ACL Reconstruction - Physiotherapy Protocol at 1 Month Post-Op

Before Advancing: Criteria to Enter This Phase

• Full passive knee extension (symmetrical to contralateral side)
• Knee flexion AROM > 90-120°
• Symmetrical gait pattern, FWB without crutches, no limp
• Effusion ≤ 2+ on stroke test
• Good neuromuscular control during closed-chain exercises (CKC) without reactive effusion

Phase Goals at 4-6 Weeks

Detailed Exercise Program (Weeks 4-6)

1. Range of Motion

• Passive extension: Prone hangs, pillow under heel - maintain full (0°) extension
• Knee flexion: Self-ROM exercises targeting 0-135° (wall slides, sitting slides, heel slides)
• Stool scoots / stool crawl: active-assisted flexion
• Gastroc/soleus and hamstring stretching
• Patellar mobilizations: Superior, inferior, medial, lateral glides
• Cycling (stationary bike): Begin low resistance when ROM is adequate (>110°); gradually increase to 30 minutes

2. Strengthening

• Mini-squats: 0-30° knee flexion (tibia vertical, emphasize hip hinge + glute activation); progress to 0-45° at week 8
• Wall sits (single-leg): Maximal effort holds to fatigue
• Leg press: Bilateral first, progress to single-leg; emphasize eccentric control
• Lateral step-ups (4-inch step): When able to perform single-leg quarter squat
• Forward and lateral step-down exercises
• Lateral and forward lunges
• Multi-hip machine (4 directions)
• Heel raise / toe raise

• SLR in 4 planes with progressive ankle weights (when able to perform SLR with 10 lb)
• Hamstring curls (prone/standing) with weights - progress with resistance
• Knee extension isometrics: 90-30° range, maximal effort without pain, 30-second holds
• Knee extension isotonics (90-60°): Submaximal, with anti-shear pad if available. NOTE: Avoid open-chain knee extension 0-60° due to excessive anterior tibial shear on graft until week 6+
• Straight-leg deadlifts

Graft-specific note: For hamstring autograft (hamstring tendon used as graft), delay isolated hamstring curl exercises until week 8 to protect the graft harvest site.

3. Neuromuscular / Proprioception Training

• BAPS (Biomechanical Ankle Platform System): Progress from double-leg to single-leg
• Single-leg balance: Progress from firm to unstable surface (foam roller, wobble board)
• Cup walking / hesitation walk for dynamic proprioception
• Steamboats in 4 planes (single-leg dynamic perturbations)
• Plyotoss: Single-leg stance with ball toss
• Roller board / rocker board: Bilateral to unilateral progression (anterior-posterior then medial-lateral perturbations)

4. Cardiovascular / Aerobic Conditioning

• Stationary bike: Primary modality - start with low resistance, increase duration to 30 minutes
• Treadmill walking (forward and backward): Emphasize normal gait mechanics
• Stairmaster (forward and backward): Begin at 4-6 weeks
• Elliptical: Can begin at ~6 weeks if ROM and strength are adequate
• Swimming (pool walking, kicks with a board) is generally safe from 4-6 weeks post-op (once wound is healed)

5. Edema / Swelling Management

• Cryotherapy (ice): 15-20 minutes after each session
• Compression: Compression bandage or sleeve
• Elevation: Rest with leg elevated after exercise
• Electrical stimulation / NMES: As needed for quadriceps re-education if poor quad activation

6. Bracing

• Post-op brace: Typically discontinued at week 4 (surgeon-dependent)
• Functional brace: May be fitted and used during exercise as needed

What NOT to Do at 4-6 Weeks

• Avoid full open-chain knee extension (60-0°) - high anterior tibial shear stress risks graft failure
• No running yet (typically cleared at 8-10 weeks minimum, criteria-based)
• No cutting, pivoting, or jumping maneuvers
• No deep squats beyond 90° with heavy load at this stage
• Do not ignore effusion - reactive swelling after exercise is a sign to reduce load; if >2+ effusion at 4 weeks, contact surgeon

Upcoming Milestones

Current Evidence Notes

• A 2024 systematic review (PMID 38887689) found that CKC and OKC exercises can both be used safely post-ACL reconstruction; combining them produces better functional outcomes than either alone.
• A 2025 systematic review in Am J Sports Med (PMID 38622858) found that criterion-based RTP protocols (not purely time-based) reduce re-injury risk in athletes.
• Blood flow restriction (BFR) training is supported by current evidence (Campbell's 2026) as an adjunct to attenuate quad atrophy at low loads, particularly valuable in the early-intermediate phase.