Your physical therapist will formulate a rehabilitation program that takes into account your specific circumstances. However, the following guidelines are based on my experience as well as on the available orthopedic literature related to ACL rehabilitation, and should help guide physical therapy.

Before surgery

Stiffness (arthrofibrosis) is a potential complication after ACL reconstructive surgery. Current thinking is that the timing of ACL surgery can influence the incidence of this complication. Because of the risk of stiffness, I typically do not recommend surgery while the knee is still inflamed, swollen, and painful from the initial injury.

An initial course of physical therapy, before any surgery, helps control swelling, helps restore knee range of motion, and helps strengthen the muscles.

Goals of the physical therapy at this stage include:

1. Nearly normal gait
2. Full range of motion
3. Little if any swelling
4. Ability to do 20 SLR's without lag
5. Crutch training and preparation for surgery

To achieve the above pre-surgery goals, the patient should:

1. Use nonsteroidal anti-inflammatory medications for the first week (typically ibuprofen)
2. Ice the knee, especially for the first 2 days, but generally no longer than one week after the injury
3. Perform range of motion exercises, 3 times each day, for 10 minutes each
   1. Extension exercises
      1. Passive (gravity) extension, e.g., heel prop, by placing pillows under the heel and allowing gravity to straighten the knee
      2. Prone extension
      3. Active assisted extension, e.g., by using the other leg to help straighten the knee
   2. Flexion exercises
      1. Passive flexion (bending) exercises, e.g., allow the foot to dangle from the edge of a bed
      2. Heel slides (see picture below)
      3. Assisted flexion, e.g., by using your hands to help bend the knee
   3. Patella mobilization
4. Straight leg raises

After surgery

The time frames below are approximate. Progression from one phase to the next may be different in different patients.

Phase 1, the Immediate Postoperative Phase

Goals:

1. Full knee extension
2. Quadriceps control (20 no lag straight leg raises)
3. Control of pain and swelling
4. Normalized gait

Recommendations:

1. Elevate, whenever possible
2. Ice for the first 24-48 hours, 15 minutes each hour
3. May discontinue brace when comfortable
4. May shower, but do not bathe/immerse in water; pad dry over the steri-strips afterwards
5. Ambulation with crutches
   1. You are allowed to put full weight on your knee unless a meniscus repair or other procedure was performed in addition to the ACL reconstruction
   2. May discontinue crutches when you feel comfortable and safe without them
6. Take pain medications and anti-inflammatory medications as prescribed
7. Motivated patients with desk jobs may return to work when they stop taking opioid pain medications
8. Driving
   1. You may not drive if you are taking pain medications
   2. If you had surgery in the left knee and your car transmission is automatic, and you feel that you are able to control the car with the right leg, then you can drive at this time
   3. If you had surgery on the right knee, then you have to wait until you have no pain and full control of your right leg (usually 6 weeks)
9. Start performing exercises, similar to those after the initial injury (see above)
10. Start formal physical therapy
    1. Patella mobilization exercise
    2. Obtain full extension
    3. Obtain full flexion
    4. Avoid strenuous exercise
11. Start a few muscle exercises
    1. Quadriceps sets
    2. Straight leg raises - no lag
    3. Electric stim (optional)
    4. Double leg starter squats
    5. Standing theraband resisted terminal knee extension
    6. Hamstring sets and curls
    7. Prone hip extension
    8. Quad/ham co-contraction, supine
    9. Hip abduction, lying on the side
    10. Ankle pumps with theraband
    11. Heel raises
12. Do not
    1. Run or jump
    2. Avoid forceful extension of the knee, active or passive
13. Call Dr Qeli with any problems

To progress to phase 2, patient must demonstrate:

1. 20 no lag SLR
2. Comfortable without crutches and brace
3. Normalized gait
4. ROM 5-110 degrees

Phase 2: Weeks 3 - 6

Goals:

1. Full range of motion
2. Progress with strengthening and neuromuscular retraining

Exercises:

1. Continue range of motion exercises
   1. Low load, long duration, assisted PRN
   2. Heel / wall slides
   3. Heel prop / prone hang
   4. Bike
2. Strengthening
   1. Quad sets
   2. Mini-squats / wall squats
   3. Step-ups
   4. Knee extension from 90 to 40 degrees
   5. Leg press
   6. No jumping
   7. Hamstring curls
   8. Resistive SLR with sports cord
   9. Hip abduction
   10. Heel raises, including single
   11. Calf press
   12. Bike, elliptical
3. Neuromuscular training
   1. Wobble/rocker board
   2. Single stance training
   3. Slide board
   4. Perturbation training, etc.

To progress to phase 3, patient must demonstrate:

1. Full ROM
2. Minimal pain
3. No problems with activities of daily living

Phase 3, Weeks 6 - 12

1. Goals
   1. Strength and control
   2. Running
   3. Hopping without pain, swelling, and without giving-way
2. Continued strengthening exercises
   1. Squats
   2. Leg press
   3. Hamstring curls
   4. Knee extension, 90 degrees to full extension
   5. Lunges
   6. Shuttle
   7. Wall squats
   8. Sports cord
3. Neuromuscular training
   1. Wobble/rocker/roller board
   2. Perturbation training, etc.
   3. Varied surfaces

To progress to phase 4, patient must demonstrate:

1. Running and hopping without pain
2. No difficulty with neuromuscular and strength training exercises

Phase 4, weeks 12 - 16

1. Goals
   1. Running and hopping at 75% speed
   2. Hop tests at 75% of controlateral values
2. Strengthening is more aggressive
   1. Squats
   2. Lunges
   3. Plyometrics
   4. Running patterns at 50-75% speed
3. Neuromuscular training
   1. Wobble/rocker/roller board
   2. Perturbation training, etc.
   3. Varied surfaces

To progress to phase 5, patient must demonstrate:

1. 75% of controlateral hop tests
2. Figure 8 run at 75% speed without difficulty
3. Maximum vertical jump without difficulty

Phase 5, return to sports

1. Goals
   1. 85% strength
   2. Hop tests at 85% of controlateral values
   3. Sports specific training without difficulty
2. Strengthening
   1. Squats
   2. Lunges
   3. Plyometrics
3. Sports specific activities

In order to return to sports you must feel comfortable and confident, without pain when running, cutting, jumping, etc., at full speed.

Please keep in mind that the state of the art is such that it takes about one year to fully return to sports. This is true for professional players as well, who receive the best care and the best therapy that money can buy.

Please remember that ACL reconstruction involves using a graft. Right after surgery this graft is dead tissue which over time is invaded by the body's live cells and turned into a live part of the body. As a consequence of the ingrowth and remodelling, the ACL graft is weakest at about 6 months after surgery and it takes a full year for it to be fully incorporated. Therefore, contact sports may injure the grafted ACL more easily during the first year.