Post ACL Reconstruction Protocol

Week 1 -3

–   After surgery, the incisions need to heal and the swelling needs to settle down.  It’s important to limit activities as much as possible until pain and swelling start to improve.  Ice and ice modalities are used liberally as well as elevation of extremity.   The pace of the postop rehab has to be individualized.  There is no “one size fits all”.

–   Early ROM with the CPM machine may be started.  Many insurance companies are no longer covering CPM machines post-ACL.  I continue to think them important after a patellar tendon graft, but not usually after a hamstring or allograft ACL reconstruction.  Motion needs to get to 90 degrees at least by the end of the first week.  Full extension exercises need to start.  Prone hangs for extension.  Seated or supine heel slides are good.  Also knee extension with a roll towel under the ankle.

heel slides

supine heel slides

–  The patient will be in a post-op IROM brace that is set at 0-90 degrees.  The brace is to be worn at all times, except when in bed  or in the CPM machine.  The patient should ambulate with crutches and brace until a normal gait is established.  Full knee extension is necessary for a normal gait pattern.

–  Early quad work can begin.  Start with quad sets (10 x 10 secs for 10 times a day).  Electrical stimulation can be used to initiate contractions.  Once quad sets are good, you can advance to straight leg raises (SLR’s).  Again, full knee extension is necessary for this to work.
–  Gait training with WBAT unless otherwise instructed in brace.  No limping!  Crutches until you can walk without a limp.  Very important to get full extension or walking off crutches difficult. Can move to single crutch when ready in opposite hand, then to none as tolerated.

–  Others:  Multi-hip raises,  calf raises, Total Gym, bicycle once 100 degrees is reached is good for early quad work, electrical stim to generate initial quad contractions


Week 3 – 6

–   Continue with Week 1 – 3 goals until met.  Full range of motion especially extension important.  Continue ice modalities and controlling activities for swelling.  At 3 weeks if good quad contraction is obtained you can wean out of the IROM brace.  Also can wean off crutches once good gait pattern is established.  You need to have a good heel – toe gait.  No limping!

–  Continue ice for residual inflammation.  I like using a bag of frozen peas for this.  It’s the right temperature, and the right amount of time.  It’s also easy.

–   Continue quad strengthening.  I prefer closed chain kinetic quad strengthening such as leg presses and squats because it is less hard on the patellofemoral joint and it helps with proprioception.  Total Gym is good for this.  Focus weight more on heels than toes.  I like wall squats when not in the gym with controlled weight distribution holding onto support.  You can put more weight on the involved side as you get stronger.

Leg presses

Leg presses





–   Hamstring curls can begin.  Don’t forget hamstring stretching as well as calf raises and stretching.

–    Can start aerobic conditioning such as stationary bike or elliptical machine.  Very gradually increase duration and intensity as tolerated.  Use presence of swelling as a guide as to how much is okay.

–   Patella mobilization especially superior and inferior.


Week 6 -12

–   Closed chain kinetic quad strengthening with goal of side to side symmetry  –   Leg presses, wall squats, etc.  Can advance hamstring strengthening at 6 weeks.  The quadriceps muscle is the key to leg function.  Concentrate on getting it back!

–   Step-ups can begin if quad is doing well.  Slow and controlled.  Plus or minus hand weights.

–   Continue ice after activities.

–   Aerobic activities okay –  stationary bike, regular bike, elliptical, pool.  No running or sports yet.  The ACL graft has not matured enough for sports.  Again can increase intensity of swelling/inflammation under control.

–    Balance – plyotoss, single leg stance.


Month 3

–   Continue working towards full quad and hamstring strength. Previous exercises still apply.   Usually at this time a functional ACL brace will be fitted if quad atrophy gone.  Once brace is obtained, can start straight line gradual jogging.

–   Straight line jogging can start once you get the brace.  Again this should be a gradual process with good technique not pushed past the point of quad fatigue..  Can continue other aerobic activities.  Ice after activities.


Month 4-5

–   Make sure all of the above goals are met.  Can add backward running.  Box 4 drills.  Sport specific drills can often be added here.  Check with Dr. Maffet first.   No competitive pivoting sports yet!

–  Neuromuscular training should be concentrated on here including plyometrics or jump training and agility drills.  P90X has a good home plyometric program.  Squat jumps. Tuck jumps. Box jumps. 180 jumps. Cone jumps. Scissors jumps. Combo patterns.

–  Initiate sprints and cutting drills. Straight line. Figure of 8. Circles. 90 degree cuts.

–  Sportsmetrics – geared toward female athletes.  Well publish program that teaches techniques of proper landing. stopping, and jumping to prevent future ACL injury.

Month 6

–   Gradual return to sports (RTS) activities.  Need to have all of the above goals met.  Can take up to a year for full confident return.

–   I recommend you wear the functional ACL brace for the first year of sports return. After that it is optional.

–   Continue neuromuscular training you’ve been taught.  You get better with time.  Published studies show a higher risk of ACL rein jury, contralateral ACL injury, and other orthopedic injuries in the first 2 years of RTS after an ACL reconstruction.

–  Single leg hop test ( distance of 2 consecutive hops on one leg) needs to be 80% of uninjured leg.