ACL Rehab Protocol

ACL Reconstruction

Rehabilitation Protocol

One of the most common complications following ACL reconstruction is loss of motion,

especially loss of extension.

I-Preoperative Rehabilitation Phase

Goals: *

  • Control pain and swelling
  • Restore normal range of motion
  • Develop muscle strength sufficient for normal gait and ADL
  • Mentally prepare the patient for surgery

Before proceeding with surgery the acutely injured knee should be in a quiescent state with little or no swelling, have a full range of motion, and the patient should have a normal or near normal gait pattern.

More important than a predetermined time before performing surgery is the condition of the knee at the time of surgery.

Control Pain and Swelling

Icing along with nonsteroidal anti-inflammatory medications are used to help control pain and swelling.

The nonsteroidal anti-inflammatory medications are continued for 7 – 10 days following the surgery regardless if there is no pain.

Restore normal range of motion

You should attempt to achieve full range of motion as quickly as possible. Quadriceps

isometrics exercises, straight leg raises, and range of motion exercises should be started


Full extension is obtained by doing the following exercises:

1) Passive knee extension.

• Sit in a chair and place your heel on the edge of a stool or chair.

• Relax the thigh muscles.

• Let the knee sag under it’s own weight until maximum extension is achieved.

2) Heel Props:

• Place the heel on a rolled towel making sure the heel is propped high enough to

lift the thigh off the table.

• Allow the leg to relax into extension.

• 3 – 4 times a day for 10 – 15 minutes at a time.

3) Prone hang exercise.

• Lie face down on a table with the legs hanging off the edge of the table.

• Allow the legs to sag into full extension.

Bending (Flexion) is obtained by doing the following exercises:

1) Passive knee bend

• Sit on the edge of a table and let the knee bend under the influence of gravity.

2) Wall slides are used to further increase bending.

• Lie on the back with the involved foot on the wall and allow the foot to slide down

the wall by bending the knee. Use other leg to apply pressure downward.

3) Heel slides are used to gain final degrees of flexion.

• Pull the heel toward the buttocks, flexing the knee. Hold for 5 seconds.

• Straighten the leg by sliding the heel downward and hold for 5 seconds.

• In later stages of rehabilitation, do heel slides by grasping the leg with both

hands and pulling the heel toward the buttocks.

Develop muscle strength

Once 100 degrees of flexion (bending) has been achieved you may begin to work on

muscular strength:

1) Stationary Bicycle. Use a stationary bicycle two times a day for 10 – 20 minutes to help increase muscular strength, endurance, and maintain range of motion.

2) Swimming is also another exercise that can be done during this phase to develop muscle strength and maintain your range of motion.

3) Low impact exercise machines such as an elliptical cross-trainer, leg press machine, leg curl machine, and treadmill can also be used.

This program should continue until you have achieved a full range of motion and good

muscular control of the leg (you should be able to walk without a limp).

Mentally prepare

• Understand what to realistically expect of the surgery

• Make arrangements with a physical therapist for post-operative rehabilitation

• Make arrangements with your work

clear travel, flight or holiday abroad for at least 6 weeks.

• Make arrangements with family and/or friends to help during the post-operative


• Read and understand the rehabilitation phases after surgery

Understanding Surgery

This section provides an understanding of the pre and post-operative phases of surgery.

Key terms: Pain control, Drainage tube, Knee Immobilizer, TED


II- Post-operative Rehabilitation Phase

 • The postoperative knee brace can be used to support the knee from unexpected fall.

• After surgery, your leg will be wrapped in soft cotton bandage. You can remove the bandage to change the dressings only if oozing.

You will not be allowed to drive a car for two week at least. until you walk fully weight without pain.

Postoperative week 1-2:


  • Control pain and swelling
  • Care for the knee and dressing
  • Early range of motion exercises
  • Achieve and maintain full passive extension
  • Prevent shutdown of the quadriceps muscles
  • Gait training

Control Pain and Swelling

1) Control Swelling. Following discharge from the hospital you should go home elevate your leg and keep the knee iced if swollen.

