Tag Archives: ACL

ACL rehab and return to play protocol: My approach

Anterior Cruciate Ligament (ACL) reconstruction rehabilitation: what’s your stance?  There are tons of different protocols and guidelines out there, and I recognize and respect that there are lots of successful approaches.   As part 3 of my series (in case you missed, here’s part 1 and part 2) on the ACL, I’m sharing my personal perspective and experience in rehabilitation post-surgery.  What I’m going to share is a regularly and thoroughly-reviewed approach that I’ve developed over the last 12 years, through a combination of mentors, research, and experience.  One thing I really like about it is the focus on goals and objectives in each phase, regardless of rehab exercise choice.  The reason I want to share my approach – being straight-forward: I’m extremely confident in my approach to ACL rehab, and I want to help others to have this same success.  This is based on the highly consistent positive outcomes (both short- and long-term) of the many that I’ve guided back to beyond their normal activity level as well as positive feedback from my colleagues and peers.  (Warning to the “Joes”, from here on out it may get a bit technical!)

Pre-operative “pre-hab”:  I’ve found the following to be an ideal “jumpstart” to an easier first few months post-op.  The amount of time b/t when the injury occurs and surgery can be anywhere from a few days to a few months.  Use this “pre-hab” time wisely! Exercises

used here are dictated by the pain level,  effusion amount, and injured structures involved.

  • Pre-op goals:
    • Full ROMsingle-leg-squat on box
    • Minimal swelling/effusion
    • Address any hip/lower body strength imbalances (esp. quads and hamstrings)
    • Improve proprioception and balance
    • Patient education – biomechanics, pain management, expectancies of operation/rehabilitation

Now it’s time for surgery.  Following surgery, it is imperative that the overseeing physician(s) and rehabilitative team communicate regarding which structures were damaged/repaired and any special post-surgical restrictions to ensure safe and effective post-surgical rehabilitation with minimal (if any) setbacks.

    • Special considerations:
      • When electing surgery using a hamsting (HS) tendon graft, avoid active isolated HS exercises until 2 weeks post-op, and wait 4 weeks before using open-kinetic-chain (OKC) resisted HS.
      • When electing a patellar tendon graft, main concern is monitoring and addressing signs/symptoms of patellar tendonitis if/as they arise.
      • If surgery involves a repair of meniscus, lots to consider.  Note that I said “repair”, not simply a scope and shaving.
        • Brace locked at 0 deg for first 4 weeks while walking.  Non weight-bearing (NWB) 0-2wks –> partial weight-bearing with crutches (PWB) week 3 –> Full weightbearing (FWB) starting week 4.  Unlock brace for gait after week 4.
        • Range of motion (ROM) only to 90 deg knee flexion until 4 weeks, then progress as pain-free (to avoid “pinching” repaired meniscus).
        • No isolated HS contraction when posterior horn repair (risk of pulling on repaired structure) for 8 weeks.
        • Squat/Lunge Depth:  Avoid bodyweight squatting/lunges > 60 deg knee flexion until 8 weeks; stay < 90 deg flexion until 12 weeks; avoid with rotation/twisting at knee until 16 weeks.  Also delay single-leg squats/leg press until beyond 6 weeks
      • Involved MCL repair, brace 4-6 weeks, progress ROM as pain-free.  No OKC HS for 6-8 weeks (since the medial hamstring tendons cross the ligament and “pulling” can impede healing).
      • Involved lateral-collateral ligament (LCL) repair, limit knee ROM 0-30 deg for 3-6 weeks, dependent on the extent of repair.  Often when LCL or MCL is involved and not being repaired surgically, surgeon will elect to delay ACL surgery for up to a month to give the LCL/MCL ligament a “head-start” on healing.
      • Injury involved Posterior Cruciate Ligament (PCL) tear? No OKC active isolated hamstring exercises for 4 weeks following injury.

