steven traina, md, nathan lilley, mpt, ocs, cscs · 2019. 12. 26. · steven traina, md, nathan...

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One Surgeon. One Patient.SM 1

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ACL Performance Enhancement ProgramSteven Traina, MD, Nathan Lilley, MPT, OCS, CSCS

Nathan Lilley, MPT, OCS, CSCS, earned his Bachelors degree in Biology as well as his Masters degree in Physical Therapy from Rockhurst University in Kansas City, Missouri. Nate has been in the orthopedic clinical setting for the last 11 years. In 2005, Nate was recognized as a Board Certified Clinical Specialist in Orthopedic Physical Therapy from the American Physical Therapy Association. In addition, he is a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association. Nate is co-owner of Physio Pro Physical Therapy in Denver Colorado. His clinic specializes in orthopedic and manual physical therapy with a strong emphasis in sports medicine, and general care in youth through geriatric patient populations. Over the years, he has worked with numerous collegiate athletes as well as local professional athletes affiliated with the NBA, NHL, AFL, and PGA. He developed and implemented the “Physio Pro ACL Performance Enhancement Program“ in 2001. Nate continues to promote wellness, injury prevention, and sports enhancement to the local community as well as many local youth athletic teams.

Steven M. Traina, M.D., is a fellowship trained Board Certified Orthopedic Surgeon. He practices in Denver, Colorado with Western Orthopaedics. Dr. Traina has been serving as the team physician for the Denver Nuggets for the last 24 years and in the past has been a consultant for the Denver Broncos football team and the Colorado Avalanche hockey team. He has published and spoken extensively on sports medicine topics.

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ACL Performance Enhancement Protocol


Steven Traina, MDWestern Orthopaedics

Denver, Colorado

Nathan Lilley, MPT, OCS, CSCSPhysio Pro

Denver, Colorado

Exercise Protocol

The following is an evidenced–based Functional Testing Algorithm (FTA) protocol that has specific guidelines for progressing treatment based off selected objective criteria. Before entering the next phase of rehab, specific goals must be met. Specific functional tests must be completed with satisfactory results before the next phase of rehabilitation may begin. High intensity plyometrics are integrated into the final phase of the protocol. This portion of the program stems largely from the last 15 years of research coming from the Cincinnati Sports Medicine Research and Education Foundation. Our complete Impact protocol is outlined but please reference the training manual and DVD for a complete profile of the program. The entire protocol is derived from the latest research. All references can be found at the end of the DVD.

Patients must commit themselves to a vigorous but four to six month rehab regime to help protect their new ACL before returning to unrestricted activities.

The first seven weeks of rehab are not outlined. The standard ACL protocol for the first seven weeks should be at the hands of surgeon and physical therapist depending upon the severity of the patient’s surgery. The program should not begin any sooner than eight weeks post–op and the patient must meet the criteria in order to enter the performance enhancement program. Progression of the program is at the discretion of the therapist/physician. Sound clinical judgment is essential for progression. If the criteria are not met then standard therapy will continue until objective measures are adequate.

There are a total of five phases of rehabilitation to complete before a return to competition can be considered. Although estimated time frames are outlined, not all patients will progress equally as there may be complicating factors that may hinder or expedite rehabilitation. Below are the criteria for progression through the various phases of our protocol. Anticipated timelines and suggested interventions are found on the following pages.

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ACL Performance Enhancement Program

Patient Name ______________________

Steven Traina, MD, Nathan Lilley, MPT, OCS, CSCS

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Functional Testing

Exercise No. of Reps/Time

Squat Test 10 reps

I min. Eccentric Step–Down Test I min. (Ea. Leg)

Broad Jump Test (Warm up: 2 x 50%, 2 x 75%), 3x 100%

Single Leg Hop Test (Warm up: 2 x 50%, 2 x 75%), 3x 100% (Ea. Leg)

Vertical Jump Assessment 3 x (Warm Up), 3 x 100%

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Patient Name ______________________


ROM 0–0–125

Effusion Minimal to none, no joint line tenderness

Strength 65% Quadriceps, 50% HS/Quad Ratio

Special Testing Satisfactory Lachman/Drawer Test

Functional Score >6 score on Cinti Knee Rating System

Functional Testing 1min. Step Test >60% Satisfactory Squat Test, Step–Down Test

Impact Phase A: CriteriaEstimated Weeks 8–10

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4 5

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Patient Name ______________________


Impact Phase A: Entry Level PlyometricsEstimated Weeks 8–10

Exercise No. of Reps/Time Day 1 Day 3 Day 5

Shuttle–Bilateral 3 x 20 reps

Shuttle–Alternating 3 x 20 reps

Lateral Bounding in Place 3 x 30 sec.