2) Do not sit for long periods of time with your foot in a dependent position (lower than the rest of your body), as this will cause increased swelling in your knee and leg. When

sitting for any significant period of time, elevate your leg and foot.

3) Control Pain. You will be sent home with a prescription for pain control take them regularly and not as required.

4) As your pain and swelling decrease you can start to move around more and spend more time up on your crutches.

Caring for your knee

1) The first night and day after the surgery you can expect the white elastic stocking and

bandages to get bloody. This is normal! We want the blood to drain out of the knee on

to the dressings rather than build-up in your knee and cause swelling and pain.

If the dressings become extremely bloody or wet you should contact the hospital to reinforce the dressing as needed.

 you could add extra bandage to cover the bleeding area but do not expose the wound otherwise will bleed more.

2) you could limit weight bearing to prevent swelling.

3) You can start using a stationary bike. Cycling is an excellent conditioning and building exercise for the quadriceps. Start with the seat fairly high and use a short diameter pedal if available so that the knee doesn’t bend too much.

At this early stage, you should just “spin” without any resistance. Use your good leg to turn the pedal.

4) You may shower, but you must keep your incisions dry for the first 7-10 days. This can be achieved by placing a waterproof dressing or plastic bag over your leg.

5)  A follow-up visit should be scheduled 2 weeks following the operation at the time of discharge from the ward.

7) You may remove the knee brace while doing exercises or if you are in a safe, protected environment. 

Early Range of Motion and Extension

1) Passive extension of the knee by using a rolled towel under the heel.

2) Active-assisted extension is performed by using the opposite leg and your quadriceps

muscles to straighten the knee from the 90 degree position to 0 degrees.

3) Passive flexion (bending) of the knee to 90 degrees.

• Sit on the edge of a bed or table and letting gravity gently bend the knee.

• The opposite leg is used to support and control the amount of bending.

• This exercise should he performed 4 to 6 times a day for 10 minutes. It is

important to achieve at least 90 degrees of passive flexion by 5 – 7 days after


Exercising Quadriceps

1) You should start quadriceps isometric contractions with the knee in the fully extended

position as soon as possible.

• Do 3 sets of 10 repetitions 3 times a day.

• Each contraction should be held for a count of 6 sec.

This exercise helps to prevent shut down of the quadriceps muscle and decreases

swelling by squeezing fluid out of the knee joint.

2) Begin straight leg raises (SLR) with the knee immobilizer on 8 sets of 10 repetitions 3

times a day. Start by doing these exercises while lying down.

• This exercise is performed by first performing a quadriceps contraction with the

leg in full extension. The quadriceps contraction “locks” the knee and prevents

excessive stress from being applied to the healing ACL graft.

• The leg is then kept straight and lifted to about 45-60 degrees and held for a

count of six.

• The leg is then slowly lowered back on the bed. Relax the muscles.

Exercising Hamstrings

1) For patients who have had ACL reconstruction using the hamstring tendons it is

important to avoid excessive stretching of the hamstring muscles during the first 6

weeks after surgery.

• The hamstring muscles need about 6 weeks to heal, and excessive hamstring

stretching during this period can result in a “pulled” hamstring muscle and

increased pain.

• Unintentional hamstring stretching commonly occurs when attempting to lean

forward and put on your socks and shoes, or when leaning forward to pick an

object off the floor.

• To avoid re-injuring the hamstring muscles, bend your knee during the activities

below, thus relaxing the hamstring muscles.

2) The hamstring muscles are exercised by pulling your heel back producing a hamstring


• This exercise should be performed only if your own patellar tendon graft was

used to reconstruction the ACL.

• If a hamstring tendon graft from your knee was used to reconstruct the ACL, this

exercise should be avoided for the first 4 – 6 weeks, as previously mentioned.

Returning to Work

1) As far as returning to work, if you have a desk type job you can return to work when

your pain medication requirements decrease, and you can safely walk with your

crutches. Typically this is around 2 weeks days after surgery.

