Phase I (Days 1–7)

Weightbearing status
• Two crutches, locked knee brace, weight bearing as tolerated
after nerve block wears off .
Exercises
• Heel slides/wall slides/sitting assisted knee flexion
• Ankle pumps
• Isometric quad sets in full extension with and without neuromuscular
electrical stimulation (NMES) or biofeedback
• Hamstring sets (not for hamstring autograft)
• Gluteal sets
• Straight leg raise (SLR) flexion, abduction, extension with brace
locked in full extension
• Prone hangs or heel propped in supine for passive knee extension
• Weight shifting in standing for weightbearing tolerance
(anteroposterior and side to side)
• Continuous passive motion (CPM) 6 hours/day, increasing 5–10
degrees/day
• Gait training with crutches and brace, level ground and stairs
• Cryotherapy to reduce edema 
Manual Therapy
• Patellar mobilizations
• Soft tissue mobilizations to hamstrings for spasm control 
Goals
• Active range of motion (AROM) 0–90 degrees within 10 days
• Good, active quadriceps contraction
• Full weight bearing (FWB) with crutches and brace
• Edema control
• Graft protection
• Wound healing 
Criteria to Progress to Phase II
• SLR with or without lag in brace
• Clean and dry wound
• Progressing range of motion (ROM)
• Able to bear weight on involved limb
Phase II (Days 8–14)
Weightbearing Status
• Weight bearing as tolerated
• Two crutches to single crutch
• Brace unlocked gradually as quad control improves (SLR without
lag before unlocking brace beyond 30 degrees) 
Exercises
• Stationary bike for ROM (from rocking to full revolutions)
• Isometric quad sets in full extension and at 90 degrees with and
without NMES or biofeedback
• Single-leg stance in brace
• Balance board anteroposterior in bilateral stance
• Continue ROM exercises.
• Gait training: single-leg walk (pawing) on treadmill, step-over
cones forward
• Begin partial weight mini-squats (0–30 deg) on total gym/shuttle
• Heel raises
• Continue SLR, all four directions
• Terminal knee extension in standing with band
• Prone knee bridges
• Active standing hamstring curls (do not perform for postoperative
hamstring autograft reconstruction) 
Manual Therapy
• Continue patellar mobs as indicated.
• Continue hamstring mobs as indicated. 
Goals
• AROM 0–120 degrees within 3 weeks
• SLR without quad lag
• Normal gait pattern with single crutch and unlocked brace 
Phase III (Weeks 2–4)
Weightbearing Status
• FWB, normal gait without assistive device or brace by 3 weeks 
Exercises
• Stationary bike with gradual progressive resistance for endurance
• Isometric quad sets in full extension and at 90 to 60 degrees
flexion with and without NMES or biofeedback until equal quad
contraction bilaterally
• Closed kinetic chain squat/leg press 0 to 60 degrees, gradual
progressive resistance
• Balance board bilateral in multiple planes
• Single-leg balance eyes open/closed, variable surfaces
• Sport Cord or treadmill walking forward and backward
• Standing SLRs, each LE and with resistance 
Manual Therapy
• Continue patellar mobilizations as indicated.
• Initiate scar mobilizations as needed.
• Manual extension or flexion ROM as needed 
Goals
• Full AROM, equal to nonsurgical knee
• Normal gait without assistive device
• Independent activities of daily living (downstairs may still be
difficult)
Criteria for Progression to Phase IV
• Equal bilateral knee AROM
• Normal gait without assistive device
• Understanding of precautions regarding state of graft
• Single-leg standing without assistance 
Phase IV (Weeks 4–8)
Precautions
• State of graft at its weakest during this postoperative period.
