ACL CLINICAL PRACTICE GUIDELINE

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine Physical Therapy at 614-293-2385 if questions arise.

Summary of Recommendations
Precautions 1. No testing of repaired or reconstructed ligaments (Lachman, Anterior/Posterior Drawer,
Varus/Valgus Stress) prior to 12 WEEKS
2. No isotonic resisted hamstring exercises for 8 weeks with hamstring autograft
3. No loaded open kinetic chain knee extension beyond 45 degrees for 8 WEEKS
4. Meniscus Repair:
a. No weight-bearing (WB) therapeutic exercise >90º x 8 WEEKS
b. PWB x4 WEEKS
c. No forced flexion beyond 90º x4 WEEKS

Outcome Collect at least one of the following at initial evaluation, monthly and discharge. Be consistent
Tools with which outcome tool is collected each time.
1. IKDC
2. KOOS
3. ACL-RSI
4. Tegner
Strength 1. Isometric testing anytime- fixed at 90º
Testing 2. Isokinetic testing no earlier than 12 weeks

Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure

Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar
Assistive glide and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation

Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and
Running 300º/sec
and Jumping 3. Effusion: 1+ or less
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place

Criteria for 1. ROM: full, painfree knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and
Sport 300º/sec
3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance

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Early Post-Operative Phase (Post-ACLR – 4 weeks)
Appointments Post-operative evaluation should be performed 3-5 days following surgery. Follow-up
appointments 1-2x per week, depending on progression towards goals.
Precautions 1. No testing of repaired or reconstructed ligaments (Lachman, Anterior/Posterior Drawer,
Varus/Valgus Stress) prior to 12 WEEKS
2. No loaded open kinetic chain knee extension for 8 WEEKS
3. Meniscus Repair:
a. No weight-bearing (WB) therapeutic exercise >90º x 8 WEEKS
b. PWB x4 WEEKS
c. No forced flexion beyond 90º x4 WEEKS

Pain and ≥ 2+ (using Modified Stroke Test)

Effusion Cryotherapy and compression (ie. Donut, ace wrap, limited WB therapeutic exercise)
ROM Extension: Emphasis on achieving full knee extension immediately following surgery. If full
extension is not achieved by 4 weeks, contact surgeon regarding ROM concerns.
Flexion: No forced flexion past 90º for meniscus repairs. ACLR and meniscectomy are able to
push for symmetrical flexion as appropriate.
Therapeutic • Emphasis on quad activation without gluteal co-contraction
Exercise • Restore patellar mobility
• Symmetrical ROM
• Decrease effusion
• Ambulation with appropriate joint loading and without obvious gait deviation
Suggested • Extension ROM: bag hangs or prone hangs
Interventions • Flexion ROM: heel slides, wall slides, upright bike
• Patellar mobilization: superior, inferior, medial, lateral
• Quad Isometrics; SLR 4-way
• TKE: prone and standing
• LAQ
• Weight shifting, SL balance
• Neuromuscular re-education using electrical stimulation (NMES) at 60º knee flexion
NMES • NMES pads are placed on the proximal and distal quadriceps
Parameters • Patient: Seated with the knee in at least 60º flexion, shank secured with strap and back
support with thigh strap preferred. The ankle pad/belt should be two finger widths superior to
the lateral malleoli
• The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage without
knee joint pain
• 10-20 seconds on/ 50 seconds off x 15 min
Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure
Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation

Criteria to ROM: ≥ 0-120 degrees

Progress to Strength: Quadriceps set with normal superior patellar translation, SLR x 10 seconds without
Middle Phase extensor lag
of Rehab Goals: (These do not limit progression to next phase; however, should be addressed with
interventions)
Effusion: 2+ or less with Modified stroke test
Weight Bearing: Able to tolerate CKC therex program without increased pain and ≥≤ 2+ effusion
Middle Phase of Rehabilitation (4-12 weeks)

Appointments Goal to increase lower extremity strength. 1-2 visits per week with emphasis on patient
compliance with resistance training as part of HEP (2-3 days per week outside of therapy).
Precautions Open Chain knee extension:
• Initiate submaximal leg extension 90-45 degrees
• Initiate active knee ROM 90-0 degrees (modify if painful)
No isolated resisted hamstrings strengthening until 8 weeks
Pain and Cryotherapy/compression as needed for reactive effusion.
Effusion Patellar taping to reduce PF symptoms if present
ROM • Monitor and progress knee ROM, patellar mobility, and LE flexibility
• Begin more aggressive techniques to achieve/maintain full knee extension (i.e. weighted
bag hang) as needed
• Continue bike for ROM and warm up
• If full AROM knee extension is not achieved by 4 weeks, contact surgeon regarding ROM
concerns.

