 
Massachusetts General Brigham Sports Medicine 
Rehabilitation Protocol for Anterior Cruciate Ligament (ACL) 
Reconstruction 
This protocol is intended to guide clinicians through the post-operative course for ACL Reconstruction. This protocol is 
time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs 
of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes 
contained within this guideline may vary based on surgeon’s preference, additional procedures performed, and/or 
complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with 
the referring surgeon. 
 
The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic 
interventions should be included and modified based on the progress of the patient and under the discretion of the 
clinician.  
 
Considerations for allograft and hamstring autograft  
Early weight bearing and early rehabilitation intervention vary for allograft and hamstring autograft. Please reference 
specific instructions below. Expectations are the early return to sport phase will be delayed.  
 
Considerations with concomitant injuries 
Be sure to follow the more conservative protocol with regards to range of motion, weight bearing, and rehab 
progression when there are concomitant injuries (i.e. meniscus repair). 
 
Post-operative considerations 
If you develop a fever, intense calf pain, excessive drainage from the incision, uncontrolled pain or any other symptoms 
you have concerns about you should call your doctor. 
 
PHASE I: IMMEDIATE POST-OP (0-2 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Protect graft 
• Reduce swelling, minimize pain 
• Restore patellar mobility 
• Restore full extension, gradually improve flexion 
• Minimize arthrogenic muscle inhibition, re-establish quad control, regain full active extension 
• Patient education 
- Keep your knee straight and elevated when sitting or laying down. Do not rest with a 
towel placed under the knee 
- Do not actively kick your knee out straight; support your surgical side when performing 
transfers (i.e. sitting to laying down) 
- Do not pivot on your surgical side 
Weight Bearing 
Walking 
• Initially brace locked, crutches (per MD recommendation) 
• May start walking without crutches as long as there is no increased pain, effusion, and proper 
gait 
- Allograft and hamstring autograft continue partial weight bearing with crutches for 6 
weeks unless otherwise instructed by MD  
• May unlock brace once able to perform straight leg raise without lag  
• May discontinue use of brace after 6 wks per MD and once adequate quad control is achieved 
• When climbing stairs, lead  with the non-surgical side when going up the stairs, and lead with 
the crutches and surgical side when going down the stairs 
 
 
Interventions 
Swelling Management 
• Ice, compression, elevation (check with MD re: cold therapy) 
• Retrograde massage  
• Ankle pumps 
 
Range of motion/Mobility 
• Patellar mobilizations: superior/inferior and medial/lateral 
- **Patellar mobilizations are heavily emphasized in the early post-operative phase 
following patella tendon autograft** 
• Seated assisted knee flexion extension and heel slides with towel 
• Low intensity, long duration extension stretches: prone hang, heel prop 
• Standing gastroc stretch and soleus stretch 
• Supine active hamstring stretch and supine passive hamstring stretch 
 
Strengthening 
• Calf raises 
• Quad sets 
• NMES high intensity (2500 Hz, 75 bursts) supine knee extended 10 sec/50 sec, 10 contractions, 
2x/wk during sessions—use of clinical stimulator during session, consider home units 
distributed immediate post op 
• Straight leg raise 
- **Do not perform straight leg raise if you have a knee extension lag 
• Hip abduction  
• Multi-angle isometrics 90 and 60 deg knee extension 
Criteria to 
Progress 
• Knee extension ROM 0 deg 
• Quad contraction with superior patella glide and full active extension 
• Able to perform straight leg raise without lag 
 
PHASE II: INTERMEDIATE POST-OP (3-5 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Continue to protect graft 
• Maintain full extension, restore full flexion (contra lateral side) 
• Normalize gait 
Additional 
Interventions 
*Continue with 
Phase I 
interventions 
Range of motion/Mobility 
• Stationary bicycle 
• Gentle stretching all muscle groups: prone quad stretch, standing quad stretch, kneeling hip 
flexor stretch 
 
Strengthening 
• Standing hamstring curls 
• Step ups and step ups with march  
• Partial squat exercise 
• Ball squats, wall slides, mini squats from 0-60 deg 
• Lumbopelvic strengthening: bridge & unilateral bridge, sidelying hip external rotation-
clamshell, bridges on physioball, bridge on physioball with roll-in, bridge on physioball 
alternating, hip hike 
 
Balance/proprioception 
• Single leg standing balance (knee slightly flexed) static progressed to dynamic and level 
progressed to unsteady surface 
• Lateral step-overs 
• Joint position re-training 
Criteria to 
Progress 
• No swelling (Modified Stroke Test) 
• Flexion ROM within 10 deg contra lateral side 
• Extension ROM equal to contra lateral side 
 
 
 
PHASE III: LATE POST-OP (6-8 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Continue to protect graft site 
• Maintain full ROM 
• Safely progress strengthening  
• Promote proper movement patterns 
• Avoid post exercise pain/swelling 
• Avoid activities that produce pain at graft donor site 
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions  
Range of motion/Mobility 
• Rotational tibial mobilizations if limited ROM 
 
Cardio 
• 8 weeks: Elliptical, stair climber, flutter kick swimming, pool jogging 
 