No impact activities such as running, jumping, pivoting, or cutting, and
no deep squatting (limits remain 0–60 degrees)
• Pay attention to scar mobility; use manual soft tissue mobilizations as
indicated 
Exercises
• Stationary bike: increase resistance and some light intervals
• Squats/leg press: bilateral to unilateral (0–60 degrees) with progressive
resistance
• Lunges (0–60 degrees)
• Stairs: concentric and eccentric (not to exceed 60 degrees of knee
flexion)
• Calf raises: bilateral to unilateral
• Contrakicks (steamboats) (Fig. 47.8): progress from anteroposterior to
side to side, then circles/random
• Rotational stability exercises: static lunge with lateral pulley
repetitions
• Sport Cord resisted walking all four directions
• Treadmill walking all four directions
• Balance board: multiple planes, bilateral stance
• Ball toss to mini-tramp or wall in single-leg stance
• Single-leg deadlifts (Fig. 47.9): wait for 6–8 weeks if hamstring
autograft
• Core strengthening: supine and prone bridging, standing with
pulleys
• Gait activities: cone obstacle courses at walking speeds in multiple
planes 
Criteria for Progression to Phase V
• Bilateral squat to 60 degrees (no more) with equal weight distribution
• Quiet knee (minimal pain and effusion and no giving way)
• Quad girth within 1 to 2 cm of nonsurgical thigh at 10 cm proximal to
superior patella
• Single-leg balance on involved limb >30 seconds with minimal
Movement
Phase V (Weeks 8–12)
Things to Watch Out for
• Patellar tendinitis 
Exercises
• Squats/leg press: bilateral to unilateral (0–60 degrees) progressive
resistance
• Lunges (0–60 degrees)
• Calf raises: bilateral to unilateral
• Advance hamstring strengthening
• Core strengthening
• Combine strength and balance (e.g., ball toss to trampoline on
balance board, mini-squat on balance board, Sport Cord cone
weaves, contrakicks)
• Advanced balance exercises (e.g., single-leg stance while reaching
to cones on floor with hands or opposite foot, single-leg stance
while pulling band laterally)
• Lap swimming generally fine with exception of breaststroke; caution
with deep squat push-off and no use of fins yet
• Stationary bike intervals 
Goals
• Equal quad girth (average gain of 1 cm per month after first
month with good strength program)
• Single-leg squat to 60 degrees with good form 
Criteria for Progression to Phase VI
• Nearly equal quad girth (within 1 cm)
• Single-leg squat to 60 degrees
• Single-leg balance up to 60 seconds
• Minimal, if any, edema with activity
Phase VI (Weeks 12–16)
Things to Watch Out for/Correct
• Landing during exercises at low knee flexion angles (too close to
extension)
• Landing during exercises with genu varum/valgum (watch for
dynamic valgus of knee and correct)
• Landing and jumping with uninvolved limb dominating effort 
Exercises
• Elliptical trainer: forward and backward
• Perturbation training*: balance board, roller board, roller board
with platform
• Shuttle jumping: bilateral to alternating to unilateral, emphasis
on landing form
• Mini-tramp bouncing: bilateral to alternating to unilateral, emphasis on
landing form
• Jogging in place with Sport Cord: pulling from variable directions
• Movement speed increases for all exercises
• Slide board exercises
• Aqua jogging 
Criteria to Progress to Phase VII
• Single-leg squat, 20 repetitions to 60 degrees of knee flexion
• Single-leg stance at least 60 seconds
• Single-leg calf raise 30 repetitions
• Good landing form with bilateral vertical and horizontal jumping
• Hop testing†: 80% of uninvolved limb performed prior to running 
Phase VII (Weeks 16–24)
Exercises
• Progressive running program‡
• Hop testing and training†
• Vertical, horizontal jumping from double to single leg
• Progressive plyometrics (e.g., box jumps, bounding, standing
jumps, jumps in place, depth jumps, squat jumps, scissor jumps,
jumping over barriers, skipping)
• Speed and agility drills (e.g., T-test, line drills) (make these similar in
movement to specific sport of athlete)
• Cutting drills begin week 20
• Progress to sport-specific drills week 20 
For Revision ACL Reconstructions
Per specific physician recommendation, follow typically similar protocol
until 12 weeks, then extend weeks 12 to 16 through to 5- to 6-month
timeline, when patients can then begin running and progress to
functional sports activities. See Fig. 47.8 for an illustration of abduction
contrakicks/steamboats (flexion, extension, and adduction contrakicks
can be performed by rotating patient 90 degrees at a time).