Phase	Phase I: Weeks 0-2	Phase II: Weeks 2-6	Phase III: Weeks 6-12	Phase IV: Weeks 12-20	Phase V: Weeks 20+
Precautions	Range of motion (ROM): progress as tolerated (do not force ROM) 90 Degrees (deg) over first 2 weeks Adhere to weight bearing restrictions 20% foot flat weight bearing (FFWB) with bilateral axillary crutches for 2 weeks Brace Guidelines Ambulation with brace locked and bilateral axillary crutches Sleep with brace locked in extension for 1 week Avoid pillow under knee to prevent knee flexion contracture Control post-operative swelling	Progress ROM as tolerated: do not force motion Weeks 2-4: partial weight bearing up to 50% with crutches Weeks 4-6: weight bearing as tolerated Brace guidelines: Weeks 2-4: Unlock brace when proper quad control is established Discharge brace at 4 weeks (may use knee sleeve at this point, if needed) Avoid pillow under knee to prevent knee flexion contracture Control post-operative swelling	Progress to full ROM Avoid pain with therapeutic exercises and functional activities Continue to control post-operative swelling	Avoid pain with therapeutic exercises and functional activities Control post-operative edema Monitor overall load and volume	Avoid pain with advanced strengthening, and plyometric activity Avoid pain with progression of return to running program Be cautious of patellofemoral overload with increased activity level Continue to control post-operative swelling Monitor overall load and volume
ROM/ Soft Tissue	Immediate ROM after surgery Do not force ROM Emphasize full knee extension immediately Heel prop multiple times per day Lower extremity stretching (hamstring/gastrocnemius/soleus) Patellar mobilization as indicated (all planes)	ROM goals (use as a guide) Week 3- 0-105° Week 4- 0-115/120° Week 6- 0-130° (progressing to full ROM) Continue exercises from phase 1 Heel slides against wall (if difficulty gaining ROM) Step knee flexion stretch, and supine hip flexor stretch when tolerated Maintain passive knee extension and patellar mobility Continue LE soft tissue treatment and stretching as needed	Gradual increase of ROM to full ROM Continue exercises from phase 2 Prone knee flexion stretches Maintain full passive knee extension Continue patellar mobilization as needed Continue with LE soft tissue program as needed Initiate foam rolling program Continue with LE stretching program (hip, hamstring, gastrocnemius/soleus) Add hip flexor and quad stretching	Patient should demonstrate full ROM without limitations Continue LE soft tissue treatment as needed	Continued LE stretching Continued foam rolling program Adjunct with soft tissue massage if needed
Strength	Quadriceps re-education. Quad sets, straight leg raises (SLR) with NMES SLR’s (all planes) Emphasize no extension lag during exercise initiate primary core stabilization/Kinetic linking program Ab sets Pelvic bracing BKFO Side lying clam shells Ankle progressive resistive exercises (PRE) Consider blood flow restriction (BFR) program with FDA approved device and qualified therapist if patient cleared by MD Independent with home exercise program (HEP) that addresses primary impairments	Continue Quadriceps re-education with NMES as needed Continue blood flow restriction (BFR) program if patient cleared by MD Bilateral Leg Press 60° → 0° arc (week 2-4) 90° → 0° arc (week 4-6) Initiate core stabilization/Kinetic linking program Standing bilateral heel raises-Week 2-3 Short Crank Bike progressing to upright bike with adequate ROM (110-115 degrees of ROM) Multiplanar glute/Core/hip strengthening Bridges with t-band Standing clamshells Weight shift exercises with UE support Bilateral weight bearing proprioception exercises Single leg balance/proprioceptive activities after proper quad control obtained Hydrotherapy when incisions are healed for gait, proximal strengthening, functional movements, balance and edema control- week 4-6 Underwater treadmill/ anti-gravity treadmill gait training if gait pattern continues to be abnormal	Progress stationary bike time Initiate interval bike program between weeks 10-12 for cardio Progress to elliptical Single leg pawing → retrograde treadmill Multiplanar gluteal/core/hip strengthening Continue exercises from phase II Romanian Dead Lift (RDL): double leg single leg Initiate open kinetic chain (OKC) knee extension (multiple angle isometrics) Progressing to isotonics (PRE) Progress to eccentric leg press (2 up/1 down) Emphasis onsloweccentric lowering