Phase 1:

Acute Post-Operative Care

ACL program

After the operation

The main aim of the initial period following surgery is to keep swelling and pain to a minimum and to maintain some muscle tone and flexibility. This can be achieved in the following ways:

  • Apply ice to the knee for 10 to 15 minutes after each set of exercises, i.e. 3-4 times per day. When applying ice, keep the leg in elevation. Sitting with your leg up on a stool is not adequate; you need to have the whole leg above the level of your heart. For example, lie on floor/bed with foot up on chair/pillows etc.
  • You will be advised to wear a compression bandage during the day
  • The amount and level of exercise will be determined by swelling and pain
  • Frequency of Exercises

    3-4 times per day, unless otherwise indicated.


    • Effusion/swelling control
    • Muscle activation
    • Restore range of movement
    • Gait re-education
    • Quadriceps control
    • Progressive limb loading

    Full extension is obtained by doing the following exercises:

    1) Passive knee extension

    • Sit in a chair and place your heel on the edge of a stool or chair
    • Relax the thigh muscles
    • Let the knee sag under its own weight until maximum extension is achieved
    • Then contract quads to accentuate stretch

    2) Heel Props

    • Place the heel on a rolled towel making sure the heel is propped high enough to lift the thigh off the table
    • Allow the leg to relax into extension
    • 3 - 4 times a day for 10 - 15 minutes at a time

    3) Prone hang exercise

    • Lie face down on a table with the legs hanging off the edge of the table
    • Allow the legs to sag into full extension

    Bending (Flexion) is obtained by doing the following exercises:

    1) Passive knee bend

    • Sit on the edge of a table and let the knee bend under the influence of gravity
    • You may support with your other leg

    2) Wall slides are used to further increase bending

    • Lie on the back with the involved foot on the wall and allow the foot to slide down the wall by bending the knee. Use other leg to apply pressure downward if you feel comfortable

    3) Heel slides are used to gain final degrees of flexion

    • Pull the heel toward the buttocks, flexing the knee. Hold for 5 seconds

    Straighten the leg by sliding the heel downward and hold for 5 seconds. In later stages of rehabilitation, do heel slides by grasping the leg with both hands and pulling the heel toward the buttocks

    Outcome Measures and Goals for Progression to Phase 2:

    Measure Test Description & Reference
    Goal -> Purpose/ reasoning
    Knee Flexion Athlete is supine, goniometer used on the following landmarks: greater trochanter, lateral femoral condyle, and the lateral malleolus (Norkin & White 1995) >90˚

    To enable cycling

    Effusion Stroke test (Sturgill et al, 2009).

    Zero: No wave produced on downstroke

    Trace: Small wave on medial side with downstroke

    1+: Large bulge on medial side with downstroke

    2+: Effusion spontaneously returns to medial side after upstroke

    3+: So much fluid that it is not possible to move the effusion out of the medial aspect of the knee

    Zero to 1+

    To minimise quadriceps inhibition

    Knee Extension Athlete is supine, goniometer used on the following landmarks: greater trochanter, lateral femoral condyle, and the lateral malleolus (Norkin & White 1995)

    To restore full ROM

    Quadriceps Lag Test With the athlete seated, the examiner lifts the heel until the relaxed knee is in full extension.  The subject is required to maintain full extension for 5 seconds once the examiner removes support (Stillman, BC. 2004). 0˚ lag

    To monitor quadriceps control and knee stability

    Functional Score
    IKDC Subjective Knee Evaluation Form (Irrgang et al, 2001) Score >40
    Bilateral Squat to Parallel
    Subject stands on 2 floor scales, squats to 60-90˚ knee flexion 5 times (Nietzel et al, 2002). >95% equal limb loading Even symmetrical weight bearing
    Standing Hamstring Activation
    Subject flexes the knee in standing to 90˚ (Seto et al. 1988)

    Prone knee bend without resistance.

    >20 reps

    Encourage knee flexion range and hamstring activation

    Short Lever Bridge
    Subject raises pelvis off ground 10 times while lying supine with knees bent to 90˚ 20+, no greater than 5 rep difference between limbs

    Maintain calf strength

    Calf Raises
    Standing on the edge of a step, the subject performs full range unilateral heel raises to fatigue. 1 repetition every 2 seconds. (Schlumberger et al, 2002) Lower limb power and control
    Unipedal Stance Test
    Subject stands on one leg with other leg raised and arms crossed over the chest. The assessor uses a stopwatch to time how long stance is maintained on one leg with a) eyes open, and b) eyes closed. Time ends when;

    • Arms are used (uncrossed)
    • Use of the raised foot (touches down or other leg)
    • Movement of the stance foot
    • 45 secs has elapsed (maximum time)
    • Eyes opened on eyes closed trials

    (Springer et al, 2007)

    • A (eyes open) 43 seconds
    • B (eyes closed) 9 seconds

    Normative data for 18-39 year olds

    Test for balancel