ACL Reconstruction: University of Virginia Rehab Protocol

PHASE I: Immediate post-operative (weeks 1-4)


Protect graft and graft fixation
Control inflammation/swelling
0-120 flexion AROM as tolerated first 4 weeks.

*Caution: avoid hyperextension greater than 10 degrees.

Educate patient on rehabilitation progression
Restore normal gait on level surfaces

Weight bearing Status:

Weight-bearing as tolerated immediately post-op with crutches
Wean from crutches for ambulation by 2 weeks as patient demonstrates normal gait mechanics and good quad control.


Patellar mobilization/scar mobilization
For Hamstring Autograft Reconstruction: Delay hamstring strengthening for 12 weeks
Heel slides (limit to 90° for hamstring tendon autograft procedure)
Quad sets (consider NMES for poor quad sets)
Gastroc/Soleus stretching
Hamstring stretches (very gentle if hamstring autograft)
Gastroc/Soleus strengthening (for patellar tendon autograft procedures)
SLR, all planes. Add weight as tolerated to hip abduction, adduction and extension.
If available, deep-water jogging for ROM and swelling.

For patellar tendon autograft procedures only:

Hamstring curls –add weight as tolerated
Closed Kinetic Chain Quadriceps strengthening activities as tolerated (wall sit, step ups, mini squats, leg press 90-30 degrees)
Quadriceps isometrics at 60° and 90°
If available, aquatics for normalizing gait, weight bearing and strengthening
Stationary Bike –initially for promotion of ROM –progress light resistance as tolerated

Criteria for advancement to Phase II:

Full PROM flexion/extension
Good quad set, SLR without extension lag
Minimal swelling/inflammation
Normal gait on level surfaces

PHASE II: Post-operative weeks 4 to 10


Restore normal gait with stair climbing
Maintain full extension, progress toward full flexion range of motion
Protect graft and graft fixation
Increase hip, quadriceps, hamstring and calf strength
Increase proprioception


Continue with range of motion/flexibility exercises as appropriate for the patient
Continue closed kinetic chain strengthening as above for patellar tendon autograft procedures, progressing as tolerated – can include one-leg squats, leg press, step ups at increased height, partial lunges, deeper wallsits, lunge walks.
Initiate CKC quad strengthening and progress as tolerated for hamstring
tendon autograft procedures (wall sits, step-ups, mini-squats, Leg Press 90-30 degree, lunges)
Stairmaster (begin with short steps, avoid hyperextension)
Nordic Trac or elliptical machine for conditioning.
Stationary bike-progress time and resistance as tolerated
Continue to progress proprioceptive activities for patellar tendon autograft procedures, initiate for hamstring tendon autograft procedures – ball toss, balance beam, mini-tramp balance
Continue hamstring, gastroc/soleus stretches
Continue to progress hip, hamstring and calf strengthening as tolerated
If available, begin running in the pool (waist deep) or on an unweighted treadmill at 8 weeks.

Criteria to advance to Phase III include:

No patellofemoral pain
Minimum of 120 degrees of flexion
Sufficient strength and proprioception to initiate running.
Minimal swelling/inflammation

PHASE III: Post-operative weeks 10 to 16


Full range of motion
Improve strength, endurance and proprioception of the lower extremity to prepare for sport activities
Avoid overstressing the graft, for hamstring tendon autograft progressively increase resistance of hamstring strengthening.
Protect the patellofemoral joint
Normal running mechanics
Strength approximately 70% of the uninvolved lower extremity perisokinetic evaluation (if available)


Continue flexibility and ROM exercises as appropriate for patient
Initiate OKC Knee extensions 90°-30°, progress to eccentrics
If available, isokinetics (with anti-shear device) –begin with mid range speeds (120o/sec-240o/sec)Progress toward full weight bearing running at 12 weeks for BTB autograft (16 weeks for hamstring tendon autograft procedures).
Begin swimming if desired
Recommend isokinetic test with anti-shear device at 12 weeks (14- 16 weeks for hamstring tendon autograft procedures) to guide continued strengthening
Progressive hip, quadriceps, hamstring, calf strengthening
Cardiovascular/endurance training via Stairmaster, elliptical, bike
Advance proprioceptive activities

Criteria for advancement to Phase IV:

No significant swelling/inflammation.
Full, pain-free ROM
No evidence of patellofemoral joint irritation
Strength approximately 70% of uninvolved lower extremity per isokinetic evaluation
Sufficient strength and proprioception to initiate agility activities
Normal running gait

PHASE IV: Post-operative months 4 through 6


Symmetric performance of basic and sport specific agility drills
Single hop and 3 hop tests 85% of uninvolved lower extremity
Quadriceps and hamstring strength at least 85% of uninvolved lower extremity per isokinetic strength test


Continue and progress flexibility and strengthening program based on individual needs and deficits.
Initiate plyometric program as appropriate for patient’s athletic goals
Agility progression including, but not limited to:

Side steps


Figure 8 running

Shuttle running

One leg and two leg jumping



Agility ladder drills

Continue progression of running distance based on patient needs.

Initiate sport-specific drills as appropriate for patient

Assessment of running on treadmill

Criteria for advancement to Phase V:

No patellofemoral or soft tissue complaint
Necessary joint ROM, strength, endurance, and proprioception to safely return to work or athletics

PHASE V: Begins at 6 months post-op


Safe return to athletics/work
Maintenance of strength, endurance, proprioception
Patient education with regards to any possible limitations