Full return to sport or activity can be a 5-month to a full year process for the post-surgical ACL reconstruction. Successful return to activity is dependent on following post-surgical precautions and completing a structured post-surgical rehabilitation program. In addition, sport specific training prior to returning to the desired sport is mandatory and has been shown to significantly reduce the risk of injury. Length of rehabilitation time is affected by many factors including age, athletic make up, and type of surgical reconstruction. The rehabilitation program we use at Back to Function is a combination of evidence-based protocols and our own experience and clinical decision making. General time frames are presented, but individuals will progress at different rates depending on age, associated injuries, health status, rehabilitation compliance and injury severity.

PHASE 1: IMMEDIATE POST-OP (0-2 WEEKS AFTER SURGERY)

Goals:

1. Protection of healing graft
2. Reduce swelling
3. Restore patellar mobility
4. Restore full extension, gradually improve flexion
5. Minimize muscle inhibition, re-establish quadriceps control, regain full active extension

Activities:

1. Soft tissue therapy and mobilization (including patella)
2. Use electrotherapy (MarcPro) to reduce pain and swelling
3. Ankle pumps
4. Extension and heel slides with towel
5. Low intensity, long extension stretches; heel prop, supine active hamstring stretch and passive hamstring stretch (avoid if HS graft)
6. Standing gastrocnemius/soleus stretch or seated with towel/strap
7. Calf raises (non-weight bearing)
8. Straight leg raise: supine until can perform with no extension lag then progress to sitting
9. Quad set (VMO tone)
10. Hip abduction/side leg lift
11. Multi-angle isometrics 90 and 60 degrees knee extension
12. Stationary bike: begin when can flex to 110 degrees (do not adjust bike to increase or force motion at any time)
13. Weight shifts side to side
14. Brace: to be worn at all times for 4-6 weeks
15. Brace must be worn at night while sleeping

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

Goals:

1. Continue to protect graft
2. Maintain full extension, restore full flexion
3. Normalize gait
4. Improve strength
5. Reduce effusion and pain
6. Voluntary VMO/ Quad activation

Activities:

1. Soft tissue therapy and mobilization (including patella)
2. Continue Phase I exercises/increase intensity as able
3. Stretching: prone quadriceps stretch, standing quadriceps stretch, kneeling hip flexor stretch, sumo squat progression, single leg reach to knee drive (continue previous Phase I stretching)
4. Appropriate PRI exercises based on BTF functional screen
5. Step ups/step ups with march
6. Step down (weight through heel)
7. Standing quad sets with resistance to tolerance (good VMO tone)
8. Squat to chair: 90 degrees maximum
9. Ball squats, wall squats, TRX assisted squats
10. Glut Bridge (Pball), one leg bridge (with sequence), hip cuff, side-lying hip clamshell (progress to resistance)
11. Romanian deadlift
12. Stationary bike: increase time and intensity
13. Plank (with progression), side plank, push crunch, core strength exercises
14. Single leg standing balance (knee slightly flexed) static progressed to dynamic and level progressed to unsteady surface (Propriofoot)

1. Lateral step-overs, hurdle step over, 2 stick hip mobilization, standing hip CARs
2. Brace: to be worn at all times for 4-6 weeks
3. Brace must be worn at night while sleeping

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

Goals:

1. Continue to protect graft
2. Maintain full ROM
3. Safely progress strengthening
4. Promote proper movement patterns
5. Initiate lateral movements
6. Avoid post exercise pain/swelling
7. Avoid activities that produce pain at graft site

Activities:

