Initial

 Postoperative  Instructions  

ACL  Reconstruction  

Dr.  Mia  S.  Hagen  

Medication:  You  will  receive  the  following  prescriptions:  

• Percocet  –  this  is  a  strong  narcotic  combined  with  Tylenol.  The  narcotic  can  have  side  
effects  such  as  constipation,  nausea,  vomiting,  itchy  rash,  and  it  can  make  your  head  
feel  full/lightheaded/weird.  Do  not  take  with  alcohol  or  additional  Tylenol  as  it  can  put  
you  at  risk  of  liver  damage.  You  can  take  1-­‐2  pills  every  4  hours  as  needed  for  pain.  
• Naproxen  –  this  is  an  anti-­‐inflammatory.  You  will  take  a  prescription-­‐strength  dose  of  
this  for  10  days  and  then  you  can  taper.  Take  with  food  and  do  not  continue  taking  if  it  
causes  pain  in  your  stomach.  You  will  take  this  twice  a  day.  
• Colace  –  this  prevents  constipation  caused  by  Percocet.  You  can  take  this  twice  a  day.  
• Zofran  –  this  is  to  prevent  nausea/vomiting  caused  by  Percocet.  Also  taking  the  Percocet  
with  food  can  help.  You  can  take  one  pill  every  6  or  8  hours.  
• If  you  experience  itchiness  you  can  take  over-­‐the-­‐counter  Benadryl.  You  can  take  one  25  
mg  tablet  every  6  or  8  hours.  
• If  you  are  at  an  increased  risk  of  blood  clots  you  will  likely  receive  a  2-­‐week  prescription  
of  low-­‐dose  Aspirin,  one  pill  taken  daily.    

 
Dressing:    

• You  may  remove  your  dressing  after  48  hours.  It  is  normal  to  see  bloody  bandages  when  
you  take  off  the  dressing.  
• Leave  the  tape  strips  (“Steri-­‐Strips”)  over  your  incisions.  Do  not  remove.  They  will  stay  
on  for  1-­‐2  weeks  and  slowly  peel  off.  You  can  apply  gauze  or  Band-­‐aids  over  the  
wounds,  make  sure  you  change  them  daily.  
• You  may  shower  and  let  the  water  run  over  your  incisions  (and  the  white  tape  strips)  48  
hours  after  your  surgery.  Do  not  scrub  the  incisions.  Pat  dry.  Do  not  soak  the  incisions  in  
a  bath,  hot  tub,  or  pool  until  at  least  3  weeks  after  surgery.  
• Your  stitches  will  be  removed/trimmed  around  1-­‐2  weeks.  
• DO  NOT  APPLY  LOTION/OINTMENT  TO  YOUR  INCISION.  
• You  will  be  given  thigh-­‐high  compression  stockings  after  surgery.  These  are  to  reduce  
the  risk  of  blood  clots.  They  also  decrease  swelling  in  your  feet  after  surgery.  You  should  

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 wear  these  at  all  times  for  the  first  2  weeks  after  surgery.  You  may  take  them  off  to  
sleep,  shower  or  to  clean  them  (hand  wash  then  air  dry).  Alternatively  you  can  use  an  
ace  wrap.  
 

Weight  bearing  &  activities:  

• You  may  begin  to  put  weight  on  your  leg  when  you  have  the  feeling  back  in  your  leg.  
Focus  on  striking  the  ground  with  your  heel.  You  may  wean  off  the  crutches  as  guided  by  
your  PT.  
• Rest  and  elevate  your  leg  (above  the  level  of  your  heart  if  possible)  for  the  first  24  hours  
by  placing  a  pillow  under  your  calf  and/or  ankle.    
• Do  NOT  place  a  pillow  under  your  knee  as  it  will  keep  you  from  straightening  your  knee.  
• IT  IS  VERY  IMPORTANT  TO  GET  YOUR  LEG  AS  STRAIGHT  AS  POSSIBLE  AS  SOON  AS  
POSSIBLE.  
• Start  physical  therapy  (PT)  within  the  first  week  after  surgery.  Please  give  the  “Post-­‐
Operative  ACL  Rehabilitation”  guidelines  (pages  5-­‐7  of  this  packet)  to  your  PT.  
 

Ice/Ice  Cooling  Unit:  

• Icing  will  help  a  lot  with  pain.  

• Ice  up  to  20  minutes  every  hour.  Use  routinely  for  the  first  2  days.  Then  you  can  taper  to  
at  least  3  times  per  day  for  2  weeks,  and  then  as  needed  after  that.  
• Do  not  put  ice  in  direct  contact  with  skin.  If  you  have  an  ice  cooling  unit,  do  not  place  
the  pad  in  direct  contact  with  skin.  
• Do  not  wear  ice  or  cooling  unit  when  you  are  sleeping  –  it  can  burn  your  skin  and  lead  to  
serious  injury.    
 