Ok, so now surgery has happened and it’s time to rehab.  What next?  Post-op, the rehab team should provide monthly progress notes to the overseeing physician until discharged. Also, as noted in parts 1 and 2, maintain awareness of any psychological/emotional/social concerns during recovery process and offer assistance.  Refer to a counselor if needed.  The following 5 phases are discussed assuming a straight-forward ACL repair and none of the above noted modifications are needed.  Pre-protocol BONUS point:  Make sure to check out the “Load/Repetition Assignment Chart” at the end of this blog.  One of the biggest misjudgements of exercise prescription post-ACL (and in a lot of other rehabs for that matter) that I see is improper loading based on the goals of the phase.  Why is someone STILL performing 3 sets of 10 straight leg raises with an 8# cuff weight at 10 weeks post-op??  As rehab professionals, we MUST know the load/rep continuum when prescribing our exercises.  Far too many times, patients are not pushed as hard as necessary to overcome the deficits that they have in a timely (if at all) manner.  Maybe it’s a fear of producing a “setback”?  Well if the tremendous positive outcomes I have with my s/p ACL clients is any indication, some rehab pros need to respectfully get over that fear (while still using proper evaluative judgement).  Yes, you absolutely can heavily load someone’s squat and deadlift through phase 3 and 4 (if you’ve progressed them properly leading up to it)!  While we are on the topic…PROGRESS THOSE HOME PROGRAMS regularly.

Phase 1: day 1 to 2 weeks

  • Goals: Protect graft and graft fixation, decrease pain and swelling, control inflammation, active ROM 0-115 deg, regain quad NM control and patellar mobility, and patient educated on home exercise program for phase 1 and wound care.
  • Limitations: WB as tolerated with 2 crutches, brace locked in full ext for walking and sleeping, and no OKC knee extension resisted exercises
  • Orthotics:  I recommend an accommodative foot orthosis once full WB to limit subtalar joint/midfoot overpronation –> tibial rotation –> stress to graft.  Discontinue @ 3 months if desired and if gait mechanics are OK).

Some phase 1 ther-ex ideas:

  • Complimentary upper body and core workout (“6-sided”) program modified to protect ACL
  • Quad re-ed: Quad Setting w/ Russian NMS, Stick/MFR to quads, Kinesiotaping
  • Patellar mobility
  • P/A/AAROM in appropriate range based on limitations (strap, AA off end of table, AA w/ bike)
  • Stretches (Thomas, Gastroc, HS)
  • Weight ShiftsHip_Abduction wall slides
  • Mini Squats/Mini lunges
  • 4-way ankle, seated/standing heel and toe raises
  • 6-way hip (standing march, standing HS curl, Supine SLR Flx, S/L SLR Abd/add, Bent-over SLR Ext
  • Gait training w/ crutches (forward, backward, side step)

Phase 2: 2 weeks to 6 weeks

  • Goals: Regain normal gait mechanics (2 crutches –> 1 crutch –> D/C crutches as gait mechanics return), AROM full by 6 weeks, patient educated on HEP for phase 2, progressively regain strength and endurance in hips, quads, HS, and low leg with PREs as appropriate to prepare for functional activities, improve balance and proprioception, hip/ankle/patella mobility WNL and equal bilateral, and no increased knee pain or swelling during/after exercises
  • Limitations: No OKC knee ext PREs, and brace worn for ambulation (off for rehabilitation) until acceptable quad NM control and dynamic balance achieved
  • Some ther-ex ideas for phase 2:
    • Continue Phase 2 ex as needed (and only if needed!)sit to stand
    • Complimentary upper body and core workout (“6-sided”) program modified to protect ACL
    • Bike
    • Begin leg press and step up/step down progression @ 4” (Fwd, Lateral, Retro)
    • Begin squat progression (i.e. chair sits, variable load position, assisted –> unassisted)
    • OH squatBegin lunge progression (assisted –> unassisted, multidirectional)
    • Single leg and 2-leg balance exercises/weight shifts
    • Gait training w/o crutch (Fwd, bckwd, side step), progressing to resisted/variable incline gait training
    • Functional ADL training: stairs (fwd/bckwd), functional lifting patterns (i.e. deadlift)

