ACL Reconstruction

Rehabilitation Protocol

ACL Reconstruction Rehabilitation Protocol

Rehabilitation Philosophy

This protocol is criteria-based, biologically informed, and function-driven, designed to support safe return to sport while protecting ACL graft healing.

Timelines are guides only, progression is dictated by objective clinical findings, symptom response, movement quality, and functional performance, not time alone.

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

  • Progression is criteria-based, not time-based

  • Early priorities:

    • Full knee extension

    • Quadriceps activation

    • Effusion control

  • Gradual exposure to:

    • Load

    • Speed

    • Plyometrics

    • Sport-specific demands

  • Movement quality and symptom response govern progression at all stages

Preoperative Phase (Prehabilitation)

Goals

  • Full knee extension

  • No flexion contracture

  • Voluntary quadriceps activation

  • Patient education regarding staged rehabilitation

Notes

  • Minimum of one pre-operative physiotherapy visit recommended

  • Additional sessions if deficits persist

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

Goals

  • Restore full knee extension

  • Reduce swelling

  • Activate quadriceps

  • Achieve safe early weight bearing

Rehabilitation Focus

  • Immediate active ROM (avoid immobilisation)

  • Progressive WBAT unless otherwise instructed

  • Static quadriceps exercises and straight leg raises

  • NMES to assist quadriceps activation

  • Swelling control and cryotherapy

    • Early postoperative use encouraged

    • Educate patients on safe application

    • Compressive cryotherapy may offer additional benefit
      (Dr Lynskey’s preference: Game Ready®)

Avoid

  • CPM

  • Dry needling

  • Aggressive loading

Phase 2 – Protected Strength & Foundation (2–6 Weeks)

Goals

  • Restore ROM

  • Improve quadriceps and hamstring strength

  • Maintain graft protection

Rehabilitation Focus

  • Early closed kinetic chain exercises

  • Leg press from ~3 weeks (0–45°)

  • Open kinetic chain quadriceps from Week 4 (90–45°)

  • Early eccentric quadriceps loading (20–60°)

  • Blood Flow Restriction (BFR) training where appropriate

  • Aquatic therapy from weeks 3–4 (once wounds healed)

Monitor Closely

  • Anterior knee pain

  • Effusion response
    → Any reactive effusion warrants immediate load reduction and review with Dr Lynskey

Phase 3 – Strength, Capacity and Motor Control (6–12+ Weeks)

Goals

  • Restore limb symmetry

  • Improve neuromuscular control

  • Prepare for running and agility

Rehabilitation Focus

  • Combined OKC + CKC strengthening

  • Concentric and eccentric loading

  • Isotonic ± isokinetic training

  • Core stability

  • Agility drills and controlled plyometrics

Phase 4 – Advanced Strength & Movement (3–5 Months)

Goals

  • Restore symmetrical strength

  • Improve dynamic knee control

  • Increase tolerance to multiplanar loads

  • Prepare for work- or sport-specific demands

Rehabilitation Focus

  • Higher-load strengthening

  • Multiplanar movement control drills

  • Controlled deceleration tasks

  • Gradual introduction of jogging only if criteria met and surgeon-approved

Return To Running (Minimum Criteria)

All must be met

  • 90% knee flexion ROM

  • Full extension

  • No or trace effusion

  • Quadriceps strength LSI ≥80%

  • CMJ eccentric impulse LSI ≥80%

  • Pain-free:

    • Aqua jogging

    • Alter-G running

    • Balanced, controlled, symmetric single-leg squat

Return To Sport (Clearance Criteria)

    • No pain or effusion

    • Full ROM

    • Stable knee on examination (Lachman, pivot shift)

    • Normalised IKDC

    • ACL-RSI

    • Tampa Scale of Kinesiophobia

    • Isokinetic quadriceps and hamstrings:

      • Goal of 100% symmetry for pivoting sports

    • CMJ and drop jump ≥90% symmetry

    • Reactive Strength Index:

      • ≥1.3 (double-leg)

      • ≥0.5 (single-leg)

    • ≥90% symmetry in high-speed running forces

    • Normalised jumping, landing, and change-of-direction mechanics

    • Completion of a structured sport-specific rehabilitation programme

Surgeon Notes (VBJS)

  • Accelerated rehabilitation may be appropriate only if objective criteria are met

  • Modify rehabilitation for:

    • Concomitant meniscal repair

    • Revision ACL reconstruction

    • Multiligamentous injury

  • Persistent swelling, pain, or failure to progress mandates load reduction and review with Dr Lynskey

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 (if repaired)

  • 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 to 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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