Suggested • Multi-angle knee isometrics from 60-90⁰ for patients unable to tolerate high-intensity NMES
Interventions
• Initiate open chain knee extension exercises
and timelines
o Unweighted full range LAQ
o Protected range with isotonic progression
• Progress WB quadriceps and hamstring exercises with emphasis on proper LE mechanics
(no isolated HS strengthening until 8 weeks)
• Progress gluteal and lumbopelvic strength and stability
• Progress single leg balance
• Endurance: low impact - treadmill walking, stepper, elliptical (6 weeks)
• Initiate PWB plyometrics on shuttle (8-10 weeks, see precautions to begin full WB
plyometrics)
• NMES (see parameters in week 1-4)
Criteria to d/c • <20% quadriceps deficit on isometric or isokinetic testing
NMES OR- If a Biodex machine in not available:
1. 10 SLR without quad lag
2. Normal gait
3. 10 heel taps to to 60 degrees with good quality
4. 10 rep max on LP and similar effort bilaterally
5. Inability to break quad MMT

Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running and 3. Effusion: 1+ or less
Jumping 4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place
Criteria to 1. ROM: Maintain full, pain free AROM including PF mobility
Progress to 2. Effusion: 1+ or less
Late Phase of 3. Strength: Isometric or isokinetic quadriceps and hamstrings strength >/= 80%
Rehab
4. Weight Bearing: Able to tolerate therapeutic exercise program, including jogging
progression, without increased pain or >1+ effusion
5. Neuromuscular Control: Demonstrates proper lower extremity mechanics with all therapeutic
exercises (bilaterally)
6. Outcome Tools: >/=7/10 on #10 IKDC Questionnaire
Late Phase of Rehabilitation (weeks 12-Return to Sport)

Appointments Increased frequency from previous stage to 1-2x per week when appropriate to initiate
plyometric training and return to running program.
Precautions Criteria to initiate hopping
• Full, pain free ROM
• ≤ 1+ effusion
• ≥ 7 /10 on #10 IKDC Questionnaire (Appendix A)
• ≥ 80% isometric strength symmetry (hamstrings and quadriceps) OR 20 heel touches
on 8 inch step with good mechanics

Criteria to initiate jogging (in addition to above criteria)

• Hop downs with appropriate landing mechanics
• Audible rhythmic strike patterns and no gross visual compensation
Pain and Effusion may increase with increased activity, ≤1+ and/or non-reactive effusion for progression of
Effusion plyometrics
ROM Full, symmetrical to contralateral limb, and painfree with overpressure
Therapeutic • Performance of the quadriceps, hamstrings and trunk dynamic stability
Exercise • Muscle power generation and absorption via plyometrics
• Sport- and position-specific activities
• Begin agility exercises between 50-75% effort (utilize visual feedback to improve mechanics
as needed)
• Advance plyometrics: Bilateral to single leg, progress by altering surfaces, adding ball toss,
3D rotations, etc.
Suggested Therapeutic Exercise/Neuromuscular Re-education
Interventions • Squats, leg extension, leg curl, leg press, deadlifts, lunges (multi-direction), crunches,
rotational trunk exercises on static and dynamic surfaces, monster walks, PWB to FWB
jumping
• Single-leg squats on BOSU with manual perturbation to trunk or legs, Single-leg BOSU
balance, single-leg BOSU Romanian deadlift
Agility
• Side shuffling, Carioca, Figure 8, Zig-zags, Resisted jogging (Sports Cord) in straight
planes, backpedaling

Plyometrics
• Single-leg hop downs from increasing height (up to 12” box), Single-leg hop-holds,
Double and single-leg hopping onto unstable surface, Double and single-leg jump-turns,
Repeated tuck jumps
Criteria for 1. ROM: full, pain free knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
Sport 3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance