Dr.

Mark Price
Mass General Sports Medicine Center
175 Cambridge Street, 4th floor
Boston, MA 02114

Anterior Cruciate Ligament (ACL) Reconstruction

The anterior cruciate ligament (ACL) is one of four

major ligaments that stabilize the knee joint. A
ligament is a tough band of fibrous tissue, similar
to a rope, that connects the bones together at a
joint. The ACL prevents the lower bone (the tibia)
from sliding forward too much and stabilizes the
knee joint to allow cutting, twisting and jumping
activity.

The most common mechanism that tears the ACL

is the combination of a sudden stopping motion of
the leg while quickly twisting the knee. This can
happen in sports such as basketball and soccer
when a player lands on the leg when coming down
from a rebound, or is running down the field and
makes an abrupt stop to pivot. In skiing the ACL is
commonly injured when a skier slides back while
falling. These excess forces cause the ACL to pop. knee usually regains its range of motion and is
painless after six to eight weeks. The knee will
When the ACL tears the person feels the knee typically feel completely normal, but may be a
move out of joint and often hears or feels a “pop.” “trick” knee. If a knee does not have and ACL, it can
If he or she tries to stand on the leg it may feel give way or be unstable when the person pivots or
unstable and give out. The knee usually swells a changes direction. It is usually possible to run
great deal initially (often within two hours), and it straight ahead without any problems, but when
becomes painful and difficult to walk. the athlete makes a quick turning motion the knee
tends to give way and collapse. This abnormal
It is also possible to injure other structures inside motion can damage other structures in the knee.
your knee when the ACL is torn. The meniscus is a
crescent shaped shock absorber between the If a person does not engage in sports and is
femur and tibia, and each knee has one on the relatively inactive, the knee can feel quite normal
inside (medial) and outside (lateral) of the knee even if the ACL is torn. Thus, many patients,
joint. When the tibia suddenly moves forward the especially over the age of 30 may not need to have
meniscus can also be torn. Similarly the articular the ACL reconstructed, especially if they do not
cartilage (the smooth liner of the joint) can also be participate in sports that require quick changes in
injured. If this articular cartilage is injured the direction. In younger athletic patients or those
joint no longer moves smoothly. Stiffness, pain, older patients that still participate in sports at a
swelling and grinding can occur. Eventually high level, however, the knee will tend to reinjure
arthritis can develop. Finally, it is also possible to frequently and give way during activities in which
injure the other ligaments of the knee which can the person quickly changes direction. Therefore in
cause pain or instability with activity. Tears of the these groups it is best to reconstruct the torn ACL.
outer ligament (the lateral collateral ligament, or
LCL) often dorequire surgical repair, while tears of In those in whom ACL reconstruction is not
the inner ligament (the medial collateral ligament, undertaken it may be necessary to modify
or MCL) often heal completely over six to eight activities and avoid high risk sports such as
weeks and usually do not require surgery. basketball, football, and soccer. Wearing a knee
brace may help prevent further injury but will not
If no other structure than the ACL is injured the completely stabilize a knee that has a torn ACL.

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Exercises that restore the muscle strength, power, done arthroscopically instead of making big
coordination, and endurance will also improve incisions. Associated injuries such as torn menisci,
knee function and help stabilize the knee. loose bodies, etc. are addressed at the same time.
However, a fully rehabilitated knee that has a torn If patellar tendon graft is used, a small incision is
ACL can still give way if a quick change in direction made on the inner side of the leg just below the
is unexpected. knee cap to take the graft (this results in a small
area of numbness on the front of the knee). If a
It is best to wait for the pain and swelling from the hamstring tendon graft is used a small incision is
initial injury to subside and allow other associated made on the inside of the leg below the knee joint.
injuries to heal prior to performing ACL surgery. If Guides are used to place the graft in the proper
surgery is done too soon after injury, position of your knee. The graft is then pulled into
rehabilitation is difficult; the knee may get stiff bony tunnels and secured in place with screws.
and have permanent loss of motion. The athlete
will usually get back to sports more quickly if the
knee is allowed to recover from the initial injury
and regain its full painless range of motion prior to
any surgery (usually about six weeks).

