What is the post-operative protocol for a patient following quadriceps repair surgery?

Post-Operative Quadriceps Repair Protocol

Begin immediate mobilization and isometric quadriceps exercises within the first postoperative week, progressing to early functional rehabilitation with full weight-bearing as tolerated, as this approach is safe and does not lead to inferior outcomes or increased complication rates compared to restrictive protocols. 1

Immediate Post-Operative Phase (Week 1)

Weight-Bearing and Mobilization:

• Initiate immediate full weight-bearing as tolerated if the patient demonstrates correct gait pattern (with crutches if necessary) and experiences no pain, effusion, or temperature increase during or after walking 2
• Early functional rehabilitation with full weight-bearing does not increase re-rupture rates (2% in both early mobilization and restrictive protocols) 1
• Immediate weight-bearing decreases the incidence of anterior knee pain without affecting stability 2

Quadriceps Activation:

• Start isometric quadriceps exercises (static quadriceps contractions and straight leg raises) in the first postoperative week when they provoke no pain 2
• Isometric exercises are safe from the first postoperative week and confer advantages for faster recovery of knee range of motion at 1 month without compromising stability 2, 3
• Consider adding neuromuscular electrostimulation to isometric strengthening during the first 6-8 weeks to re-educate voluntary contraction and increase quadriceps strength 2

Pain Management:

• Apply cryotherapy in the first postoperative week to reduce pain, as it is inexpensive, easy to use, has high patient satisfaction, and is rarely associated with adverse events 2
• Compressive cryotherapy may be more effective than cryotherapy alone if available 2

Early Phase (Weeks 2-4)

Exercise Progression:

• Transition from isometric to concentric and eccentric exercises when the quadriceps is reactivated, provided the knee does not react with effusion or increased pain 2
• Prioritize closed kinetic chain (CKC) exercises from week 2 postoperative to mitigate patellofemoral stress while allowing safe quadriceps loading 2, 3
• CKC exercises can be performed safely from week 2 without compromising stability 2

Range of Motion:

• Early mobilization improves early phase knee flexion and extension range of motion without compromising stability 2
• Immediate knee mobilization within the first week is critical to increase joint range of motion, reduce knee pain, and prevent soft tissue-related adverse events such as extension deficit 2

Intermediate Phase (Weeks 4-12)

Open Kinetic Chain Exercises:

• Introduce open kinetic chain (OKC) exercises as early as 4 weeks postoperatively in a restricted range of motion of 90-45° of knee flexion 2, 3
• Progress ROM gradually: 90-30° in week 5,90-20° in week 6,90-10° in week 7, and full ROM in week 8 2
• Extra resistance can be added for quadriceps tendon repairs (unlike hamstring grafts in ACL reconstruction) 2

Neuromuscular Training:

• Add neuromuscular training to strength training to optimize outcomes and prevent reinjuries 2
• Include unstable surface training using balance pads or foam rollers to improve knee joint proprioception 4
• Incorporate single-leg dynamic balance exercises to challenge postural control and increase muscle activation 4
• Pay attention to correct quality of movement for prevention of reinjuries 2

Advanced Phase (3-6 Months)

Progressive Strengthening:

• Continue concentric and eccentric strengthening exercises through full range of motion at moderate to slow controlled speed 4
• Perform traditional quadriceps exercises at 8-12 repetitions for adults under 50-60 years, or 10-15 repetitions at reduced resistance for older individuals 4
• Use moderate repetition duration: 3 seconds concentric phase, 3 seconds eccentric phase 4
• Single-set programs performed minimum 2 days per week are highly effective and promote adherence 4

Functional Training:

• Add plyometric and agility training during advanced phases for improved subjective function and functional outcomes 5
• The combination of plyometric and eccentric training demonstrates superior improvements in balance, subjective function, and functional activities 4, 5
• Integrate sport-specific exercises into neuromuscular training programs 4

Return to Activity (6-12 Months)

Rehabilitation Duration:

• Continue rehabilitation for 9-12 months, depending on the final return-to-work or play goals 2
• The majority of patients (>90%) return to pre-injury levels of function and work 6
• Patients typically return to work approximately 10 days earlier with early functional rehabilitation compared to restrictive protocols, though this difference is not statistically significant 1

Functional Assessment:

• Do not rely solely on time-based criteria for return to activity; combine with functional testing 5
• Assess quadriceps strength symmetry and neuromuscular control 5
• Perform an extensive test battery for quantity and quality of movement, including strength testing 2

Common Pitfalls and Complications

Expected Deficits:

• Quadriceps muscular atrophy and muscle strength deficit are present in most cases but do not preclude good functional outcomes 7
• Near-full recovery in range of motion is expected, with studies reporting <5° deficit compared to the contralateral limb 6

Complications to Monitor:

• Most commonly reported complications are knee stiffness and quadriceps muscle atrophy, both treatable with proper rehabilitation 6
• Rare complications (<3%) include deep venous thrombosis/pulmonary embolism, superficial/deep infection, and tendon re-rupture 6, 7
• Heterotopic ossifications occur in 6.9% of patients 7

Critical Timing:

• Delayed operative treatment is associated with worse outcomes and increased complication rates 6, 7
• Surgical repair should be performed as soon as possible from the time of injury to minimize risks and achieve optimal outcomes 6