ACL RECONSTRUCTION

Guidelines for Physical Therapy

Preoperative Phase (2-4 weeks pre-op for Physical Therapy)
Surgical Date Goals:
1. Full extension
2. Knee flexion within functional range (120-135) pain free
3. Ability to Isolate Quadriceps
4. Knowledge of home exercise program
5. Inflammation and pain reduction
Exercises:
1. Quadriceps isolation
2. Hamstring strengthening
3. Knee ROM exercises to 0 degrees extension
4. Knee ROM exercises flexion to pain tolerance
5. Ankle strengthening
6. Gait and stair training with or without assistive device
7. Hip and lumbopelvic stabilization/strengthening
8. Modalities prn
9. Closed Kinetic Chain activities

Immediate Post-op Phase (Day 1-7)

Goals:
1.
2.
3.
4.
5.
6.
7.
8.

Restore full passive knee extension

Reduce joint edema and pain
Restore patellar mobility
Gradually improve knee flexion (0-90)
Decrease fibrosis
Prevent quad atrophy
Absolute control of external forces to protect graft
Ambulate with crutches with brace WBAT

Post-op Day (POD) #1

1. Brace per physician
2. Crutches WBAT

3. Exercises
a. Ankle pumps
b. Overpressure into full passive knee extension
c. Active/passive knee flexion
d. SLRx4 in brace or AAROM
e. Quad sets (NMES as needed)
f. Glut sets
g. Hamstring/gastrocsoleus stretching
h. Modalities as needed
POD #2-7
1. Continue brace as above
2. Continue crutch ambulation WBAT
3. Exercises
a. Remove or unlock brace 4-5 times per day for self ROM
b. Exercises as above
c. Multi angle isometrics for knee extension at 60 and 90 degrees flexion
d. Active knee extension 90-40
e. Mini squats 0-30
f. Standing weight shifts
g. Patellar mobilizations
h. Hamstring curls (unless HS graft)
i. Proprioceptive and Balance activities

Maximal Protective Phase (Weeks 2 and 3)

Criteria to enter: Must achieve week 1 goals
Goals:
1.
2.
3.
4.
5.
6.

Maintain full passive knee extension

Gradually increase knee flexion (0-125)
Prepare for ambulation without crutches
Diminish swelling and pain
Muscle control and activation
Normalize patellar mobility

POD #8-14 exercises:

1. Exercises as above (immediate post-op phase)
2. Brace locked at 0 for ambulation only, unlocked for ROM
3. Multi angle isometrics at 90, 60, and 30
4. Mini squat 0-40
5. PROM 0-105
6. Hamstring and gastroc-soleus stretching
7. Well leg exercises
8. PRE program beginning with 1 lb and progress 1lb per week

POD #15-21 exercises:

1. DC locked brace-open from 0-125 for ambulation
2. Continue week 2 exercises
3. PROM 0-125
4. Bicycle for ROM
5. Initiate eccentric quads from 40-100
6. Leg press 0-60
7. Stepper
8. Pool walking program (if incision is closed)

Moderate Protection with Neuromusculature Control Phase

(Weeks 4-12)
Criteria to enter: Active ROM 0-115, quad strength at 60% or greater measured at 60
degrees knee flexion measured isometrically, minimal effusion.
Weeks 4-8
Goals:
1. Controlled forces during ambulation
2. Brace discontinued
3. Self ROM 4-5 times daily
4. Emphasis on maintained 0 degrees passive knee extension
5. Active ROM 0-125
Weeks 4-8 Exercises:
1. Continue week 3 exercises
2. PROM 0-130
3. Step ups
4. Lateral step overs
5. Progress proprioceptive activities
6. Increase CKC exercises
7. Leg press-increased gradually to 100 degrees
8. Lateral lunges
9. Wall squats-progress 0-100
10. Toe/Calf raises
11. Pool program (backward running at 4-6 weeks; forward running and agility drills
at 6-8 weeks)
*If hamstring graft, begin submax isometric HS contractions at week 5
**At week 6-8, light resisted hamstring exercises
***At week 8, progressive hamstring strengthening program
Weeks #9-12
Criteria to enter: AROM 0-125, no patellofemoral complaints, and minimal effusion.
Goals:
1. Maximal strengthening for quads and lower extremity

Weeks 9-12 Exercises:

1. Continue to progress week 4-8 exercises
2. Bicycle for endurance
3. Isokinetic exercises 90-40

Light Activity Phase (Weeks 12-16)

Criteria to enter: AROM 0-125, Quad strength 70% of contralateral side, minimal to no
effusion.
Goals:
1. Development of strength, power, and endurance
2. Preparation for return to functional activities
Exercises:
1. Continue strengthening exercises
2. Initiate plyometric program
3. Initiate agility drills
4. Initiate sport specific training and drills
5. Initiate running
a. Criteria for running:
i. Functional tests (including hop test) 70% or greater of
contralateral leg
ii. Isokinetic Test concentric knee extension/flexion @ 180o/second
1. Quadriceps bilateral comparison 75%
2. Hamstrings equal bilateral
3. Hamstrings/quadriceps ratio 66-75%
iii. No change in KT-1000 (within 2 mm of opposite)- 20 and 30 lb
and Manual Maximum Test

Return to Activity Phase (Weeks 16+)

Criteria to enter: Functional test of 85% or greater of contralateral leg and
proprioceptive test of 100% of contralateral leg; Isokinetic quad 80% or greater,
hamstrings 110% or greater, hamstring/quad ratio 70% or greater; KT-1000 within 2.5
mm of opposite side
Goals:
1. Achieve maximal strength
2. Increase neuromuscular coordination
3. Increase endurance
Exercises:
1. Continue strengthening program
2. Continue plyometric program
3. Continue running and agility program
4. Accelerate sport specific training and drills

St. Luke's Physical Therapy Protocol Committee:

Monica Miller, MSPT; Timothy Miller, MSPT, CSCS; Julie Spencer MPT

Revised 11/08References
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