Postoperative rehabilitation protocols

Match the protocol to the exact procedure in the operative note. If more than one procedure was performed, use the most protective restriction until Dr. Morton gives a different written order. A therapist should not accelerate weight bearing, brace removal, range of motion or impact activity simply because pain is improving.

Progression is based on both time for tissue healing and measured function. New or increasing swelling, limping, loss of motion, mechanical locking, instability, wound drainage or a painful pop should prompt reassessment rather than repeated attempts to push through the problem.

For general recovery planning, see Physical Therapy & Rehabilitation Protocols and the Your Surgery Hub.

Choose the procedure below for the complete, printable directions. Each full protocol page contains the entire pathway and a matching PDF download.

Joint replacement & reconstruction

• Total knee replacement — PDF
• Direct anterior total hip replacement — PDF
• Revision total hip replacement - posterior approach — PDF
• Extensor mechanism reconstruction - Marlex mesh — PDF
• Kneeling conditioning after knee replacement — PDF

ACL & meniscus

• Partial meniscectomy — PDF
• Meniscus repair — PDF
• Meniscus root repair — PDF
• Primary ACL repair — PDF
• BEAR ACL repair — PDF
• BEAR ACL repair + meniscus repair — PDF

Cartilage restoration

• MACI - single tibiofemoral lesion — PDF
• MACI - single patellofemoral lesion — PDF
• MACI - multiple tibiofemoral lesions — PDF
• MACI - multiple patellofemoral lesions — PDF
• MACI - mixed tibiofemoral + patellofemoral lesions — PDF
• CartiHeal Agili-C implant — PDF

Hand procedures

• Ultrasound-guided trigger finger release — PDF
• Ultrasound-guided carpal tunnel release — PDF

Total knee replacement

Weight bearing: weight bearing as tolerated with walker or crutches; wean only when gait is safe without meaningful limp or buckling. Brace: none routinely. Motion: no routine flexion ceiling; prioritize full extension early and increase flexion without force.

• Days 0-14: short frequent walks, swelling control, heel-prop extension, heel slides, quadriceps activation and safe stairs. Aim for full extension and flexion generally 90 degrees or more as tolerated.
• Weeks 2-6: progress cycling, sit-to-stand, squats, step-ups and gait. Target about 0-110 degrees or more by roughly 6 weeks while keeping full extension the priority.
• Weeks 6-12: build quadriceps, hip and calf strength, reciprocal stairs, balance and low-impact endurance. Running and repetitive jumping are not routine goals after TKA unless specifically cleared.

Direct anterior total hip replacement

Weight bearing: weight bearing as tolerated with walker or cane as needed. Brace/pillow: none routinely. Precautions: no routine posterior hip precautions; during the first 6 weeks avoid forceful passive end-range extension or external rotation and aggressive combined extension plus external rotation or twisting.

• Weeks 0-2: short frequent walks, normal step-through gait, gluteal and quadriceps activation, heel slides and sit-to-stand. Avoid repeated straight-leg raises or resisted hip flexion if they provoke groin pain.
• Weeks 2-6: wean the cane once gait is symmetrical without trunk lean; progress bridge, standing hip work, step-ups, balance and low-resistance cycling.
• Weeks 6-12: advance hip strength, single-leg control and low-impact endurance. Restore functional motion rather than forcing extreme range.

Revision total hip replacement - posterior approach

Revision hip rehabilitation is order-specific. The therapist must confirm the written weight-bearing limit, posterior precautions and any trochanteric or abductor restrictions before advancing treatment. Do not assume weight bearing as tolerated after a revision.

• Default posterior precautions when no different order is written: for 6 weeks, no hip flexion beyond 90 degrees, no adduction past midline and no internal rotation beyond neutral; avoid the combined position of flexion, adduction and internal rotation.
• Weeks 0-6: gait and transfers within the prescribed load, ankle pumps, quad/gluteal sets and hip motion only within the written limits.
• Weeks 6-12: advance loading only after surgical review; gradually restore motion and begin/progress gluteal work only after any abductor or trochanter restriction is released.
• After 12 weeks: progress gait, strength, stairs and low-impact aerobic work once fixation and soft-tissue healing are confirmed.