and good alignment Suspension training squats and chair/box squats Band around knees to promote gluteal activation and avoid valgus breakdown Promote movement through hips and proper form Progressively lower seat height per strength gains Progress to adding weights as appropriate (PRE’s) Introduce step-up progression (week 6-8) Start with 4” step → 6” then step →8” step Emphasize proper movement pattern (no hip drop, no valgus breakdown) Progress to adding weights as appropriate (PRE’s) Front lunges Traveling lunges (don’t force ROM) Progressive gluteal/hip strengthening Continue phase II exercises Lateral/Monster walks, Three-point steps/Hip clocks, SL wall push, Windmills, Clamshells in modified side plank, and Bridge progression Progress balance/proprioception Rockerboard and SL rebounder (Progress to foam pad/ ½ foam roller) Sports specific balance Core/kinetic linking progression Progress BFR program to more weight bearing activities (i.e. squats, leg press) Introduce eccentric step-down program (week 8-12) Start with 4” step →6” step →8” step (assisted with railing) Emphasize proper movement pattern (no hip drop, no valgus breakdown) Progress to adding weights as appropriate (PRE’s)	Emphasize eccentric strength and control Continue to progress with squat program (PRE’s) Continue to progress with eccentric leg press (PRE’s) Progress with suspension training squats Eccentric DL squats (5/5/1 count) SL squats focusing on control and technique (proper hip hinge pattern) Progress with interval biking for endurance/fitness (time and resistance) Progress with step-ups/downs by increasing height and adding weight (intrinsic load) Advanced proprioception training (perturbations) Continue to progress with aquatic program if available Stair master/Versaclimber Continue with kinetic linking/core progression Continue with LE stretching Progress isotonic knee extension OKC – progress to isokinetics: moderate to high speeds Initiate running progression with Anti-gravity treadmill or pool running - weeks 16-18 Must have good eccentric control with 8” step down Be cautious of overloading the knee – monitor for swelling	Advanced strength program 3-4 times/week Cardiovascular endurance training with continued low load methods Bike/elliptical /stair machine/ rower Glute activation exercises Chair/box squats Leg press (DL/SL) Eccentric leg press with proper control and alignment Multiplanar hip strengthening Front/side/back lunges RDL (DL/SL) Advanced kinetic linking progression Chops/lifts LE stretching/foam rolling program Plyometric program (DL SL) Individualized per sport and patient need Progress strength and flexibility through entire kinetic chain (hips, knees, ankle) Agility and balance drills Progress with sport specific programs Return to running program at month 6 Must have good eccentric control with 8” step down Progress with interval treadmill program (monitor knee load) Cardiovascular training Bike/eliptical/Rower/Versaclimber Anaerobic interval training Gluteal activation exercises Chair/box squats Double leg (5/5/1) Modified SL (eccentric control) Multiplanar hip strengthening Front/side/back lunges SL Runners RDL
Criteria for advancing	Maintain knee ROM: 0-90 deg Control post op pain/swelling SLR flexion without extensor lag Adherence to post-op restrictions Independent with HEP	Full weight bearing with crutches, discharge brace Demonstrate a normal gait pattern without deviations Progressing toward full ROM Normal patellar mobility (all planes) Proximal strength > 4/5 Minimal edema Well controlled pain Independent with progressive HEP	Full pain-free ROM Chair/box squats with proper form and without complaints of pain SL stance > 30 sec with proper form and control Demonstrate ability to ascend 8” step with proper form, no pain Descend 6” step with good eccentric control, no pain Independent with HEP	80% limb symmetry (quadriceps and hamstring) with handheld dynamometry and functional testing No pain/inflammation after activity Movement without asymmetrical deviations and a hip dominant strategy Independent with HEP	90% limb symmetry (quadriceps and hamstring) with handheld dynamometry and functional testing Isokinetic test > 90% limb symmetry (if available) Independent with gym strengthening and maintenance program Movement without asymmetrical deviations and a hip dominant strategy Lack of apprehension with sports specific movement (eg. acceleration/deceleration, cutting)