ACL Reconstruction with Meniscus Repair and/or Microfracture: University of Virginia Protocol

Phase I: Immediately postoperative (weeks 0-4)

• Protect graft and graft fixation
• Minimize effects of immobilization
• Control inflammation/swelling
• ROM: 0-90 when supine (such as heel slides).
• Caution: avoid squatting and flexion for leg press beyond
90-degrees until 4 months post-op.
• Brace 0-90 degrees for ADLs until 6 weeks post-op
• Educate patient on rehabilitation progression

Weight bearing Status:
• TTWB (25%) for 2 weeks, 50% until 6 weeks post-op, then advance to full
weight bearing.

• Patellar mobilization/scar mobilization
• Delay hamstring strengthening for 12 weeks. (for hamstring tendon
autograft procedure only)
• Hamstring curls –add weight as tolerated (for patellar tendon autograft
procedure only)
• Heel slides (to 90° only for hamstring tendon autograft procedure)
• Quad sets (consider NMES for poor quad sets)
• Gastroc/Soleus stretching
• Hamstring stretches (very gentle for hamstring tendon autograft
• Gastroc/Soleus strengthening (for patellar tendon autograft procedures)
• SLR, all planes, with brace in full extension until quadriceps strength is
sufficient to prevent extension lag –add weight as tolerated to hip
abduction, adduction and extension.

For patellar tendon autograft procedures only:
• 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°
• Balance/Proprioception
• 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 after brace is discontinued at 6
• Maintain full extension, progress toward full range of motion at 6+ weeks
• 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
• 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 wall
sits, lunge walks.
• Initiate CKC quad strengthening and progress as tolerated for hamstring
tendon autograft procedures (wall sits, step – ups, mini – squats, Leg Press,
lunge at 90°-30°
• 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 per
isokinetic 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 tendonautograft procedures) to guide continued
• 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 perisokinetic
• 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

• Gradual return to sports participation
• Maintenance program for strength, endurance