Slide Board 3 x 30 sec.


Shuttle–Bilateral 3 x 20 reps


Lateral Bounding in Place 3 x 30 sec.

Slide Board 3 x 30 sec.

Jog in Place 3 x 30 sec.

High Knees in Place 3 x 30 sec.

Gluteal Kicks in Place 3 x 30 sec.

Week 8

Week 9

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Patient Name ______________________


ROM 0–0–130


Strength 70% Quadriceps, 60% HS/Quad Ratio



Functional Testing None

Impact Phase B: CriteriaEstimated Weeks 10–12

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Patient Name ______________________


Impact Phase B: Transitional Plyometrics/Phase Level I AgilityEstimated Weeks 10–12


Shuttle–Bilateral Grid Jumps 20 reps CW, 20 reps CCW


Shuttle–Unilateral Grid Hops 20 reps CW, 20 reps CCW

Lateral Bounding in Place– 3 Point 3 x 40 sec.

Lateral Bounding with Rotation 1 x 30 sec. R, 1 x 30 sec. L


Shuttle–Bilateral Grid Jumps 20 reps CW, 20 reps CCW


Shuttle–Unilateral Grid Hops 20 reps CW, 20 reps CCW

Lateral Bounding in Place– 3 Point 3 x 40 sec.

Lateral Bounding with Rotation 1 x 30 sec. R, 1 x 30 sec. L

Step Work: Quick Feet 1 x 30 sec.

Step Work: Ali Shuffle 1 x 30 sec.

Step Work: Lateral Quick Feet 1 x 30 sec.

Step Work: Lateral Skaters 1 x 30 sec.

Return to Jogging Program (Treadmill) 3W–1J–1W–3J–3W–5J–1W

Week 10

Week 11

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Patient Name ______________________


ROM 0–0–135


Strength 75% Quadriceps, 60–65% HS/Quad Ratio



Functional Testing No pain, gait deviation with 10min. jog

Impact Phase C: CriteriaEstimated Weeks 12–14

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Patient Name ______________________


Impact Phase C: Level II Agility, Sport Specific MovementEstimated Weeks 12–14


Jog in Place 20–30 sec.

Giant Arm Circles 20 reps (Ea. Direction)

Trunk Rotation 20 reps (Ea. Direction)

Pelvic Circle 20 reps (Ea. Direction)

Hip Circumduction 20 reps (Ea. Leg)

Hip Step w/ Exaggerated Arm Swing 15yds 2x

Gluteal Kicks 15yds 2x

Skipping Bound 15yds 2x

Side Shuttle 15yds 2x

Cariokas 15yds 2x

High Knees 15yds 2x

Sprint/Back Pedal 15yds 2x

Ankle Hops 10 sec.

Dynamic Sports Routine Warm Up

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Patient Name ______________________


Impact Phase C: Level II Agility, Sport Specific MovementEstimated Weeks 12–14


Jump Rope: Bilateral 1 x 1 min.

Jump Rope: Alternating 1 min. R, 1 min. L





Lateral Bounding with Rotation–3 Point 2 x 30 sec. R, 2 x 30 sec. L

Sport Cord: Forward 2 x 20 reps (1/2 Speed)

Sport Cord: Backwards 2 x 20 reps (1/2 Speed)

Sport Cord: 3 Point Lateral Bounding 2 x 30 sec. R, 2 x 30 sec. L


Jump Rope: Bilateral 1 x 1 min.

