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  • Writer's pictureRandon Hall, MD

Explaining an ACL Rehab Protocol

Understanding an ACL Rehab Protocol

It is with continuing frequency we see stories of many athletes being reported to be “ahead of schedule” after an ACL reconstruction. I have been closely following the case of Carson Wentz who tore his ACL in December. There werem countless reports of how good he looks and how he is ahead of schedule”. Needless to say, the decision to return an athlete back to play after an ACL is certainly not based on watching them run. Although it makes for good headlines, it is circumstantial evidence at best. It is like watching a car drive down the road and being able to tell what condition it is under the hood. ACL return to play is based on two key factors: time and evidence based functional assessments. Although protocols typically end around 6 months it is believed the healing process of the surgically repaired ligament requires around 9 months to significantly reduce the risk of a re-tear. In other words, even if the athlete looks phenomenal, the research shows the longer the ligament is allowed to heal, the lower the likelihood of a re-tear.

This post is going to take you step by step through the highlights of an ACL return to play protocol. Keep in mind the protocols vary based on surgeon, particular surgery and surgical technique. The protocol below is for an autograft procedure, which is the use of the patients own tendon, either hamstring or patella tendon. If you are recovering from your own ACL tear please follow your surgeons instructions as this is an abbreviated general approach for educational purposes.


Weeks 1 - 4

  • Weight-bearing as tolerated immediately post-op with crutches

  • Wean from crutches for ambulation by 2 weeks if tolerated

  • Calf Stretching

  • Hip Strengthening with Single Leg Raises

  • If available, aquatics for normalizing gait, weight bearing and strengthening

If Patella Tendon Graft:

  • Closed Kinetic Chain Quadriceps strengthening activities as tolerated

  • (wall sit, step ups, mini squats, leg press 90- 30 degrees)

  • Hamstring curls – add weight as tolerated

If Hamstring Graft:

Hamstring stretches (very gentle for hamstring tendon autograft procedures)

Delay hamstring strengthening for 12 weeks. (for hamstring tendon autograft procedure only)


Weeks 4 - 10

  • Range of motion/flexibility exercises as appropriate for the patient

  • Continue hamstring, gastroc/soleus stretches

  • Continue to progress hip, hamstring and calf strengthening as tolerated

  • Elliptical machine for conditioning. Stationary bike - progress time and resistance as tolerated

  • If available, begin running in the pool (waist deep) or on an unweighted treadmill at 8 weeks. ​

If Patella Tendon Graft:

  • Closed Kinetic Chain Quadriceps strengthening activities as tolerated

  • (wall sit, step ups, mini squats, leg press 90 - 30 degrees)

  • Continue to progress proprioceptive and balance activities

  • ball toss, balance beam, mini-tramp balance

If Hamstring Graft:

  • Initiate quad strengthening and progress as tolerated for hamstring tendon autograft procedures

  • wall sits, step-ups, mini-squats, Leg Press 90 - 30 degrees, lunges

  • Initiate proprioceptive and balance activities

  • ball toss, balance beam, mini-tramp balance

  • Delay hamstring strengthening for 12 weeks.


Weeks 10 - 16

Progress toward full weight bearing running at 12 weeks for patella tendon autograft and16 weeks for hamstring tendon autograft procedures.

  • Begin swimming if desired

  • Progressive hip, quadriceps, hamstring, calf strengthening

  • Cardiovascular/endurance training via Stairmaster, elliptical, bike

  • Advance proprioceptive activities


Months 4 - 6

  • Continue and progress flexibility and strengthening program based on individual needs and deficits.

  • Initiate plyometric program as appropriate for patient’s athletic goals

  • Continue progression of running distance based on patient needs.

  • Initiate sport-specific drills as appropriate for patient

  • Agility progression including, but not limited to:

  • Side steps

  • Crossovers

  • Figure 8 running

  • Shuttle running

  • One leg and two leg jumping

  • Cutting Acceleration/deceleration/sprints

  • Agility ladder drills


  • Symmetric performance of basic and sport specific agility drills

  • If available battery of tests performed in motion analysis lab looking at strength and agility

  • Quadriceps and hamstring strength at least 85% of uninvolved lower extremity per strength test


After 6 Months

  • Maintenance of strength, endurance, proprioception and balance

  • Gradual return to sports participation

  • Maintenance program for strength, endurance

More information on ACL Tears....


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