Dr. Brett Fritsch, Orthopaedic Knee Surgeon - Sports Knee & Arthroplasty Specialist Chatswood NSW
Dr. Brett Fritsch - Orthopaedic Knee Surgeon : 9411 7166

ACL Rehabilitation Protocol

General Guidelines

  • Initial rehab is focused on protecting the graft whilst it incorporates into the body (revascularises and heals to bone)
  • Later stages focus on regaining knee function and strength
  • Supervised physical therapy continues for 6-9 months

General progression of activities of daily living

Wound care

  • The wounds are kept dry until healed (2 weeks)
    • The wounds are closed with sutures and are covered with a waterproof dressing under an outer bandage. The outer bandage may be removed 48 hours after the surgery, and the smaller waterproof dressings are to be left intact until the sutures are removed at the first post-op visit

    • You may shower, keeping the wounds dry. Do not soak the wound but you may allow the water to flow over it. Do not scrub the wounds. If the water gets under the dressings, remove the dressing, pat the wound dry gently, and apply a new dressing

  • If the smaller waterproof dressings come off before the first post-op visit, a new dressing should be reapplied. These may be given to you when you leave hospital, or they can be purchased from a chemist


  • You may bear your full weight immediately, though for the first weeks crutches will be used. These aid in your balance whilst the muscles of the leg regain function. Your therapist or Surgeon will advise when you can cease using the crutches and this will occur when you have full knee extension and can walk without a limp. There will likely be a transition time from the use of 2 to 1 crutch.


  • 1 week for automatic cars if the surgery is the left leg
  • 2-4 weeks for manual cars, or any surgery on the right leg

Progression of Rehabilitation

  • The frequency of physical therapy visits, and the speed of progression through the rehabilitation program, are tailored to the needs of each individual

  • The following is a general guideline which is just that, a guide. Your surgeon and therapist will work together to optimise your recovery in the safest, but quickest, time possible

Phase 1 – Acute post-op (0-2 weeks)


  • Patient education re gait, swelling control, strength of repair, Do’s and don’ts
  • Increase ROM (0-90°) and particularly obtain full extension (including any hyperextension)
  • Control pain and swelling
  • Establish muscle control
  • Progress off crutches and regain normal gait


  • Swelling control
    • Ice
    • Elevation
    • Co-contractions

Weight bearing and brace

  • FWB as tolerated
    • May transition from PWB to FWB as tolerated
  • Crutches
    • Must use crutches until:
      • Full extension
      • No limp
    • Will gradually transition form 2, to 1, to no crutches over 2-4 weeks


  • Patella mobilisations
  • Aiming for ROM 0-90°
    • Passive and active techniques
    • Closed chain only
    • Exercises :
      • Bike circles
        • High seat 1/2 circles forward and back
          • High seat full circles
            • Lower seat full circles
      • Heel slides
      • Prone leg hangs

Strength and flexibility

  • Quadriceps – all CLOSED chain
    • Quad isometrics (tightening without leg movement) seated and standing (0°, 60°, and 90°)
    • Sit to stand, Static lunge, Mini squat, Wall squat
  • Hamstrings
    • Isometrics
      • Hamstring strengthening begins with static weight-bearing co-contractions and gradually progresses to active free hamstring contraction by day 14
      • Resisted hamstring strengthening is avoided for 6 weeks
    • Prone knee flexion
    • Standing knee flexion to 90°
    • Gentle hamstring stretching (1 week)
  • Other
    • Standing heel raises
    • Hip
      • Standing flexion, extension, abduction, adduction
      • Prone hip extension
      • Side lying hip abduction
    • Calf stretching


  • 1 foot standing 60 seconds – eyes open à eyes closed


  • Ice
  • Muscle stimulation (quads)
  • Interferrential current therapy
  • Biofeedback to aid return of coordinated muscle function
  • Aquatic therapy
    • May commence after 1st post-op visit
    • Normalise gait, weightbearing strengthening, aquajogging (deep water) for ROM and swelling

Stage 2 : 2-6 weeks


  • Achieve full ROM (flexion and extension)
  • Normal gait
  • Continued strengthening Quads hamstrings, hip, calves
  • Increasing focus on proprioception
  • Maintain cardiovascular fitness


