Quadriceps Reconstruction
Mesh or Allograft

Postoperative Physical Therapy Protocol

General Considerations

• This protocol addresses patients who have undergone TKA with quadriceps reconstruction using mesh or allograft tissue, often due to chronic extensor mechanism failure, tendon rupture, or poor tissue quality.
• The protocol is intentionally more conservative to protect the graft while balancing the need to prevent postoperative stiffness common in TKA patients.
• Progression is based on healing constraints of the reconstruction, not standard 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 full extension (0–0°)
• Brace: Locked at 0–0° at all times during ambulation
• Range of Motion (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 (except 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
  • No active flexion until cleared

Therapeutic Exercises:

• Seated assisted heel slides within range
• Quad sets with NMES
• Standing hip abduction/adduction (band resistance proximal to knee)
• Straight-leg bridging with brace on
• Standing calf raises
• Balance drills (double leg stance, no perturbation)

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 brace gradually per MD approval
• ROM: Advance active-assisted ROM to 0–90°

Therapeutic Exercises:

• Wall slides (0–90° limit)
• Stationary bike (no resistance)
• Double leg bridges
• Mini step-ups
• Terminal knee extensions (short arc quads)
• Supported treadmill walking

Manual Therapy:

• Patellar glides
• Soft tissue mobilization to quads, IT band, lateral retinaculum

Phase IV – Reconditioning Phase (Weeks 10–16)

Goals:

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

Therapeutic Exercises:

• Full ROM cycling (add resistance)
• Leg press (0–60° arc)
• Mini squats, lateral step-ups
• Single-leg balance drills
• Begin pool-based gait and light resistance drills
• Elliptical if pain-free

Manual Therapy:

• Patellar taping if indicated for tracking
• Joint mobilization for stiffness

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

Goals:

• Maximize strength, endurance, and proprioception
• Begin return to recreational and low-impact athletic activities
• Normalize gait and functional movements

Therapeutic Exercises:

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

Criteria to Progress:

• Full ROM matching contralateral limb
• No extensor lag
• Quad strength ≥ 80% contralateral side
• Independent gait with proper mechanics