How to Get Better After Reconstructing the Anterior Cruciate Ligament (ACL)

Recovering After ACL Reconstruction Surgery: This plan helps doctors know what to expect after ACL surgery. It follows both time and specific criteria based on how well the tissue heals. The treatment should be based on the individual’s needs, considering the exam results and clinical decisions. It also includes the expected timeframes for recovery.

The details in this guide may vary based on the surgeon’s preferences, additional procedures, or complications. If a doctor needs assistance with a patient’s recovery after surgery, they should consult with the surgeon who referred the patient.

Thinking about allograft and hamstring autograft options

For allograft and hamstring autograft, there are specific instructions for early weight-bearing and rehabilitation. Check the details below. The early return to sports may be delayed.

Considerations for multiple injuries

When you have more than one injury at the same time, it’s safer to be careful with how much you move, how much weight you put on, and how quickly you go through rehabilitation. This is especially important after a meniscus repair.

What to consider after surgery.

After surgery, watch for signs like fever, strong calf pain, too much drainage from the cut, or uncontrolled pain. If these happen, call your doctor immediately.

PHASE I: RIGHT AFTER OPERATION (0–2 WEEKS AFTER SURGERY)

Recovery Objectives

Keep the graft safe. Reduce pain and swelling. Restore patellar mobility. Regain full extension and gradually improve flexion. Reduce muscle inhibition, regain control of the quads, and achieve full active extension. Patient education: Keep your knee straight and raised when sitting or lying down. Don’t put a towel under your knee when resting. Support your surgical side when moving from sitting to lying down. Avoid turning on your surgical side.

Putting on weight

Take a walk Start with the brace locked and crutches (as recommended by the doctor) Gradually walk without crutches if the pain, swelling, and gait are improving. Patients with allograft and hamstring autograft may need crutches for 6 weeks unless the doctor advises otherwise. Unlock the brace once you can perform a straight leg raise without any delay. Stop using the brace after 6 weeks if advised by the doctor and when you have good control over your quadriceps. When climbing stairs, lead with the side that wasn’t operated on. When descending stairs, lead with the crutches and the surgical side.

Interventions:

Swelling Management

• Ice, pressure, and incline (for cold treatment, talk to your doctor first).
• Backwards massage
• Foot pump

Ice, pressure, and incline (for cold treatment, talk to your doctor first).

Backwards massage:

Foot pump:

Mobility or freedom of movements

Move your kneecap in two ways: up and down, and side to side. This is crucial in the initial weeks after surgery with a patella tendon graft.

Bend and straighten your knee, and slide your heel while sitting with the aid of a towel.

Perform gentle, prolonged stretches to extend your knee: try prone hanging and heel prop. Stretch your calf muscles while standing and stretch your hamstrings while lying down and keeping still.

Patellar mobilizations:

Seated assisted knee flexion extension

Heel Slides With Towel

Low intensity, long duration extension stretches: Prone Hang

heel prop

Standing gastroc stretch

Soleus Stretch

Supine Active Hamstring Stretch

Supine Passive Hamstring Stretch

Strengthening

Calf Raises

Quadriceps Setting Exercise

NMES: high intensity (2500 Hz, 75 bursts) Supine knee extension: 10 sec/50 sec, 10 contractions, 2x/wk during sessions. Use clinical stimulator during sessions and explore home units for immediate post-op.

Straight Leg Raise Exercise **Do not perform straight leg raise if you have a knee extension lag

Hip Abduction

Multi Angle Quadriceps Isometric

Criteria to Progress

Knee Extension 0 to 45 degrees

Patella Mobilizations with Paul Marquis PT

Able to perform straight leg raise without lag

PHASE II: INTERMEDIATE POST-OP (3-5 WEEKS AFTER SURGERY)

Rehabilitation Goals

• Continue to protect graft
• Maintain full extension, restore full flexion (contra lateral side)
• Normalize gait

Additional Interventions *Continue with Phase I interventions

Range of motion/Mobility

Gentle stretching all muscle groups:

Patella Mobilizations with Paul Marquis PT : Prone Quad Stretch

Standing Quad Stretch

Standing Quad Stretch

Kneeling Hip Flexor Stretch

Strengthening

Prone Hamstring Curls

Prone Hamstring Curls

Step Ups with March

Partial Squat Exercise

Ball Squats

Wall Slide Exercise

Wall Slide Exercise

Lumbopelvic strengthening:

Balance/proprioception

Criteria to Progress

• No swelling (Modified Stroke Test)
• Flexion ROM within 10 deg contra lateral side
• Extension ROM equal to contra lateral side

PHASE III: LATE POST-OP (6-8 WEEKS AFTER SURGERY)

Rehabilitation Goals	• Continue to protect the graft site. • Maintain complete range of motion • Strengthen safely • Encourage good movement patterns • Reduce post-exercise soreness and edema • Avoid activities that cause pain at graft donor site.
Additional Interventions *Continue with Phase I-II Interventions	Range of motion/Mobility Rotational tibial mobilizations if limited ROM Cardio 8 weeks: Elliptical, stair climber, flutter kick swimming, pool jogging

Strengthening Gym equipment:

o Hamstring autograft can begin resisted hamstring strengthening at 12 weeks

• Progress intensity (strength) and duration (endurance) of exercises

**The following exercises to focus on proper control with emphasis on good proximal stability

Balance/proprioception

Progress single limb balance including perturbation training

Criteria to Progress

After exercise, there is no swelling, edema, or discomfort. The gait is normal, the range of motion is equal to the contralateral side, and the joint position feeling is equal (with a margin of error of less than 5 degrees).

