NON OPERATIVE PHYSIOTHERAPY PROTOCOL FOR ROTATOR CUFF

INJURY:

PHASE I WEEKS 0-4

PRECAUTIONS
Avoid provocative exercises that causes discomfort
Patient may have an underlying coracoacromion bursitis therefore ROM &
muscle strengthening exercises should begin with arm in less than 90ᵒ of
abduction
Avoid abduction with rotation that create impingement maneuver
Avoid empty can exercises.
IMMOBILIZATIO Sling immobilization for short period only 3-6 days
N
PAIN CONTROL Medications: NSAIDS
Subacromion/intra articular injection of corticosteroids or local anaesthetic
Therapeutic modalities:
 Ice ,US, HVGS
 Moist heat before exercises and ice at the end of session.
SHOULDER MOVEMENTS
GOALS Internal & External rotation equal to contra lateral side with arm positioned in
less than 90ᵒ abduction
EXERCISES Begin with codman exercises
Passive ROM exercises
 Forward flexion & extension
 Internal & external rotation
 Capsular stretching for anterior, posterior and inferior capsule
Avoid assisted motion exercises
Progress to AROM exercises
 Finger ladder
ELBOW Passive to active movements
MOVEMENTS  Flexion/extension 0-130ᵒ
 Pronation to supination
MUSCLE Grip Strengthening
STRENGTHENING
Use of arm for ADLs below shoulder level
CRITERIA FOR PROGRESSION TO PHASE II
Minimal pain & tenderness
Improvement of PROM
Return to functional ROM

PHASE II WEEKS 4-8

GOALS Improve shoulder complex strength, power & endurance
RESTRICTIONS Avoid provocative manoeuvres or exercises that causes discomfort
IMMOBILIZATIO Not needed
N
PAIN CONTROL Same as before
SHOULDER Equal to contra lateral shoulder in all planes of movements
MOVEMENTS
EXERCISES Passive ROM
 Capsular stretching
Active assisted motion exercises
AROM exercises
ELBOW Passive to active movements
MOVEMENTS  0-130ᵒ flexion/extension
 Pronation& supination as tolerated
MUSCLE Strengthening of remaining rotator cuff muscles.
STRENGTHENING
Begin closed chain isometric strengthening
 Internal & external rotation
 Abduction
Progress to open chain strengthening exercise with very low weight dumbbells
 Exercises performed with elbow 90ᵒ flexion
 Starting with shoulder in neutral position of 0ᵒ forward flexion,
abduction & external rotation
 Exercises done through an arc of 45ᵒin each of 5 planes of motion
Strengthening of deltoid
Strengthening of scapular stabilizers
 Closed chain exercises
o Scapular retraction and protraction
o Scapular depression and elevation
 Progress to open chain scapular stabilizer strengthening
CRITERIA FOR PROGRESSION TO PHASE III
Painless & complete ROM
No pain & tenderness with strengthening exercises

PHASE III WEEKS 8-12

GOALS Improve neuromuscular control & shoulder proprioception
Prepare for gradual return to ADLs
Home exercise program including strengthening & stretching exercises
FUNCTIONAL Plyometric exercises
STRENGTHENING
Maximal improvement is expected by 4-6 months

POST-SURGICAL REHABILITATION PROTOCOL FOR ROTATOR CUFF

INJURY

PHASE I IMMEDIATE POST SURGICAL PHASE (DAY 1-10)

GOALS Maintain integrity of repair
Gradually increase in PROM
Diminish pain & inflammation
Prevent muscular inhibition
DAY 1-6 Sling or abduction brace
Shoulder passive supine ROM
 Shoulder flexion to tolerance 0-140ᵒ
 ER 0-40ᵒ
Scapular depression and retraction
 Active elbow/wrist/hand (E/W/H) gripping and ROM exercises
Stretching of neck and upper quarter
Cryotherapy (15-20 minutes every hour) for pain& inflammation
Night sling or brace
DAY 7-10 Continue use of sling
Progress PROM to tolerance
 Shoulder flexion to at least 140ᵒ supine
 ER/IR in scapular plane to 35-45ᵒ
Continue active E/W/H ROM exercises
Stretching of neck and upper quarter
Initiate submaximal isometric
Continue use of ice for pain control
Night brace
PRECAUTIONS Avoid lifting objects
Avoid excessive shoulder extension
Avoid excessive stretching
Avoid supporting of body weight by hands
Keep incision clean & dry

PHASE II PROTECTION PHASE (DAY 11-WEEK 6)

