BEAR ACL Implant Rehab Protocol

About This Protocol

The pages that follow are the manufacturer's official BEAR Implant Rehabilitation Protocol (Miach Orthopaedics). Please follow this specialized protocol unless directed otherwise by Dr. Allred.

The BEAR (Bridge-Enhanced ACL Restoration) procedure is not a standard ACL reconstruction and follows a different rehabilitation pathway. Anticipated return to sport is typically 9–12 months and is criterion-based.

Protocol authored by Miach Orthopaedics; distributed by the office of Darin W. Allred, M.D. Content is unmodified.

BEAR® Implant Rehabilitation Protocol

Miach Orthopaedics · 69 Milk Street, Westborough, MA 01581 · (800) 590-6995 | www.miachortho.com · ML-1014 Rev H 1/2023

Table of Contents

• Date of surgery:
• Name of patient:
• Name of operating surgeon:
• Contact for operating surgeon:

Treatment Overview

This patient received the BEAR Implant as treatment for a torn ACL. This is not an ACL Reconstruction (ACLR), and the Rehabilitation Protocol is different. Please follow this specialized BEAR Implant Rehabilitation Protocol in the pages that follow, unless instructed differently by the operating surgeon.

Physical therapists: For questions and to be connected with our rehab consultant, please contact Miach Orthopaedics 1-800-590-6995 or Info@miachortho.com

Pre-Surgical Preparation for Surgical Team

• The patient should begin their home exercises within the first week after surgery. Please teach these exercises to the patient at the last pre-operative visit
  • These exercises will be reviewed again at their first PT visit to ensure proper form and frequency
• Notify the patient at their last pre-op visit that they should schedule their first Physical Therapy visit to take place within first week post-op

Weight Bearing Status

• Partial Weight Bearing
• Brace locked in extension for partial weight bearing for 4 weeks
• With clearance from PT and surgeon, patient may advance to WBAT with crutch wean at 4 weeks, only if the following criteria are met
  • able to walk with normal gait pattern
  • no pain
  • no extensor lag
  • good quad control
  • ability to safely ascend/descend stairs without noteworthy pain or instability

Bracing Instructions

ACL hinged knee brace (TROM or equivalent) for weight bearing activities

• Locked for ambulation at 0° for the first 4 weeks post-op
• Locked for sleep at 0° for first 6 weeks post-op
• Unlock for range of motion (ROM) to specified degrees when seated or at physical therapy for gait training after 2 weeks
• Advance to unlocked brace for PWB ambulation at week 4 if the patient is comfortable doing so and if they demonstrate appropriate quadriceps control (should not flex past 90° until week 4)

Brace Range

Treatment Overview Cont'd

Recommendations

• No scar massage until phase 3
• No manual PROM during any point in phase 1-3 of the protocol/rehabilitation
• No CPM
• Driving: No driving until patient is off all narcotics; for patient with RIGHT leg procedure, no driving until the patient is full weight bearing without crutches and has at least 60° of flexion
• Jobs with physical labor: Restrictions per operating surgeon and in the following PT protocol
• The only modalities for muscular strengthening to be used are NMES (NeuroMuscular Electrical Stimulation) and optional low intensity Blood Flow Restriction (BFR) strength training for patients limited by pain or poor load tolerance
• If stiffness is observed at any phase, please contact the operating surgeon and:
  • Ensure proper post-op management of pain and swelling
  • Ensure patient is following the recommended BEAR Implant rehab protocol
    • If operating surgeon has specifically recommended a protocol deviation, please consult with the operating surgeon before action is taken

Additional Instructions

Phase 0: Preoperative PT and Immediately After Surgery

Preoperative Recommendations

Phase Goals: Begin as soon as possible following initial injury to re-establish the following goals prior to surgery

• Full active (AROM) and passive (PROM) knee extension
• Knee flexion ROM within 10° of uninvolved limb
• Trace to zero knee effusion
• No knee extension lag with straight leg raise (SLR)
• Quadriceps Strength Index (QI) ≥80% of uninvolved limb - Retain values for post-operative comparison to minimize overestimation of strength
• Teach the Home Exercises to patient/guardian(s) at the last pre-operative visit (see After Surgery Instructions document). Also highlight the importance of rehabilitation compliance
• Educate on brace, crutch use and PWB

Patient Education

• Importance of prehab for optimal post-operative outcomes
• What to do immediately after surgery (0-48 hours)
• Anticipated return to sport timeline: 9-12 months
• Expected outcomes: Return to prior level of competition is often difficult, but possible
• Osteoarthritis risk

Surgical team to review the After Surgery Instructions and teach the Home Exercises to patient/guardian(s) at the last pre-operative visit (see After Surgery Instructions document). Also highlight the importance of rehabilitation compliance