Phase 3: 6 weeks to 12 weeks (maximum protection phase)

  • Goals: Maintain full, normal ROM, improve confidence in knee, progressively regain strength and endurance in hips/quads/HS/low leg with PREs as appropriate to prepare for functional activities (appropriate rep/load ranges), improve dynamic balance/proprioception/core stability, progress from bike to non-impact standing aerobic conditioning (elliptical, Stairmaster), aquatic jogging at 8-10 weeks <50% WB (when available and if wounds fully healed)
  • Ther-ex ideas:
    • Continue Phase 1& 2 ex (only if needed, otherwise move on)
    • Scar desensitization/patellar mobility
    • Progress bilateral and unilateral squat variations1-leg dead lift
    • Progress deadlift variations1-leg dead lift1-leg dead lift
    • Progress multidirectional lunge variations
    • Progress dynamic balance exercisesplate squat
    • Progress core/glute/lateral hip stabilizers (hip hikes, mini band walking, bridging/plank/side plank series, RNT)
    • HS strengthening (esp. eccentric): RDLs, seated HS curls, Ball/TRX curls, Russian hamstrings
    • Jogging prep -“Non-impact” jogging, elliptical, Stairmaster, bike sprints

Phase 4 : 12 weeks to 20 weeks – Before progressing, perform 3 month functional knee assessment (see Index)

    • Expectations at 12 weeks:
      • Knee AROM WNL and pain-free
      • 12” Lateral Step Down technique correct, symmetrical, and endurance within 10% of unaffected leg
      • Quads strength and endurance within 20% of unaffected
      • HS strength and endurance within 10% (may be delayed when limited by posterior horn lateral meniscus and/or MCL/LCL involvement)
      • Dynamic balance within 10% of unaffected leg
      • Girth within 5% of unaffected (mid patella, 3” superior to patella, 1/2 way b/t patella and ASIS)
      • Core stability endurance w/i 5% ant/post/right/left (Goal = 90 seconds)
  • Phase 4 Goals: Develop good dynamic hip/knee/ankle strategy, initiate progressive intensity/volume jogging program as appropriate, modified “Couch to 5K” progression (see index), initiate progressive plyometric program (as appropriate) focusing on training force absorption NM control, and initiate progressive intensity agilities (linear –> multidirectional) as appropriate.
  • Limitations: Can utilize OKC knee ext in the range of 90-30 degrees after week 12 (focus on eccentrics and utilize resistance point more proximal on tibia), and be cautious of impact training volume, avoiding recurrence of swelling/loss of motion.
  • Ther-ex ideas:  
      • Continue Phase 1-3 ex as neededplyo-squat-jumps
      • Address any “less than ideal” 12-week functional knee assessment findings
      • Force absorption/creation training: (quick drops, quick hops, jump/landing training)
      • Jogging progression (see index)
      • Continue to address any remaining LE strength deficits,
        with focus on strength and power development (8 or less rep range, appropriate loads)

Phase 5: 20 weeks and beyond: now it’s time for the 5 month “Functional Knee Assessment (see INDEX)

