Effective ACL Rehabilitation with Pro Fitter

by Cindy Merrick M.S.P.T. and Lisa Lehman, S.P.T.

Active participation in an effective rehabilitation program following and ACL reconstruction is crucial to the functional outcome of the lower extremity. Treatment protocols must be specifically designed for patients based upon their pre- and post-operative state. A successful rehabilitation program helps the patient achieve full motion, early weight bearing, appropriate patellar tracking and strength gains of the VMO and posterior knee musculature. Improving coordination, agility, balance and endurance will also aid in the return to full participation in pain-free activities.

This article presents a Pro Fitter rehabilitation protocol specifically designed for the patient following ACL reconstruction. This program, based on recent research and clinical experiences, is designed to incorporate techniques for ROM and strength while preserving the stability of the knee joint.

Use of the Pro Fitter can easily accommodate the needs of a post surgical ACL individual. By adjusting the tension, one can vary the required muscle contraction. The tension ranges from 0 (passive) to 4 (maximum resistance).

This variable becomes significant during the progressive states of the rehabilitation program. Passive, isometric and isotonic exercises can all be performed on the Pro Fitter ski trainer.

All major muscle groups surrounding the knee can be strengthened with the Pro Fitter. It provides unique techniques to actively strengthen the posterior musculature of the knee, important in preventing anterior excursion of the tibia. By emphasizing closed kinematic chain activities, the Fitter also places a functional stress on the lower extremity in ways similar to weight-bearing activities. Thus, the Pro Fitter provides inherent joint stability and a strenuous workout without the sheering forces seen in most open chain activities. By carefully selecting proper foot position while exercising, the Pro Fitter ski simulator can also emphasize appropriate patellar tracking by recognizing the VMO and lateral stabilizers.

It is, however, the clinician’s responsibility to recognize the signs and symptoms of an exercise inappropriate for a specific individual. The chart below progressively outlines several ACL rehabilitation exercises using the Fitter.

Effective ACL Rehabilitation with Fitter

Developed by Cindy Merrick and Lisa Lehman of Therapy in Motion in conjunction with the University of Oklahoma