  • Normalised gait with full WB and no crutches


  • Continued as above
    • No limitation of flexion
    • Achieve full end-range extension


  • Progression as tolerated of Closed Kinetic Chain quad strengthening
    • Step ups – 4”-6”-8”
    • Wall squats
    • Leg press – 2 to 1 leg
    • Bungy lunge
    • Squats with pulleys
  • Hamstrings
    • Take care to avoid hamstring strain in this phase
    • Gradual increase in repetition of strengthening
    • Low resistance, high repetition weights
    • Exercises – Seated knee flexion with weights and pulleys, seated knee flexion with bungy cord, seated hamstring curls, reverse stairmaster
  • Hip
    • Standing abduction with puuleys/weights/bands
  • Other
    • Heel drops
    • Shuttle drops
    • Mini-tramp bouncing
    • Single heel raise


  • Elliptical
  • Nordic track
  • Stationary bike
  • Swim – no whip kick


  • Single leg balance
  • Ball toss
  • Mini-tramp
  • Balance board
  • Wobble board


  • Aquatic therapy
    • Pool running
    • Step ups/down
    • Walking
    • Squats

Stage III – 6-12 weeks


  • Full, pain free ROM
  • Intermediate proprioception
  • Functional quads strength
  • Increasing cardio fitness
  • Note – The graft is at its weakest point now and as such open chain exercises should continue to be avoided


  • Progression to more dynamic movements
  • Progress resistance on gym equipment
  • Start cycling on a normal bike
  • May begin running in a straight line on a flat surface from 9-12 weeks provided regaining of sufficient ROM, strength, and proprioception (your therapist will advise)


  • Progression from previous phase
  • Increase dynamic activities – slide board, lateral stepping etc

Stage IV – 12-20 weeks

Criteria to advance to stage IV :

  • No patellofemoral pain
  • Full extension
  • Minimum 120° flexion
  • Sufficient proprioception to increase complexity of exercises
  • Minimal swelling and pain


  • Sport specific quads and hamstring strength
  • Sport specific proprioception training
  • Sport specific cardio fitness
  • Continuing flexibility and strength progression


  • Progression of resistance :
    • Leg press and curls weight
    • Wall squats
    • Step work with progressing height of step
    • Half squats with resistance
    • Stepper and rowing machine
  • Commencement of pool plyometrics in deep water à shallow water


  • Add jumping and hopping activities – focus on good landing technique
  • Commence agility work – sideways running, skipping, shuttle runs
  • Add sport specific proprioception exercises

Stage V – 20+ weeks


  • Graduated return to sport specific activities
    • Continue sport specific strengthening
    • Continue sport specific proprioception
    • Continue sport specific cardio fitness
  • Therapist may perform Cybex testing at 16-20 weeks
    • This defines any specific strength deficiencies (strength, power, endurance, and balance between the hamstrings ad quadriceps)
    • This can be used to tailor progress retraining


  • Back to sport for upper body skills
  • Practice drill ideas :
    • Straight forward and backward running
    • Figure 8’s of gradually decreasing radius
    • Zig-Zag running
    • Cross-over stepping
    • Backwards with cutting
    • Stop and go drills

Return to sport

Criteria for return to sport

  • Symmetric performance of basic and sport specific agility drills
  • Single hop and 3-hop tests 85% of uninvolved leg
  • Quads and hamstring strength at least 85% of uninvolved leg per each isokinetic strength test
  • Peak torque : Body weight (BW) ratio
    • Quads > 80%
    • Hamstring > 60%
  • Quads : Hamstring peak torque ratio
    • Aim for 3 : 2 (hamstring strength of at least 66% quads strength)

General timeline

  • Begin gentle jogging in straight line on a flat surface at 9-12 weeks
  • Commence agility work 12-16 weeks
  • Commence sport specific agility work 20 weeks
  • Return to training and sport specific skill 6-7 months (depending on progress)
  • Return to sport 9-12 months (depending on progress and sport)
    • See criteria above
    • Delay to 12 months if :
      • Patient younger than 21
      • Hyperlaxity
      • These patients have been identified as having an increased risk of re-injury

Sport Bracing

  • Generally no brace is used, though this is a controversial area with an evolving body of evidence
Dr. Brett Fritsch
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