Anterior Cruciate Ligament Reconstruction

Delayed Rehab
Dr. Walter R. Lowe

This rehabilitation protocol has been designed for patients who have
undergone an ACL reconstruction (HS graft/PTG/Allograft) in addition to
other surgical issues that may delay the initial time frame of the
rehabilitation process. Dependent upon the particular procedure, this
protocol also may be slightly deviated secondary to Dr. Lowe’s medical
decision. The ACL protocol for Hamstring Tendon Grafts and Allografts is the
same as for the Bone Patellar Tendon Bone Grafts with the following
exceptions:
1. When performing heel slides, make sure that a towel/sheet is
used to avoid actively contracting the hamstrings.
2. Do not perform isolated hamstring exercises until the 4th
week post-op.
The following may be considered criteria for this protocol:
• Concomitant meniscal repair
• Concomitant ligament reconstruction
• Concomitant patellofemoral realignment procedure
• ACL revision reconstruction
The protocol is divided into several phases according to postoperative weeks and
each phase has anticipated goals for the individual patient to reach. The overall
goals of the reconstruction and the rehabilitation are to:
Control joint pain, swelling, hemarthrosis
Regain normal knee range of motion
Regain a normal gait pattern and neuromuscular stability for
ambulation
Regain normal lower extremity strength
Regain normal proprioception, balance, and coordination for
daily activities
Achieve the level of function based on the orthopedic and patient
goals
The physical therapy is to begin 2nd day post-op. It is extremely important for the
supervised rehabilitation to be supplemented by a home fitness program where
the patient performs the given exercises at home or at a gym facility.
Important post-op signs to monitor:
Swelling of the knee or surrounding soft tissue
Abnormal pain response, hypersensitive
Abnormal gait pattern, with or without assistive device
Limited range of motion
Weakness in the lower extremity musculature (quadriceps,
hamstring)
Insufficient lower extremity flexibility

Return to activity requires both time and clinic evaluation. To safely and most
efficiently return to normal or high level functional activity, the patient requires
adequate strength, flexibility, and endurance. Isokinetic testing and functional
evaluation are both methods of evaluating a patient’s readiness to return to
activity.

Dr. Walter R. Lowe

Phase 1-Weeks 1-2 Delayed Protocol

WEEK EXERCISE GOAL

1-2 ROM 0-90°
ROM (passive)
--meniscus repair, MCL, ACL revision
0-90°
--patellar realignment
0-75°
Patellar mobs
Ankle pumps
Gastroc/soleus stretches
Heel slides
Wall slides
STRENGTH
Quad sets x 10 minutes
SLR (flex and abd)
Heel raise/Toe raise
Wall squats
WEIGHT BEARING
--meniscus repair – NWB
--MCL – wt bearing as tolerated per Dr. Lowe
--ACL revision – wt bearing as tolerated
MODALITIES
Electrical stimulation as needed
Ice 15-20 minutes with knee at 0° ext
BRACE
Remove brace to perform ROM activities
I-ROM when walking with crutches
GOALS OF PHASE:
• ROM (see above, depends on procedure)
• Control pain, inflammation, and effusion
• Adequate quad contraction
• NWB to TDWB per Dr. Lowe (depends on procedure)
 Phase 2-Weeks 2-4 ACL Delayed

WEEK EXERCISE GOAL

2-4 ROM 0-90°
Passive, 0-90°
Patellar mobs
Ankle pumps
Gastoc/soleus stretch
Light hamstring stretch at wk 4
Heel/Wall slides to reach goal
STRENGTH
Multi-angle isometrics (90-60°)
Quad sets with biofeedback
SLR (flex, abd, add)
Wall Squats
Heel raise/Toe raise
BALANCE TRAINING
Weight shifts (side/side, fwd/bkwd)
Single leg balance (dependent upon procedure)
MODALITIES
E-stim/biofeedback as needed
Ice 15-20 minutes
BRACE
I-ROM when walking with crutches

