Patellar Tendon Repair

Phase 1 · 0–6 weeks after surgery

Goals

• Protect surgical repair
• Minimize pain and swelling
• Activation of the quad muscle
• ROM: 0°–90°

Precautions

• ROM
  • Weeks 1–2: 0°–30°
  • Week 3: NWB, knee ROM 0°–60°; progress by 10° each week
• Follow WB restrictions at discretion of Ortho

Brace

• Wear brace locked in extension for ambulation
• May unlock or remove for rehab

Wound care

• Post-op dressing remains intact until post-op day #3 (~72 hours after surgery)
• Shower after post-op day #4 (no need to cover incision site)
• DO NOT SUBMERGE knee in water until authorized to do so by Ortho
• Suture removal @ 10–14 days post-op per Ortho

Cryotherapy

• Cold with compression/elevation (ice with compression wrap)

Rehabilitation

• Begin scar massage after incision has healed and scar is formed
• Begin patellar mobilizations
• ~Weeks 1–2
  • Quad, glute and HS isometrics (submaximal contraction intensity); use e-stim if needed
  • Multi-directional open chain hip muscle endurance exercises
  • Calf pumps with theraband
  • Heel slides (assisted as needed)
  • Supine passive extension to 0°
• ~Weeks 3–6
  • Continue exercises from weeks 1–2 as appropriate
  • Gradually increase knee flexion to goal of 90 degrees by Week 6
  • Multi-directional open chain hip muscle endurance exercises with increased resistance
  • Progressive PF strengthening
  • Short arc quads
  • General LE stretching
  • Stationary bike within limits of ROM
  • Beginner level pool exercises when incisions are fully healed; primarily in the sagittal plane (i.e. no breaststroke or whip kick motion)

Follow-up

• Supervised rehab: 2–3x per week
• PT re-eval: every 1–2 weeks
• Ortho re-eval: ~2 and ~6 weeks

Phase 2 · 7–12 weeks after surgery

Goals

• Normal gait and stair ambulation
• > 80% quad and HS strength relative to uninvolved limb
• Full ROM

Precautions

• Avoid tendon overload (i.e. squatting, deep knee bends, and lunges)
• Be careful walking up/down steps or inclined surfaces
• NO RUNNING
• NO PARTICIPATION in contact/collision sports or physically demanding training programs

Brace

• D/C brace & crutches when gait is normal and 120° knee flexion is achieved

Rehabilitation

• Continue Phase 1 exercises as needed
• Progress to the following exercises and increase intensity gradually when patient is ready (i.e. no increase in knee pain or effusion since the previous exercise session)
• ~Weeks 7–8
  • Stationary bicycle or elliptical for conditioning
  • General LE strengthening with very gradual increase on loading of knee extension exercises (i.e. squats, lunges, and leg press)
  • Gait training as needed (i.e. cone walking, marching, retrowalking, and cariocas)
  • Forward, lateral, and retro step-ups (start with 2" step and progress as tolerated)
  • Continue beginner level pool exercises (i.e. no breaststroke or whip kick motion)
• ~Weeks 9–10
  • Continue progressing exercises from Weeks 7–8 as appropriate
  • DL balance and proprioceptive exercises; progress to SL
  • General LE stretching
  • Elliptical: add gradually with stationary bike for conditioning
  • Progressive LE strengthening (i.e. calf press, leg press, squats 0°–45°, HS curls, and hip abductors/adductors)
  • Progressive pool program as tolerated
• ~Weeks 11–12
  • Continue progressing exercises from Weeks 9–10 as appropriate
  • Progress ROM of squats, leg press, etc. while being mindful of ROM restrictions and pain

Follow-up

• Supervised rehab: 2–3x per week
• PT re-eval: every 2–3 weeks
• Ortho re-eval: ~12 weeks post-op

Phase 3 · 3–6 months after surgery

Goals

• Full ROM
• Jog at own pace and distance without pain
• > 90% quad and HS strength return
• > 90% of uninvolved limb on hop test battery (i.e. hop for distance, triple hop, crossover hop, and 6-meter timed hop)
• Meet occupational requirements at 6–8 months

Precautions

• Minimal to no pain at the repair site

Rehabilitation

• Continue Phase 2 exercises as needed
• Progress to the following exercises and increase intensity gradually when patient is ready (i.e. no increase in knee pain or effusion since the previous exercise session)
• Build up resistance and repetitions gradually
• ~Weeks 13–16
  • Swimming
  • Step-up progression
  • Gradual quad stretching
  • Progressive SL balance and proprioceptive training as needed
  • Progressive LE strengthening (i.e. calf press, leg press, squats 0°–60°, HS curls, and hip abductors/adductors)
• ~Weeks 16–20
  • Progressive strengthening of quads while monitoring symptoms closely
  • Step-down progression
  • Initiate walk to jog progression
• ~Weeks 20–26
  • Progressive speed/agility training beginning at 25–50% intensity and progress gradually (i.e. jumping, hopping, directional jogging, cariocas, and shuffles)
  • Jump training initiated after 24 weeks

Follow-up

• Supervised rehab: 1–2x per week
• PT re-eval: monthly
• Ortho re-eval: ~6 months post-op

Miscellaneous

• After 6 months post-op, Phase 3 exercises are continued and gradually increased in intensity and duration as tolerated
• Pass a return-to-sport / fitness test at 9–10 months
• Progress activities for return to sport/collision sports or aggressive physical training (e.g. tactical or military training) based on the patient's functional performance and endurance. This time period will be directed by the Ortho Surgeon and the Physical Therapist. This may require between 9–12 months before cleared without restrictions.

References

• Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. Journal of Orthopedic Sports Physical Therapy. 2006; 36(6): 385–402.
• Myer, GD, Paterno MV, Hewett TE. Back in the game: a four-phase return-to-sport program for athletes with problem ACLs. Rehab Management. 2004; 17(8): 30–33.

Abbreviations

AROM / AAROM / PROM: active / active-assisted / passive range of motion. ROM: range of motion. ER / IR: external / internal rotation. ABD / ADD: abduction / adduction. FLEX / EXT: flexion / extension. WBAT / PWB / TTWB / NWB: weight bearing as tolerated / partial / toe-touch / non-weight bearing. SLR: straight leg raise. HS: hamstrings. ITB: iliotibial band. UE / LE: upper / lower extremity. UBE: upper body ergometer (arm bike). BAPS: balance board. BFR: blood flow restriction training. PREs: progressive resistance exercises. D/C: discontinue. prn: as needed. POD: post-operative day. TENS: transcutaneous electrical nerve stimulation. ADLs: activities of daily living.

Source

Adapted from Defense Health Agency, Tri-Service Post-Operative Rehabilitation Guidelines, "DHA Patellar Tendon Repair Rehab", May 2020, published by William Beaumont Army Medical Center (a work of the U.S. Government in the public domain). Original: DHA Patellar Tendon Repair Rehab.pdf. Army-specific wording in the original (military schools, Service fitness test, military training, airborne school) was replaced with civilian equivalents.

This protocol is general guidance for the rehabilitation team and does not replace the specific plan, restrictions and follow-up we set together. Your own situation may differ: if anything here does not match what we talked about, what we talked about wins, so please ask me.

Current version and every other protocol: aaronweymd.com/post-op-protocols