Week-wise physiotherapy rehabilitation after ACL reconstruction (32-year-old male)

Before surgery (prehabilitation)

• Aim for full extension, minimal effusion, and good quadriceps activation before surgery.
• A 2025 systematic review found prehabilitation safe and beneficial in the short and long term.

Phase 1: Weeks 0-2 (protection, extension, quadriceps activation)

• Patellar mobilisations, especially superior and inferior glides.
• Quad sets and straight-leg raises (SLR) in all planes, with no extension lag.
• Prone and standing hamstring curls.
• Passive extension: prone hangs, heel on a pillow, heel-elevated extension.
• Knee flexion ROM: heel slides, wall slides, sitting slides, prone towel pulls.
• Edema control: ice, compression pump, elevation.
• Electrical stimulation only if quad set is poor.

• 50-75% partial weight bearing with crutches. Weight bearing to tolerance without crutches is allowed if the brace is locked in extension.
• Sleep in the brace locked in extension.

• Full extension.
• 90° flexion.
• Good quad set.
• Normal gait pattern.

Phase 2: Weeks 2-4

• Brace unlocked for full ROM. Progress flexion to 120° by week 4.
• Weighted SLR and hamstring curls.
• Stationary bike for ROM, then low resistance.
• Full weight bearing. Stop crutches once walking without a limp.
• Balance work on a BAPS board, double-leg then single-leg.
• Light, high-repetition double-leg press.
• Wall sits at about 45° with the tibia vertical.
• 4-inch lateral step-ups once a single-leg quarter squat is possible.
• Treadmill walking, forward and backward, with a normal gait.
• Submaximal knee extension from 90° to 60° with manual resistance.

• 0-120° ROM.
• Full weight bearing with no limp.

Phase 3: Weeks 4-6

• Reach full ROM by week 6.
• Hamstring isotonic and isokinetic progression.
• Quadriceps work from 90° to 40° with an antishear pad. Isokinetics start at week 6, at higher speed for endurance.
• Stair machine, forward and backward.
• Progress closed-chain exercises and add aquatic exercises.

Phase 4: Weeks 8-10

• Progress all of the above.
• Slow running-form drills with a sport cord, forward and backward.
• Isokinetic quadriceps at 60, 90 and 120°/s.
• Begin lunges.
• Slide board from week 10.

Phase 5: Weeks 12-16 (strength)

• Full-range isotonic quadriceps work, moving the antishear pad down.
• Knee extension machine with low weight and high repetitions.
• Slow, controlled lateral sport cord drills.
• Test hamstrings on the dynamometer. Stop isokinetic hamstring work once they reach about 90% of the other leg.
• Progress isokinetic quadriceps to full extension by week 16.

Phase 6: Weeks 16-20 (power and running)

• Test quadriceps strength.
• Start plyometrics (shuttle, mini-trampoline, jump rope) and a jogging programme. The criteria are quadriceps strength of about 65% or more, no effusion, full ROM, and a stable knee.

Phase 7: Weeks 20-36 (agility and sport-specific)

• Agility training.
• Sport drills: carioca, 45° cutting, figure-of-eight.
• Retest quadriceps as needed.

Phase 8: Week 36 onward (return-to-sport testing)

• Knee flexion above 130°.
• Hamstrings above 90% of the other leg.
• Quadriceps above 85% of the other leg.
• Sport-specific agility training completed and testing passed.
• Maintenance exercises 2-3 times per week.

Key principles from the textbook (Campbell's, Box 50.8)

• Full extension early. Use a brace in extension from the start to prevent a flexion contracture, but allow flexion immediately.
• No routine CPM. Continuous passive motion is only for arthrofibrosis.
• Open-chain quad exercises. Resisted open-chain quad work strains the graft, especially in the last degrees of extension. Closed-chain work is preferred, with less patellofemoral pain and better satisfaction.
• Electrical stimulation. It does not prevent atrophy or give a long-term strengthening effect. Use it sparingly for re-education.
• Blood flow restriction. BFR with low-load exercise can limit atrophy.
• Ice. Use it liberally, though benefit for swelling and ROM is not proven.
• Postoperative bracing. Miller's Review notes bracing has not proved beneficial after ACLR except in downhill skiers, and accelerated and non-accelerated programmes give similar outcomes.

Practical adjustments for this patient

• Hamstring graft: delay heavy resisted hamstring work for about 6-12 weeks.
• Patellar tendon graft: watch for anterior knee pain and extensor lag.
• Meniscal repair: limit weight bearing and flexion beyond 90° for about 4-6 weeks.
• Red flags: persistent effusion, loss of extension, or giving way means slowing progression and informing the surgeon.

