Quadriceps Reconstruction with Mesh or Allograft Following Total Knee Arthroplasty (TKA)

Postoperative Physical Therapy Protocol

General Considerations

This protocol addresses patients who have undergone TKA with quadriceps reconstruction using mesh or allograft tissue. It is designed to protect the surgical repair while balancing the risk of postoperative stiffness common in TKA. Progression is guided by tissue healing and not by typical TKA timelines.

Phase I – Protective Phase (Weeks 0–4)

Goals:

• Protect reconstruction site
• Minimize inflammation and swelling
• Prevent stiffness while preserving full extension
• Begin neuromuscular activation (VMO emphasis)

Precautions / Restrictions:

• Weight Bearing: WBAT with brace locked in extension (0–0°)
• Brace: Locked at 0–0° at all times during ambulation
• ROM: Weeks 0–2: No ROM
  Weeks 2–4: Passive ROM only, 0–20°

Therapeutic Exercises:

• Ankle pumps
• Isometric quadriceps sets (with NMES or biofeedback)
• Hamstring and calf stretching (to maintain extension)
• Patellar mobilization (gentle medial glides)
• Leg raises in multiple planes (avoid hip flexion)
• Core and contralateral limb strengthening

Cardiovascular:

• Upper Body Ergometer
• Well-leg cycling

Manual Therapy:

• Soft tissue mobilization to surrounding musculature only
• Effleurage for edema management
• Avoid contact with surgical portals or “no-touch zone” (2 inches around graft)

Phase II – Limited Motion Phase (Weeks 4–6)

Goals:

• Continue protection of reconstruction
• Gradually reintroduce ROM
• Maintain quadriceps and gluteal activation
• Improve mobility without stressing graft

Precautions / Restrictions:

• Brace: Continue locked in extension during ambulation
• ROM: Advance passive ROM to 0–50° by end of Week 6

Therapeutic Exercises:

• Seated assisted heel slides within range
• Quad sets with NMES
• Standing hip abduction/adduction (resistance band above knee)
• Straight-leg bridging with brace on
• Standing calf raises
• Balance drills (double leg stance)

Manual Therapy:

• Soft tissue mobilization around patellofemoral joint and suprapatellar pouch
• Portal/scar mobilization if incisions fully healed

Phase III – Progressive Motion and Strength (Weeks 6–10)

Goals:

• Achieve 90° of flexion without stressing graft
• Begin active range of motion and closed-chain strength
• Normalize gait mechanics

Precautions / Restrictions:

• Brace: May unlock gradually in therapy per MD approval
• ROM: Advance active-assisted ROM to 0–90°

Therapeutic Exercises:

• Wall slides (limit to 90°)
• Stationary bike (no resistance)
• Double leg bridges
• Mini step-ups
• Terminal knee extensions
• Supported treadmill walking

Manual Therapy:

• Patellar glides
• Soft tissue work to quadriceps, IT band, lateral retinaculum

Phase IV – Reconditioning Phase (Weeks 10–16)

Goals:

• Restore full ROM
• Improve quadriceps strength and symmetry
• Introduce unilateral loading and dynamic balance

Therapeutic Exercises:

• Stationary bike with resistance
• Leg press (0–60°)
• Mini squats, lateral step-ups
• Single-leg balance drills
• Pool-based gait and resistance drills
• Elliptical (if pain-free)

Manual Therapy:

• Patellar taping for tracking issues
• Joint mobilization as indicated

Phase V – Return to Function (Months 4–6)

Goals:

• Maximize strength, endurance, and proprioception
• Return to recreational and low-impact athletic activities
• Normalize gait and functional movement patterns

Therapeutic Exercises:

• Eccentric strengthening: leg press, decline squats
• Running progression (if criteria met)
• Agility drills and dynamic balance training
• Plyometric drills (low box jumps, step-downs)

Criteria to Progress:

• Full ROM equal to contralateral limb
• No extensor lag
• Quadriceps strength ≥ 80% of the uninvolved side
• Independent ambulation with normalized gait