Rehabilitation Protocol for Anterior Cruciate Ligament (ACL

Massachusetts General Brigham Sports Medicine

Rehabilitation Protocol for Anterior Cruciate Ligament (ACL)

Reconstruction

This protocol is intended to guide clinicians through the post-operative course for ACL Reconstruction. This protocol is

time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs

of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes

contained within this guideline may vary based on surgeon’s preference, additional procedures performed, and/or

complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with

the referring surgeon.

The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic

interventions should be included and modified based on the progress of the patient and under the discretion of the

clinician.

Considerations for allograft and hamstring autograft

Early weight bearing and early rehabilitation intervention vary for allograft and hamstring autograft. Please reference

specific instructions below. Expectations are the early return to sport phase will be delayed.

Considerations with concomitant injuries

Be sure to follow the more conservative protocol with regards to range of motion, weight bearing, and rehab

progression when there are concomitant injuries (i.e. meniscus repair).

Post-operative considerations

If you develop a fever, intense calf pain, excessive drainage from the incision, uncontrolled pain or any other symptoms

you have concerns about you should call your doctor.

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

Rehabilitation

Goals

• Protect graft

• Reduce swelling, minimize pain

• Restore patellar mobility

• Restore full extension, gradually improve flexion

• Minimize arthrogenic muscle inhibition, re-establish quad control, regain full active extension

• Patient education

o Keep your knee straight and elevated when sitting or laying down. Do not rest with a

towel placed under the knee

o Do not actively kick your knee out straight; support your surgical side when performing

transfers (i.e. sitting to laying down)

o Do not pivot on your surgical side

Weight Bearing

Walking

• Initially brace locked, crutches (per MD recommendation)

• May start walking without crutches as long as there is no increased pain, effusion, and proper

gait

o Allograft and hamstring autograft continue partial weight bearing with crutches for 6

weeks unless otherwise instructed by MD

• May unlock brace once able to perform straight leg raise without lag

• May discontinue use of brace after 6 wks per MD and once adequate quad control is achieved

• When climbing stairs, lead with the non-surgical side when going up the stairs, and lead with

the crutches and surgical side when going down the stairs

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Interventions

Swelling Management

• Ice, compression, elevation (check with MD re: cold therapy)

• Retrograde massage

• Ankle pumps

Range of motion/Mobility

• Patellar mobilizations: superior/inferior and medial/lateral

o **Patellar mobilizations are heavily emphasized in the early post-operative phase

following patella tendon autograft**

• Seated assisted knee flexion extension and heel slides with towel

• Low intensity, long duration extension stretches: prone hang, heel prop

• Standing gastroc stretch and soleus stretch

• Supine active hamstring stretch and supine passive hamstring stretch

Strengthening

• Calf raises

• Quad sets

• NMES high intensity (2500 Hz, 75 bursts) supine knee extended 10 sec/50 sec, 10 contractions,

2x/wk during sessions—use of clinical stimulator during session, consider home units

distributed immediate post op

• Straight leg raise

o **Do not perform straight leg raise if you have a knee extension lag

• Hip abduction

• Multi-angle isometrics 90 and 60 deg knee extension

Criteria to

Progress

• Knee extension ROM 0 deg

• Quad contraction with superior patella glide and full active extension

• 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

• Stationary bicycle

• Gentle stretching all muscle groups: prone quad stretch, standing quad stretch, kneeling hip

flexor stretch

Strengthening

• Standing hamstring curls

• Step ups and step ups with march

• Partial squat exercise

• Ball squats, wall slides, mini squats from 0-60 deg

• Lumbopelvic strengthening: bridge & unilateral bridge, sidelying hip external rotation-

clamshell, bridges on physioball, bridge on physioball with roll-in, bridge on physioball

alternating, hip hike

Balance/proprioception

• Single leg standing balance (knee slightly flexed) static progressed to dynamic and level

progressed to unsteady surface

• Lateral step-overs

• Joint position re-training

Criteria to

Progress

• No swelling (Modified Stroke Test)

• Flexion ROM within 10 deg contra lateral side

• Extension ROM equal to contra lateral side

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

Rehabilitation

Goals

• Continue to protect graft site

• Maintain full ROM

• Safely progress strengthening

• Promote proper movement patterns

• Avoid post exercise pain/swelling

• Avoid activities that produce 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: leg press machine, seated hamstring curl machine and hamstring curl machine,

hip abductor and adductor machine, hip extension machine, roman chair, seated calf machine

