ACL Bone-Tendon-Bone Rehabilitation Protocol | Print |
Patients who have undergone an ACL Bone-tendon-Bone Reconstruction need to understand the biological healing that is taking place in there knee after surgery. Initially, the repair is usually held by either metal or bioabsorbable screws until the body heals the tissue. During that time period protective exercise needs to be performed in order not to damage the reconstruction. The first week post-operatively is a real rest week. Patients should be at home with their ice and continuous passive motion [CPM] machines.The CPM can be increased to tolerance unless specific instructions were given. If the CPM hurts the range of motion should be lowered to tolerance. If it still hurts, do not use the machine and call the office. The ice machine can usually be on 24/7 as long as there is no discomfort.

Obtaining extension [full straightening] of the knee is your primary goal after surgery. In order to achieve this goal place pillows underneath the heel. This simple position will encourage full straightening of the knee. DO NOT PUT A PILLOW UNDERNEATH THE KNEE even if it feels better. During the first 3-4 weeks, I will have patients wear a knee immobilizer (removable brace) in order to protect the repair. Return to full sport usually will occur at 5-6 months post-operatively.

Until you have full range of motion (FROM) and no swelling do not think that more walking, standing or stair climbing will ultimately enhance the function of your knee. That is a myth. The above activities early on have a potential for overloading your knee and causing more pain and swelling.

Focus on your therapy program which initially will encourage range of motion and strengthening in a controlled, supervised manner. As you progress, I will encourage return to full activity as tolerated.

Stretching should be provided by one-on-one supervision in the therapy center and done on a daily basis at home. The therapist should instruct you on a home program before you attempt to perform these exercises at home.

Strengthening should only be performed in a very slow manner. Initially, one should start with a multi-angle isometric program (tightening the muscles) and progress to a PRE (progressive resistive exercise program i.e. lifting weights). When lifting weights, lift the weight over a 10 second time period and lower the weight over 5 seconds. If pain develops during any part of the range of motion, inform the therapist. The therapist will have 3 options.

1) To lower the weight and continue the exercise through a full range of motion.
2) To avoid the range of motion which is painful
3) To stop the exercise totally.

The exercises should initially be performed for one set and 12-15 repetitions. Patients may progress as tolerated. Ideally, one should perform one set of 6-8 repetitions. Upon the last repetition the patient will have total muscle fatigue but absolutely no pain in the joint i.e. in an open knee extension exercise the patient will attempt to raise his leg but it just won’t go. There is no pain but the muscle is totally fatigued. Exercises should be performed for all muscle groups of both lower extremities.

1. Achieve FROM
2.  No swelling
3.  Obtain full strength
Knee immobilizer worn full time
For the first 2-3 weeks, limit aerobic activity only for warm-up and cool down until full ROM, no swelling and adequate strength is achieved.


  1. Increased knee pain >24 hours
  2. Increased knee swelling that is not reduced with ice and elevation
  3. Increased redness, localized skin temperature and/or drainage or bleeding from surgical site.


Progress weight bearing as tolerated.
Usually full weight bearing @3-4 weeks
Obtain ROM 0-110 degrees @2-3 weeks
FROM @ 5-6 weeks
2-4 weeks
1. Multi-angle isometrics
progress to pre’s
2.  Patellar mobility
3. Aquatic therapy


2) No pain or effusion
3) Satisfactory clinical exam

1) Continual stretching and strengthening exercises
2) Increase functional aerobic activity level specific to the patient’s functional goals i.e. do not aggressively utilize the elliptical if the patient’s goals are to increase their everyday walking
3) Walking program can be initiated after 5-6 weeks if in phase 2
4) Straight running can begin at week 10
5) Cutting can begin at week 14
6) Progress to sport-specific skill training as required @4-6 months
7) Avoid plyometrics that are not sport-specific