1. Continue Phase I/II stretching 
2. Slant board gastrocnemius/soleus stretch
3. Dynamic warm up
4. Stationary bike: increase time from phase II
5. Continue previous exercises (phase I/II) (good VMO tone)
6. Squat to chair
7. Multi hip with resistance (flexion, abduction, adduction, extension)
8. Bridge progression: double (Pball, slide board), single (single leg bridge with opposite leg sequence, resistance)
9. Multi lunges (stationary, reverse, walking, lateral, X-connect)
10. Step ups/down: with X-connects
11. Side step and monster walk with resistance
12. TRX 1-leg squats & skater lunge
13. Dumbbell single-leg Romanian deadlift
14. Continue core strengthening
15. Rocker/wobble board
16. BOSU: both sides, double and single limb balance and squats
17. Run progression: 15-30 seconds run/1 min walk up to 10 minutes total, progress as symptoms allow 30-60 seconds run/ 1 min walk to 20 min (not on hard surface)
18. Brace: Functional brace when ready to initiate running
19. Brace: to be worn with all lateral movements, running, agility, plyometrics, functional drills

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

Goals:

1. Full ROM by week 8 (-3 degrees hyperextension to 135 degrees flexion)
2. Improving balance/proprioception
3. Promote proper movement patterns
4. Initiate functional activities
5. Initiate functional movement
6. Confident with side-to-side drills
7. Patient subjective report 75-80% recovered
8. Avoid post exercise pain?swelling
9. Avoid activities that produce pain at graft site

Activities:

1. Begin sub-maximal sport specific training in the sagittal plane
2. Bilateral partial weight bearing plyometrics progressed to full weight bearing plyometrics
3. Continue previous strength and stretching Phase I-III (increase intensity as able to build strength)
4. Drop vertical jump with good control
5. Slide board
6. Turn disc
7. Ladder drills
8. Initiate shuffles, carioca, figure 8 at sub-maximal speeds
9. Continue with running progression (not on hard surface)
10. Balance continue progression (perturbation or removing vision)
11. 3-D balance reach/lunge

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

Goals:

1. Safely progress strengthening
2. Safely initiate sport specific training program
3. Promote proper movement patterns
4. Avoid post exercise pain/swelling
5. Avoid activities that produce pain at the graft site
6. Single leg squat
7. Confident with side to side drills
8. 90% on all strength and balance testing comparing involved to uninvolved
9. Clearance from surgeon to return to sport

Activities:

1. Interval running program
2. Progress to plyometric and agility program (with functional brace)
3. Completion run program without pain/swelling
4. Patient should be able to complete home maintenance core/agility program and understands importance continuing maintenance
5. Continue previous strengthening and proprioceptive exercises

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

Goals:

1. Continue progression strengthening and proprioceptive exercises
2. Symmetrical performance with sport specific drills
3. Safely progress to full sport

Activities:

1. Multi-plane sport specific plyometrics
2. Multi- plane sport specific agility program
3. Slide board
4. Included hard cutting and pivoting depending on the individuals goals (approximately 7 months)
5. Soft tissue therapy & mobilization as needed
6. Practice continuum:
   1. movement patterns: sprinting, shuffle, carioca, cutting, shuttle, change of direction
   2. closed drills: sport specific without opposition in controlled environment
   3. 1-on-1 drills: full speed with game necessary contact
   4. Team scrimmage: (no-contact) contact restrictions during team scrimmaging when appropriate
   5. Team scrimmage: full contact
   6. Return to full play

This post-surgical ACL reconstruction rehabilitation protocol has been adapted from the following sources cited below. It is not intended to be a substitute for clinical decision making regarding the patient’s own individual progression and/or the presence of post-operative complications. If you have a knee issue that needs to be evaluated, please give us a call at (310) 534-1900 or email us at [email protected].

References:

Massachusetts General Hospital, Sports Physical Therapy Program. Rehabilitation Protocol for ACL Reconstruction.

Baylor College of Medicine, Sports Medicine. Anterior Cruciate Ligament Reconstruction Accelerated Rehab.

Cavanaugh, John, Powers, Matthew. ACL Rehabilitation Progression: Where are we now?

UW Health. University of Wisconsin Sports Medicine. Rehabilitation Guidelines for ACL Reconstruction in the Adult Athlete