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 ACL Tear Nonoperative Rehabilitation




Restore full passive knee extension

Diminish joint swelling and pain

Restore patellar mobility

Gradually improve knee flexion

Re-establish quadriceps control

Restore independent ambulation


Post-Injury Day 1- 3


Brace: Brace/Immobilizer applied to knee, locked in full extension during ambulation as directed by physician


Weight Bearing: Two crutches, weight bearing as tolerated



*Ankle pumps

*Overpressure into full, passive knee extension

*Active and Passive knee flexion (90 degree by day 5)

*Straight leg raises (Flexion, Abduction, Adduction)

*Quadriceps isometric setting

*Hamstring stretches/ calf stretches

*Closed kinetic chain exercises:  mini squats, weight shifts        


Muscle Stimulation:              Use muscle stimulation during active muscle exercises (4-6 hours per day)


Ice and Elevation:                  Ice 20 minutes out of every hour and elevate with knee in full extension, may

                                                      use e-stim for edema control             

Post-Injury Day 3 to 7


                  Brace:  Locked at zero degrees extension for ambulation and unlocked for sitting


                  Weight Bearing: Two crutches weight bearing as tolerated


                  Range of Motion: Remove brace to perform range of motion exercises 4-6 times per day, knee flexion 90 degrees by day 5,     approximately 100 degrees by day 7



*Multi-angle isometrics at 90 and 60 degrees (knee extension)

*Knee Extension 90-40 degrees

*Overpressure into extension

*Patellar mobilization

*Ankle pumps

*Straight leg raises (3 directions)

*Mini squats and weight shifts

*Standing Hamstring curls

*Quadriceps isometric setting

*Proprioception and balance activities

*Continue Hamstring and calf stretching



Muscle Stimulation:              Electrical muscle stimulation (continue 6 hours daily)


Ice and Elevation:                  Ice 20 minutes of every hour and elevate leg with knee full extension




Criteria to Progress to Phase II


  1. Quad Control (ability to perform good quad set and SLR)

  2. Full passive knee extension

  3. PROM 0-90 degrees

  4. Good patellar mobility

  5. Minimal joint effusion

  6. Independent ambulation


Goals:     Maintain full passive knee extension (at least 0 to 5-7 hyperextension)

Gradually increase knee flexion

Diminish swelling and pain

Muscle training

Restore proprioception

Patellar mobility

Week Two


Brace:                                         Discontinue brace or immobilizer at 2 to 3 weeks per physician


Weight Bearing:                     As tolerated (goal is to discontinue crutches 10-14 days post injury)


Range of Motion:                   Self-ROM stretching (4-5 times daily), emphasis on maintaining full, passive range of motion progress flexion as tolerated


Exercises:                                    *Muscle stimulation to quadriceps exercises

                                                      *Isometric quadriceps sets

                                                      *Straight Leg raises (4 planes)

                                                      *Leg Press (0-60 degrees)

                                                      *Knee extension 90-40 degrees

                                                      *Half squats (0-40)

                                                      *Weight shifts

                                                      *Gait training with cones                                       

                                                      *Front and side lunges

                                                      *Hamstring Curls                                    


                                                      *Proprioception training

                                                      *Tilt board squats

                                                      *Dip walking

                                                      *Overpressure into extension

                                                      *Passive range of motion from 0 to 50 degrees

                                                      *Patellar mobilization

                                                      *Well leg exercises

                                                      *Progressive resistance extension program – start with 1 lb., progress 1 lb. per week

                                                      *Continue stretching program


Swelling control:                     Ice, compression, elevation, e-stim

Week Three


Brace:                                         Discontinue


Range of Motion:                   PROM should be full or near full ROM


Passive Range of Motion:   Continue range of motion stretching and overpressure into extension


Exercises:                                  *Continue all exercises as in week two

                                                      *Passive Range of Motion as tolerated

                                                      *Bicycle for range of motion stimulus and endurance

                                                                        *Pool walking program (if incision is closed)

