PCL Reconstruction Protocol

The intent of this protocol is to provide the clinician with a guideline for the post-operative rehabilitation course of a patient that has undergone a PCL or PCL/ACL reconstruction. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a patient’s post-operative course based on their exam findings, individual progress, and/or presence of post-operative complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.

GENERAL GUIDELINES

  • No open chain hamstring work.
  • Typically it takes 12 weeks for graft to bone healing time.
  • Caution against posterior tibial translation (gravity, muscle action).
  • Typically no CPM.
  • PCL with posterolateral corner or LCL repair follows different post-op care (i.e. crutches x 3 months).
  • Resistance for hip PRE’s should be placed above the knee for hip abduction and adduction; resistance may be placed distally for hip flexion.
  • Supervised physical therapy generally takes place for 3-5 months post-operatively.

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated, unless otherwise specified by the surgeon:

  • Bathing/showering without brace (sponge bath only until suture removal)- 1 week post-op.
  • Typically patients can return to driving: 6-8 weeks post-op.
  • Typically begin sleeping without brace: 8 weeks post-op.
  • Full weight-bearing without assistive devices: 8 weeks post-op (with surgeon’s clearance based on structural integrity of repair). The exception is PCL with posterior lateral corner (PLC) or LCL repair, as above.

REHABILITATION PROGRESSION

PHASE I: Immediately post-operatively to week 4

Goals:

  • Protect healing bony and soft tissue structures.
  • Minimize the effects of immobilization:
    • Early protected range of motion (protect against posterior tibial sagging).
    • PRE’s for quadriceps, hip, and calf with an emphasis on limiting patellofemoral joint compression and posterior tibial translation.
  • Patient education for a clear understanding of limitations and expectations of the rehabilitation process, and need for supporting proximal tibia/preventing sag.

Brace:

  • 0-1 week: post-op brace locked in full extension at all times.
  • At 1 week post-op, brace is unlocked for passive ROM performed by a physical therapist or PT assistant.
  • Technique for passive ROM is as follows:
    • Patient supine; therapist maintains anterior pressure on proximal tibia as knee is flexed (force on tibia is from posterior to anterior).
    • For patients with combined PCL/ACL reconstructions, the above technique is modified such that a neutral position of the proximal tibia is maintained as the knee is flexed.
    • It is important to prevent posterior sagging at all times.

Weight-bearing status:

  • Weight-bearing as tolerated (WBAT) with crutches, brace locked in extension.

Special considerations:

  • Position pillow under proximal posterior tibia at rest to prevent posterior tibial sag.

Therapeutic exercises:

  • Patellar mobilization.
  • Quadriceps sets.
  • Straight leg raise (SLR).
  • Hip abduction and adduction.
  • Ankle pumps.
  • Hamstring and calf stretching.
  • Calf press with exercise bands, progressing to standing calf raise with full knee extension.
  • Standing hip extension from neutral.
  • Functional electrical stimulation (as needed for trace to poor quadriceps contraction).

PHASE II: Post-operative weeks 4 to 12

Criteria for progression to Phase II:

  • Good quadriceps control (good quad set, no lag with SLR).
  • Approximately 60 degrees knee flexion.
  • Full knee extension.
  • No signs of active inflammation.

Goals:

  • Increase ROM (particularly flexion).
  • Normalize gait.
  • Continue to improve quadriceps strength and hamstring flexibility.

Brace:

  • 4-6 weeks: Brace unlocked for gait in controlled environment only (i.e. patient may walk with brace unlocked while attending PT or when at home).
  • 6-8 weeks: Brace unlocked for all activities.
  • 8 weeks: Brace discontinued, as allowed by surgeon.

*Note, if PCL or LCL repair, continue brace until cleared by surgeon.

Weight-bearing status:

  • 4-8 weeks: WBAT with crutches.
  • 8 weeks: May discontinue crutches if patient demonstrates:
    • No quadriceps lag with SLR.
    • Full knee extension.
    • Knee flexion 90-100 degrees.
    • Normal gait pattern (May use 1 crutch/cane until gait normalized).
  • If PLC or LCL repair, continue crutches for 12 weeks.

Therapeutic Exercises:

  • 4-8 weeks:
    • Wall slides/mini-squats (0-45 degrees).
    • Leg press (0-60 degrees).
    • Standing 4-way hip exercise for flexion, extension, abduction, adduction (from neutral, knee fully extended).
    • Ambulation in pool (work on restoration of normal heel-toe gait pattern in chest-deep water).
  • 8-12 weeks:
    • Stationary bike (foot placed forward on pedal without use of toe clips to minimize hamstring activity; seat set slightly higher than normal).
    • Closed kinetic chain terminal knee extension using resisted band or weight machine. Note: important to place point of resistance to minimize tibial displacement.
    • Stairmaster.
    • Elliptical trainer.
    • Balance and proprioception exercises.
    • Seated calf raises.
    • Leg press (0-90 degrees).

PHASE III: Post-operative months 3 to 9

Criteria for progression to Phase III:

  • Full, painfree ROM. (Note: it is not unusual for flexion to be lacking 10-15 degrees for up to 5 months post-op.)
  • Normal gait.
  • Good to normal quadriceps control.
  • No patellofemoral complaints.
  • Clearance by surgeon to begin more concentrated closed kinetic chain progression.

Goals:

  • Restore any residual loss of motion that may prevent functional progression.
  • Progress functionally and prevent patellofemoral irritation.
  • Improve functional strength and proprioception using close kinetic chain exercises.
  • Continue to maintain quadriceps strength and hamstring flexibility.

Therapeutic exercises:

  • Continue closed kinetic chain exercise progression.
  • Treadmill walking.
  • Jogging in pool with wet vest or belt.
  • Swimming (no breaststroke or “frog kick”).

PHASE IV: Post-operative Month 9 until return to full activity

Criteria for progression to Phase IV:

  • Clearance by surgeon to resume full or modified/partial activity (i.e. return to work, recreational, or athletic activity).
  • No significant patellofemoral or soft tissue irritation.
  • Presence of necessary joint ROM, muscle strength and endurance, and proprioception to safely return to athletic participation.
    • Full, painfree ROM.
    • Satisfactory clinical examination.
    • Quadriceps strength 85% of uninvolved leg.
    • Functional testing 85% of uninvolved leg.
    • No change in laxity testing.

Goals:

  • Safe and gradual return to work or athletic participation.
    • This may involve sport-specific training, work hardening, or job restructuring as needed.
    • Patient demonstrates a clear understanding of their possible limitations.
  • Maintenance of strength, endurance, and function.

Therapeutic exercises:

  • Continue closed kinetic chain exercise progression.
  • Cross-country ski machine.
  • Sport-specific functional progression, which may include but is not limited to:
    • Slide board.
    • Jog/Run progression.
    • Figure 8, carioca, backward running, cutting.
    • Jumping (plyometrics).
  • Work hardening program as indicated by physical therapist and/or surgeon recommendation. Patient will need a referral from surgeon to begin work hardening.