Strengthening 
• Gym equipment: leg press machine, seated hamstring curl machine and hamstring curl machine, 
hip abductor and adductor machine, hip extension machine, roman chair, seated calf machine 
- Hamstring autograft can begin resisted hamstring strengthening at 12 weeks 
• Progress intensity (strength) and duration (endurance) of exercises 
**The following exercises to focus on proper control with emphasis on good proximal stability 
• Squat to chair 
• Lateral lunges 
• Romanian deadlift 
• Single leg progression: partial weight bearing single leg press, slide board lunges: retro and 
lateral, step ups and step ups with march, lateral step-ups, step downs, single leg squats, single 
leg wall slides 
• Knee Exercises for additional exercises and descriptions 
• Seated Leg Extension (avoid anterior knee pain):  90-45 degrees with resistance 
 
Balance/proprioception 
• Progress single limb balance including perturbation training 
Criteria to 
Progress 
• No effusion/swelling/pain after exercise 
• Normal gait 
• ROM equal to contra lateral side 
• Symmetrical Joint position sense (<5-degree margin of error) 
 
PHASE IV: TRANSITIONAL (9-12 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Maintain full ROM 
• Safely progress strengthening  
• Promote proper movement patterns 
• Avoid post exercise pain/swelling 
• Avoid activities that produce pain at graft donor site  
Additional 
Interventions 
*Continue with 
Phase II-III 
interventions 
• Begin sub-max sport specific training in the sagittal plane 
• Bilateral PWB plyometrics progressed to FWB plyometrics 
 
Criteria to 
Progress 
• No episodes of instability 
• Maintain quad strength 
• 10 repetitions single leg squat proper form through at least 60 deg knee flexion 
• Drop vertical jump with good control  
• KOOS-sports questionnaire >70% 
• Functional Assessment 
- Quadriceps index >80%; HHD or isokinetic testing 60d/s 
- Hamstrings ≥80%; HHD or isokinetic testing 60 d/s 
- Glut med, glut max index ≥80%  HHD 
 
 
 
PHASE V: EARLY RETURN TO SPORT (3-5 MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
• Safely progress strengthening  
• Safely initiate sport specific training program 
• Promote proper movement patterns 
• Avoid post exercise pain/swelling 
• Avoid activities that produce pain at graft donor site 
Additional 
Interventions 
*Continue with 
Phase II-IV 
interventions 
• Interval running program 
- Return to Running Program 
• Progress to plyometric and agility program (with functional brace if prescribed) 
- Agility and Plyometric Program 
Criteria to 
Progress 
• Clearance from MD and ALL milestone criteria below have been met 
• Completion jog/run program without pain/effusion / swelling 
• Functional Assessment 
- Quad/HS/glut index ≥90%; HHD mean or isokinetic testing @ 60d/s 
- Hamstring/Quad ratio ≥66% 
- Hop Testing ≥90% compared to contra lateral side, demonstrating good landing 
mechanics 
 
PHASE VI: UNRESTRICTED RETURN TO SPORT (6+ MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
• Continue strengthening and proprioceptive exercises 
• Symmetrical performance with sport specific drills 
• Safely progress to full sport 
Additional 
Interventions 
*Continue with 
Phase II-V 
interventions 
• Multi-plane sport specific plyometrics program 
• Multi-plane sport specific agility program 
• Include hard cutting and pivoting depending on the individuals’ goals (~7 mo) 
• Non-contact practice→ Full practice→ Full play (~9 mo) 
 
Criteria to 
Progress 
• Functional Assessment 
- Quad/HS/glut index ≥95%; HHD mean or isokinetic testing @ 60d/s 
- Hamstring/Quad ratio ≥66% 
- Hop Testing ≥95% compared to contra lateral side, demonstrating good landing 
mechanics 
• KOOS-sports questionnaire >90% 
• International Knee Committee Subjective Knee Evaluation >93 
• ACL-RSI 
Revised 11/2021 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
 
References: 
 
1. 
Adams D, Logerstedt D, et al. Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation Progression. JOSPT 
2012 42(7): 601-614. 
 
2. 
Di Stasi S, Myer GD, Hewett TE. Neuromuscular Training to Target Deficits Associated with Second Anterior Cruciate Ligament Injury. JOSPT 2013 43 
(11): 777-792. 
 
 
3. 
Glazer DD. Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of Athletic 
Training. 2009;44(2):185-189. 
 
4. 
Haitz K, Shultz R, et al. Test-restest and interrater reliability of the functional lower extremity evaluation. JOSPT. 2014. 44(12): 947-954. 
 
5. 
Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am 
J Sports Med. 2001;29:600-613. 
 
6. 
Logerstedt DS, Scalzitti D, et al. Knee stability and movement coordination impairments: knee ligament sprain revision 2017. JOSPT. 2017. 47(11): 
A2-A47. 
 
 
 
7. 
Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior 
Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003-1010. 
8. 
Noehren B, Snyder-Mackler L. Who’s afraid of the big bad wolf? Open-chain exercises after anterior cruciate ligament reconstruction. JOSPT. 2020. 
50(9): 473-475. 
9. 
Wright RW, Haas AK, et al. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines. Sports Health 2015 7(3): 239-243. 
 
