 
 
Rehabilitation Protocol for Non-Operative Management of ACL 
Injuries 
  
This protocol is intended to guide clinicians through the non-operative course for ACL injuries. This protocol is time 
based 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 physician’s preference, concomitant injuries, and/or complications. If a clinician requires 
assistance in the progression of a patient, they should consult with the referring provider. 
  
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.  
  
PHASE I: IMMEDIATE POST-INJURY ( 0-2 WEEKS) 
Rehabilitation 
Goals 
• Reduce swelling, minimize pain 
• 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 
Weight Bearing 
Walking 
• Initially brace locked, crutches 
• May start walking without crutches as long as there is no increased pain 
- 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, make sure you are leading with the non-surgical side when going up the stairs, 
make sure you are leading with the crutches and surgical side when going down the stairs 
Precautions 
• Activities that result in continued locking of the knee 
• Activities that result in continued episodes of giving way 
• Continued/worsening of pain and/or edema with progressed physical therapy 
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 
• Hip abduction  
Multi-angle isometrics 90 and 60 deg knee extension 
 
Criteria to 
Progress 
• Full knee ROM 
• Quad contraction with superior patella glide and full active extension 
• Able to perform straight leg raise without lag 
• Able to perform SL balance on affected limb > 30 sec 
• Edema and pain well managed 
 
PHASE II: INTERMEDIATE (3-5 WEEKS) 
Rehabilitation 
Goals 
• Maintain ROM and flexibility 
• Restore muscle strength 
• Increase proprioception and neuromuscular responses 
• Restore normal gait with stair climbing 
• Eliminate instability 
 
Additional 
Intervention 
*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 
• Tolerance of Phase II exercises without adverse events or swelling 
• Sufficient strength to initiate agility activities as indicated by: 
 
>80% 1RM Leg Press of uninvolved leg*** 
 
• Sufficient proprioception to initiate agility activities as indicated by:  
Y Balance Test Composite Score >= 90% of unaffected side  
• No signs of active inflammation 
• No episodes of instability 
 
 
PHASE III: LATE/CHRONIC (6-8 WEEKS) 
Rehabilitation 
Goals 
• Progressive strengthening 
• Maintain ROM and flexibility 
• Restore neuromuscular responses with plyometrics and advanced proprioceptive exercises 
• Return to running 
 
 
 
Additional 
Intervention 
*Continue with 
Phase I-II 
Interventions  
• Continue to increase intensity of proprioceptive training from Phase II 
• Exercises to add for progressive agility training: 
• Lateral shuffle (distance changes to inc or dec COD) 
• Cariocas 
• Cone drills (figure 8, forward/backward running, T-Test) 
Criteria to 
Progress 
• Completion jog/run program without pain/effusion / swelling 
 
PHASE IV: UNRESTRICTED RETURN TO SPORT (8-12+ WEEKS) 
Rehabilitation 
Goals 
• Progressive strengthening 
• Maintain ROM and flexibility 
• Safe return to work and/or sport activities (with MD clearance if applicable) 
• Quadriceps and hamstring strength to >90% of uninvolved leg per isokinetic strength test (if 
available) 
• Single leg hop tests >90% of uninvolved leg 
• Patient education regarding potential limitations and activity modifications 
• Patient education regarding sports bracing if applicable 
• Patient education regarding maintaining healthy BMI 
 
Additional 
Intervention 
*Continue with 
Phase II-V 
interventions 
• Continue to progress strengthening exercises with increasing resistance assuming proper form 
and technique 
• Advance Phase III plyometric training to single leg 
• Advance agility training to sport-specific movements at competition speed 
• Progress aerobic and metabolic conditioning appropriate for sport 
 
Criteria to 
Discharge 
• Clearance from MD and ALL milestone criteria below have been met 
• 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 
• KOOS-sports questionnaire >90% 
• International Knee Committee Subjective Knee Evaluation >93 
 
   Revised 9/2021 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
 
References: 
 
1. 
Wilk, Kevin E., Arrigo, Christopher, A., Rehabilitation of the Anterior Cruciate Ligament Reconstructed Knee. Clin Sports Med (2017) 36: 189-
232. https://www.ncbi.nlm.nih.gov/pubmed/27871658 
 
2. 
Braund, Rhiannon & Abbott, J. Haxby. (2007). Analgesic recommendations when treating musculoskeletal sprains and strains. The New 
Zealand Journal of Physiotherapy. 35. 54-60. 
https://www.researchgate.net/publication/233823393_Analgesic_recommendations_when_treating_musculoskeletal_sprains_and_strains 
 
3. 
Oiestad BE, Chu C; Early Clinical Findings May Predict Long-Term Development of Radiographic Knee Osteoarthritis in Patients with Anterior 
Cruciate Ligament Reconstruction. Annals of Joint (2018) 3:72 http://aoj.amegroups.com/article/view/4560/5140 
 
4. 
Paterno, Mark, Non-operative Care of the Patient with an ACL-Deficient Knee. Curr Rev Musculoskeletal Med (2017) 10: 322-327. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577432/ 
 
5. 
Hurd, W., Axe, M., Snyder-Macklet, L., Management of the Athlete with Acute Anterior Cruciate Ligament Deficiency. Sports Health (2009) (1)1 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445111/ 
 
 
 
6. 
Eitzen, I., Moksnes, H., Snyder-Mackler, L., Risberg, MA., A Progressive 5-Week Exercise Therapy Program Leads to Significant 
Improvement in Knee Function Early After Anterior Cruciate Ligament Injury, J Orthop Sports Phys Ther. 2010 November; 40(11): 705-
721. https://www.ncbi.nlm.nih.gov/pubmed/20710097 
 
 
 