Jump Rope: Alternating 1 min. R, 1 min. L





Lateral Bounding with Rotation–3 Point 2 x 30 sec. R, 2 x 30 sec. L



Dynamic Sports Routine 1x

Agility Ladder: High Knees 3x (Down & Back)

Agility Ladder: Lateral High Knees 3x (Down & Back)

Agility Ladder: Lateral Quick Feet Ins & Outs 3x (Front Lead) (Down & Back)

Agility Ladder: Lateral Quick Feet Ins & Outs 3x (Back Lead) (Down & Back)

Agility Ladder: Ali Shuffle 3x (Down & Back)

Agility Ladder: Icky Shuffle 3x (Down & Back)

Week 12

Week 13

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Patient Name ______________________


ROM Within 90% contralateral limb


Strength 75–80% Quadriceps, 50–70% HS/Quad Ratio



Functional Testing SL hop 50%, Broad Jump with sound mechanics

Impact Phase D: CriteriaEstimated Weeks 14–16

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Patient Name ______________________


Impact Phase D: Level IIII Agility, Level Sport Specific MovementEstimated Weeks 14–16











Cariokas 15yds 2x

High Knees 15yds 2x


Ankle Hops 10 sec.

Dynamic Sports Routine Warm Up

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Patient Name ______________________



Dynamic Sports Routine (Warmup) 1x



Sport Cord: Lateral Shuffles 1 x 20 reps R Lead, 1 x 20 reps L Lead

Sport Cord: 3 Point Lateral Bounding w/ Rotation 2 x 30 sec. (Ea. Side)






Dynamic Sports Routine (Warmup) 1x



Sport Cord: Lateral Shuffles 1 x 20 reps R Lead, 1 x 20 reps L Lead

Sport Cord: 3 Point Lateral Bounding w/ Rotation 2 x 30 sec. (Ea. Side)

Sport Cord: 3 Point Drill (Forward) 20x

Sport Cord: 3 Point Drill (Backwards) 20x





Agility Ladder: Ali Shuffle 4x (Down & Back)

Agility Ladder: Icky Shuffle 4x (Down & Back)

Week 14

Week 15

Impact Phase D: Level III Agility, High Level Sport Specific MovementEstimated Weeks 14–16

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Patient Name ______________________







Functional Testing SL hop 60%, Broach Jump with sound mechanics, Good form with Eccentric Step–Down Test

Impact Phase E: CriteriaEstimated Weeks 16–22

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Patient Name ______________________


Impact Phase E: Jump ProgramEstimated Weeks 16–22











Cariokas 15yds 2x

High Knees 15yds 2x


Ankle Hops 10 sec.

Dynamic Sports Routine Warm Up (Utilized all 6 weeks)

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Patient Name ______________________




Wall/Block Jump 20 sec.

Broad Jump 5 reps

Squat/Vertical Jump 20 sec.

180/Half Spin Jump 20 sec.

Lateral Bounding in Place 20 sec.

Scissors/Rudder Jump 20 sec.

Richochets–Bilateral–Back to Front 20 sec.

Richochets–Bilateral–Side to Side 20 sec.

Plyometrics Phase I: Week 16

Plyometrics Phase I: Week 16 Functional Strengthening


Hip Hinges: Sustained Isometric Squat 2 x 30 sec.

Cook Hip Lift 2 x 10 reps

Fire Hydrants 2 x 10 reps

Split Leg Squat/Chair Dip 2 x 10 reps

Isometric Plank x4 5 sec. Hold 5x Thru ea. Position

Multidirectional Lunge 3x (Down & Back)

Unilateral Straight Leg Dead Lift 2 x 10 reps

Straight Leg Abduction with External Rotation 2 x 10 reps

Lunge Walk 25 Forward, 25 Backward

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Patient Name ______________________



Plyometrics Phase I: Week 17

Plyometrics Phase I: Week 17 Functional Strengthening



Broad Jump 10 reps


180/Half Spin Jump 25 sec.

Lateral Bounding in Place 25 sec.









Isometric Plank x4 5 sec. Hold 5x Thru ea. Position



Straight Leg Abduction with External Rota-tion 2 x 10 reps


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Patient Name ______________________





Tuck Jump 30 sec.

Jump, Jump, Jump, Vertical Jump 5 reps


Lateral Bounding for Distance 2 runs




Richochets–Unilateral–Back to Front 30 sec.

Richochets–Unilateral–Side to Side 30 sec.

