while standing (hold yourself for support and be careful)
• Hip raises, bridge, clams, leg raises with weight on ankles (straight, lateral, back), knee bends, strengthening of dorsal and plantar foot flexors with bended knee, heel raises, advanced core exercises, leg press, squat (no lower than 90 degrees) – these exercises need to be kept up once a day with the previously given sets and reps
• Exercise bike with resistance setting 20 mins once a day
• Swimming (no breaststroke)

Week 8-9 – all previous exercises from weeks 6-8, once a day

• Sitting leg extensions 5 sets
• Swimming with flippers
• Outdoor bicycle

Week 9-12 – all previous exercises from weeks 6-9, once a day

• Bending movements up to 135 degrees
• Balancing on one foot
• Advanced proprioception and co-contraction exercises
• Strength progression (focus on hamstring and quadriceps exercises)
• Walking correction on treadmill

Week 12-16 – all previous exercises from weeks 6-12, once a day

• Fast walking on treadmill, if there are no complications
• Good strength and control of quadricepses is necessary
• Strength assessment – isokinetic dynamometry
• After 4 months of steady and well controlled walking on the treadmill, carefully begin with running on even terrain in a straight line (interchange 2 min walk/1 min running)
• Prevention of injury mechanisms
• Stability on outdoor terrain

After 5 months

• Zigzag running
• Running in the form of an 8

After 6 months

• Low jumps, max 15 cm with two-foot landing
• Acceleration and deceleration exercises
• Jump rope
• Isokinetic strength training
• Training progression

From 7 months on

• Specific sport activities
• Contact sports

A specific sport can be practiced again when

1. The motion range in the joint is complete
2. There is good balance
3. There is no swelling
4. Isokinetic evaluations don’t show a difference greater than 10% (quadriceps/hamstrings)
5. The ligament is stable
6. The patient is capable of carrying out a running workout
7. Most importantly, the patient is psychologically ready for it: if the patient is unsure or is weary of injury, they should not go back to practicing sport, even if all previous points are rated positively