ANATOMIC ACL RECONSTRUCTION RECOVERY
& REHABILITATION PROTOCOL

• PREOPERATIVE:  
If  you  have  suffered  an  acute  ACL  injury  and  surgery  is  planned,  the  time  between  injury  and  
surgery  should  be  used  to  regain  knee  motion,  decrease  swelling,  and  maintain  muscle  tone.  
Physical  Therapy  may  be  necessary  prior  to  surgery.    

•  POSTOPERATIVE:    
Pain  Medicine:  You  will  be  sent  home  with  a  prescription  for  narcotic  pain  medicine  
(oxycodone,  hydrocodone,  or  propoxyphene),  Ibuprofen,  and  Toradol  (ketorolac).  Narcotic  
pain  medication  is  usually  helpful  for  the  first  week.  Ibuprofen,  an  anti-­‐inflammatory,  should  be  
used  regularly  for  the  first  2-­‐3  weeks.  TENS,  an  electrical  device,  may  also  help  with  your  pain  
control.    

Ice:  Ice  is  essential  for  pain  relief  and  to  reduce  swelling  for  the  first  several  weeks  after  
surgery,  and  can  be  helpful  for  several  months  (particularly  after  physical  therapy  sessions).  
Ice  should  be  used  at  least  3-­‐4  times  a  day  for  20  minutes.    

Activity:  You  may  fully  weight-­‐bear  on  your  surgical  leg  with  crutches.    

CPM  machine  (Continuous  Passive  Motion):  A  CPM  machine  may  be  delivered  to  your  house  
with  instructions  on  usage.  CPM  is  used  for  approximately  3  weeks  after  surgery.  It  will  assist  
with  bending  and  straightening  your  knee.    

Dressings:  You  may  remove  your  dressings  48-­‐72  hours  after  surgery  and  cover  your  incisions  
with  band-­‐aids  or  gauze.  Steristrips  should  be  left  in  place  (strips  of  white  tape  covering  each  
incision).  You  may  shower  once  your  incisions  are  completely  dry,  without  any  drainage  
(usually  5-­‐7  days  after  surgery).    

Braces:  A  post-­‐operative  brace  will  be  fitted  to  your  leg  on  the  day  of  surgery.  The  brace  should  
be  locked  in  full  extension  while  you  are  walking  to  prevent  your  knee  from  giving  way  or  
buckling.  Otherwise,  it  may  be  unlocked  to  allow  knee  motion.  The  brace  can  be  discontinued  
when  your  quadriceps  strength  is  adequate,  upon  recommendation  from  your  surgeon  or  
physical  therapist.  However,  you  should  continue  to  use  the  brace  for  dangerous  activities  such  
as  walking  on  uneven  ground,  sand,  snow,  ice,  etc.  Later,  you  will  be  fitted  for  a  functional  ACL  
knee  brace,  which  you  will  use  for  jogging,  agility  training,  and  return  to  any  athletic  or  
pivoting  activities.    
  
 
Crutches:  You  will  be  sent  home  with  crutches  to  aid  your  ambulation.  Starting  the  day  after  
surgery,  you  can  put  as  much  weight  on  your  leg  as  tolerated.  You  will  need  the  crutches  only  
until  you  can  walk  normally  without  a  limp.  This  varies  from  person  to  person.  Your  surgeon  or  
PT  will  advise  you  at  your  follow  up  appointments  when  you  can  discontinue.  

Home  Exercises:  On  the  day  after  surgery  you  should  start  performing  knee  motion  exercises  
as  detailed  in  this  protocol.  Within  2-­‐3  weeks  you  should  achieve  full  knee  extension  and  90  
degrees  knee  flexion.    
Goals  of  the  first  2-­‐3  weeks:    
1. Knee  Motion:  full  extension  to  90  degrees  flexion  (exercises)    
2. Decrease  swelling  (ice,  ibuprofen,  elevation)    
3. Maintain  Quadriceps  muscle  tone  (exercises)    
4. Straight  Leg  Raises  without  extensor  lag    
5. Good  Patella  mobility    
 
Physical  Therapy:  You  should  start  Physical  Therapy  within  1-­‐2  weeks  after  surgery.  Before  
that,  you  will  do  your  exercises  at  home  (as  above).  Several  months  of  formal  Physical  Therapy  
and  a  devoted  home  exercise  program  are  essential  in  order  to  achieve  a  good  outcome  for  
your  knee.  Please  give  a  copy  of  this  ACL  Rehabilitation  Protocol  to  your  therapist.    

Follow  Up:  You  will  return  to  see  your  surgeon  at  the  following  intervals  after  surgery:    
1. 7-­‐10  days    
2. 1  month    
3. 3  months    
4. 6  months    
5. 1  year    
  
 
 
 
•  EXERCISES    

You  should  perform  your  exercises  3-­‐4  TIMES  DAILY,  starting  the  day  after  surgery.    