10. Wilk KE, Macrina LC, et al. Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries. JOSPT 2012 42(3): 153-171. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Return to Running Program 
 
This program is designed as a guide for clinicians and patients through a progressive return-to-run program. Patients 
should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or 
meniscus repair). Specific recommendations should be based on the needs of the individual and should consider clinical 
decision making. If you have questions, contact the referring physician.  
 
PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Day 
1 
2 
3 
4 
5 
6 
7 
Week 1 
W5/J1x5 
 
W5/J1x5 
 
W4/J2x5 
 
W4/J2x5 
Week 2 
 
W3/J3x5 
 
W3/J3x5 
 
W2/J4x5 
 
Week 3 
W2/J4x5 
 
W1/J5x5 
 
W1/J5x5 
 
Return 
to Run  
Key: W=walk, J=jog 
**Only progress if there is no pain or swelling during or after the run 
 
PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Week 
Sunday 
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
1 
20 min 
 
20 min 
 
20 min 
 
25 min 
2 
 
25 min 
 
25 min 
 
30 min 
 
3 
30 min 
 
30 min 
 
35 min 
 
35 min 
4 
 
35 min 
 
40 min 
 
40 min 
 
5 
40 min 
 
45 min 
 
45 min 
 
45 min 
6 
 
50 min 
 
50 min 
 
50 min 
 
7 
55 min 
 
55 min 
 
55 min 
 
60 min 
8 
 
60 min 
 
60 min 
 
 
 
Recommendations 
• Runs should occur on softer surfaces during Phase I 
• Non-impact activity on off days 
• Goal is to increase mileage and then increase pace; avoid increasing two variables at once 
• 10% rule:  no more than 10% increase in mileage per week 
 
 
 
 
 
Agility and Plyometric Program 
 
This program is designed as a guide for clinicians and patients through a progressive series of agility and plyometric 
exercises to promote successful return to sport and reduce injury risk. Patients should demonstrate > 80% on the 
Functional Assessment prior to initiating this program. Specific intervention should be based on the needs of the 
individual and should consider clinical decision making. If you have questions, contact the referring physician.  
 
PHASE I: ANTERIOR PROGRESSION 
Rehabilitation 
Goals 
• Safely recondition the knee 
• Provide a logical sequence of progressive drills for pre-sports conditioning 
Agility 
• Forward run 
• Backward run 
• Forward lean in to a run 
• Forward run with 3-step deceleration 
• Figure 8 run 
• Circle run 
• Ladder  
Plyometrics 
• Shuttle press: Double leg
alternating leg
single leg jumps 
• Double leg:  
- Jumps on to a box
 jump off of a box
 jumps on/off box 
- Forward jumps, forward jump to broad jump 
- Tuck jumps 
- Backward/forward hops over line/cone 
• Single leg (these exercises are challenging and should be considered for more advanced 
athletes):  
- Progressive single leg jump tasks 
- Bounding run 
- Scissor jumps 
- Backward/forward hops over line/cone 
Criteria to 
Progress 
• No increase in pain or swelling 
• Pain-free during loading activities 
• Demonstrates proper movement patterns 
 
PHASE II: LATERAL PROGRESSION 
Rehabilitation 
Goals 
• Safely recondition the knee 
• Provide a logical sequence of progressive drills for the Level 1 sport athlete 
Agility 
*Continue with 
Phase I 
interventions 
 
• Side shuffle 
• Carioca 
• Crossover steps 
• Shuttle run 
• Zig-zag run 
• Ladder 
Plyometrics 
*Continue with 
Phase I 
interventions 
• Double leg:  
- Lateral jumps over line/cone 
- Lateral tuck jumps over cone 
• Single leg (these exercises are challenging and should be considered for more advanced 
athletes):  
- Lateral jumps over line/cone 
- Lateral jumps with sport cord 
Criteria to 
Progress 
• No increase in pain or swelling 
• Pain-free during loading activities 
• Demonstrates proper movement patterns 
 
 
 
 
 
 
PHASE III: MULTI-PLANAR PROGRESSION 
Rehabilitation 
Goals 
• Challenge the Level 1 sport athlete in preparation for final clearance for return to sport 
Agility  
*Continue with 
Phase I-II 
interventions 
• Box drill 
• Star drill 
• Side shuffle with hurdles 
Plyometrics 
*Continue with 
Phase I-II 
interventions 
• Box jumps with quick change of direction 
• 90 and 180 degree jumps  
Criteria to 
Progress 
• Clearance from MD 
• Functional Assessment 
- Quad/HS/glut index ≥90% contra lateral side (isokinetic testing if available) 
- Hamstring/Quad ratio ≥70% 
- Hop Testing ≥90% contralateral side 
• KOOS-sports questionnaire >90% 
• International Knee Committee Subjective Knee Evaluation >93 
• Psych Readiness to Return to Sport (PRRS) 
 
 
 
 
 
 
 