• Educate on brace, crutch use and PWB if PT was not done preop

Phase 1: Weeks 0 to 4

Home Program with PT Supervision & 1-2 Week Visit with Surgeon

Important Instructions for Phase 1

• Facilitated by PT: The After Surgery Instructions and Home Exercises should be reviewed and taught again at the first post-op clinic visit with surgeon and again with PT at their week 1 and 2 post-op visits

Recommendations

Criteria for progression to Phase 2

• 4 weeks out of surgery

Phase 2: Weeks 4 to 7

Early Post-Operative Physical Therapy

Goals

1. Full knee extension
2. Flexion ROM >90°
3. Good quadriceps isometric contraction
4. Minimize pain and swelling

Recommendations

Stiffness has been observed in this phase and is most associated with "fear avoidance," rehab non-compliance, and in patients with concomitant procedures such as meniscal repair. In the case of stiffness, the following should be implemented:

• Ensure proper post-op management of pain and swelling
• Ensure patient is compliant with the recommended protocol (please consult the operating surgeon before any action is taken in the case where the patient's protocol has been altered for any reason)
• Additional modalities/exercises are recommended:
  • Continue recommended exercises
  • Patella mobilizations: high grade more often
  • Supine bag hangs (weighted)

Criteria for progression to Phase 3

• 7 weeks out from surgery
• ROM full extension to >90°

Phase 3: Weeks 7 to 12

Post-Operative Physical Therapy

Goals

1. Minimize pain and swelling
2. Full knee extension ROM; flexion to within 15° of the contralateral
3. Good quadriceps control (≥20 no lag SLR)
4. Normal gait pattern

Recommendations

Criteria for progression to Phase 4

• Minimum of 12 weeks from surgery
• 20 reps no lag SLR
• Normal gait
• Crutch/Immobilizer D/C
• ROM: No greater that 5° active extension lag and 90° active flexion
• QI = 60-80%

Phase 4: Weeks 12 to 20

Early Strengthening & Rehabilitation

Goals

1. Full extension ROM, flexion ROM with 10° of uninvolved knee
2. Improve muscle strength
3. Progress neuromuscular retraining

Recommendations

Criteria for progression to Phase 5

• Full ROM
• Minimal effusion and pain
• Functional strength and control in daily activities (QI ≥80% LSI)
• Minimum 20 weeks out from date of surgery

Phase 5: Weeks 20 to 30

Strengthening & Control

Goals

1. Maintain full ROM
2. Running without pain or swelling
3. Hopping without pain, swelling or giving way

Recommendations

Criteria for progression to Phase 6

• Running without increase in pain or swelling
• Neuromuscular and strength training exercises without difficulty
• Able to hold single leg balance for 60 seconds
• 50% hop height on operated leg (hop test in brace)
• Completion of functional hop testing and clearance by operating surgeon
• Minimum of 30 weeks out from date of surgery
• QI ≥80%

Phase 6: Weeks 30 to 36

Advanced Training

Goals

1. Running patterns (figure-8, pivot drills, etc.) at 75% speed without difficulty
2. Jumping without difficulty
3. Hop tests at 85% contralateral values (Cincinnati hop tests: single-leg hop for distance, triple-hop for distance, crossover hop for distance, 6-meter timed hop)

Recommendations

Criteria for progression to Phase 7

• Maximum vertical jump without pain or instability
• 85% of contralateral on hop tests
• Run at 85% speed without difficulty
• IKDC Question #10 (Global Rating of Knee Function) score of ≥8 (suggested criteria; see page 11)
• Completion of functional hop testing showing 85% function and clearance by operating surgeon
• 85% QI

Phase 7: Weeks 36 to 52

Return-to-Sport

Goals

1. 90% contralateral quad strength
2. 90% contralateral on hop tests
3. Sport-specific training without pain, swelling or difficulty

Recommendations

Return-to-Team Training Criteria

• No functional complaints
• Confidence when running, cutting, jumping at full speed
• 90% contralateral values on hop tests
• 90% QI
• IKDC Question #10 (Global Rating of Knee Function) of ≥9 (suggested criteria; see page 11)
• Clearance by operating surgeon

Current Function of Your Knee: Daily Activities

IKDC Question #10

How would you rate the function of your knee on a scale of 0 to 10, with 10 being excellent function and 0 being the inability to perform any of your usual daily activities which may include sports?

1 · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 — where 1 = Cannot perform and 10 = No limitation

Tests include:*

1. Dynamometer strength testing of hamstring and quadriceps
2. KT testing for AP laxity
3. Single, triple, crossover, and timed hop tests

*Patient should bring ACL functional brace (if required by surgeon) for this testing.