General Principles
- Progression is criterion-based; timelines are approximate guidelines.
- Avoid active knee extension for the first 6 weeks to protect the repair.
- Begin patellar mobilization early to prevent adhesions; cryotherapy/elevation for edema; DVT prophylaxis; pain management as needed.
Phase 1 · Weeks 0–2 (Maximum Protection)
- Brace locked in full extension for ambulation and sleep; WBAT with crutches, knee locked in extension.
- ROM: passive flexion 0–45° (up to 90° if comfortable, no need to push); gravity-assisted passive extension; no active knee extension; patellar glides.
- Quad sets, ankle pumps, SLR (brace locked) in hip flexion/abduction/adduction, gluteal sets.
- Goals: wound healing, edema control, maintain full passive extension, independent transfers/ambulation with device.
Phase 2 · Weeks 2–6 (Early Motion)
- Brace: unlock for ROM, lock in extension for ambulation; progress crutches → single crutch/cane.
- Progressive passive flexion ~10–15°/week (0–60° by week 3; 0–90° by week 4). Continue patellar mobilization; no active knee extension against gravity.
- Prone/gravity-assisted flexion; seated heel slides; stationary bike once ~90° (no resistance); multi-plane hip strengthening; core.
- Goals: 90° passive flexion by week 4; maintain full extension; normalize gait in brace.
Phase 3 · Weeks 6–12 (Progressive Strengthening)
- Discontinue brace (typically ~6 weeks, per surgeon); full weight bearing without a device.
- Progress to full passive and active ROM; begin gentle active knee extension (short-arc quads 90–40°). Goal: full ROM by weeks 10–12.
- Closed-chain (mini-squats, limited-arc leg press, low step-ups); bike with resistance; balance/proprioception; aquatic therapy; concentric quad program.
- Goal: full ROM; quad strength ≥60% of the other leg.
Phase 4 · Weeks 12–20 (Advanced Strengthening)
- Full unrestricted ROM. Progressive closed-chain (deeper squats, lunges, single-leg press); open-chain knee extension (light → full arc); eccentric quad program.
- Reciprocal stair training; elliptical, swimming, walking; advanced balance/perturbation.
- Goal: quad strength ≥80% of the other leg; normal stairs; pain-free functional activities.
Phase 5 · Weeks 20–24+ (Return to Activity)
- Sport/occupation-specific training; plyometrics, agility/cutting (if applicable); running progression (walk/jog intervals); maintenance strengthening.
Return-to-Sport / Activity Criteria
- Full, pain-free ROM; no effusion or pain with sport-specific activity.
- Quadriceps strength ≥90% of the other leg; hop-test limb symmetry ≥90%.
- Surgeon clearance.
Red Flags — Contact Surgeon
- Sudden loss of active extension (possible re-rupture) or a palpable gap at the repair.
- Significant increase in swelling/pain; wound drainage, erythema, or dehiscence; fever or signs of infection.
References
- Rehabilitation Protocol for Quad and Patellar Tendon Repair. Lahey Hospital & Medical Center.
- Patellar Tendon Repair Rehabilitation Guideline. Sanford Health.