 
If  you  received  a  Nerve  Block:  
• You  were  given  an  injection  before/after  surgery  to  block  the  conduction  of  your  
femoral  nerve  which  controls  pain,  sensation,  and  your  quadriceps  muscle  contraction.  
• You  should  be  relatively  pain  free  for  the  first  night  but  have  little  control  of  your  leg.  
You  should  wear  the  knee  immobilizer  until  the  feeling  returns  in  your  leg  (this  will  keep  
you  from  falling  if  you  put  weight  on  your  leg).  
• Make  sure  to  start  the  Percocet  on  the  first  night  before  you  go  to  sleep,  even  if  you  
don’t  feel  any  pain  because  the  block  may  wear  off  during  the  night  and  it  can  be  
difficult  to  catch  up  with  the  pain.  

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Follow-­‐up:  

You  will  be  seen  by  Travis,  our  physician  assistant,  at  1-­‐2  weeks  after  surgery  for  a  wound  check  
and  removal  or  trimming  of  stitches.  You  will  be  seen  by  Dr.  Hagen  at  6  weeks  after  surgery.  
Timing  and  length  of  additional  follow-­‐ups  will  be  determined  by  your  progress.  

Crutch  Use  
To  walk  with  crutches:   Going  upstairs:  
• Pull  crutches  under  your  arms  and  press  them   • Start  close  to  the  bottom  step,  and  push  down  
into  your  ribs   through  your  hands  
• Move  the  crutches  ahead  of  you  6-­‐12  inches   • Step  up  to  the  first  step,  remember  to  good  
• Push  down  on  the  handgrips  as  you  step  up  to   foot  goes  up  first!  
or  slightly  past  your  crutches   • Next,  step  up  to  the  same  step  with  the  other  
• Make  sure  to  bear  weight  on  your  hands,  not   foot,  making  sure  to  keep  the  crutches  with  
under  your  arms   your  affect  leg  
• Check  your  balance  before  you  continue   • Check  your  balance  before  you  proceed  to  the  
  next  step  
To  sit  down  in  a  chair:   • Make  sure  someone  is  there  if  you  need  it  
• Back  into  the  chair  until  you  feel  it  on  your  legs    
• Put  both  crutches  in  your  hand  on  the  affected   Going  downstairs:  
side,  reach  back  for  the  chair  with  the  other   • Start  at  the  edge  of  the  step,  keeping  your  hips  
hand   beneath  you.  
• Lower  yourself  into  the  chair   • Slowly  bring  the  crutches  with  your  affected  
  limb  down  to  the  next  step  (the  operative  leg  
To  get  up  from  the  chair:   goes  down  first!)  
• Hold  both  crutches  on  your  affected  side   • Be  sure  to  bend  at  the  hips  and  knees  to  
• Slide  to  the  edge  of  the  chair     prevent  leaning  too  far  forward,  which  could  
• Push  down  on  the  arm  of  the  chair  on  the  good   cause  you  to  fall  
side   • Make  sure  someone  is  there  if  you  need  it
• Stand  up  and  check  your  balance  
• Put  crutches  under  your  arms,  pressing  
crutches  into  ribs  
 
 
 
 
 
 
 
 
 
 
 
 
 

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 After  Surgery,  Call  the  Clinic  if  you  have…  

• A  fever  higher  than  101°  (38.3°  C)

• Changes  in  your  incision:   Call  9-­‐1-­‐1  immediately  
o Opening if  you  have:  
o Drainage • Chest  pain  
o Redness   • Shortness  of  
• Numbness,  tingling,  or  loss  of  function  of  your  leg. breath  
o Please  note  that  if  you  receive  an  anesthetic  
nerve  block  on  the  day  of  surgery,  it  can  last  for  24  hours  or  more.  You  may  
notice  some  unusual  tingling  on  occasion  after  the  block  wears  off.  This  should  
go  away  in  a  few  days.  If  not,  please  call  the  office.
• Increased  pain  in  the  knee  that  is  not  helped  by  your  medications.
• Increased  pain  or  swelling  in  your  calf.
• Nausea  or  other  side  effect  not  controlled  by  the  medications  you  are  given.
• Any  symptom  you  do  not  fully  understand.  
• Number  to  call  during  business  hours  (8  am  –  5  pm,  M-­‐F,  excluding  holidays):  
o (206)  598-­‐3294.  Wait  for  Option  8  and  ask  to  speak  to  a  nurse.  
• Number  to  call  after  hours:  
o (206)  598-­‐6190.  You  should  receive  a  call  back  within  30  minutes.  If  not,  call  
again.  
• Please  do  not  hesitate  to  call  us  if  you  have  any  questions  or  concerns!!  

