ACL Rehab Protocol

Written By: Chloe Wilson, BSc(Hons) Physiotherapy
Reviewed by: KPE Medical Review Board

An ACL rehab protocol is designed to work through a graded return to exercise and activities to ensure that you make a full recovery after ACL surgery. 

ACL rehab is a slow process and it can take up to a year to return fully to sports but it is really important not to rush things. 

When an ACL rehab protocol is followed, the success rate of surgery is excellent with approximately 90% of patients returning to their pre-injury activity levels. Most of the problems associated with ACL reconstruction surgery comes either from a poorly designed rehab program, or failure to comply with the program.

ACL reconstruction surgery is advised for people who have torn their ACL and are either:

• Having problems with recurrent instability
• Wanting to return to pivoting type sports e.g. football, skiing

You can find out more about the indications for surgery in the ACL surgery overview.  During surgery, the ACL is replaced with a new graft, fashioned either from the patella tendon, hamstring tendon or donor tissue. ACL surgery is usually done arthroscopically (keyhole surgery).

An ACL rehab protocol is split into 5 phases of recovery, each targeting different areas of rehab and recovery.

• Aim: strengthen the quads and regain knee extension
  
  
• Starting Position: Lying flat or sitting up with your leg stretched out, heel resting on a prop such as rolled up towel or phone book so it is slightly raised and the knee is free (nothing underneath it)
  
  
• Action: Push the knee gently downwards by tightening the muscles on the front of the thigh until you feel a stretch in the back of your knee.  Hold for 10 seconds and repeat 10 times, 3-4 times daily

• Aim: Loosen the knee and regain flexion without requiring much strength
  
  
• Starting Position: Lying flat or sitting up with your leg stretched out
  
  
• Action: Slide your heel towards your bottom, bending your hip and knee.  Keep your foot in contact with the bed/floor throughout.  Hold for 3-5 seconds and then straighten the leg back out.  Repeat 10-20 times, 3-4 times daily
  
  
• Top Tip: Place a plastic carrier bag or smooth tray underneath your heel so there is less friction, making it easier to slide the heel

• Aim: Regain knee flexion
  
  
• Starting Position: Lie on your back with your legs up on a wall or closed door
  
  
• Action: Slowly slide your foot down the wall as far as possible, bending the knee.  Hold for 3-5 seconds.  Then push the foot gently into the wall and slide the foot back up until the knee is straight.  Repeat 10-20 times, 3-4 times daily
  
  
• Progression: You can progress this exercise by hooking your other foot over the top of your affected leg and gently pushing down, to further increase flexion
  
  
• Top Tip: You can reduce the friction by placing a small towel underneath your heel (as shown in the picture)

• Aim: Increase quads strength and control.  Doing squats against the wall instead of free squats helps ensure better control and makes it slightly easier.  You can progress to doing them away from the wall
  
  
• Starting Position: Stand leaning against a wall, feet apart and a few inches away from the, toes pointing forwards
  
  
• Action: Slowly slide down the wall allowing the knees to bend.  Check with your physio how far to go, (usually around 45 degrees knee flexion initially).  Hold for 5 seconds and then slide back up straight.  Repeat 10-20 times, 3-4 times daily
  
  
• Top Tips: a. It can help to place a soft ball (football sized) in between your knees and gently squash it slightly as you do this exercise as it helps target the kneecap muscles
  b. Make sure your kneecap stays in line with your second toe i.e. does not move inwards as you squat

• Aim: Strengthen the quads, hamstrings, glutes and core
  
  
• Starting Position: Lie on your back with your knees bent, feet flat on the floor
  
  
• Action: Clench your glutes and slowly lift your hips up off the floor until you are resting on your shoulder blades (there should be a straight diagonal line from your knees to your shoulders).  Hold for 5 seconds and slowly lower.  Repeat 10-20 times, 3-4 times daily
  
  
• Top Tips: Make sure you don’t arch your back
  
  
• Progression: Perform a bridge and then straighten one leg out, without dropping your hips.  Hold for 5-10 seconds and then lower.  Repeat on the other side.

• Aim: Improve knee flexion and hamstring function
  
  
• Starting Position: Lie on your tummy, legs stretched out.  Hook the unaffected foot underneath the operated leg
  
  
• Action: Leading with the unaffected leg, bring your feet towards your bottom, bending the knees, keeping your hip and knee in contact with the floor/bed.  Hold for 10 seconds and slowly lower the legs down.  Repeat 10-20 times, 3-4x daily
  
  
• Top Tips: a. Clench your glutes slightly as you do this to stop your back arching
  b. By getting the unaffected leg to lead the movement, you avoid putting too much strain through the new graft
  c. In phase 3 of rehab you can add a weight with this exercise

Retraining balance and proprioception is really important in this phase of an ACL rehab protocol. The simplest way to start is to practice standing on one leg. Sounds simple, but see how long you can balance for, comparing your operated and non-operated side. It can help to keep a record to see how you are progressing. 

Once you can stand on one leg happily for around thirty seconds, try some of the following variations, whilst still standing on one leg:

• Reach forwards and sideways with your arms
• Throw and catch a ball (either to someone or against the wall)
• Close your eyes: much harder than it sounds!

• Aim: Improve strength, stability and control
  
  
• Starting Position: Stand on the operated leg, holding something for balance e.g. table or wall
  
  
• Action: Bend your knee and lower your body towards the floor.  Ensure that your knee stays in line with your second toe and does not move in front of your foot (you should be able to see your toes throughout).  Hold for 5-10 seconds and then return to standing position.  Repeat 10-20 times, 2-3 times daily

You can progress your one leg standing exercises in the following ways:

• Standing on a wobble board/balance board: there is no end to the activities you can do on these e.g. throwing and catching, one leg standing, small squats etc
• Sport related activities balancing on operated leg: e.g. soccer drills and racquet or stick manoeuvers
• Cone taps: arrange cones in a circle around you and reach to touch them so moving in all directions

• Skipping: start with small strides at low velocity.  You can go forwards, backwards and sideways
• Side steps
• Carioca steps: crossing one leg in front, one behind
• Tip toe and heel walking: walking on your tip toes or heels
• Heel to toe walking in different directions: backwards, forwards, circles, figures of 8 etc.  You can lay a rope out on the floor in different patterns and walk on it so changing direction
• Lunge exercises: forwards, backwards and sideways as guided by your physical therapist

1. Jumping activities: practising both push offs and landings.  Examples of activities you might do include squat jumps, box jumps, rotational jumps doing all of these in different directions
2. Stop and Go activities: Jogging a few paces then stopping, then setting off again (thus practising quick acceleration and deceleration activities).  Again this should be multi-directional.
3. Hopping: working on height, distance and speed
4. Cutting and pivoting drills: starting at low speed and ensuring equal weight on each leg (not favouring the operated leg)