The best treatment for the initial period after an

ACL injury is to protect the joint and apply ice and
use crutches for several weeks. As the swelling
and pain subside, and the patient can put weight
on the leg the crutches can be discontinued. The
emphasis is then on regaining knee motion.
Exercises designed to build up knee strength
should not be done at this point in order to avoid
damaging the cartilage under the knee cap Postoperatively, an accelerated rehab program
(patella). allows the quickest return of function. A knee
brace and crutches are used for the first 2-6 weeks
There may be some examples when immediate after surgery, depending on the choice of graft.
surgery is indicated following injury, such as in a The amount of weight you are allowed to put on
knee dislocation when multiple ligaments are your leg will depend on the choice of graft as well.
torn. Your doctor will discuss this with you should Numerous studies have been done to try to prove
you fall into one of these categories. superiority of one graft choice over another, and
as it currently stands no choice offers clear
ACL Reconstruction Surgery benefits over all the others in all situations. Your
surgeon will discuss with you the pros and cons of
Surgical reconstruction of a torn ACL involves the various graft options.
replacing the torn ACL with a tendon (called a
graft) from another part of the knee or a cadaver
donor, and putting it into a position to take the
place of the torn ACL.

Examples of commonly employed grafts include

the middle third of the patellar tendon (the tendon
connecting the knee cap to the tibial bone),
hamstring tendons, and Achilles tendons. In the
case of patellar tendon and hamstring grafts, they
may be obtained either from your own tissue or a
cadaver donor (called allograft). In the case of
Achilles tendon, the are always obtained from a
cadaver donor.
For most of these procedures the operation is

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The risks of ACL reconstruction include but are not limited to:
Permanent numbness in the front of the knee 100%
Other nerve injuries 0.5%
Patellofemoral pain (knee cap) 5%
Stiffness or reduced motion of the knee 10%
Reinjury 5-10%
Superficial infection 1%
Deep infection 0.5%
Blood clots 2-3%
Delay in regaining motion 5%

How soon will I…?

Return to work Return to sports

Sedentary 1-2 weeks Normal walking/stairs 1-2 months

General office 2-3 weeks Light individual sports 3-4 months

Light physical 6-8 weeks Running/jumping 6 months
Medium 3 months Contact/high performance 9 months

Heavy 4 months

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Postop Instructions

You will wake up in the operating room with a You will be sent home with a prescription for pain
brace and ice pack in place. You will also have medication. In addition to the pain medication you
white compression stockings on both legs. These should take one adult strength aspirin every day
are to help prevent blood clots and should be worn for 14 days, in order to help prevent blood clots.
for the first two weeks following surgery. The pain medication can make you constipated. If
this is the case, take an over the counter stool
Depending on your surgery, you may have a softener such as Colace while taking the pain
continuous passive motion (CPM) machine which medication.
is designed to help your knee move and regain
your full motion. You should plan on using this at You will be sent home from the recovery room
least 10 hours per day. The machine should be set after a few hours. You will need someone else to
to -5° of extension and 30-40° of flexion. It is set to drive you home.
pause for five seconds in extension.
• After 4-5 days try to have the CPM
machine to 90° of flexion
• The most important aspect is to have your
knee out straight
• You can adjust the speed. Many patients
find it easier to sleep with the machine in
slower speeds, and have faster speeds
when up during the day.

Activites & advice for in the hospital and while at home

1. Please call with any concerns: 617-726-6648

2. Apply ice to the knee as it will be quite helpful. After two days, you can change the dressing to a smaller
one to allow the cold to better get to the knee. Be sure to leave the little pieces of tape (steri-strips) in
place.
3. After two days it is okay to shower and get the wound wet, but do not soak the wound as you would in a
bath tub or hot tub.
4. After knee surgery there is a variable amount of pain and swelling. This will dissipate after several days.
Continue to take the pain medicine you were prescribed as needed. Remember it is called pain control,
not pain elimination. If you notice calf pain or excessive swelling in the lower leg, call your doctor.
5. Physical therapy will have either been scheduled or will begin immediately after your first post-op
appointment.
6. You will have an office visit scheduled 10-14 days after your surgery.

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Phase I: 0-2 weeks after surgery

Goals:
1. Protect the reconstruction
2. Ensure wound healing
3. Attain and maintain full knee extension
4. Gain knee flexion (bending) to 90 degrees
5. Decrease knee and leg swelling
6. Promote quadriceps muscle strength
7. Avoid blood pooling in the leg veins

Activities:
1. Continuous passive motion (CPM). This should be used at least 10 hours per day. You may use it
anywhere that is comfortable. Use it at night while sleeping. It is very important that you straighten
your knee completely. After 5-7 days of using the machine, if you have achieved greater than 100
degrees of flexion you can stop using the CPM machine.

2. Brace/crutches/weightbearing: your knee brace is set to allow you to bend and straighten your
knee. Use it when walking or out of bed, but it may be removed for range of motion exercises.
a. If you had a patellar tendon autograft (your own tendon), you can put as much weight on
your leg as you feel like. You should use the crutches in the beginning, but can stop using
them when you feel as though your knee can support you. You will still need to wear your
brace for the first six weeks after surgery. There may be some circumstances where
restricted weight bearing will be necessary. Your doctor and therapist will discuss this with
you if this is the case.
b. If you had a hamstring autograft or allograft, you will be allowed to put 50% weight on your
leg with crutches and a brace for the first six weeks after surgery.
c. If you had a patellar tendon allograft (cadaver tendon) you will be allowed to put 50%
weight on your leg with crutches and a brace for the first six weeks after surgery.

3. Your nurse or therapist will demonstrate the proper form for walking with crutches:
a. Put the crutches forward about one step’s length
b. Put the injured leg forward in line with the crutch tips
c. Touch the foot of the injured leg to the floor and put as much weight down as is comfortable
(brace on and locked)
d. While bearing weight on the injured leg, take a step through with the uninjured leg.

4. Elastic stockings: wear an elastic stocking below the knee until your first postoperative visit. Do at
least 10 ankle pump exercises each hour to help prevent blood clots. Take one adult aspirin daily
for the first two weeks

5. It is okay to remove your bandage on the second morning after surgery but leave the small pieces of
white tape (steri-strips) across the incision. You can wrap an elastic bandage (ACE wrap) around
the knee at other times to control swelling. You may shower and get your incision wet (unless there
is any drainage from your incisions). Do not soak the incision in a bathtub or hot tub until the
stitches have been removed.

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Exercises:
Program: 7 days per week, 3-4 times per day
Quadriceps setting 1-2 sets 15-20 reps
Heel prop 5 minutes
Heels slides with towel assist 5-15 minutes
Sitting heel slides 1-2 sets 15-20 reps
Straight leg raises 1-2 sets 15-20 reps
Patellar mobilization 1 set 15-20 reps
Hip abduction 3 sets 10 reps
Ankle pumps 10 per hour
Prone hang 5 minutes

Quadriceps Setting
Lie or sit with knee fully straight. Tighten and hold the front thigh muscle making the
knee flat and straight (this should make your knee flatten against the bed or floor). Hold
5 seconds for each contraction.

Heel Prop
Lie on your back with a rolled up towel under your heel, or sit in a chair with the heel on
a stool. Let the knee relax into extension (straight). If the knee will not straighten fully,
you can place a small weight (2-5 lbs) on the thigh just above the knee cap. Try to hold
for 5 minutes. Try to practice quadriceps setting in this position.

Heel slides with towel assist

While sitting or lying on your back, actively slide your heel backward to bend the knee.
Hold this bent position for five seconds then slowly relieve the stretch and straighten the
knee. While the knee is straight, you may repeat the quadriceps setting exercise. You can
assist by using a towel to pull your heel back.

Sitting Heel Slides

While sitting in a chair or over the edge of the bed, support the operated leg with the
uninvolved leg. Lower the operated leg, with the unoperated leg controlling, allowing the
knee to bend. Do not go past 600 of bend at the knee. Hold for 5 seconds and slowly
relieve the stretch by lifting the foot upward with the uninvolved leg to the straight
position.

Ankle Pumps
Move the ankle up and down to help stimulate circulation in the leg.

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Straight leg lift
Tighten the quadriceps as much as you can. Lift your heel 4-6 inches from the
floor. Tighten the quadriceps harder. Lower your leg back to the floor while
continuing to tighten the quadriceps. If your knee bends when you attempt to lift
do not do this exercise.

Hip abduction
Lie on your unoperated side. Keep your knees fully extended (straight). Raise
the operated limb upward to a 450 angle. Hold for one second then lower
slowly.

Patellar Mobilization
With the knee fully extended, grasp the edges of your knee cap between your
thumb and index finger. Move the knee cap side to side and up and down.

Prone Hang
Lie face down across your bed so that the kneecap is just off the edge of the
mattress. Let your leg drop down toward the floor so that your knee straightens
fully. If the knee will not fully extend, then attach a weight around the ankle to help
pull the leg down. Use an amount of weight as described in the heel prop exercise.

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Phase II: 2-4 weeks after surgery (early rehabilitation phase)

Goals:
1. Maintain full passive knee extension (at least 0-50 of hyperextension)
2. Gradually increase knee flexion
3. Diminish swelling and pain
4. Muscle control and activation
5. Restore proprioceptive and neuromuscular control
6. Normalize patellar mobility
7. Normal gait without crutches (if autograft)

Criteria to progress to phase II:

1. Quad control (ability to perform good quad set and straight leg raise)
2. Full passive knee extension
3. Good patellar mobility
4. Minimal joint effusion
5. Independent ambulation

Activities:
1. Continue to use ice to decrease swelling. It should be used 20 minutes at least three times per day.
2. Brace/crutches: In cases where patellar tendon autograft is used, you can discontinue using your
crutches when you are comfortable doing so. Continue using your brace. In cases of hamstring
grafts or allograft patellar tendons continue with partial (50%) weightbearing with the crutches
and brace.
3. You may stop wearing the compression stockings and can stop taking the aspirin.
4. You will have a visit with Dr. Price at 10-14 days after surgery. If your wound is dry, you will likely
be able to get the wound wet in a bath or hot tub at this point. Irrespective of whether your right or
left leg was operated on, it is unlikely you will be allowed to drive at this point.

Exercises:
The following exercises will be demonstrated to you by your physical therapist. He or she will also give you
a home exercise program. You should strive to do your home exercise program at least 3-4 times per day,
every day. The success of your reconstruction depends on your rehab.

Week 2 exercises:
• Muscle stimulation to quadriceps • Stationary bicycle
exercises • Proprioception training
• Isometric quadriceps sets • Overpressure into extension (quadriceps
• Straight leg raises (4 planes) setting)
• Leg press (0-60°) • Passive range of motion from 0-100°
• Knee extension (90-40°) • Patellar mobilization
• Half squats (0-40°) • Well leg exercises
• Weight shifts • Progressive resistance extension program
• Front and side lunges – start with 1 lb, progress 1 lb per week
• Hamstring curls standing (active ROM)
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Proprioception/Neuromuscular training:
• OKC passive/active joint repositioning 90°, 60°, 30°
• CKC joint repositioning during squats/lunges
• Initiate squats on tilt board

Week 3 exercises:
• Continue week 2 exercises
• Passive range of motion 0-115°
• Pool walking program/flutter kicks (if incision closed and dry)
• Eccentric quadriceps program 40-100° (isotonic only)
• Lateral lunges (straight plane)
• Front step downs
• Lateral step overs using cones
• Progress proprioception and neuromuscular control drills.

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Phase III: 4-10 weeks after surgery (strengthening & neuromuscular control phase)

Goals:
1. Restore full knee range of motion (0-1250)
2. Improve lower extremity strength
3. Enhance proprioception, balance and neuromuscular control
4. Improve muscular endurance
5. Restore limb confidence and function

Criteria to progress to phase III:

1. Active ROM 0-115°
2. Quadriceps strength >60% contralateral side (isometric test at 600)
3. Minimal to no joint effusion
4. No joint line or patellofemoral pain

Activities:
1. The brace can be discontinued after you see Dr. Price at your 6 week visit. Concentrate on walking
with a heel to toe gait without a limp. In some cases, use of the brace will continue if your knee
requires a longer period of protection.
2. Continue to use ice for 20 minutes after each workout
3. You are cleared to drive when bearing weight on your operative leg is comfortable and you have
good control of the leg. If your left leg was operated on, you should be clear to drive at this point.

