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ACL Reconstruction Rehabilitation Protocol (BTB graft)


1. If co-contaminent extra-articular stabilisation: Follow surgeon

post-op instructions.
2. If partial menisectomy, respect precautions of menisectomy
3. If MCL, respect precautions.


Give patient pre/post- op advice and patient exercise sheet

Explain/teach post-op regime/exercises
Chest care advice and teach deep breathing/coughing exercises
Anti-embolic advice and exercises: toe curls, ankle pumps, static
Record active knee ROM
Review precautions
Measure for crutches
Brace to be measured
Lysholm Knee score
PHASE 1: POST OP: Inpatient Care: 0-1 week

Physiotherapy 2x daily am/pm

General advice re: precautions: no OKC quadriceps, praying on
chair, non-forced knee flexion


Check post operative notes for any specific instructions

WB status
Neurovascular status
Cardiovascular status
Erythema/Abnormal Temperature
Wound (dressed)
Liase with nursing staff re: pain control


Chest care: Teach deep breathing exercises

(3 deep breaths hourly, add FET)
Anti-embolic exercises: hourly
Upper limb exercises: bilateral hand pumps, wrist ROM, bicep
curls, shoulder circles, chest press, shoulder raise etc.
ON BED (supine/sitting)

Regular cryocuff + elevation + ankle pumps

CPM management on prescription from surgeon
Multi-directional patella mobilization + teach patient
Compex (disuse atrophy protocol) low-medium intensity + SQ
Isometric exercises:
1. Quadriceps setting (3x10x 6 sec hold)
2. Static gluteals (3 x 10 x 6 sec hold)
3. Adduction with pillow between knees (3x10x6 sec hold)
Gravity assisted passive knee extension (heel on pillow)
Active/assisted knee flexion with sliding board: (aim 0-90)
(3x10x6sec hold)
Hip AROM with sliding board: abduction/adduction (3x10)
Co-contraction in supine 20, 40, 60 degree flexion (3x10)
Heel digs 20,40,60 degrees flexion (3x10)
Prone knee bends (active assisted) (hamstring curls) 3x10
Prone knee extension (3x10x6 sec hold)
Teach transfers: in/out of bed, on/off chair


Active assisted knee flexion with sliding board

(3x10x 6 sec hold)
Gravity-assisted passive knee extension (heel on stool)
Toe raises (3x10)
Heel raises (3x10)


Gait re-education with appropriate walking aid

Teach stairs/ forwards/backwards stepping
CRITERIA: Plan discharge from hospital when:

Target knee active assisted ROM: 0-90 flexion

Independently mobile with appropriate aid
Independent in transfers
Swelling is controlled
Patient independent with HEP
Record Lysholm Knee Score Post-op
Patient educated in rehabilitation process and scheduled for
outpatient physiotherapy


1. Frequency of rehabilitation: 5 x week

2. Patients to receive early class rehabilitation brochure: home
exercises to be completed an additional 2 x daily
3. Progressive WBAT
4. Tubigrip application for swelling management
5. Removal of brace + walking aid (at discretion of the surgeon)
when the following criteria are achieved:

Satisfactory quadriceps strength (10 SLRs w/o a lag)

0-120 AROM
Unilateral balance for 30 seconds
Normal pattern of gait

Week 1-2


Multi-directional patella mobilisation

Patella tendon mobilization
Quadriceps soft tissue therapy
Quadriceps setting +/- EMG (VMO) (3x10x6 sec hold)
Compex (disuse atrophy protocol/ACL protocol) for quadriceps
+ hamstrings
Passive knee extension (heel on cushion)
SLR 4 directions (3x10)
Isometric hamstring digs at 20, 40, 60 of flexion, 10 reps
each angle (6 sec hold)
Active flexion/assisted extension heel slides for ROM (3x10)
Wall slides (3X10) in supine: Active knee flexion + assisted
Co-contractions (3x10x6 sec hold)
Prone knee bend and hold in the end of ROM (3x10)
Sit stand (3x10) (with UL support > without support)
Dorsiflexion against theraband resistance (3x10)
Calf stretches (4 x 30sec)


Active knee flexion/assisted extension (3x10)

Unilateral proprioception: involved leg on wobble board (AP)

To progress exercises at this time we need:

Minimum swelling
90 of active flexion
Almost full extension
Fair quadriceps control


Mini squats with UL support (0-45) 3x10x6 sec hold

Gait re-education:
-Forward and backward step with toe touch 3x20

RICE + ankle pumps: 15 minutes

Week 2 4

Body Conditioning Maintenance: (upper body + uninvolved LL)

Hydrotherapy phase 1: if incision site closed


Scar mobilisation
Bilateral bridging (3x10)
Isometric hamstring contraction against PT shoulder (3x10x6
sec hold) mid-outer range
Prone knee bends with thera-band resistance (3x10)
CKC leg press with sports cord (3x10)


Active Hip flexion (3x10)

Hamstring Stretches (4x30 sec hold)
Hamstring strengthening with theraband (3X10)


Bilateral forward and backward step with WBAT (3x20)

