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Institute of Advanced Orthopedics, MOSC Hospital and Medical College, Kolenchery, Ernakulam, Kerala

Knee Rehab – ACL reconstruction

Note before starting exercises: If you have undergone any associated procedure like Meniscus repair or HTO (High tibial Osteotomy) or OATS (Osteochondral Autograft Transfer System) please consult you doctor  / Physical therapistbefore embarking on the ACL protocol (You have to compare the protocols of the different procedures and follow the one which is slower in progression for the given time period, or you may damage the associated meniscus or sensitive ligament repair)


Before the operation it is important that you have as near to full pain free movement as possible. Ideally a few weeks before the surgery you should start exercises building up your quadriceps and hamstring strength. This trains the muscles up and makes it easier to get going after the surgery.


Phase1. (0-1 weeks following surgery)

This phase involves regaining a full range of movement (especially full extension).

It is important that these exercises are performed for short periods but regularly (rather than one longer period)

Calf exercises

Move the foot up and down from the ankle to maintain good circulation

Extension exercises

Sit on a firm surface and fully straighten your knee. To help the knee go straighter tighten the front thigh muscles (quadriceps). Pull your toes up towards your face and at the same time push your knee back into the floor. Hold for 10 seconds and repeat. (After 2 weeks of surgery, you should do this knee extension exercise keeping a rolled towel under the back of the heel to get backward movement of the knee joint)

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Knee bends

Slide your heel up and down a firm surface bend- ing and straightening your knee.

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Static hamstrings

With the knee bent to about 30deg from fully straight push the heel into the floor and hold for 10 seconds. 


Knee bends in standing

Standing upright bend your operated knee bringing your heel to your bottom. Lower the foot slowly back into a straight position.

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Phase 2 (1-8weeks following surgery)

This phase is about improving muscle strength and continuing to improve movement back to full.

It is important to perform these exercises regularly and we recommend at least twice a day. The more effort that is put into the rehabilitation the better the recovery and quicker the return to full activities.

Straight leg raise

Lie on your front. Lift the leg straight up in the air and lower. Try and stop the downward fall of the leg by “quickly” contracting your muscles. As you progress you can add weight to your ankle.

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Leg raise in side lying

Lie on your side with your operated leg uppermost. Lift and lower the leg using your outer thigh muscles. Change sides so the operated leg is at the bottom (lowermost). Lift the operated leg up and down us- ing the innermost thigh muscles.

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With your knees bent push your heels into the floor and lift your bottom clear. Pro- gress to just using your operated leg.

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Sit to Stand

Slowly stand up from a chair. As you progress put the un- operated leg forward so more of the work is done by the operated leg.

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One leg balance

Stand on the operated leg with it slightly bent. Try to bal- ance for 30 seconds. As you progress try closing your eyes.

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Hamstring catches

Stand on your un-operated leg. Bring your other heel to your bottom. Then lower your foot, try and stop the downward movement by “quickly” con- tracting your hamstring mus- cles.

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Rope walk

Place a skipping rope along the floor. Walk along it carefully keeping your

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Calf stretch

Feet pointing forward, oper- ated leg behind you with knee straight and heel down. Lean in towards the wall, hold for 20 seconds

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Hamstring stretch

Stand with operated leg straight out in front of you, heel on the floor. Bend forwards from the hips and rest your hands on your bent un-operated leg keeping your back straight. Hold for 20 seconds.

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 Phase 3 (8-16 weeks following surgery)

At this stage phase 2 exercises can be progressed at increased speed, weight and number of repetitions. You can now start building in some exercises to help proprioception (joint stability coordination).

  1. Skipping
  2. Step-ups and downs
  3. Quadriceps stretch
  4. Jogging
  5. Cycling
  6. Swimming
  7. Gym work.
  8. Wobble board
  9. Single leg squats

 Phase 4 (16 weeks following surgery) 

Rehabilitation can now be directed at graded return to sports.

Solo sports such as hitting a tennis ball against a wall, or shooting some baskets helps build up proprioceptive reflexes in a controlled environment.

When jogging you can start to build in some direction changes initially running long curves, but as you progress making the di- rection changes more acute.

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Advanced Knee strengthening

3rd to 6th month after surgery is an important time when you will be building up the thigh muscles. You could reinsure your knee if you do not build your thigh muscles to the adequate strength to support your body weight and the extra load while playing games. (The knee has to withstand more than 3 times the body weight when you do a cutting movement in football).

The important exercises are Quadriceps, Hamstring curls, Leg press and slow progression to Squats and weighted squats

Progression on each of these exercises should be graded, according to your existing strength.

Quadriceps weights can start with 5 or 7.5kg (both legs together) when you extend the knee with the roller on the front of your ankle. Do 20 repetitions; Give a break for 10 seconds, again do two more sets of the same exercise. Gradually increase the weight by 2.5kg every week to reach half your body weight (you can progress faster if your knees feel stronger). (You should under stand that when you get up from a chair or climb a stair, your leg is lifting your trunks weight, which is more than half your body weight and a weak muscle will not be able to do it easily. Avoid squats until you reach half the body weight in quadriceps exercise.)
For hamstring exercise and Leg-press start with similar weight to quadriceps, but aim to reach 1/4th your body weight. Sets of 20 repetitions, 3 times.
When you have reached the desired goal for the first set of exercises, you can start doing squats. Then slowly progress to weighted squats.
Now you are ready to try sports.
(If you are not able to find a way to go the gym, you can do wall slides to strengthen the thigh muscles. But remember that this is not as effective in gradually strengthening the thighs to support your body’s load while doing steps and chairs) 

At 6 months following surgery if the musculature is sufficient sport specific training exercises can be started.We would not recommend return to competitive sport until at least nine months following surgery.

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