GOALS OF PHASE:
• ROM to 90° flexion and 0° extension
• Diminish pain, inflammation, and effusion
• Quad control
• Initiate weight bearing as permitted by Dr. Lowe
 Phase 3-Week 4-6 ACL Delayed

WEEK EXERCISE GOAL

4-6 ROM 0-125°
Passive, 0-125°
Gastoc/soleus/hs stretch
Heel/wall slides to reach goal
STRENGTH
Progressive isometric program
SLR in 4 planes with ankle weight/tubing
Heel raise/Toe raise
Mini-squats/Wall squats
Initiate isolated hamstring curls
Multi-hip machine in 4 planes
Leg Press-double leg eccentric
Initiate bike when 110° flexion
EFX/Retro treadmill
Lateral/Forward step-ups/downs
Lunges
BALANCE TRAINING
Single leg stance
Weight shift
Balance board/two-legged
Cup walking/hesitation walking
WEIGHT BEARING
PWB to FWB as allowed by quad control Discharge
crutches
when FWB is
allowed
MODALITIES
Ice 15-20 minutes
BRACE Discharge
Measure for functional brace I-ROM with
issuance of
functional brace

GOALS OF PHASE:
• ROM 0-125°
• Increase lower extremity strength and endurance
• Minimize pain, swelling, and effusion
• Increase weight-bearing status from PWB to FWB
 Phase 4-Week 6-12 ACL Delayed

WEEK EXERCISE GOAL

6-10 ROM 0-135°
Passive, 0-135°
Gastoc/soleus/hs stretch
STRENGTH
Continue exercises from wk 4-6
Leg Press-single leg eccentric
Lateral lunges
BALANCE TRAINING
Two-legged balance board
Single leg stance with plyotoss
Cup walking
½ Foam roller work
MODALITIES
Ice 15-20 minutes
BRACE
Functional brace as needed
10-12 ROM 0-135°
Passive, 0-135°
Gastoc/soleus/hs stretch
STRENGTH
Continue exercises from wk 4-10
Initiate jogging protocol-start on minitramp
as tolerated, progress to treadmill
Progress with proprioception training
Walking program
Bicycle for endurance
MODALITIES
Ice 15-20 minutes
GOALS OF PHASE:
• Full weight bearing, normal gait
• Restore full knee ROM (0-135°)
• Increase strength and endurance
• Enhance proprioception, balance, and neuromuscular control
 Phase 5-Week 12-16 ACL Delayed
WEEK EXERCISE
12-16 ROM
Continue all stretching activities
STRENGTH
Continue exercises from wk 4-12
Initiate plyometric training drills
Progress jogging/running program
Initiate isokinetic training (90-30°), (120-240°/sec)
MODALITIES
Ice 15-20 minutes
GOALS OF PHASE:
• Restore functional capability and confidence
• Restore full knee ROM (0-135°)
• Enhance lower extremity strength and endurance
 Phase 6-Week 16-20 ACL Delayed
WEEK EXERCISE
16-20 ROM
Continue all stretching activities
STRENGTH
Continue all exercises from previous phases
Progress plyometric program
Increase jogging/running program
Swimming (kicking)
Backward running
FUNCTIONAL PROGRAM
Sport specific drills
CUTTING PROGRAM
Lateral movement
Carioca, figure 8’s
MODALITIES
Ice 15-20 minutes as needed
GOALS OF PHASE:
• Maintain muscular strength and endurance
• Perform selected sport-specific activity
• Progress skill training
• Enhance neuromuscular control

Phase 7-Week 20-36 ACL Delayed

WEEK EXERCISE
20-36 STRENGTH
Continue advanced strengthening
FUNCTIONAL PROGRAM
Progress running/swimming program
Progress plyometric program
Progress sport training program
Progress neuromuscular program
MODALITIES
Ice 15-20 minutes as needed
GOALS OF PHASE:
• Return to unrestricted sporting activity
• Achieve maximal strength and endurance
• Progress independent skill training
• Normalize neuromuscular control drills

At six and twelve months, a follow-up isokinetic test is suggested to guarantee

maintenance of strength and endurance. Advanced weight training and sport
specific drills are advised to maintain a higher level of competition.