ACL Reconstruction (Bone–Patellar Tendon–Bone Allograft)

Physical Therapy Protocol

Restrictions Summary

• Brace: Hinged knee brace locked in extension until straight leg raise (SLR) without lag. Then gradually unlocked as tolerated.
• Weight Bearing: Weightbearing as tolerated (WBAT) immediately with crutches. Discontinue crutches once walking without limp.
• Range of Motion (ROM): Full passive ROM encouraged early. Emphasis on regaining full extension, then gradual flexion.

Phase I – Protective Phase (Weeks 0–2)

Goals:

• Protect surgical graft
• Reduce swelling and pain
• Achieve full extension
• Initiate gentle ROM and quad activation
• Normalize gait with crutches and brace

Brace & Weightbearing:

• Brace locked in extension
• WBAT with crutches

Exercises:

• Patella and tendon mobilizations
• Ankle pumps
• Quad sets
• Hamstring sets
• Heel slides (wall and seated)
• Gentle sit-and-reach for hamstrings

Cardio:

• Bike/rowing with well leg only

Phase II – Early Motion and Strengthening (Weeks 2–6)

Goals:

• Normalize gait pattern
• Restore full ROM
• Initiate light strengthening
• Improve neuromuscular control and balance

Brace & Weightbearing:

• Unlock brace once SLR achieved without lag
• Discontinue crutches once walking without limp

Exercises:

• Continue ROM (wall slides, seated flexion, extension mobilization)
• Toe and heel raises
• Balance training series
• Stationary bike (start without resistance, then add)
• Aquajogging
• Treadmill walking (7% incline)
• Light quad and hamstring strengthening
• Double leg bridges
• Static reverse lunge holds
• Begin cord resistance exercises

Phase III – Progressive Strengthening & Proprioception (Weeks 6–12)

Goals:

• Normalize strength and balance
• Achieve full pain-free ROM
• Initiate dynamic stability drills
• Progress endurance and strength

Exercises:

• Balance squats
• Leg press
• Single leg deadlifts
• Elliptical, rowing, stair stepper
• Swimming with fins
• Increase resistance on bike
• Jogging progression (single plane by weeks 10–12)

Phase IV – Return to Sport Training (Weeks 12–24)

Goals:

• Achieve full strength and neuromuscular control
• Initiate sport-specific drills
• Restore normal biomechanics

Exercises:

• Agility drills (multi-directional, cone drills)
• Functional sports testing
• Golf, outdoor biking, hiking, snowshoeing
• Return to high-level sports (soccer, basketball, football, etc.) with MD clearance

Clearance Criteria for Return to Sport:

• Symmetrical strength and ROM
• Normal movement mechanics
• Pass functional sports test
• Surgeon clearance required