Week  1:    
1 Ankle  Pumps  (see  diagram  1)    
2 Quad  Sets  (2)    
3 Hamstring  Sets  (3)    
4 Patella  Mobilization  (4,  5,  6)    
5 Hip  Abduction  (8  -­‐perform  in  brace  locked  in  extension)    
6 Hip  Adduction  (9  -­‐perform  in  brace  locked  in  extension)    
7 Hamstring  Stretching  (10)    
8 Sitting  Range  of  Motion  (12)    
 
Weeks  2-­‐4:  Add  the  following  exercises:    
1 Straight  Leg  Raises  (7  -­‐perform  in  brace  locked  in  extension)    
2 Prone  Hip  Extension  (13)    
3 Prone  Leg  Curls  (14)    
4 Heel  Slides  (15)    
5 Prone  Passive  Knee  Extension  Stretch  (16)    
 
Optional  Exercises  (if  you  have  access  to  a  pool):    
1 Active  ROM  from  0-­‐90  degrees  with  buoyancy  assisted  extension    
2 Flutter  kicking  performed  with  knee  fully  extended  and  motion  occurring  at  the  hips    
3 Walking  in  chest  deep  water  forward  and  backwards    
4 Hip  Exercises    
 
Weeks  4-­‐8:    
1.  Active  and  active-­‐assisted  range  of  motion:  0-­‐130  degrees    
2.  Leg  press    
a.  Begin  with  45-­‐60  degrees  flexion    
b.  Calf  raises    
3.  Proprioception  board    
a.  Balancing  exercises    
4.  Multi-­‐Angle  quadriceps  isometrics  between  90  and  60  degrees,  every  15  degrees  (6-­‐8  
weeks).    
5.  Add  the  following  under  Physical  Therapy  supervision  and  guidance:    
a.  Straight  Leg  Raises  with  ankle  weights  (NO  EXTENSOR  LAG).  Progress  1-­‐2  pounds/week,  20  
  
 
repetitions  3  times  daily.    
b.  Hip  Abduction  with  ankle  weights.  Progress  1-­‐2  pounds/week,  20  repetitions  3  times  daily.    
c.  Standing  Knee  Curls  with  ankle  weights.  Progress  1-­‐2  pounds/week,  20  repetitions  3  times  
daily.    
d.  Wall  slides  without  weights.  10  repetitions,  3  times  daily.    
e.  Hip  Adduction  without  weights.  20  repetitions  3  times  daily    
 
At  6  weeks,  add  the  following:    
1.  Stationary  Bicycling:    
a.  Adjust  seat  such  that  the  down  leg  is  in  slight  flexion    
b.  Low  load  &  high  speed  for  endurance    
 
2.  One-­‐legged  cycling  for  hamstring  activity  At  8  weeks,  add  the  following:    
1 Stairmaster  using  shallow  steps.  Start  at  5  minutes,  adding  2  minutes  per  session  
progressing  to  15  minutes.    
2 Nautilus-­‐type  leg  extensions  using  both  legs  to  lift,  and  surgical  leg  to  lower  (eccentric  
quadriceps  strength).    
3 Concentric  quadriceps  90-­‐45  degrees  on  leg  extension  machine  with  low  weight  on  the  
surgical  leg.    
 
At  3  months:    
nd   rd  
1.  Light  Jogging:  10  minutes  every  2 or  3 day,  increasing  2  minutes  per  week.  Monitor  
knee  for  signs  of  swelling.  If  swelling  occurs,  jogging  should  be  delayed.    

At  4  months:    
1.  Agility  Training    

At  5-­‐6  months:    
1.  Limited  non-­‐contact  sport-­‐specific  activities  with  permission  from  your  physician.    
2.  More  aggressive  strengthening:    
a.  Leg  Press:  progress  with  weights  (do  not  exceed  90  degrees  flexion)    
b.  Leg  Curls:  progress  with  weights    
c.  Leg  Extensions:  concentric  and  eccentric  (90-­‐30  degrees)    
3.  Stationary  Bicycle:  increase  resistance  and  duration    
4.  Step-­‐up’s:  progress  from  2  to  6  inch  step.  Lower  with  the  heel  of  the  uninvolved  leg  first.  
Progress  rapidly  toward  lowering  with  the  involved  leg.    
5.  Jump  Rope:  two  feet  progressing  to  one  foot    
6.  Agility  Training  in  functional  knee  brace:    
a.  Side  to  side  steps:  controlled  lateral  agility,  emphasize  eccentric  phase    
b.  Running  forward/backward    
  
 
c.  Side  to  side  hops    
d.  Carioca  crossover  steps  alternating  front  to  back    
 
At  6-­‐8  months:  You  may  return  to  competitive  athletics  under  the  following  conditions:    
1 No  knee  swelling    
2 Full  range  of  motion    
3 Adequate  strength:  at  least  90%  strength  &  endurance    
4 Adequate  knee  stability    
5 You  must  use  your  functional  knee  brace.  Continue  to  use  your  functional  knee  brace  
during  athletic  activity  for  at  least  12  months  after  surgery.  You  may  discontinue  the  brace  
under  instruction  from  your  surgeon.