		Phase 1 Days 1-7	Phase 2 Weeks 2-3	Phase 3 Weeks 4-5	Phase 4 Weeks 6-12	Phase 5 Mos. 3-4
1. Heel Slides   Sit in chair. Place uninvolved foot on platform with involved foot resting on top. The uninvolved leg performs the active movement passively taking the involved leg through the available ROM Rationale: restore ROM, prevent adhesions		Tension: 0 ROM: 0-90 Time:  5-10  mins	Tension: 0 ROM: 5 -110 Time: 5-10 mins
2. Wall Leg Press   Sit on platform. Place feet on wall with knees bent at 20. Push into the wall with the feet maintaining the bent knee position. Rationale: increase gastrocnemius & soleus strength, promote poster knee stability, improve venus return & decrease edema.		Tension: 2-3 Reps:  10-20 Sets: 3-4	Tension: 2-3 Reps  15-25 Sets:  3-4	Single Leg Tension: 4 Reps: 10-20 Sets:  3-4	Single Leg Tension: 4 Reps: 15-25 Sets: 4-5	Single Leg Tension: 4 Reps: 15-25 Sets: 3-4
		Hold each rep 5-10 seconds, Keep knee bent at 30°
3. Quad/ Hamstring Co-Contractions   Sit on platform, placing uninvolved leg on edge. Lift involved leg six inches and hold. Slowly push into Fitter with uninvolved lower extremity, holding involved lower extremity in air. Rationale: co-activates quads & hamstrings, increases hip flexor stability, provides sensory motor input from uninvolved leg contractions.		Tension: 2-3 Reps: 10-20 Sets: 3-4	Tension: 2-3 Reps: 15-25 Sets: 3-4
		Keep knee bent at 30°
4. Hamstring Strengthening   Sit in chair. Place foot on far edge of platform. Bend knee in attempt to pull foot to chair. Rationale: increase hamstring strength, improve posterior stability of knee.		Tension: 4 Isometrics ROM: 0-90 Tension: 1-2 Reps: 10 Sets: 3	ROM: 0-105 Tension: 2 Reps: 10-15 Sets: 3-5	ROM: 0-120 Tension: 2-3 Reps: 15 Sets: 3-5	ROM: 0-130 Tension: 3 Reps: 15 Sets: 3-5
5. Reverse Action Hamstrings   Sit on platform with edge of seat placed on far edge of Fitter. Pull buttocks to feet. Rationale: increase hamstring strength, contract hamstring in reverse action.			Double Leg Tension: 1-2 Reps: 10 Sets: 3-4	Single Leg Tension: 1-2 Reps: 10 Sets: 3-4	Single Leg Tension: 2-3 Reps: 10 Sets: 3-4	Increase Tension Increase Reps Increase Sets
6. Quad Strengthening   Sit on chair placing foot on platform. Press foot into Fitter to straighten the leg. Rationale: increase quad strength, can promote appropriate patellar tracking and provide close kinematic chain rehabilitation.		Tension: 4 Isometrics ROM: 90-49 Tension: 1-2 Reps: 10 Sets: 3	ROM: 90-30 Tension: 2 Reps: 10 Sets: 3-4	ROM: 90-20 Tension: 2-3 Reps: 15 Sets: 3-5	ROM: 90-10 Tension: 3-4 Reps: 15 Sets: 3-5	ROM: 90-0 Increase Tenison Increase Reps Increase Sets
7. Sitting Leg Press   Sit on platform with feet placed on edge of Fitter. Straighten legs to move platform away from the Fitter. Rationale: increase quad strength, provide close kinematic chain rehabilitation.			Double Leg Tension: 2-3 Reps: 10 Sets: 3-4 ROM: 90-30	Single Leg Tension: 20-3 Reps: 10-12 Sets: 3-5 ROM: 90-20	Single Leg Tension: 3-4 Reps: 12-15 Sets: 3-5 ROM: 90-10	Increase Tension Increase Reps Increase Sets ROM: 0-10
8. Hip Extension   Stand on edge with back towards platform, weight on uninvolved leg. Bend involved knee & place bottom of foot on edge of platform (could be performed with involved leg as weight bearing pillow). Rationale: increase glutea strength, provides co-contraction efforts.			Tension: 1 Reps: 10 Sets: 3-4 ROM: 90-30	Tension: 2-3 Reps: 10-12 Sets: 3-4 ROM: 90-20	Tension: 3-4 Reps: 12-15 Sets: 3-5 ROM: 90-10	Increase Tension Increase Reps Increase Sets ROM: 90-0
9 & 10. Hip Adduction/ Abduction   Stand with uninvolved leg on end of Fitter. Place involved foot between foot plates and pull involved leg towards body. Rationale: increase adductor/abductor strength, initiate VMO strengthening.		Tension: 1 Reps: 10-20 Sets: 3	Tension: 1/2-3 Reps: 10-22 Sets: 3-4
11. Single Leg Mini-Squats   Stand with involved leg on platform and uninvolved leg off to side. Slowly flex involved leg and hold at 30°. Rationale: increase eccentric quad strength, provide closed kinematic, chain rehabilitation.				Tension: 4 Reps: 8-10 Sets: 3-4 Use poles	Tension: 4 No poles Add handheld dumbbell weights	Tension: 4 Increase Weights Increase Reps Increase Sets
12. Step Ups/Downs   Slowly step up and down from platform. Secure platform stability by setting tension at 4. Stepping may be in lateral & forward fashion. Rationale: provides eccentric quad strengthening.				Emphasize step downs Use poles & uninvolved leg to push up Tension: 4 Reps: 10 Sets: 3-5	Step up & down No poles Add hand weights Tension: 4 Reps: 1-12 Sets: 3-5	Increase Weights Increase Reps Increase Sets
13. Balance Activity   Stand on platform with weight on involved extremity, poles in each hand. Maintain balance as long as possible. Progress to balancing with eyes closed, balancing while foot in plate, balancing without poles. Rationale: improve proprioceptive input			Tension: 4 Use poles Eyes open	Tension: 4 Use poles Eyes closed	Tension: 4 Use poles Eyes open Foot in plate	Tension: 4 Use poles Eyes closed Foot in plate
14. Runner’s Lunge   Assume runner’s start position with hands on floor. Place involved foot against platform and press back into platform to achieve contraction of hip extensors, hamstrings, quads & calf muscles. Rationale: increase strength of major leg muscles, improve endurance.			Tension: 1-2 Reps: 10-15 Sets: 3-4 ROM: 90-40	Tension: 2-3 Reps: 10-15 Sets: 3-4 ROM: 90-30	Tension: 3-4 Reps: 10-15 Sets: 3-4 ROM: 90-10	Increase tension Increase reps Increase sets ROM: 90-0
15. Lateral Shifts   Place feet in footpads. Perform small side-to-side movements using poles for stability. Progress by increasing ROM and not using poles. Rationale: improve balance & motor coordination.					Use poles Short range Tension: 2-3 Reps: 10-15 Sets: 3-5	Full range Tension 3-4 Reps: 15-25 Sets: 3-5
16. Front to Back Shifts   Stand on platform. Face the end with uninvolved foot in front of involved foot. Slowly move platform in a front to back fashion. Keep knees bent, use poles for support, progress to positioning feet side-by-side or with involved foot in front. Rationale: improve balance, proprioception, coordination& weight shifts.				Use poles Foot in back Tension: 1-2 Reps: 15-20 Sets: 3-5	Use poles Side by side Tension: 3 Reps: 15-20 Sets: 3-5	Use poles Foot in front Tension: 3-4 Reps: 20-30 Sets: 3-5