 
Prescription  Refills:  Call  (206)  598-­‐3294  x8.  Call  before  running  out  of  your  medication  –  
please  allow  3  business  days  for  refills.  Do  not  have  your  pharmacy  call  us,  we  must  speak  
directly  to  you.  Percocet  and  other  narcotic  pain  prescriptions  cannot  be  faxed/mailed  to  the  
pharmacy  –  they  must  be  picked  up  from  the  clinic  or  mailed  to  your  home.  

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 Post-­‐Operative  ACL  Rehabilitation:  Isolated  primary  ACL  Reconstruction  

Dr.  Mia  S.  Hagen  

Please  give  this  handout  to  your  therapist  

 
Phase  0:  Preoperative  visit  

Goals   Ready  for  Surgery  When  

• Patient  education   • Minimal  effusion  
! Phase  1  exercises   • Active  ROM  0-­‐120  
! Crutch  use   • Strength  returned  
! Wound  care   ! 20  straight  leg  raises  (SLR)  without  lag  
• Normal  gait    
• Minimal  effusion  
• Optimize  ROM  &  strength  
 
 

Phase  1:  Immediate  Postoperative  (0-­‐2  weeks)  

Goals   Exercise  Suggestions   Criteria  for  Progression  

• Normal  gait  pattern   • ROM:   • Crutches  dc’d:  
! Crutches   ! Extension:  low  load,  long  duration  (5  min)   ! To  do  so,  must  
initially"WBAT   stretching  (heel  prop,  prone  hang,  calf   have  normal  
• Full  knee  extension   stretch,  hamstring  stretch;  minimize  co-­‐ gait  pattern  
! No  brace   contracture  and  nociceptor  response)   and  can  go  up  
• Quad  control:     ! Flexion:  wall  slides,  heel  slides,  seated   &  down  stairs  
! 20  SLR  without  lag   assisted  knee  flexion,  bike  (rocking-­‐for-­‐ without  pain  or  
• Minimize  pain   range)   instability  
• Minimize  swelling   ! Patellar  mobilization:  monitor  for  reaction  to   • SLR  no  lag  >20  reps  
• Patellofemoral  precautions   effusion  &  ROM   • Normal  gait  
• Strength:   • ROM:  110°  active  
! Quad  re-­‐education:  e-­‐stim,  biofeedback   flexion,  no  greater  
! Quad  sets,  SLR  no  lag,  double-­‐leg  quarter   than  5°  active  
squats,  standing  Thera-­‐Band  resisted  TKE   extension  lag  
! Hamstring  sets,  ham  curls,  quad/ham  co-­‐ ! NOTIFY  
contraction  supine   SURGEON  IF  
! Leg  press  in  90°-­‐40°  arc  –  start  w/eccentrics   EXTENSION  
! Side-­‐lying  hip  add/abduction   GOALS  NOT  
! Prone  hip  extension,  seated  hip  flexion   MET  BY  4  WKS  
! Ankle  pumps  with  Thera-­‐Band  calf  press  or    
heel  raises  
• Other:    
! Cardiopulmonary:  upper  body  erg  machine  
! Scar  massage  when  incision  healed  
! Cryotherapy  

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Phase  2:  Early  Rehabilitation  (3-­‐6  weeks)  

Goals   Exercise  Suggestions   Criteria  for  Progression  

• Full  ROM   • ROM:   • Full  ROM  
• Improve  muscle   ! Low  load,  long  duration   ! NOTIFY  SURGEON  IF  
strength     ! Heel  slides,  wall  slides,  heel  prop,  prone   ALL  ROM  GOALS  NOT  
• Progress   hang,  bike  with  lower  seat  height   MET  BY  6  WKS  
neuromuscular   ! Flexibility  stretching  all  major  groups   • Minimal  effusion/pain  
retraining   • Strength:   • Functional  strength  and  
  ! Quad:  quad  sets,  mini-­‐squats,  wall-­‐squats,   control  in  daily  activities  
step-­‐ups,  knee  extension,  leg  press,  shuttle   • IKDC  Question  #10  score  ≥7:  
press  without  jump   ! “How  would  you  rate  
! Ham:  ham  curls,  resistive  SLR  with  sports   the  function  of  your  
cord   knee  on  a  scale  of  0-­‐10  
! Hip  add/abduction  with  resistance,  multi-­‐ with  10  being  
hip  machine   normal/excellent  
! Standing  heel  raises  from  double  to  single   function  and  0  being  
leg  support,  seated  calf  press   the  inability  to  perform  
• Neuromuscular  training:   any  of  your  usual  daily  
! Wobble  board,  rocker  board,  single-­‐leg   activities?”  
stance,  slide  board,  fitter    
• Cardiopulmonary:    
! Stationary  bike,  elliptical,  Stairmaster,  
NordicTrack  