        • Expectations at 20 weeks:
          • No patellofemoral or soft-tissue complaints (if present, must be minimal and patient effectively able to self-manage).
          • 12” Lateral Step Down technique correct and symmetrical, and endurance equal bilateralmovement-skills
          • Normal gait (walking and running) mechanics and appropriate dynamic biomechanics (jump/landing technique, avoidance of dynamic genu valgus, postural proprioceptive control)
          • Functional Movement Screen score >15/21 with no scores of “1”
          • Dynamic balance symmetrical
          • Quads and hamstring strength and endurance within 5% of unaffected leg and HS/Quad ratio b/t 65-75%
          • Core stability endurance w/i 5% ant/post/right/left (Goal = 90 seconds)
        • Phase 5 Goals: Progressive, full return to beyond pre-injury speed/agility/power/conditioning and level of activity/sports with goal of full return to sport at 6-9 months (return to sport time-frame varies dependent on risk of sport and age/physical maturity/injury history of athlete).  Resolve any residual lower extremity weaknesses or functional deficits noted in a full functional movement assessment, and educate patient regarding maintenance home exercise program, progression of training volume (varies per sport/activity), and any possible remaining limitations.
        • Bracing:  I recommend the use of a knee brace for 1 year for contact/potential-contact sports

FInally, here’s the phase 5 return-to-sports volume progression that I use.  This will vary per sport, athlete age, and injury history.  It’s important to continue to incorporate strength, power, balance, and core training into routine weekly.  In the event that mild swelling or knee pain occurs that lingers constantly for more than 2 days, no practice/games for 3 days.  If symptoms resolve, return to play as instructed.  If symptoms do not resolve, follow-up with sports medicine team.  The athlete only moves on to next “phase” if able to tolerate current phase without swelling or knee pain occurring.  I also remind them that it is normal to feel “achy” in knee during times of increased intensity and volume more than normal, especially around patella and in area of scar.  As long as this does not cause swelling and ceases shortly following activity, there is no reason for concern.

      • Weeks 17-20 (Month 5):
        • Focus on improving multidirectional agilities in a controlled setting (no “live” drills @ practice)
        • Focus on increasing speed, power, endurance, and improving sport-specific skills
      • Weeks 21-24 (Month 6):
        • Gradual return to sports/practice participation
        • “1 on, 1 off” practice schedule:
          • This pertains to “live” drills, and not sprints/aerobic conditioning or controlled-intensity skill work.  This means that every other practice, athlete takes part in “live, game-like drills”.
          • In game-like scrimmaging, volume is limited to no more than that equal to ¼ of a full game
          • No participation in games
      • Weeks 25-28 (Month 7):
        • “2 on, 1 off” practice schedule first two weeks, then “3 on, 1 off”.
          • This pertains to “live” drills/scrimmaging at practices, and not sprints/aerobic conditioning or controlled-intensity skill work.
          • In game-like scrimmaging, volume is limited to no more than that equal to 1/2 of a full game for first 2 weeks, then ¾ of a full game next two weeks
          • No participation in games 1st two weeks, then playing no more than ½ of game next two weeks
      • Beyond week 28 (Month 8):
        • Full practice/game participation.  No restrictions.  Continue to work on balance, strength, flexibility, and conditioning in conjunction with sport-specific skills.

INDEX:  For a full description of my 3 month and 5 month post-ACL “Functional Knee Assessments”, my modified “Couch to 5K” jogging progression, and references, here’s a downloadable version of my ACL rehab and return to play protocol.

Load/Repetition Assignments Based on Training Goal


Training Goal


(% 1RM)

Goal Reps



< 6

Power:        Single-effort eventMultiple effort event








Muscular Endurance

< 67

> 12





Re-patterning/NM Re-ed



Would love to hear your feedback on my protocol!  Questions, comments –> leave them below.

All the best!

The ACL: Much more than “just a ligament”

ACL injuryWelcome to part two of my three-part series dedicated to understanding the recovery from ACL injury.  In part one, we heard from Veronica and Melinda about their experiences and challenges (physically, mentally, and emotionally).  Now, I’m going to share the experiences of two more people who both dealt with multiple ACL tear episodes, using different types of surgery, and making different decisions when faced with their most recent and final episode of re-injury.