GOALS Allow soft tissue healing
Regain dynamic shoulder stability
Decrease pain & inflammation
DAY 11-14 Continue use of sling
PROM to tolerance in supine
 Shoulder flexion 0-170ᵒ
 ER/IR at least 45ᵒ in scapular plane
Continue all isometric exercises
Overhead pulleys
Continue use of Cryotherapy as needed
Continue all precautions
WEEK 3-4 Patient should have full PROM
Continue scapular stabilization exercises & initiate scapular strengthening
Initiate resisted scapular retraction
Initiate active ER supine in scapular plane using wand to stretch at terminal range
Initiate isotonic elbow flexion
Initiate self-capsular stretches
Continue use of ice as needed
May use heat prior to ROM exercises
Continue sling
WEEK 5-6 Discontinue use of sling
May use heat prior to exercise
Initiate AAROM & stretching exercises
 AA flexion with active extension to neutral and AA abduction with active
adduction
Initiate AROM exercises
 Shoulder flexion scapular plane
 Shoulder abduction
 ER/IR side lying
 Prone rowing
  Prone horizontal abduction
Biceps curls
Start upper body ergometer below 90ᵒ elevation
PRECAUTIONS Avoid lifting heavy objects
Avoid excessive behind the back movements
Avoid supporting of body weight by hands & arms
Avoid sudden jerking motions

PHASE III INTERMEDIATE PHASE (WEEK 7-14)

GOALS Full AROM (week 8-10)
Dynamic shoulder stability
Gradual restoration of shoulder strength and power
Gradual return of functional activities
WEEKS 7 Continue stretching and PROM
Continue dynamic stabilization drills
Initiate isotonic strengthening program pain free
 ER/IR supine
 Prone rowing
 Prone horizontal abduction
 Prone extension
 Elbow flexion/extension
Patient must be able to elevate arm without shoulder or scapular hiking before
initiating isotonic, if unable, continue humeral head/ scapular stabilization
exercises
WEEK 8-13 Continue all exercise listed above
ER side lying
Lateral raises
Full can in scapular plane
Initiate light functional activities
WEEK 14 Continue all exercises listed above
Progress to fundamental shoulder exercises

PHASE IV ADVANCED STRENGTHENING PHASE (WEEK 15- 22)

GOALS Maintain full non-painful ROM
Enhance functional use of upper limb
Improve muscular strength and power
Gradual return to functional activities
WEEK 15 Continue ROM & stretching to maintain full ROM
Continue shoulder strengthening to fundamental shoulder exercises
Initiate Plyometrics

NON OPERATIVE PHYSIOTHERAPY PROTOCOL FOR ACL INJURY:

PHASE I MOTION AND PROTECTION

Goals To decrease pain and edema
To increase strength of muscles
To maintain ROM
 To improve patellar mobility
Independent ambulation
To reduce pain & RICE Therapy
swelling
US, TENS, IFT or EMS
Ankle pumps
Strengthening Isometric of quadriceps, hamstring, hip abductors, adductors, abdominals and
exercises quadratus lumborum
Electrical stimulation to VMO and quadriceps
ROM Patellar mobilization
PROM/AROM
Stretching Stretching of quadriceps, hamstring, hip flexors, ITB, calf muscles
CCE Light close chain exercise e.g. mini squats
Proprioceptive Initiate neuromuscular control and proprioceptive exercise
exercise

PHASE II MOTION AND CONTROL

Same as above
Wear brace for functional activities
CKCE Progress CCE: step ups, leg press, theraband kicks
OKCE Initiate open kinematic chain exercise with precaution as it may cause
excessive anterior translation of tibia on femur

PHASE III STRENGTH AND PROPRIOCEPTION

Goals Pain free and complete AROM
Normal strength of VMO
Less than 20% quadriceps deficit
Treatment Same as above
Eccentric exercises of quadriceps and hamstring muscles
Progress proprioceptive exercises
Balance and coordination exercises

PHASE IV STRENGTH, FUNCTION AND ENDURANCE

Goals Less than 10% strength deficit and proper hamstring / Quadriceps ratio
Treatment Same as above
Progressive resistance exercises
Light plyometrics
Forward and backward step over

POST-SURGICAL PHYSIOTHERAPY PROTOCOL FOR ACL INJURY:

PHASE I WEEK 0-2

Goals Protect graft fixation
Reduce pain and inflammation
Achieve full knee extension and 0-90ᵒ knee flexion
Brace Drop lock brace locked in extension for ambulation and sleeping
WB WBAT with 2 crutches
Discontinue crutches as tolerated after 7 days
Exercises RICE therapy
 Heel slides, wall slides
Quadriceps and hamstring sets
Patellar mobilization
NWB gastrocnemius and hamstring stretch
SLR with brace in full extension until quadriceps strength is sufficient to
prevent extensor lag
Prone leg hangs