Extensor mechanism reconstruction after TKA - Marlex mesh

This pathway is intentionally much more protective than a primary tendon repair.

• Weeks 0-12: long-leg cast incorporating the foot; knee in full extension or about 5 degrees flexion per surgeon technique. No knee ROM. Toe-touch weight bearing in the cast unless the operative order differs.
• Month 4 (weeks 12-16): hinged brace full-time, 0-45 degrees. Flexion is active gravity-assisted only; no passive stretching or therapist overpressure. Lock the brace at 0 degrees for standing and walking.
• Month 5 (weeks 16-20): brace 0-60 degrees; continue locked-extension gait.
• Month 6 (weeks 20-24): brace 0-90 degrees; continue controlled flexion without force.
• After about 6 months: surgeon reassessment before motion beyond 90 degrees, brace weaning and progressive quadriceps loading.

Kneeling conditioning after knee replacement

Begin only after the incision is completely healed and the surgeon has cleared kneeling - commonly around 12 weeks after an uncomplicated TKA. Do not use this protocol after recent extensor-mechanism repair or reconstruction until specifically cleared.

1. Week 1: couch or soft bed surface, 5-10 minutes daily.
2. Week 2: thick couch cushion on the floor.
3. Week 3: thin pillow, foam pad or thick carpet.
4. Week 4: thin carpet or rug.
5. Week 5: firm floor or outdoor ground, using a thin pad initially if needed.

Partial meniscectomy

Use only after isolated partial meniscectomy or meniscal debridement. Weight bearing: as tolerated with crutches as needed. Brace: none routinely. ROM: as tolerated, with immediate emphasis on full extension.

• First week: swelling control, heel-prop extension, heel slides, quadriceps sets, straight-leg raise without lag, calf/hip work and gait normalization.
• Days 8-14: progress sit-to-stand, mini-squat, step-up, bridges, balance and cycling.
• Weeks 2-6: build closed-chain and single-leg strength. Consider a graded running program once ROM is full and pain-free, effusion is absent or trace, gait is normal, single-leg control is good and quadriceps strength is about 80% or better.

Meniscus repair - stable vertical/longitudinal tear

This pathway applies only when the surgeon documents a stable peripheral vertical or longitudinal repair. Early protection: weight bearing as tolerated with crutches and the brace locked straight for walking; gentle ROM 0-90 degrees during weeks 0-4. Keep a 90-degree cap through week 6 if specifically ordered.

• No pivoting, deep loaded flexion, kneeling, jumping or rotation for at least 4 months.
• Avoid resisted hamstring curls until week 6; posterior horn or complex repairs may need longer.
• Running may be considered at 4 months or later after surgeon clearance, full comfortable motion, quiet knee, normal gait and quadriceps strength about 80% or better.
• Unrestricted sport is usually 6-9 months, with at least 90% strength/function and no mechanical symptoms.

Meniscus root repair

• Weeks 0-6: non-weight bearing with two crutches or walker; brace locked at 0 degrees for transfers/walking; assisted motion 0-90 degrees.
• After the 6-week review: advance loading about 25% body weight every 3-4 days toward full loading if the knee remains quiet and gait controlled.
• No active hamstring heel-pull in the first 6 weeks and no isolated resisted hamstring curls before week 12.
• No deep loaded flexion beyond 90 degrees, kneeling, jumping or twisting for at least 4 months.
• Running assessment at 6 months or later; sport commonly 6-9 months or later depending on healing and associated procedures.

Primary ACL repair

For a surgeon-confirmed stable proximal native ACL suture repair, with or without internal-brace augmentation. It is not the BEAR protocol or an ACL reconstruction protocol.

