ACL Reconstruction + Meniscal Repair

Rehabilitation Protocol

ACL Reconstruction + Meniscal Repair Rehabilitation Protocol

Rehabilitation Philosophy

This protocol is criteria-based, biologically informed, and function-driven.
Timelines are provided as guides only, progression is determined by tissue healing, symptom response, movement quality, and objective functional criteria, not time alone.

ACL graft maturation and meniscal healing occur on different biological timelines.
When procedures are combined, meniscal protection takes priority over accelerated ACL progression.

Core Rehabilitation Priorities

  • Effusion and pain control

  • Restoration of full knee extension

  • Early quadriceps activation

  • Gradual, protected exposure to load and movement complexity

Clinical Governance & Escalation

Persistent or reactive effusion, increasing pain, loss of motion, mechanical symptoms, or failure to progress warrants immediate load modification and review with Dr Lynskey.

Close communication between surgeon and physiotherapist is expected throughout rehabilitation.

View all Rehabilitation Protocols

Key Principles

  • Rehabilitation must be individualised based on:

    • Meniscal tear pattern (bucket-handle, ramp, radial, root)

    • Repair technique

    • Graft type

    • Sport and risk profile

  • Early restoration of:

    • Full knee extension

    • Quadriceps activation

  • Flexion limited to ≤90° for the first 6 weeks

  • Weight-bearing dictated by meniscal repair type

  • Avoid pivoting, twisting, and deep flexion early

  • Movement quality and symptom response govern progression

  • Time alone must not be used as the determinant of readiness

Meniscal-Specific Modifiers (Non-Negotiable)

Weight Bearing

  • Radial or root repairs:
    → Strict non-weight bearing for 6 weeks

  • Bucket-handle and ramp repairs:
    → Protected or partial weight bearing as directed
    → Rehabilitated similarly due to posterior horn shear forces

Range of Motion

  • Extension to 0° immediately

  • Flexion:

    • ≤90° for first 6 weeks

    • Avoid loaded flexion and sustained deep squatting

Preoperative Phase (Prehabilitation)

Goals

  • Full passive knee extension

  • Adequate voluntary quadriceps activation

  • Minimise effusion

  • Educate patient regarding combined ACL + meniscal constraints

Phase 1 – Protection & Activation (0–2 Weeks)

Goals

  • Protect ACL graft and meniscal repair

  • Control pain and swelling

  • Restore full knee extension

  • Activate quadriceps

  • Achieve safe mobility

Rehabilitation Focus

  • Brace: not routinely used, check operation report / allied health referral

  • ROM:

    • Extension to 0° immediately

    • Flexion ≤90°

  • Quadriceps activation:

    • Quad sets

    • Straight leg raises (brace on if required)

  • Patellar mobilisation

  • Gait training with aids

  • Cryotherapy / compressive cryotherapy (e.g. Game Ready®)

  • NMES for quadriceps activation

Criteria to Progress (All Must Be Met)

  • Pain controlled

  • No progressive effusion

  • Full passive extension

  • Safe, controlled mobility within restrictions

Phase 2 – Protected Strength & Motor Control (2–6 Weeks)

Goals

  • Maintain graft and meniscal protection

  • Improve quadriceps control

  • Normalise gait within WB restrictions

Rehabilitation Focus

  • ROM progressed cautiously (≤90°)

  • Closed Kinetic Chain strengthening (shallow range only):

    • Elevated sit-to-stand

    • Mini squats ≤60°

  • Hip and core strengthening

  • Balance training (DL → supported SL)

  • Upright stationary cycling (low resistance, when ROM allows)

Clinical Emphasis

  • Avoid loaded flexion and rotation

  • Any effusion or joint-line pain → regress load and contact surgeon

Phase 3 – Strength, Capacity & Movement (6–12 Weeks)

(Following clearance of meniscal restrictions)

Goals

  • Restore full ROM

  • Improve quadriceps and posterior chain strength

  • Develop neuromuscular control

Rehabilitation Focus

  • Progressive strengthening:

    • Squats (gradual depth progression restricting to 90 degrees)

    • Step-ups / step-downs

    • Split squats

  • Hamstring strengthening (cautious with posterior horn/ramp repairs)

  • Proprioception and dynamic balance

  • Low-impact conditioning (bike, elliptical)

Criteria to Progress

  • Full ROM without pain

  • No reactive effusion

  • Demonstrated single-leg control

Phase 4 – Running & Advanced Loading (≈3–5 month)

Criteria to Commence Running (All Required)

  • Full ROM

  • No or trace effusion

  • Quadriceps strength ≥80% LSI

  • Excellent single-leg control (Balanced, controlled, symmetric single-leg squat)

  • Pain-free hopping and deceleration drills

Phase 5 - Return To Sport (Criteria-Based)

Minimum Clearance Criteria:

Clinical

  • No pain or effusion

  • Full, or near full, pain-free ROM

  • Satisfactory surgical knee examination

Strength

  • Quadriceps and hamstrings ≥90–100% limb symmetry

Power & Movement Quality

  • Symmetrical jumping and landing mechanics

  • Excellent deceleration and change-of-direction control

Psychological Readiness

  • Confidence with sport-specific movements

  • Normalised ACL-RSI where applicable

Imaging & Healing Surveillance

  • Repeat MRI commonly performed at ~3 months post-op to assess meniscal healing, particularly for:

    • Bucket-handle repairs

    • Ramp lesions

    • Radial or complex tears

  • Imaging must be interpreted alongside:

    • Clinical examination

    • Symptom response

    • Functional performance

Incomplete healing warrants continued protection and delayed progression.

Surgeon Notes

  • In combined ACL + meniscal repair, meniscal healing dictates early progression

  • Ramp lesions are rehabilitated similarly to bucket-handle tears

  • Persistent effusion or joint-line pain mandates load reduction and review with Dr Lynskey

  • Modify rehabilitation for:

    • Radial/root repairs

    • Revision surgery

    • High-risk pivoting sports

Appendix: Elite Athlete Accelerated Pathway

(Selected Patients Only)

Eligibility (All Required)

  • Elite or high-performance athlete

  • High compliance

  • Excellent access to supervised rehabilitation

  • Minimal or no effusion throughout rehab

  • No radial or root meniscal repair

  • Satisfactory 3-month MRI (where performed)

  • Multidisciplinary oversight (Surgeon, Team Doctor, Physio, Strength & Conditioning team)

Accelerated Features

  • Earlier progression to running once criteria met

  • Earlier introduction of sport-specific drills

  • Increased neuromuscular and strength frequency

  • High-level monitoring of effusion and load tolerance

Non-Negotiables

Acceleration does not permit compromise of:

  • Meniscal protection

  • Movement quality

  • Strength symmetry

  • Neuromuscular control

Any effusion, joint-line pain, mechanical symptoms, or deterioration in movement quality mandates immediate regression and review with Dr Lynskey.

Key Message For Patients

Your knee progresses based on healing, strength, and control, not a calendar.
Meeting the right criteria may allow earlier return; rushing recovery risks failure.

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