Here is Niki’s story, with (some interjections by moi):

“As a 34-year old school teacher, volleyball coach, and former player, I’ve had my fair share of knee injuries and surgeries. I was a junior in high school, playing a varsity volleyball match at a rival high school. I ran to chase down a pass, stopped, changed directions, and immediately fell to the ground. I remember trying to get back up and falling again. I didn’t hear a “pop” like most people hear when tearing an ACL.  (Not all people who tear their ACL hear/feel a “pop”.  I personally know four previous clients who had no idea that they tore their ACL when it happened, reporting nearly no pain or swelling, merely a weird feeling of instability.)

I went to a recommended surgeon. He was trying a new style of surgeries (allograft – cadaver ligament via arthroscopic surgery), so I signed up.   With only 5 surgical portals, he sold me on the fact that recovery would be quicker, with less scar tissue (it’s typically true that cadaver ACL surgeries have an easier first phase of rehab, however I wouldn’t go as far to say that someone recovers quicker in the long run). He failed to mention the cadaver ligament was not as strong as other choices (Allografts have a much higher risk of rejection by your body, with more potential complications, increased knee laxity, and scientific studies show as high as a 3-fold risk of rerupture vs autograft). In February of 1997, I had surgery. I don’t remember being in pain or taking pain medication. The uncomfortable moments were sleeping and showering.  Stepping into the shower proved to be a deadly feat every day. My parents put a chair into the shower for me (external support is a key part of recovery – family and friends can play a big role in addressing daily challenges!). I no longer felt like I was going to slip, fall, and reverse all of the repairs that had just been made to my new, bionic knee (anything that can be done to boost confidence is a big “plus” during the recovery.  A lingering deficit in confidence can have a series impact on recovery).  To alleviate leg pain and to make sleeping more tolerable, I would put a pillow underneath my knee. Upon returning to my doctor for a follow-up, I told him about my new sleeping habits. He was VERY quick to scold me (Great interpersonal skills on display here by the MD <he says sarcastically>). According to him, sleeping with a pillow directly underneath your knee would lead to hip pain and other problems (Seriously?  I can think of a hundred other things the physician should be concerned about at this point post-op).

I listened diligently to my physical therapist, and hoped to recover in time to do preseason workouts for the upcoming volleyball season. (She was told) the recovery time was 6-9 months (6 months is very early for someone, especially a teenager, to be returning to full unrestricted sports participation.  Of course, it varies based on the sport.  Typically my goal for those I work with is to be full go, performing at a level higher than prior to the injury, and unrestricted around 8 months s/p – a sufficient physiological healing time-frame). Rebuilding my quad strength and regaining my range of motion were the main goals (I hope Niki’s rehab team stressed the importance of many other important goals beyond these two.  Interesting that these are the only two goals that stick out in her memory).  With the style of surgery I had, I was able to rehab faster (see above – allograft). I went to physical therapy twice a week for three months and did exercises at home. I was able to fully rehab my knee to do preseason workouts and fully participate in upcoming season. I did experience pain during jump training and sprints because it was the most impact my knee had taken in over a year (likelihood is that she was having pain due to unaddressed biomechanical issues and/or lack of proper preparation – at that point, it should not have been the most impact her knee had taken in over a year.  While occasional knee discomfort in the area of the scar tissue can be normal in the short-term, a proper reconditioning program prepares someone to withstand that stress with no problem.  THIS SHOULD NOT HAPPEN).ACL frustrated

The cadaver ligament lasted for one high school season, four years of collegiate volleyball and three years of recreational volleyball. I can’t remember the exact moment in which I re-tore the same ACL (possibly repetitive biomechanical microstress combined with decreased stability from the allograft surgery). I found a well-known surgeon in Baltimore. He recommended using my patella tendon instead of a cadaver ligament because it was so much stronger (autograft). Surgery was painful (Yes, Bone-Patellar-Bone is reportedly the most painful post-op of the surgical choices). The large incision running down my knee looked gruesome. I slept in my father’s recliner, which was more comfortable than my bed. Showering still was a scary task (confidence). I often resorted to washing my hair in the sink (just one of many daily modifications someone has to make during recovery.  The rehabilitative team needs to prepare the person best they can by providing lots of ideas for modifications). My first physical therapist this time was too easy. Feeling like I wasn’t being pushed hard enough, I switched to a more aggressive physical therapist (Good for you Niki!  It’s important that patients take accountability for their care!). We worked on gait training, strength and flexibility. My recovery was slower with this style of surgery, but I felt like I had better results (because you did).