                                                                        *Eccentric quadriceps program 40-100 (isotonic only)

                                                                        *Lateral lunges

                                                                        *Lateral step ups

                                                                        *Lateral cone step overs

                                                                        *Stair-Stepper machine

                                                                        *Progress Proprioception drills, neuromuscular control drills




Criteria to Enter Phase III


  1. Full ROM

  2. Quadriceps strength 60%>contralateral side (isometric test at 60 degree knee flexion)

  3. Minimal to no full joint effusion

  4. No joint line or patellofemoral pain


Goals:     Maintain full knee range of motion (0 to 125 degrees)

Improve lower extremity strength

Enhance proprioception, balance, and neuromuscular control

Improve muscular endurance

Restore limb confidence and function


Brace:                                         No immobilizer or brace, may use knee sleeve or fit for function all brace


Range of Motion:                   Self-ROM (4-5 times daily using the other leg to provide ROM), emphasis on

                                                      maintaining full ROM


            Week 4


Exercises                                    *Progress isometric strengthening program

                                                      *Leg Press

                                                      *Knee extension 90 to 40 degrees

                                                      *Hamstring curls

                                                      *Hip Abduction and Adduction

                                                      *Hip Flexion and Extension

*Lateral Step-Overs

                                                      *Lateral Lunges

*Lateral step ups

*Front step downs

*Wall Squats

*Vertical squats

*Toe Calf Raises

*Biodex Stability System (balance, squats, etc.)

*Proprioception drills


*Stair climber machine

*Pool program (backward running, hip and leg exercises)

                  Week 6


Exercises:                                  *Continue all exercises

                                                      *Pool running (forward) and agility drills, jumping

                                                      *Progress to balance and tilt board throws, perturbation training

                                                      *Advanced Neuromuscular control drills:

                                                                        -CKC on unstable surfaces

                                                                        -Lunges onto foam

                                                                        -Step ups on foam

                                                                        -Perturbation training

                                                      *Wall slides/squats

                                                      *Muscular training for fast reaction times

-High speed hamstring curls

*Progress dynamic stabilization drills

-Tilt board perturbations



Criteria to Enter Phase IV


  1. Full ROM

  2. Quad strength 75% of contralateral side, knee extension flexor:extensor ratio 70% to 75%

  3. No pain or effusion

  4. Satisfactory clinical exam

  5. Satisfactory isokinetic test (values at 180 degrees)

Quadriceps bilateral comparison 75%

Hamstrings equal bilateral

Quadriceps peak torque/body weight 65% at 180o/s (males) 55% at 180o/s (females)

Hamstrings/quadriceps ratio 66% to 75%

  • Subjective knee scoring >80%


Goals:     Normalize lower extremity strength

                  Enhance muscular power and endurance

                  Improve neuromuscular control

                  Perform selected sport-specific drills


Exercises:                                  *Continue all exercises

                                                   *Advanced Neuromuscular control drills:

                                                   *Plyometric program

                                                      -Leg press plyometrics

                                                      -Box jumps




                  Criteria to Enter Phase V


  1. Full Range of Motion

  2. Isokinetic Test that fulfills criteria if available

  3. Quadriceps bilateral comparison (80% or greater)

  4. Hamstring bilateral comparison (110% or greater)

  5. Quadriceps torque/body weight ratio (55% or greater)

  6. Hamstrings/Quadriceps ratio (70% or greater)

  7. Proprioceptive Test (100% of contralateral leg)

  8. Functional Test (85% or greater of contralateral side)

  9. Satisfactory clinical exam

  10. Subjective knee scoring >90%


Goals:     Gradual return to full-unrestricted sports 8 activities

                  Achieve maximal strength and endurance

                  Normalize neuromuscular control

                  Progress skill training


                  Exercises:                                     *Continue strengthening exercises

                                                                        *Continue neuromuscular control drills

                                                                        *Continue plyometrics drills

                                                                        *Progress running and agility program

                                                                        *Progress sport specific training

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