Physical Therapy Protocol:

ACL Repair or Reconstruction

 

RESTRICTIONS:

• NO open chain resisted knee extension exercises x6 weeks

Key Considerations:

• Protect graft during early ligamentization phase
• Restore full knee extension early
• Prioritize quadriceps activation and neuromuscular control
• Avoid premature high-load pivoting activities

Phase I: Protection and Early Motion (Weeks 0–6)

Primary Goals

• Protect graft fixation and control inflammation
• Restore full passive knee extension
• Gradually restore flexion range
• Re-establish quadriceps activation and normalize gait

Precautions

• Avoid open-chain resisted knee extension from 40°–0° early in rehab
• Avoid pivoting, twisting, or cutting movements
• Brace and weight-bearing status per surgeon protocol (often WBAT with brace locked in extension initially)

Interventions

Pain and Swelling Management

• Cryotherapy and compression
• Elevation and edema control strategies

 

Range of Motion

• Immediate emphasis on full passive extension
• Heel slides or wall slides for flexion progression
• Target ROM by week 6:
  • Extension: full (0°)
  • Flexion: 120–130°

Quadriceps Activation

• Quad sets with NMES if needed
• Straight leg raises (brace locked if extension lag present)
• Terminal knee extension exercises

Early Strengthening

• Closed-chain exercises:
  • Mini-squats (0–45°)
  • Leg press (0–60°)
  • Step-ups (low height)

Gait Training

• Normalize gait with progressive weight bearing
• Discontinue assistive device once gait is symmetrical

Criteria to Progress to Phase II

• Minimal effusion
• Full knee extension and ≥120° flexion
• Independent gait without assistive device
• Ability to perform straight leg raise without lag

Phase II: Strengthening and Neuromuscular Control (Weeks 6–16)

Primary Goals

• Restore full knee range of motion
• Improve quadriceps and hamstring strength
• Develop neuromuscular control and dynamic knee stability
• Initiate light functional activities

Precautions

• Avoid cutting, pivoting, or high-impact activities
• Progress resistance gradually to avoid graft overload

Interventions

Strength Progression

• Leg press progression (0–90°)
• Squats and split squats
• Step-ups and step-downs
• Hamstring strengthening (especially important with patellar tendon grafts)

Neuromuscular Training

• Single-leg balance progression
• Perturbation training
• Proprioceptive drills (balance boards, unstable surfaces)

Hip and Core Strength

• Gluteus medius strengthening
• Core stabilization to support knee control

Cardiovascular Conditioning

• Stationary cycling
• Elliptical trainer
• Pool running if available

Criteria to Progress to Phase III

• Full ROM without pain
• Quadriceps strength ≥70% of contralateral limb
• Minimal or no joint effusion
• Good control with single-leg squat

Phase III: Advanced Strengthening and Return to Sport (Weeks 16–36)

Primary Goals

• Restore strength, power, and endurance
• Develop dynamic stability during high-level activities
• Safely return to sport or demanding occupational tasks

Precautions

• Avoid premature return to cutting or pivoting sports
• Monitor for swelling or instability after higher-level activities

Interventions

Strength and Power Development

• Progressive resistance training (squats, deadlifts, lunges)
• Eccentric strengthening for quadriceps and hamstrings
• Plyometric training progression

Agility and Neuromuscular Control

• Ladder drills
• Lateral movement training
• Deceleration and change-of-direction drills

Running Progression

• Begin jogging once strength and mechanics allow (typically ~12–16 weeks)
• Gradual progression to sprinting and agility work

Sport-Specific Training

• Progressive drills replicating sport demands
• Emphasis on proper landing and cutting mechanics

Criteria for Return to Sport

• Quadriceps and hamstring strength ≥90% of contralateral limb
• Passing functional hop testing
• No pain, swelling, or instability