 
Phase  3:  Strengthening  &  Control  (7-­‐16  weeks)  

Goals   Exercise  Suggestions   Criteria  for  Progression  

• Maintain  full  ROM   • Strength:   • Running  without  pain  or  
• Demonstrate  ability   ! Squats,  leg  press,  ham  curl,  knee  extension   swelling  
to  descend  an  8”  step   90°-­‐0°,  step  up/down,  lunges,  sports  cord,   • Hopping  without  pain  or  
without  pain  or   wall  squats,  hopping  without  pain   swelling  (bilateral  and  
deviation     (bilateral  then  single  leg,  end  in  ¼  squat)   unilateral)  
• Running  without  pain   • Neuromuscular  training:   • Neuromuscular  and  
or  swelling   ! Wobble  board,  rocker  board,  roller  board,   strength  training  exercises  
• Hopping  without   perturbation  training,  varied  surfaces   without  difficulty  
pain,  swelling,  or   ! Instrumented  testing  systems    
giving-­‐way   • Cardiopulmonary:    
  ! Stationary  bike,  elliptical,  Stairmaster,  
NordicTrack  
! Straight  line  running*  no  sooner  than  12  
wks  on  treadmill  or  protected  
environment  (NO  cutting  or  pivoting)  

*Prior  to  running,  patient  must  pass  a  test  circuit  of  single  leg  squats  (3x30),  double  leg  hops  (3x30),  single  leg  hops  
(3x30),  and  sport  cord  resisted  running  3  x  90  seconds.  Pain,  fatigue,  or  break  of  form  is  a  failed  test.    

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Phase  4:  Advanced  training  (16-­‐20  weeks)  

Goals   Exercise  Suggestions   Criteria  for  Progression  

• Running  patterns   • Strength:   • Maximum  vertical  jump  
(Figure-­‐8,  pivot  drills,   ! Squats,  lunges,  plyometrics   without  pain  or  instability  
etc.)  at  75%  speed   • Agility  drills:   • 75%  of  contralateral  on  hop  
without  difficulty     ! Shuffling,  hopping,  carioca,  vertical  jumps,   tests  
• Jumping  without   running  patterns  at  50-­‐75%  speed  (e.g.   • Figure-­‐8  run  at  75%  speed  
difficulty   Figure-­‐8),  initial  sport-­‐specific  drills  at  50-­‐ without  difficulty  
• Hop  tests  at  75%   75%  effort   • IKDC  Question  #10  score  ≥8  
contralateral  values   • Neuromuscular  training:   (see  above)  
! Cincinnati  hop   ! Wobble  board,  rocker  board,  roller  board,    
tests:  single-­‐leg   perturbation  training,  varied  surfaces  
hop  for  distance,   ! Instrumented  testing  systems  –  KT-­‐1000  
triple-­‐hop  for   test,  isokinetic  testing  at  120°/second  and  
distance,   240°/second    
crossover  hop  for   • Cardiopulmonary:    
distance,  6-­‐meter   ! Running*  
timed  hop   ! Any  other  cardiopulmonary  equipment  
 

*See  separate  Return  to  Run  program  

 
Phase  5:  Return-­‐to-­‐Sport  (20-­‐24+  weeks)  

Goals   Exercise  Suggestions   Criteria  for  Progression  

• 85%  contralateral   • Aggressive  strengthening:   • Return-­‐to-­‐Sport  Criteria:  
strength   ! Squats,  lunges,  plyometrics   ! No  functional  
• 85%  contralateral  on   • Sport-­‐specific  activities:   complaints  
hop  tests   ! Interval  training  programs,  sprinting,   ! Confidence  when  
• Sport-­‐specific  training   change  of  direction,  running  patterns  in   running,  cutting,  
without  pain,   football,  pivot  and  drive  in  basketball,   jumping  at  full  speed  
swelling,  or  difficulty     kicking  in  soccer,  spiking  in  volleyball,   ! 85%  contralateral  
  skill/biomechanical  analysis  with  coaches   values  on  hop  tests  
and  sports  medicine  team   ! IKDC  Question  #10  ≥9  
• Instrumented  testing  systems   (see  above)  
• Return-­‐to-­‐Sport  evaluation  recommendations:    
! Hop  tests  (see  above),  vertical  jump,  
deceleration  shuttle  
 

Please  send  progress  notes.  Thank  you.  

  M.D.  
Mia  S.  Hagen,  
3800  Montlake  Blvd  NE  
 
Box  354060  
Seattle,  WA  98195-­‐4060  
Phone:  206-­‐598-­‐3294  opt  8  |  Fax:  206-­‐598-­‐3140  
smia@[Link]  

University  of  Washington  Department  of  Orthopaedics  &  Sports  Medicine   Page  7  of  7