PHASE IV: TRANSITIONAL (9-12 WEEKS AFTER SURGERY)

Rehabilitation Goals

• Maintain complete range of motion • Strengthen safely • Encourage good movement patterns • Reduce post-exercise soreness and swelling • Avoid activities that cause pain at patch donor site.

Additional Interventions *Continue with Phase II-III interventions

• Start submax sport-specific training in the vertical plane. • Bilateral PWB gymnastics evolved into FWB plyometrics.

Additional Interventions *Continue with Phase II-III interventionsCriteria to Progress

No episodes of instability Maintain quad strength 10 repetitions single leg squat proper form through at least 60 deg knee flexion Drop vertical jump with good control KOOS-sports questionnaire >70% Functional Assessment o Quadriceps index >80%; HHD or isokinetic testing 60d/s o Hamstrings ≥80%; HHD or isokinetic testing 60 d/s o Glut med, glut max index ≥80% HHD

PHASE V: EARLY RETURN TO SPORT (3-5 MONTHS AFTER SURGERY)

Rehabilitation Goals	• Safely progress strengthening • Begin sport-specific training program • Encourage good movement patterns • Minimize post-exercise soreness and swelling • Avoid activities that cause pain at graft donor site.
Additional Interventions *Continue with Phase II-IV interventions	Interval running program o Return to Running Program Progress to plyometric and agility program (with functional brace if prescribed) o Agility and Plyometric Program

PHASE VI: UNRESTRICTED RETURN TO SPORT (6+ MONTHS AFTER SURGERY)

Rehabilitation Goals

• Continue strengthening and proprioceptive exercises
• Symmetrical performance with sport specific drills
• Safely progress to full sport
  Additional Interventions
  *Continue with
  Phase II-V
  interventions
• Multi-plane sport specific plyometrics program
• Multi-plane sport specific agility program
• Include hard cutting and pivoting depending on the individuals’ goals (~7 mo)
• Non-contact practice→ Full practice→ Full play (~9 mo)
  Criteria to Progress
• Functional Assessment
  o Quad/HS/glut index ≥95%; HHD mean or isokinetic testing @ 60d/s
  o Hamstring/Quad ratio ≥66%
  o Hop Testing ≥95% compared to contra lateral side, demonstrating good landing
  mechanics
• KOOS-sports questionnaire >90%
• International Knee Committee Subjective Knee Evaluation >93
• ACL-RSI

Return to Running Program

This program is intended to lead professionals and patients through a stepwise return-to-run program. Prior to starting this program, patients should have a Functional Assessment score of at least 80% (after knee ligament or meniscus repair). Specific advice should be based on the individual’s needs, and clinical

Decision making. If you have questions, please contact the referring physician.

Recommendations

• Runs should occur on softer surfaces during Phase I
• Non-impact activity on off days
• Goal is to increase mileage and then increase pace; avoid increasing two variables at once
• 10% rule: no more than 10% increase in mileage per week

Agility and Plyometric Program

This program guides physicians and patients through a series of agility and plyometric exercises to encourage a successful return to sport while reducing injury risk. Before starting this treatment, patients should score at least 80% on the Functional Assessment. Individualized interventions should take into account clinical decision-making. If you have questions, please contact the referring physician.

PHASE I: ANTERIOR PROGRESSION

Rehabilitation Goals	Safely recondition the knee Provide a logical sequence of progressive drills for pre-sports conditioning
Agility	Forward run Backward run Forward lean in to a run Forward run with 3-step deceleration Figure 8 run Circle run Ladder

Agility

Plyometrics

Plyometrics

Shuttle press: Double leg alternating leg single leg jumps Double leg: o Jumps on to a box jump off of a box jumps on/off box o Forward jumps, forward jump to broad jump o Tuck jumps o Backward/forward hops over line/cone Single leg (these exercises are challenging and should be considered for more advanced athletes): o Progressive single leg jump tasks o Bounding run o Scissor jumps o Backward/forward hops over line/cone

Criteria to Progress

No increase in pain or swelling Pain-free during loading activities Demonstrates proper movement patterns

Plyometrics

Single leg (these exercises are challenging and should be considered for more advanced
athletes):

PHASE II: LATERAL PROGRESSION

PHASE I: ANTERIOR PROGRESSION

Rehabilitation Goals	Safely recondition the knee Provide a logical sequence of progressive drills for the Level 1 sport athlete
Agility *Continue with Phase I interventions	Side shuffle Carioca Crossover steps Shuttle run Zig-zag run Ladder

Plyometrics	Double leg: o Lateral jumps over line/cone o Lateral tuck jumps over cone Single leg (these exercises are challenging and should be considered for more advanced athletes): o Lateral jumps over line/cone o Lateral jumps with sport cord
Criteria to Progress	No increase in pain or swelling Pain-free during loading activities Demonstrates proper movement patterns

Single leg (these exercises are challenging and should be considered for more advanced
athletes):

PHASE III: MULTI-PLANAR PROGRESSION

Rehabilitation Goals	Challenge the Level 1 sport athlete in preparation for final clearance for return to sport
Agility *Continue with Phase I-II interventions	Box drill Star drill Side shuffle with hurdles

Plyometrics *Continue with Phase I-II interventions	Box jumps with quick change of direction 90 and 180 degree jumps
Criteria to Progress	Clearance from MD Functional Assessment o Quad/HS/glut index ≥90% contra lateral side (isokinetic testing if available) o Hamstring/Quad ratio ≥70% o Hop Testing ≥90% contralateral side KOOS-sports questionnaire >90% International Knee Committee Subjective Knee Evaluation >93 Psych Readiness to Return to Sport (PRRS)

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