Hop, Hop, Hop, Stick 5 reps

Plyometrics Phase II: Week 18

Plyometrics Phase II: Week 18 Functional Strengthening






Isometric Plank x4 5 sec. Hold 8x Ea. Position



Straight Leg Abduction with External Rotation 2 x 12 reps


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Patient Name ______________________





Tuck Jump 35 sec.

Jump, Jump, Jump, Vertical Jump 8 reps


Lateral Bounding for Distance 4 runs






Hop, Hop, Hop, Stick 8 reps

Plyometrics Phase II: Week 19

Plyometrics Phase II: Week 19 Functional Strengthening









Straight Leg Abduction with External Rota-tion 2 x 12 reps


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Patient Name ______________________





Jump Up, Jump Down, Vertical Jump 10 reps

Tuck Jump 35 sec.


Jump Into Bounding for Distance 3 runs Ea. Leg





Single Leg Hop, Hop, Hop, Stick 8 reps

Plyometrics Phase III: Week 20

Plyometrics Phase III: Week 20 Functional Strengthening









Straight Leg Abduction with External Rotation 2x 15 reps


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Patient Name ______________________





Jump Up, Jump Down , Vertical Jump 12 reps

Tuck Jump 40 sec.


Jump Into Bounding for Distance 4 runs Ea. Leg





Single Leg Hop, Hop, Hop, Stick 10 reps

Plyometrics Phase III: Week 21

Plyometrics Phase III: Week 21 Functional Strengthening









Straight Leg Abduction with External Rotation 2x 15 reps


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Patient Name ______________________


Return to Competition Criteria/Release Form

#1 #2 #3 Ave. Percentile Quality

P • F • G • E

Jump #1 Jump #2 Jump #3 Mean Jump Height Percentile Quality

P • F • G • E

R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality

% P • F • G • E

Date of Test: __________________ Doctor: ________________________________________

Dx: ________________________________________ Age: __________ Height:___________

DOI: _________________________ P/O Week: ______________________________________

Sport/Position: _____________________ Girth: R: 10cm_______ 20cm_______ Total:______

L: 10cm_______ 20cm_______ Total:______

Joint Exam: ___________________________________________________________________

Broad JumpNorms: M 90-100% Height, F 80-90% Height _________

Standing Vertical JumpNorms: M < 14:11”, 14-16:16”, 17-18:19”, > 18:22”

F < 14:10”, 14-16:11,” 17-18:13”, > 18:15” ________

Single Hop For DistanceNorms: M 90% Height, F 80% Height _________

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Patient Name ______________________







Functional Testing SL hop 85%, Ability to pass sport specific movement & physician clearance

Return to Competition Criteria/Release Form

Sport Specific Movements Quality QualityForward/Backpedaling: P • F • G • E Bounding: P • F • G • ESide Shuttles: P • F • G • E Shuttle Run: P • F • G • ECarioca: P • F • G • E High Knees: P • F • G • E Gluteal Kicks P • F • G • E Other: _______ P • F • G • E

Pass CriteriaCriteria Met( )( )( )( )( )( )( )( )

Restrictions: Non–Contact ( ) Release Pending MD Approval ( ) Contact with Brace ( ) Continue Therapy ( ) No Restrictions ( )

Evaluators Signature: _________________________________________________ Date: __________________

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Patient Name ______________________


Lower Extremity Functional Testing Record

#1 #2 #3 Ave. Percentile Quality

P • F • G • E

Jump #1 Jump #2 Jump #3 Mean Jump Height Percentile Quality

P • F • G • E

R #1 R #2 R #3 L #1 L #2 L #3 Total R Total L Hop Index Percentile Quality

% P • F • G • E

Date of Test: __________________ Doctor: ________________________________________

Dx: ________________________________________ Age: __________ Height:___________

DOI/DOS: _________________________ P/O Week: _________________________________

Sport: _____________________ Girth: R: 10cm_______ 20cm_______ Total:______

L: 10cm_______ 20cm_______ Total:___ ____%

Joint Exam: ___________________________________________________________________

Broad JumpNorms: M 90-100% Height, F 80-90% Height _________

Standing Vertical JumpNorms: M < 14:11”, 14-16:16”, 17-18:19”, > 18:22”