Weeks 4 & 5 exercises:

• Progress isometric strengthening • Lateral step ups
program • Front step downs
• Leg press (0-100°) • Wall squats
• Knee extension 90-40° • Vertical squats
• Hamstring curls (isotonic) • Standing toe calf raises
• Hip abduction and adduction • Seated toe calf raises
• Hip flexion and extension • Proprioception drills
• Lateral step overs • Stationary bicycle
• Lateral lunges (straight and multi plane • Pool program (if available): backward
drills) running, hip and leg exercises

Proprioception/neuromuscular drills:
• Tilt board squats (with and without perturbation)
• Passive/active position OKC
• CKC repositioning on tilt board with sports RAC
• CKC lunges with sports RAC

Week 6 & 7 exercises:

• Continue all previous exercises
• Pool running and agility drills
• Balance on tilt boards
• Progress to balance and ball throws
• Wall slides/squats
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Weeks 8 & 9 exercises:
• Continue previous exercises
• Leg press sets (single leg) 0-100° and 40-100°
• Plyometric leg press
• Perturbation training
• Isokinetic exercises (90 to 40° @ 120-240°/sec)
• Walking program
• Stationary bicycle
• Sports RAC neuromuscular training on tilt board, biodex stability

Week 10 exercises:
• Continue previous exercises
• Plyometric training drills
• Stretching drills
• Progress strengthening exercises and neuromuscular training

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Phase IV: 10-16 weeks after surgery (advanced activity phase)

Goals:
1. Normalize lower extremity strength
2. Enhance muscular power and endurance
3. Improve neuromuscular control
4. Perform selected sport-specific drills

Criteria to progress to phase IV:

1. AROM 0-125°
2. Quad strength 75% contralateral side
3. Knee extensor:flexor ratio 70-75%
4. No pain or effusion
5. Satisfactory clinical exam
6. Hop test 80% of contralateral leg
7. Satisfactory isokinetic test (values at 180°):
a. Hamstrings equal bilateral
b. Quadriceps peak torque/body weight 65% at 180 0/sec for males and 55% at 180 0/sec for
females

Activities
1. Your activities will increase in this phase, but it is important to remember that you are not yet fully
recovered from surgery. Progressing too quickly or engaging in sports or other activities prior to
being cleared greatly increases the risk of failure of your surgery and compromise of your results.
2. Avoid the following exercises as they place undue stress on your knee:
a. Leg extension machine
b. Stairmaster or stair climber machines
c. Deep knee lunges or squats past 90° of knee flexion
d. High impact exercises
3. Avoid pain at the patellar tendon site, as well as crepitus (crunching) at the patella
4. Build up resistance and repititions gradually
5. Perform exercises slowly and avoid quick direction changes
6. Avoid impact loading
7. Exercise frequency should be at least 2-3 times per week for strength building
8. Be consistent and regular with exercise schedule

Exercises Neuromuscular training:

• May initiate straight ahead running program (weeks 10-12) • Lateral step overs
• Light sports okay (golf – pitch and putt) (cones)
• Continue strengthening drills • Lateral lunges
o Leg press • Tilt board drills
o Wall squats • Sports RAC
o Hip abduction and adduction repositioning on tilt
o Hip flexion and extension board
o Keen extension 90-40
o Hamstring curls
o Seated and standing toe calf raises
o Step down
o Lateral step ups and lunges
• Wks 14-16 may initiate lateral agility drills & backward
running.
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Phase V: 16-22 weeks after surgery (return to activity phase)

Goals:
1. Gradual return to full-unrestricted sports
2. Achieve maximal strength and endurance
3. Normalize neuromuscular control
4. Progress skill training

Criteria to enter phase V:

1. Full ROM
2. Quadriceps bilateral comparison within 80% or greater
3. Hamstring bilateral comparison within 110% or greater
4. Quadriceps torque:body weight ratio 55% or greater
5. Hamstrings:quadriceps ratio 70% or greater
6. Prioprioceptive test 100% of contralateral leg
7. Functional test 85% or greater of contralateral leg

Exercises:
• Continue strengthening exercises
• Continue neuromuscular control drills
• Continue plyometric drills
• Progress running and agility program
• Progress sport specific training
o Running/cutting/agility drills
o Gradual return to sport drills

Guidelines for sport specific training:

Activity Weeks post surgery
Running slowly 12-16
Golf 16-20
Roller blade or ice skating 18
Tennis 20-24
Return to sports practice 24-32
Full return to sports 32-36

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