Unilateral proprioception (-20ext)
CKC against swiss ball in a corner (3x10x6 sec hold)
Mini squats (0-45) 3x10
Heel raises (3x10) with UL support (progress to unilateral
Bilateral wall squats with swiss ball (low load)

Rower: for ROM (low resistance)
Multi-hip 4 directions with resistance above knee (3x10)
Abductor/adductor: (3x10)
Hamstring curl: isometric > concentric (3x10) DAPRE
Leg press: isometric > isotonic (bilateral > unilateral (3x10)
DAPRE (increase repititions)
Calf Press (3x10) bilateral > unilateral


Transfer the patient to the intermediate ACL class or to phase 3 for

progressive rehabilitation once they meet the referral criteria below:

1. Independent gait
2. Good patella mobility
3. Full passive and active extension
4. 2/3 flexion
5. No pain through available range
6. Minimal knee swelling
7. Fair quadriceps control: quadriceps lag <5 degrees
8. Do not require 1:1 assistance

PHASE 3: 4-12 weeks


Hydrotherapy Phase 2: (3 x per week)

Total gym: mini squats (progress inclination): 3x10
Stationary bicycle: high seat, low resistance, low speed
(Knee ROM 110+)
Mini squats with sport cord (progress repetitions): 3x10
Mini squats with hand weights (progress repetitions): 3x10
Mini squats with proprioception: (progress repetitions: 3x10
Early lunge (0-45) involved leg forward (3x10)
Unilateral proprioception progression
Bilateral/unilateral heel raise (3x10) without UL support
Step up, down (3x20) (low step height>progress)

6 Weeks +


Unilateral proprioception progression: involved leg (AP)
Unilateral squats (3x5) progress repetitions
Unilateral wall squats with swiss ball: 3x10
(add proprioception, low load)
Lateral step down (3x20)
Lateral squats (uninvolved > involved > step): 3x10
Dynamic lunge: 3x10

8-12 Weeks


Hydrotherapy Phase 3
Lateral squat down with proprioception (3x10)
Unilateral proprioception (lateral)
Profitter: lateral sliding (3x20)
Hamstring strengthening in eccentric mode

Transfer the patient to the advanced ACL group or into Phase 4 when
the following criteria are achieved:

No swelling
Full pain free ROM (limitation of flexion acceptable)
Good muscle control
A normal gait pattern
No complications: patella tendinopathy, PFPS.
Biodex isokinetic test (CON/CON 60:180:300 degrees/sec):
involved leg 70% strength of uninvolved.

If involved leg >70% strength compared to uninvolved add:

OKC quadriceps strengthening (90-45) with proximal


PHASE 4: 12-24 weeks (ADVANCED GROUP)


1. Prepare for return to sport

2. Incorporate more sport specific activities
3. Introduce agility and reaction time into proprioceptive work
4. Increase strength
5. Develop patient confidence

Physiotherapy 5 x week
Hydrotherapy Phase 4

On surgeon approval add:

Initial running progression (on the spot straight line).

Progress distance/time up to 60 minutes (see attached)

16-24 weeks

If initial running progression complete, isokinetic test > 80% and

KT <2mm add:

Running progression (Acceleration 50% 70% 100%

deceleration (distance time)
Changing direction (forwards backwards lateral)
Figure of 8 (Turning > uninvolved on inside involved on
Cutting (zig-zag) (uninvolved on inside involved on inside)
Jumping (bilateral unilateral)
(vertical > multi-directional from height)
Hopping (vertical > multi-directional from height)
Sport specific training
Introduce player with team only with approved exercises

(Progress indoor outdoor uneven surfaces competitive

Progress: cuing/instruction (verbal/visual/auditory)


Biodex Test: 90% strength compared to uninvolved leg

(Bilat, con/con, 5 x 60, 5 x 180, 30 x 300 degree/sec)
Functional Tests: >90% variation on test scores
Biodex proprioception test: R = L
Completed sport specific training programme
Returned to training
Pain free in full ROM
No swelling
Lysholm knee score 90 points +
Medical Evaluation: lachman, pivot shift test
KT <2mm



Lysholm score


Biodex isokinetic evaluation (60, 180, 300 degree/sec)

Functional testing
Biodex Proprioception test
KT 2000
Medical evaluation: Lachman, pivot shift

NOTE: KT - less than 2 mm difference (functional knee)

3 to 6mm (partially functional)
More than 6mm (failure)


12 16 WEEKS

(3 x Week)

1. Jogging on spot
Knees back
Knees up

Jogging straight line (biomechanical correction)

100m jog: 300m walk (Up to 10x)

200m jog: 200m walk (Up to 8x)
400m jog: 200m walk (Up to 5x)
800m jog: 200m walk (Up to 3x)
Jog 4 x 5 minutes (2 minutes rest)
Jog 3 x 8 minutes (2 minutes rest)
Jog 3 x 10 minutes (2 minutes rest)
Jog 4 x 10 minutes (2 minutes rest)
Jog 3 x 15 minutes (5 minutes rest)
Jog 3 x 20 minutes (5 minutes rest)
Jog 2 x 30 minutes (10 minutes rest)
Jog 1 x 60 minutes