F < 14:10”, 14-16:11,: 17-18:13”, > 18:15” ________

Single Hop For DistanceNorms: M 90% Height, F 80% Height _________

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Patient Name ______________________


Lower Extremity Functional Testing Record

Sport Specific Movements

Quality QualityForward/Backpedaling: P • F • G • E Bounding: P • F • G • ESide Shuttles: P • F • G • E Shuttle Run: P • F • G • ECarioca: P • F • G • E High Knees: P • F • G • E Gluteal Kicks P • F • G • E Other: _______ P • F • G • E

Evaluators Signature: _________________________________________________ Date: __________________

R L F. E. R. Quality

P • F • G • E

Timed One Minute EccentricStep Down Test _____"Step

Step Down Test Squat Test

R + -- L + --

Recommendations: ( ) Continue Current Phase ( ) Progress to Next Phase__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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This material is intended for educational purposes only. Any medical information included herein has a mere informative purpose and shall not be used in any way as substitute for professional advice provided by a physician or liscenced health care provider. It is not meant to replace the judgement of trained surgeons on the appropriate treatment of their patients and may not be appropriate for all ACL patients.

Biomet does not practice medicine and does not recommend any particular orthopedic implant or surgical technique for use on a specific patient. This program was developed by Steven Traina, MD and Nathan Lilley, MPT, OCS, CSCS. The surgeon who performs any implant procedure is responsible for determining and utilizing the appropriate techniques for implanting prosthesis in each individual patient. Biomet is not responsible for selection of the appropriate orthopedic implant.

This handbook and all content, artwork, photographs, names, logos and marks contained in it are protected by copyright, trademarks and other intellectual property rights owned by Biomet or licensed to Biomet. This handbook must not be used, copied or reproduced in whole or in part for any purposes other than marketing by Biomet or its authorized representatives. Any other purposes are prohibited.

Biomet hereby explicitly excludes any and all liability of any kind that might be triggered by the unauthorized use of this publication or the information herein.

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References

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32. Muneta T, Sekiya I, Ogiuchi T, et al. Effects of aggressive early rehabilitation of the outcome of ACL reconstruction with multi-strand semitendinosus tendon. Internal Orthopaedics, 22: 352-6, 1998

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34. Myer et. al. Neuromuscular Training Improves Performance and Lower Extremity Biomechanics in Female Athletes. Journal of Strength and Conditioning Research, 19(1): 51-60, 2005

35. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS; Biomechanical Analysis of Human Ligament Grafts Used In Knee Ligament Repairs and Reconstructions. The Journal of Bone and Joint Surgery, 66A(3); p344-352, 1984

36. Parsons L, et. al. Static vs. Dynamic Stretching on Vertical and Static Long Jump, Department of Physical Therapy, Wichita State University. 50-51

37. Risberg MA, Mork M, Jenssen HK, Holm I. Design and implementation of a neuromuscular training program following ACL reconstruction. J of Ortho and Sports Phy Ther, 31: 620-31, 2001

38. Risberg MA, Holm I. et. al. Neuromuscular Training Versus Strength Training During the First 6 Months After ACL Reconstruction: A Randomized Clinical Trial. Physical Therapy, 6:87 737-747, 2007

39. Risberg MA, & Holm I. The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. The American Journal of Sports Medicine, 37(10), 1958-66, 2009

40. Shelbume KB, Pandy MG. Determinants of cruciate-ligament loading during rehabilitation exercise. Clinical Biomechanics, 13: 403-413, 1998

41. Shelbourne DK, Rask BP: Controversies with anterior cruciate ligament surgery and rehabilitation. American Journal of Knee Surgery, 11(2): 136-143, 1998

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43. Tsaklis P, Abatzides G. ACL rehabilitation program using a combined isokinetic and isotonic strengthening protocol. Isokinetics Exercise Science,10: 211-9, 2002

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45. Weber MD, Woodall WR Knee Rehabilitation. Physical Rehabilitation of the Injured Athlete, 15: 396-408, 2004

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References Cont.

steven traina, md, nathan lilley, mpt, ocs, cscs · 2019. 12. 26. · steven traina, md, nathan...

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