• Weeks 0-2: weight bearing as tolerated with crutches after approval of the stable-repair pathway; brace locked straight for walking and sleep; gentle ROM 0-90 degrees.
• Weeks 2-6: wean crutches when gait is normal and there is no straight-leg-raise lag; unlock/wean brace around weeks 4-6 only with good control; progress toward 125 degrees then full flexion.
• Weeks 6-12: full comfortable motion, progressive closed-chain strength, cycling/elliptical, no impact or pivoting.
• Running: may begin around week 16 after surgeon clearance, full motion, quiet knee, good single-leg mechanics and quadriceps strength at least 80%.
• Full sport: usually 9 months or later with at least 90% strength/hop symmetry and surgeon clearance.

BEAR ACL repair

• Weeks 0-2: two crutches, no more than 50% body weight; brace locked at 0 degrees for walking and sleep; permitted sitting/exercise ROM 0-45 degrees after the first 24 hours.
• Weeks 2-4: continue no more than 50% weight bearing; ROM 0-90 degrees; brace remains locked outside supervised gait training.
• Weeks 4-7: advance toward weight bearing as tolerated only with PT and surgeon clearance; progress flexion beyond 90 degrees gently and unlock the walking brace when quadriceps control permits.
• No aggressive end-range flexion stretching before week 12. Straight-line jogging may be considered during weeks 12-20 only after surgeon clearance, full motion, zero effusion and quadriceps strength at least 80%.
• Cutting/pivoting remains restricted until the advanced phase at 30 weeks or later. Unrestricted sport is usually 9-12 months after objective testing and surgeon clearance.

BEAR with meniscus repair

The meniscal repair type determines whether the combined pathway is moderately or highly protective. The BEAR restrictions remain in force even if the meniscal repair would otherwise allow faster progression.

• Stable body/vertical repair: weeks 0-6, no more than 50% body weight with two crutches; 0-45 degrees initially then 0-90 degrees after week 2; brace locked for walking through week 6.
• Root, complete radial or protected complex repair: weeks 0-6, no weight through the operated leg; 0-45 degrees initially then 0-90 degrees after week 2; brace locked at 0 degrees through week 6.
• Root/radial repairs use assisted flexion and avoid active hamstring pulling for the first 6 weeks; no isolated resisted hamstring curls before week 12.
• Stable body repairs may be considered for straight-line jogging at 4 months or later if all BEAR criteria are met. Root/radial repairs defer running to at least 6 months and surgical clearance.
• Unrestricted sport is generally 9-12 months and requires clearance of both the ACL and meniscus pathways.

MACI rehabilitation depends on where the graft is located, how many lesions were treated, whether the lesions are contained, and whether an osteotomy, meniscus or ligament procedure was added. Time starts at MACI implantation, not the earlier cartilage biopsy.

Single tibiofemoral MACI lesion

Protected loading with two crutches: week 1 15%, week 2 30%, week 3 45%, week 4 55%, week 5 65%, week 6 75%, week 7 85%, then full when cleared around weeks 8-9. Unloaded flexion progresses approximately 45, 60, 75, 90, 105 and 120 degrees across weeks 1-6, then toward full. Brace is initially locked straight for gait.

Running readiness is assessed around 6 months, with a usual running window around 7-9 months if the graft and functional testing support it. Pivoting/cutting/contact sport is generally held until at least 12 months.

Single patellofemoral MACI lesion

For one contained patellar or trochlear graft when immediate loading is authorized: weight bearing as tolerated with crutches while the brace is locked straight for gait. Passive/assisted ROM progresses from 0-45 degrees in week 1 to 0-90 degrees by week 4; gentle active motion begins after 2 completed weeks. Brace unlocking begins only after 4 completed weeks with good quadriceps control and clearance.

Multiple tibiofemoral MACI lesions

Use the same staged protected-loading framework as tibiofemoral MACI - approximately 15%, 30%, 45%, 55%, 65%, 75%, 85%, then full when cleared - while protecting every repair site and the surgeon-defined safe loaded-flexion arc. Larger total repair area or associated surgery can slow progression.