Niki’s recommendations for others: Know yourself and your needs:  My second surgeon and physical therapist were aggressive in their approaches (and she needed that). “Happy thoughts” are not going to repair your knee or regain strength (correct – you have to put in the word.  But a positive attitude can make a world of difference!).  Ask questions, and keep asking until you understand (Very important for you to be educated on your condition, restrictions, and expectations.  A good rehab professional or MD will listen and address your concerns). The surgery will repair the ligament – that’s the easy part. The difficult parts are the months that will follow (level of motivation and dedication are huge factors in the outcome).  Finding a quiet place to stay comfortable the days after surgery.  Rehabbing doesn’t end with your last physical therapy appointment. In order to maintain muscle mass and a healthy knee, stay active, do weight training.  (AMEN to this statement!  Unfortunately with PT benefits being limited to usually only the first 3-4 months, education is key for success beyond that.  Even better – when possible, work with a rehab and/or conditioning professional who can guide you through those remaining 4-5 months until you’re fully back).”

And now for another perspective from, Jen, who experienced tearing her ACL 3x over the course of 12 years (surgically-fixed the first two times, but elected no surgery the third time in functioning normally with ADLs).  She endured very challenging recoveries, facing both physical and emotional difficulties.  Jen offers her “Top 5 things she learned from her ACL”…

“Amazingly, tearing my ACL twice was a great learning experience. It was important to be patient and smart about my recovery. Time, hard work, and positive thoughts helped me reach almost 100% usage of my knee currently. The top 5 things I learned from my ACL are:

  1. Recovery is not a race. It will be frustratingly slow at times, but if you do not give your body the time to recover you are setting yourself up for setbacks.
  2. Physical therapists are magical people (as are certified athletic trainers!). Yes, the doctors and nurses are also amazing people, but your physical therapist will see you through the recovery multiple times a week over the course of several weeks. Listen to them wholeheartedly and embrace the physical and mental challenges they will put you through. When my first physical therapist told me to stand on both legs without the use of crutches I was adamant that I was not ready for that step. However, he told me that my knee is stronger than I thought it was. I listened to him and, sure enough, my knee was able to sustain my weight. I never doubted him again. 
  3. Know your body. I knew from my first ACL surgery that I have a negative reaction to anesthesia. I explained this to my doctor before my second surgery and he was doubtful of what I told him. After the third day of not being able to keep down any food and liquids, we made the decision to call the office (on a Saturday) and request an anti-nausea medication. It worked immensely and the sustenance I Was able to take in helped me recover.
  4. Know your limits. I fully accept and no longer participate in certain physical activities due to my knee not being as strong as it would be with a working ACL. I allowed myself one last “hurrah” by participating in a Tough Mudder last year, but have declined running any long distances or pivot sports since then.
  5. Be thankful. A torn ACL is nothing compared what others endure on a daily basis. Every time I went to physical therapy I was reminded of this. I think about this whenever I have to walk a longer distance than anticipated (even in a parking lot!). If the ACL is the least of your worries, than you are a very lucky person.

Thank you to Niki and Jen for sharing their stories and recommendations.  After experiencing the stories of Veronica, Melinda, Niki, and Jen, one can understand the complexity of recovery from ACL – especially when someone has to deal with a recurrence (or two!)  In the final part of this series, it’s time for me to share my personal approach and guidelines to managing ACL injuries from the time they occur until beyond full recovery.  I promise some good stuff.  Stay tuned!


Ryan Stevens, MPS, ATC, CSCS