PHASE II WEEK 2-6

Goals Restore normal gait
Restore full ROM
Protect graft fixation
Improve strength, endurance and proprioception
Brace Discontinue after 4 weeks
WB Patellar tendon graft: Continue ambulation with brace locked in extension,
may unlock for sitting and remove brace for ROM exercises
Hamstring graft: may discontinue the brace as quadriceps control is achieved.
Exercises Mini squats 0-30ᵒ
Stationary bike
CKCE : leg press 0-30ᵒ
Toe raises
Continue stretches and prone hangs

PHASE III WEEKS 6-8

Goals Avoid overstressing of graft fixation
Protect patellofemoral joint
Progress strength and proprioception
Exercises Patellar mobilization
CKCE: one leg squat, Leg press 0-60ᵒ
Stair climbing: step up and down
Plyometrics
Proprioceptive exercises: trampoline, wobble board balance

PHASE IV WEEK 8-12

Goals Return to ADLs
Exercises Continue and progress strength and flexibility program
Proprioceptive exercises
Plyometrics
Lunges
Cross over walking- agility drills

NON-SURGICAL PHYSIOTHERAPY PROTOCOL FOR PCL INJURY:

PRECAUTION Avoid more than 90ᵒknee flexion for first 6 weeks post injury.
Posterior knee pain indicates that progression is too quick
PHASE I DAY 0-10
ROM 0-60 Degrees
To reduce swelling Ice, elevation, NSAIDS
WB/Gait Protected WB (50%) with crutches
Exercises Isometric quadriceps as pain permits
AVOID Avoid open chain hamstring strengthening exercises

PHASE II DAY 10-21

ROM Early ROM within limits of pain
Active assisted and passive range of motion less than 60 Degrees
To reduce swelling Ice, elevation, NSAIDS
WB/Gait WBAT with knee brace locked in extension
Discontinue crutches when patient is able to and swelling is controlled
Exercises Isometric quadriceps when pain permits
Leg press 0-60 degrees
AVOID Avoid open chain hamstring strengthening exercises
Avoid posterior subluxation by placing a pillow under posterior aspect of
lower leg when lying down

PHASE III WEEK 3-5

ROM Progress as tolerated
To reduce swelling Ice, elevation, NSAIDS, electrical stimulation
WB/Gait WBAT
Discontinued the large hinged knee brace as tolerated
Obtain a functional PCL brace
Exercise/Functional Increase strength and endurance of quadriceps
training
Open chain knee extension exercises allowed only when no patellofemoral
symptoms present
Quadriceps sets and terminal knee extension
Hip extension with knee extension
No hamstring exercise with flexed knee
Mini squats 0-60ᵒ
Leg press 0-60ᵒ

PHASE IV WEEK 5-8

ROM Progress as tolerated
Gait/WB WBAT
Exercise/Functional Closed chain exercises to improve functional strength
training e.g. Mini squats, Wall slides, steps up , leg press
Progressive resistance exercises of quadriceps
Proprioceptive exercises: Slide board

POST OPERATIVE PHYSIOTHERAPY PROTOCOL FOR PCL INJURY:

PHASE I IMMEDIATE POSTOPERATIVE : WEEK 0-2

GOAL Control swelling & inflammation
Obtain full passive extension
Gradually increases the flexion to 90ᵒ
Patellar mobility
To reduce swelling Ice and elevation
Brace Wrap locked at 0ᵒ knee extension for ambulation and sleep only from 4 th day
onwards
WB As tolerated with 2 crutches (50%)
ROM PROM (0-90ᵒ of knee flexion) out of brace.
EXERCISES Patellar mobilization
Stretching of hamstring and calf muscles
Ankle pumps
Quadriceps sets
SLR for hip flexion, abduction and abduction
Knee extension 60-0ᵒ
EMS To quadriceps during quadriceps sets
CPM 0-60ᵒ as tolerated