Multiple patellofemoral MACI lesions

Protected pathway: week 1 15%, week 2 30%, week 3 50%, week 4 70%, week 5 90%, then full when cleared around week 6. Passive/assisted flexion progresses 45, 60, 75, 90, 105 and 120 degrees. Brace stays locked for walking for the first 4 completed weeks; gentle active motion begins after day 28.

Mixed tibiofemoral + patellofemoral MACI

Use the more protective combined pathway: tibiofemoral loading limits (15%, 30%, 45%, 55%, 65%, 75%, 85%, then full at about weeks 8-9) plus patellofemoral motion/brace protection. Keep the brace locked for walking for 4 completed weeks and begin gentle active knee motion after day 28. Running readiness is assessed later - commonly around 8 months, with a usual running window around 10-12 months when the grafts and testing support progression.

For all MACI pathways, permission for passive knee flexion does not mean loaded deep bending is safe. Avoid early impact, pivoting, forceful kneeling and unapproved graft-contact loading.

CartiHeal Agili-C osteochondral implant

Rehabilitation depends on implant location.

• Femoral condyle: no weight bearing for the first 3 weeks. After clearance, gradually increase partial loading toward full weight bearing by about week 6. A brace is not routine for an isolated condyle implant with good quadriceps control unless prescribed.
• Trochlea: weight bearing as tolerated using crutches with the knee straight; brace locked at 0 degrees for walking. Do not load a bent knee until cleared around week 6.
• Condyle + trochlea: use the condylar loading limits and the slower restriction from any associated procedure; retain locked-extension walking protection for the trochlear component.

Restore extension early and progress gentle assisted flexion - commonly toward about 90 degrees by 2 weeks, 120 degrees by weeks 4-6 and near-full motion by weeks 6-8 unless the surgeon orders a smaller arc. Low-load strengthening begins after protection is released. Running assessment is generally at 9-12 months; competitive sport is considered after 12 months with surgeon clearance and objective strength/function testing.

Ultrasound-guided trigger finger release

• Keep the original dressing clean and dry for 48 hours unless given a different instruction. After 48 hours, if the wound is closed and dry, wash gently, pat dry and cover with a clean bandage.
• No soaking, swimming, hot tub or ocean until the wound is fully closed and dry - usually about 10-14 days.
• Once numbness wears off, begin gentle finger opening, loose fist and hook motion: 5-10 repetitions, 4-6 times daily. Do not force a bent finger straight.
• First week: light eating, dressing, phone use and typing as comfortable; avoid forceful gripping, heavy lifting, power tools and pushing body weight through the hand.
• After 1-2 weeks, gradually add gripping/lifting if the wound is closed and soreness/swelling are improving.

Ultrasound-guided carpal tunnel release

• Keep the original dressing clean and dry for 48 hours unless instructed otherwise; then use gentle wound care and a clean bandage until healed.
• No soaking, swimming, hot tub or ocean until the wound is fully closed and dry - usually about 10-14 days.
• Begin gentle fist/open-hand motion, thumb-to-fingertip opposition and comfortable wrist flexion/extension after the anesthetic wears off: 5-10 repetitions, 4-6 times daily.
• A wrist splint and formal hand therapy are not routinely required after an uncomplicated release unless specifically prescribed.
• First week: light daily use and short typing periods as comfortable; avoid heavy lifting, repetitive forceful gripping, power tools and pressure through the heel of the palm. Gradually increase gripping/lifting after 1-2 weeks as wound healing and symptoms permit.

Call (808) 439-6201 for increasing wound drainage or redness, fever, a motion plateau, recurrent large swelling, new locking or giving way, a painful pop with loss of function, progressive numbness/weakness, or new calf pain and swelling. A cold, pale or blue hand/foot requires urgent evaluation. Call 911 for chest pain, trouble breathing, fainting or a severe allergic reaction.

Physical therapists may call or fax the office when a patient's operative findings do not fit the printed pathway. The goal is to protect healing tissue without leaving the patient unnecessarily restricted.