Recent evidence check

Rehabilitation protocol for frozen shoulder (adhesive capsulitis)

Core principles (textbook)

• Natural history: The condition is self-limited, lasting 12 to 18 months, but about 10% of patients have long-term problems. Earlier care usually means faster recovery. - Campbell's Operative Orthopaedics 15th Ed 2026, Ch. 51
• Initial treatment: It is nonoperative, with emphasis on pain and inflammation control. Avoid abduction early to prevent impingement until the joint becomes suppler. - Campbell's Operative Orthopaedics 15th Ed 2026, Ch. 51
• Options: Supervised physical therapy, NSAIDs, oral or intra-articular steroids, hydrodilation, manipulation, and arthroscopic capsular release. - Campbell's Operative Orthopaedics 15th Ed 2026, Ch. 51
• Conservative care: Heat, gentle stretching, NSAIDs, TENS, and intra-articular injections. Patient education is essential because recovery is slow. - Firestein & Kelley's Textbook of Rheumatology
• Prevention: Avoid over-immobilization after minor shoulder injury, and start early passive ROM after fractures or dislocations. - Rosen's Emergency Medicine

Stages and what physiotherapy targets

Phase 1: Freezing stage (painful, irritable)

• Heat before exercise, and ice if pain flares.
• Pendulum (Codman) exercises, 2 to 3 sets daily.
• Supine passive and active-assisted flexion using the other hand or a stick.
• Passive external rotation with the elbow at the side, within the pain-free range.
• Scapular setting and posture work.
• Neck and thoracic mobility.
• Submaximal isometrics to maintain cuff activation.
• Keep stretching gentle. Aggressive stretching in the irritable stage worsens pain and can prolong the course.

• TENS.
• Intra-articular corticosteroid injection, which can allow earlier exercise. A 2026 meta-analysis of RCTs compared steroid injection plus physical therapy with physical therapy alone.
• Short-course NSAIDs.
• Sleep positioning with a pillow supporting the arm.

Phase 2: Frozen stage (stiffness dominant)

• Sustained capsular stretches held 20 to 30 seconds, done at the point of tension or mild discomfort. The aim is to feel stretch without lingering pain.
• Passive and active-assisted stretches in four directions:
  • flexion with a table slide or wall walk
  • external rotation with a stick or door frame
  • cross-body adduction for the posterior capsule
  • internal rotation behind the back with a towel
• Therapist-led joint mobilisation (glenohumeral glides, graded I to IV). A 2024 meta-analysis of end-range interventions examined this approach.
• Scapular stabilisation and posterior cuff activation to prevent shrugging compensation.
• Home programme 3 to 5 times daily, with short sessions.

Phase 3: Thawing stage (recovery)

• Continue stretching to end range, including overhead reach.
• Progressive strengthening with rotator cuff and deltoid work, such as bands in external and internal rotation.
• Scapulothoracic strengthening: rows, serratus anterior, lower trapezius.
• Closed-chain and weight-bearing drills, then functional and task-specific training.
• Wean supervised therapy once motion plateaus. Keep the home programme going.

Post-manipulation or post-capsular release

• Start therapy the same day or the next day.
• Emphasise early active and passive motion, with a brief painkiller window for each session.
• Use ice and analgesia to keep pain controlled.
• Supervised therapy is typically daily or near-daily for the first 1 to 2 weeks (my addition).

Special points for this condition

• Diabetic patients: They carry about 5 times the risk, have bilateral involvement in about 50%, and are slower to recover. Check glycaemic control. - Campbell's Operative Orthopaedics 15th Ed 2026, Box 51.6
• Contralateral shoulder: 20 to 30% of patients develop adhesive capsulitis in the other shoulder.
• Workup: If there was no trauma, screen for thyroid disease and diabetes. Rule out apical lung tumour, cervical radiculopathy, and other causes of referred pain. - Firestein & Kelley's Textbook of Rheumatology
• Outcome expectations: Many patients underestimate the motion they have lost. Objective ROM may not return fully to normal even when function is good.

Progress markers and red flags

• Move to the next phase when night pain settles and stretching no longer causes pain lasting more than about 1 to 2 hours (my addition).
• Refer back to the orthopaedic surgeon if ROM has not improved after 3 to 6 months of well-supervised therapy, or if pain is progressive or severe at rest.
• Re-evaluate for another diagnosis if there are atypical findings, such as weight loss, constant pain unrelated to movement, or abnormal radiograph findings.

Recent evidence note