ACL Rehabilitation Protocol

Anterior Cruciate Ligament (ACL) Rehabilitation

The anterior cruciate ligament (ACL) is a band of connective tissue that connects from the femur to the tibia. Its role is to provide stability in the knee joint by resisting anterior tibial translation and rotation forces. The mechanism of an ACL injury typically occurs with a sudden change of direction (cutting), pivoting the firmly planted foot, or landing awkwardly from a jump. Forces generated by these mechanisms cause anterior translation of the tibia and internal rotation of the femur resulting in an ACL sprain or rupture.

In our service on evidence-based ACL rehabilitation, we discussed and outlined the different phases for evidence-based ACL recovery, the goals of each phase, and the outcomes that should be looked for when progressing an individual. The current literature on ACL rehabilitation and protocols is extensive due to the prevalence of injury in sports. In this post, you will be able to see a snapshot of what an ACL rehabilitation treatment plan might look like. Please note that this is a big picture approach and that each individual will vary on their ACL rehabilitation journey. 

1. Post-Surgical / Pre-operative Rehabilitation Phase

In the first phase of ACL rehabilitation, most patients will typically be in the acute phase in which post-ACL-reconstruction patients experience loss of range of motion (ROM), increased swelling/effusion, and loss of strength. 

It is recommended that pre-operative patients should prepare for ACL surgery by undergoing an exercise program to regain normal ROM and strength in the knee as it has been shown to be significantly beneficial in post-surgery outcomes.

The main goals of this phase are to:

  • Control overall swelling and inflammation in the knee (acute phase)
  • Restore normal range of motion in the knee; allowing for full knee extension/flexion
  • Promote muscle strengthening, specifically in the quadriceps

Outcome measures to look for during this phase:

  • Full passive ROM: knee extension & flexion
  • Control of swelling
  • Quadricep lag test (ability to maintain active knee extension while seated) 

Passive knee ROM exercises and quadriceps isometrics (post-surgery) are typically incorporated into this phase to begin developing strength and restoring normal ROM.

2. Strength and Neuromuscular Control Phase

In this phase, the focus is centered on neuromuscular training in combination with strength training. It has been shown to be effective in improving dynamic knee stability, proprioception, and motor control. The primary goals of this phase are to regain strength, balance, and coordination after regaining ROM. 

Outcome measures to look for during this phase:

  • Single balance ability
  • Regaining muscle strength
  • Single leg squat with proper technique and alignment 

Early in this phase, the focus should be more directed on light strengthening of the quadriceps through isometric exercises as tolerated. Examples of exercises that you may be performed include knee extension isometric holds, wall squat holds, and spanish squats. As the patient progresses, transition into isotonic exercises with heavier loads to focus on further muscular strengthening. Balance and proprioception exercises are also incorporated to develop appropriate motor control and coordination to prepare patients to transition into the next phase.

3. Running, Agility, and Landings

Once muscle strength and neuromuscular control is fully regained, exercises that involve agility, running, and landing are introduced into the program. In this phase, proper biomechanics during these movements are emphasized before being able to progress into sport-specific movements. There is an emphasis on eccentric exercise and working on the patient’s ability to decelerate. Strength and neuromuscular control exercises from previous phases should still be performed in conjunction. 

Outcome measures to look for during this phase:

  • Regain full strength and balance
  • Ability to perform agility exercises
  • Improving deceleration ability (ex: decelerating landings) 

Exercises can include banded sprints, ladder drills, drop squats. 

4. Return to Sport / Play

Once an athlete is ready to return to sport, it will be important to further individualize and tailor the rehabilitation program accordingly to the sport that they play in. Movements and loading should be specific to the sport and translate into on-field performance. Implementation and education of a preventative exercise program are essential to prevent future injuries and maintain the ability to maximize performance in their respective sport. 

Each phase is not distinct from one another, in which aspects of each phase should be continually worked on as an individual progresses in their recovery! 


If you have suffered from an ACL injury and haven’t recovered successfully, schedule an appointment with our Kinesiologists to see how we can help! 

If you’re interested in joining us in our next in-service, reach out to us at

Summary written by Calvin Vu 

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