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

• Squat to chair

• Lateral lunges

• Romanian deadlift

• Single leg progression: partial weight bearing single leg press, slide board lunges: retro and

lateral, step ups and step ups with march, lateral step-ups, step downs, single leg squats, single

leg wall slides

• Knee Exercises for additional exercises and descriptions

• Seated Leg Extension (avoid anterior knee pain): 90-45 degrees with resistance

Balance/proprioception

• Progress single limb balance including perturbation training

Criteria to

Progress

• No effusion/swelling/pain after exercise

• Normal gait

• ROM equal to contra lateral side

• Symmetrical Joint position sense (<5-degree margin of error)

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

Rehabilitation

Goals

• Maintain full ROM

• Safely progress strengthening

• Promote proper movement patterns

• Avoid post exercise pain/swelling

• Avoid activities that produce pain at graft donor site

Additional

Interventions

*Continue with

Phase II-III

interventions

• Begin sub-max sport specific training in the sagittal plane

• Bilateral PWB plyometrics progressed to FWB plyometrics

Criteria 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

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

Rehabilitation

Goals

• Safely progress strengthening

• Safely initiate sport specific training program

• Promote proper movement patterns

• Avoid post exercise pain/swelling

• Avoid activities that produce 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

Criteria to

Progress

• Clearance from MD and ALL milestone criteria below have been met

• Completion jog/run program without pain/effusion / swelling

• Functional Assessment

o Quad/HS/glut index ≥90%; HHD mean or isokinetic testing @ 60d/s

o Hamstring/Quad ratio ≥66%

o Hop Testing ≥90% compared to contra lateral side, demonstrating good landing

mechanics

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

Revised 11/2021

Contact

Please email MGHSportsPhysical[email protected] with questions specific to this protocol

References:

1. Adams D, Logerstedt D, et al. Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation Progression. JOSPT

2012 42(7): 601-614.

2. Di Stasi S, Myer GD, Hewett TE. Neuromuscular Training to Target Deficits Associated with Second Anterior Cruciate Ligament Injury. JOSPT 2013 43

(11): 777-792.

3. Glazer DD. Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of Athletic

Training. 2009;44(2):185-189.

4. Haitz K, Shultz R, et al. Test-restest and interrater reliability of the functional lower extremity evaluation. JOSPT. 2014. 44(12): 947-954.

5. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am

J Sports Med. 2001;29:600-613.

6. Logerstedt DS, Scalzitti D, et al. Knee stability and movement coordination impairments: knee ligament sprain revision 2017. JOSPT. 2017. 47(11):

A2-A47.

Massachusetts General Brigham Sports Medicine

7. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior

Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003-1010.

8. Noehren B, Snyder-Mackler L. Who’s afraid of the big bad wolf? Open-chain exercises after anterior cruciate ligament reconstruction. JOSPT. 2020.

50(9): 473-475.

9. Wright RW, Haas AK, et al. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines. Sports Health 2015 7(3): 239-243.

10. Wilk KE, Macrina LC, et al. Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries. JOSPT 2012 42(3): 153-171.

Massachusetts General Brigham Sports Medicine

Return to Running Program

This program is designed as a guide for clinicians and patients through a progressive return-to-run program. Patients

should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or

meniscus repair). Specific recommendations should be based on the needs of the individual and should consider clinical

decision making. If you have questions, contact the referring physician.

PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES

Day

Week 1

W5/J1x5

W4/J2x5

Week 2

W3/J3x5

W2/J4x5

Week 3

W2/J4x5

W1/J5x5

Return

to Run

Key: W=walk, J=jog

**Only progress if there is no pain or swelling during or after the run

PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES

Week

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

20 min

25 min

30 min

35 min

40 min

45 min

50 min

55 min

60 min

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

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Agility and Plyometric Program

This program is designed as a guide for clinicians and patients through a progressive series of agility and plyometric

exercises to promote successful return to sport and reduce injury risk. Patients should demonstrate > 80% on the

Functional Assessment prior to initiating this program. Specific intervention should be based on the needs of the

individual and should consider clinical decision making. If you have questions, 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

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

PHASE II: LATERAL 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

*Continue with

Phase I

interventions

• 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

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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)

Massachusetts General Brigham Sports Medicine