What is the recommended physiotherapy plan for a patient with a history of Anterior Cruciate Ligament (ACL) reconstruction, patellofemoral arthritis, and quadriceps atrophy?

6-Week Post-ACL Reconstruction Physiotherapy Chart

Begin isometric quadriceps exercises (quad sets, straight leg raises) immediately in weeks 1-2, progress to closed-chain exercises (mini-squats, leg press) at week 3, and incorporate both open and closed kinetic chain exercises throughout to maximize quadriceps strength recovery while protecting the graft. 1

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Week 1–2: Early Phase (Days 1–14)

Primary Goals: Restore full extension, reduce swelling, initiate quadriceps activation

Exercises & Dosage

• Isometric quadriceps sets: 10-second holds × 10 reps × 3 sessions/day 1

  • These can be safely prescribed during the first 2 postoperative weeks and provide faster recovery of knee range of motion without compromising stability 1

• Straight leg raises (SLR): 2 sets × 10 reps, 2-3 times daily 1

  • Critical for early quadriceps activation and ROM recovery 1

• Heel slides (active knee flexion): 2 sets × 10 reps, progressing to ~60° flexion 1

  • Early mobilization improves knee flexion and extension ROM without compromising knee laxity 1

• Patellar mobilizations: Superior-inferior & medial-lateral, 2 minutes each direction × 2 sessions/day

  • Essential for patellofemoral arthritis management and preventing patellar tracking dysfunction

• Ice application: 15 minutes × 3/day for swelling control 1

• Weight-bearing: Partial weight-bearing as tolerated 1

  • Early weight-bearing (immediate vs. 2 weeks delayed) significantly reduces patellofemoral pain from 35% to 8% without affecting laxity or function 1

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Week 3–4: Strengthening Initiation (Days 15–28)

Primary Goals: Increase quadriceps strength via closed-chain exercises, achieve full knee extension

Exercises & Dosage

• Continue: Isometric quads, SLR, patellar mobilizations, ice 1

• Leg press (0-45°): 3 sets × 10-12 reps 1

  • Starting leg press at 3 weeks improves subjective knee function and functional outcomes 1
  • Use functional pattern similar to half squat (0°-45°) to protect graft and reduce patellofemoral stress 1

• Mini-squats (wall-supported, 0-45°): 3 sets × 10 reps 1

  • Closed kinetic chain exercises are safer for patellofemoral arthritis and produce less anterior knee pain than open chain 1

• Short-arc quads (10-30° extension): 3 sets × 12 reps 1

  • Can introduce open kinetic chain at week 4 without compromising laxity, though monitor for anterior knee pain 1

• Step-ups (6-inch platform): 2 sets × 10 reps, leading with operated leg

  • Functional closed-chain exercise for quadriceps and VMO activation

• Stationary cycling (low resistance): 10-15 minutes daily 1

  • Eccentric cycle ergometer training initiated at 3 weeks results in greater strength gains and quadriceps hypertrophy persisting 1 year post-ACLR 1

• Hamstring curls (light resistance band): 2 sets × 10 reps 1

  • Starting hamstring strengthening at 3 weeks improves quadriceps and hamstring strength 1

• Side-lying hip abduction: 2 sets × 12 reps

  • Begin patellar tracking exercises to address patellofemoral arthritis 1

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Week 5: VMO & Hip Strengthening (Days 29–35)

Primary Goals: Offload patellofemoral joint, strengthen gluteus medius/VMO, improve functional control

Exercises & Dosage

• Side-lying clamshells: 3 sets × 12 reps 1

  • Hip strengthening improves patellar tracking in patellofemoral arthritis

• Hip abduction (side-lying): 3 sets × 12 reps 1

• Band walks (lateral + forward/backward): 2 sets × 15 steps each direction 1

  • Motor control training on unstable surfaces improves proprioception 1

• Wall slides (0-60°): 3 sets × 10 reps

  • Progress closed-chain ROM while protecting patellofemoral joint

• Continue: Mini-squats, step-ups (increase height to 8 inches if tolerated)

• Single-leg balance: 30 seconds × 2 each leg 1

  • Motor control training improves knee joint proprioception in early phase 1

• Cycling/elliptical: 15-20 minutes 1

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Week 6: Functional Transition (Days 36–42)

Primary Goals: Transition to functional strength, prepare for dynamic movements

Exercises & Dosage

• Single-leg mini-squats (0-45°): 3 sets × 8 reps 1

  • Both open and closed kinetic chain exercises recommended for regaining quadriceps strength 1

• Reverse lunges (50-60° knee flexion): 3 sets × 8 reps

  • Functional closed-chain exercise limiting patellofemoral stress

• Step-downs (6-8 inch platform): 2 sets × 10 reps

  • Eccentric quadriceps control for functional activities

• Single-leg balance on foam/unstable surface: 3 sets × 30 seconds each leg 1

  • Motor control training on unstable surfaces (balance pad/foam) improves proprioception 1

• Continue: Patellar tracking exercises, hip/glute strengthening 1

• Cardio: Cycle/elliptical 20 minutes 1

• Gentle jogging progression: ONLY if full extension achieved, quadriceps strength ≥90% contralateral, and no pain 1

  • Criteria-based progression is essential; accelerated timelines can be used safely under right conditions 1

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Critical Monitoring Parameters

Red Flags Requiring Regression:

• Loss of knee extension (flexion contracture) 1
• Increased swelling or effusion 1
• Patellofemoral pain exacerbation 1
• Quadriceps activation failure 2

Common Pitfalls:

• Avoid deep squats >60° until cleared by surgeon 1
• Monitor anterior knee pain with open kinetic chain exercises—these may induce more pain than closed chain 1
• Hamstring grafts may be more vulnerable to early open kinetic chain introduction compared to BTB grafts 1
• Do not introduce open kinetic chain earlier than week 4 due to lack of evidence for safety 1

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Additional Interventions

For Persistent Quadriceps Atrophy:

• Neuromuscular electrical stimulation (NMES) 2
  • Muscle atrophy contributes more to quadriceps weakness than activation failure at 6 months post-ACLR 2, 3
  • Cross-sectional area explains more variance in strength (R²=0.307) than central activation ratio (R²<0.001) 2

Nutritional Support:

• Adequate protein intake for muscle hypertrophy
• Vitamin D/calcium supplementation for joint health

Supervised vs. Unsupervised:

• Unsupervised rehabilitation can be appropriate for motivated, compliant patients with individually prescribed programs and monitoring 1
• No difference in laxity, subjective function, or strength outcomes between supervised and unsupervised programs 1

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Evidence-Based Rationale

Why This Progression Works:

1. Isometric exercises weeks 1-2 are safe and accelerate ROM recovery 1
2. Closed-chain exercises starting week 3 (leg press, mini-squats) improve function without compromising graft 1
3. Both open and closed kinetic chain exercises should be used for optimal quadriceps strength recovery 1
4. Early eccentric cycling (week 3) produces superior strength gains and muscle hypertrophy persisting 1 year 1
5. Hip/VMO strengthening addresses patellar tracking dysfunction critical for patellofemoral arthritis 1
6. Motor control training improves proprioception without additional strength benefits 1

Long-term Considerations:

• ACL injury predisposes to osteoarthritis (RR 3.89 for any grade) 4
• ACL reconstruction reduces risk of degenerative changes at 10 years compared to nonoperative management 4
• Quadriceps atrophy (not just weakness) is the primary contributor to dysfunction and must be aggressively addressed 2, 3