PHASE II MAXIMUM PROTECTION WEEK 2-6

GOALS Control extension forces to protect graft
Restore motion
Nourish articular cartilage
Decrease swelling and fibrosis
Prevents quadriceps atrophy
WEEK 2
Brace Wrap locked at 0ᵒ knee extension
WB As tolerated with 1 crutch
ROM PROM (0-90ᵒ of knee flexion) out of brace.
Exercises Multiangle isometrics 60, 40,20ᵒ
Quadriceps sets
Knee extension 60-0ᵒ
Leg press 0-60ᵒ
EMS To quadriceps during quadriceps sets
CPM 0-60ᵒ as tolerated
WEEK 3
Brace Wrap locked at 0ᵒ knee extension
WB Full WB, No crutches
ROM PROM (0-100ᵒ of knee flexion) out of brace.
Exercises Mini squats 0-45ᵒ
Wall squats 0-50ᵒ
Knee extension 60-0ᵒ
Static cycling for ROM and endurance

PHASE III CONTROLLED AMBULATION –WEEK 4-5

Goals Restore full ROM
Improve quadriceps strength
Restore proprioception
Discontinue knee immobilizer
Quadriceps strength 70% of contra lateral side
Decrease joint effusion
ROM PROM (0-120ᵒ)
Exercises Knee extension 60-0ᵒ
Leg press 0-75ᵒ
Lateral step ups
 Front and side lunges
Heel toe raises
WEEK 6-10
ROM PROM 0-130ᵒ

PHASE IV LIGHT ACTIVITY Months 3-4

Goals Develops strength, power and endurance
Begin to prepare for return to functional activities
Exercises Begin light running program
Agility drills
Initiate plyometrics

NON-OPERATIVE PHYSIOTHERAPY PROTOCOL FOR MENISCAL INJURY:

PHASE I WEEK 0-1

AIM To reduce swelling
Maintain ability to extend the knee
Knee flexion over 90ᵒ
Cryotherapy For 15 minutes after every couple of hours to reduce swelling
Compression To reduce swelling to be worn for 24 hours/day.
bandage / knee  Initial 1-2 days during complete rest a simple elastic knee sleeve is used.
support  Later on hinged knee brace is used to protect the medial knee ligaments
and cartilage while initiating walking.
Electrotherapy To reduce pain and inflammation
modalities e.g. Ultrasound, TENS, IFT
Exercises Gentle ROM exercises within limits of pain
Isometric or static quadriceps exercises
Double leg calf raises, hip abduction and extension
Resistance band hamstring exercises
Static cycling to maintain aerobic fitness

PHASE II WEEK 1-2

AIMS To eliminate knee swelling
Achieve full knee ROM
Continue Cryotherapy , knee support and electrotherapy modalities
Exercises Same as above
Closed chain exercises of lower limb
 Squats and lunges if pain allows
 Leg press initially bilaterally and gradually unilaterally
 Step up
 Hip bridges
Proprioceptive exercises: wobble board balance drill

PHASE III WEEK 2-3

AIMS Regain full knee ROM
Regain normal muscle strength
Return to ADLs
Knee support Discontinue/ not needed
Exercises Same as above
Running, swimming, road cycling
Plyometric s
Backward running, jumping, hopping and kicking

Surgical Treatment:
Indications:

 Presence of O’Donoghue’s triad (also known as unhappy triad): Combined Injury

of Anterior cruciate ligament, Medial collateral ligament and Medial meniscus.

Repair Remove (Menisectomy)

 Acute longitudinal tear > 1cm and located in  If repair is not possible
peripheral third
 Repair is also more successful with an intact
ACL
 If any associated injury is present.

POST OPERATIVE REHABILITATION PROTOCOL FOR MENICAL INJURY:

PHASE I MAXIMUM PROTECTION PHASE : WEK 1-6

Stage 1 Immediate postoperative : Day 1-Week 3
Rice therapy
Electrical muscle stimulation
Brace locked at 0ᵒ
ROM exercises ROM 0-90ᵒ
 Motion limited for first 7-21 days
 Gradual increase in flexion ROM as per pain allows
Mobilization Patellar mobilization
Scar tissue mobilization
Strengthening Quadriceps isometrics
exercises
Hamstring isometrics (when posterior horn is repaired then no hamstring exercise
for 6 weeks)
Hip abduction and adduction
Weight bearing WBAT with crutches and brace locked at 0ᵒ
Proprioceptive
exercises

Stage 2 Progressive resistance exercises

Limited range knee extension
Toe raises
Mini squats
Cycling
Flexibility exercises
PHSE II MODERATE PROTECTION PHASE : WEEK 6-10
Goals To increase strength, power and endurance
To regain full ROM of knee
Exercises Same as above
Lateral step ups
Endurance Swimming, cycling, stair climbing
exercises
Co-ordination Balance board
exercises
Backward walking
Plyometrics

PHASE III ADVANCE PHASE WEEK 11-15

Goals Increase power and endurance
Return to ADLs.
Exercises Same as above
Full ROM exercises
Initiate running programs