2) Patients who have jobs where light duty is not permitted; policemen, firemen,

construction workers, laborers, will be out of work for a minimum of 6 weeks.

Postoperative Week 3


  • Maintain full extension
  • Achieve 100 – 120 degrees of flexion
  • Develop enough muscular control to wean off knee immobilizer
  • Control swelling in the knee

Maintain Full Extension

1) Continue with full passive extension (straightening), gravity assisted and active flexion,

active-assisted extension, quadriceps isometrics, and straight leg raises.

2) Work toward 90-100 degrees of flexion (bending)

Develop Muscular Control

1) Start Partial Squats.

• Place feet at shoulder width in a slightly externally rotated position.

• Use a table for stability, and gently lower the buttocks backward and downward.

• Hold for 6 seconds and repeat.

• Do 3 sets of 10 repetitions each day.

2) Start Toe Raises.

• Using a table for stabilization, gently raise the heel off the floor and balance on

the ball of the feet.

• Hold for 6 seconds and ease slowly back down.

• Do 3 sets of 10 repetitions each day.

3) Continue to use the knee brace for walking even if you have good muscle control of the leg. This will protect your graft.

4)  You can continue using a stationary bike. Cycling is an excellent conditioning and

building exercise for the quadriceps. 

• The seat position is set so when the pedal is at the bottom, the ball of the foot is

in contact with the pedal and there is a slight bend at the knee.

• No or low resistance used. Maintain good posture throughout the exercise.

• As your ability to pedal the bike with the operative leg improves, you may start

to increase the resistance (around 5-6 weeks).

• Your objective is to slowly increase the time spent on the bike starting first at 5

minutes and eventually working up to 20 minutes a session.

• The resistance of the bike should be increased such that by the time you

complete your work-out your muscles should “burn”.


• First, you must not be taking any prescription pain medications.

• Patients who have had surgery on the left knee, and who have an automatic

transmission may drive when they can comfortably get the leg in and out of the

car, usually 2 weeks.

• Patients who have had surgery on the left knee and have standard transmissions,

should not drive until they have good muscular control of the leg. This usually

takes 3-4 weeks.

• Patients who had surgery on the right knee should not drive until they have good

muscular control of the leg. This usually takes 4-6 weeks.


Postoperative Weeks 4 – 6


  • 125 degrees of flexion pushing toward full flexion
  • Continued strength building

1) Your expected range of motion should be full extension to 125 degrees. Start to push

for full flexion. Walls slides added if your flexion range of motion is less than desired.

2) Continue quad sets, straight leg raises, partial squats, toe raises, stationary bike,

elliptical machine, leg presses, and leg curls.

3) Tilt board or balance board exercises. This helps with your balance and proprioception

(ability to sense your joint in space)

Postoperative Weeks 6 – 12


  • 135 degree of flexion
  • Continued strength
  • Introduce treadmill

1) Continue quad sets, straight leg raises, partial squats, toe raises, stationary bike,

elliptical machine, leg presses, and leg curls.

2) Hamstring reconstruction patients can start leg curls in a sitting position. If you develop

hamstring pain then decrease the amount of weight that you are lifting, otherwise you

can increase the weight as tolerated.

3) Continue tilt board and balance board for balance training.

4) Continue swimming program.

5) Start treadmill (flat only).

6) You may begin outdoor bike riding on flat roads.

Postoperative 3-6 months:


  • Continued strength
  • Introduce jogging and light running
  • Introduce agility drills
  • Determine need for ACL functional brace

1) Continue all of week 6 -12 strengthening exercises.

2) Start straight, forward and straight, backward jogging and light running program.

3) Start functional running program after jogging program is completed.

4) Optional fitting for ACL functional brace.

5) Start agility drills, zig-zags and cross over drills.

Postoperative -6 months

Goals:  * Return to sports

To return to sports you should have:

  • Quadriceps strength at least 80% of the normal leg
  • Hamstring strength at least 80% of the normal leg
  • Full motion
  • No swelling
  • Good stability
  • Ability to complete a running program