Free to download • For patients and physiotherapists
ACL and knee rehabilitation protocols
The full, criteria-based rehabilitation protocols used in Mr Osman Riaz’s practice — eight of them, covering ACL, meniscal repair, arthroscopy, PCL, osteotomy, knee replacement and patellar instability. Progression is by measured criteria, not the calendar. Free for any patient or physiotherapist to use.
Who these protocols are for
Know what should be happening to your knee and when — and what you have to achieve before moving on. Bring these to your physiotherapist; they are written to be shared.
Full outcome measures, limb symmetry index targets and progression criteria for every phase, including the Control to Chaos return-to-play continuum. Referrals and questions always welcome.
Why criteria-based matters. “Six months post-op” tells you nothing about whether a knee is ready. A quadriceps limb symmetry index of 80%, a vertical jump LSI of 85% and a cross-over hop LSI of 90% do. Returning to pivoting sport before hitting these markers is one of the clearest, best-evidenced risk factors for re-rupturing a graft — which is why every phase has numbers attached to it.
At a glance
The ACL reconstruction rehab protocol
The summary below is the backbone of the ACL protocol. Full detail for this and the other seven protocols is in the tabs further down this page.
| Phase | Focus | Criteria to progress |
|---|---|---|
| Prehab before surgery | Settle swelling, restore full range, rebuild quadriceps | Swelling <1+ • extension 0° • flexion ≥125° • quadriceps 90% of uninjured side on dynamometry • normal reciprocal gait |
| Phase 1 Weeks 1–3 | Reduce swelling, prevent arthrofibrosis, activate quadriceps, normalise gait | Extension 0° • flexion ≥125° • straight leg raise with no lag • full weight-bearing • pain 0–3 • KOOS recorded |
| Phase 2 Weeks 4–18 | Closed-chain strength: leg press, squats, lunges, step-downs, single-leg deadlifts; hamstrings from isometrics to Nordics and RDLs | Quadriceps 80% limb symmetry index by week 18 |
| Phase 3 Weeks 18–35 | Plyometrics — Stage 1 (18–22) landing mechanics and force absorption; Stage 2 (22–35) reactive, multi-planar force development | Vertical jump LSI ≥85% • triple hop LSI ≥87% • cross-over hop LSI ≥90% |
| Phase 4 Weeks 36–52+ | Return to play — the Control to Chaos continuum: high-speed running, then unplanned direction change and contact | Sport-specific chaos tolerance, then graded return to training and competition |
Full return to sport is typically 9–12 months and depends on meeting the criteria above rather than reaching a date. Where a lateral extra-articular tenodesis has been added, rehabilitation follows the same pathway.
Rehabilitation Protocol
ACL Reconstruction Surgery and Rehabilitation Protocol
ACL reconstruction is a key procedure for stabilising the knee after ACL tears. At Yorkshire Sports Knee Clinic, we offer both hamstring autograft and synthetic graft options, tailored to the needs of athletes or those who want to return to a high level of activity. The surgery focuses on restoring knee stability and function, with a comprehensive rehabilitation protocol to ensure the best outcomes.
Pre-Operative Rehab for ACL Injuries ("Prehab")
Before ACL reconstruction, pre-operative rehabilitation is crucial for optimizing the surgical outcome. It aims to reduce swelling, restore joint motion, and improve muscle strength to prepare the knee for surgery.
Pre-Operative Rehab for ACL Injuries ("Prehab")
- Reduce/Eliminate swelling
- Achieve full knee extension and hyperextension
- Achieve full knee flexion
- Normalize gait pattern
- Quadriceps/Hamstring strength ratio at 90% of the uninjured leg (if time allows)
- Patient education for post-surgery expectations and psychological preparation.
Prehab Outcome Measures:
| Outcome | Test Description | Expected Goal |
|---|---|---|
| Swelling | Sweep test, girth measurements over the patella and 3 cm above the proximal patella pole | Less than 1+; comparable to the uninjured side |
| Full Extension | Long arm goniometer | 0° or equal to the uninjured side |
| Full Flexion | Long arm goniometer | 125° or more |
| Normalized Gait | Evaluation of heel strike, toe-off, knee extension/flexion, hip extension | Full weight-bearing, reciprocal gait |
| Quadriceps Strength | Handheld dynamometer | 90% of uninjured side |
| Hamstring Strength | Handheld dynamometer | 90% of uninjured side |
| Patient Preparedness | Education and questionnaire | Confidence in post-surgery process |
ACL Reconstruction Surgery
The procedure involves replacing the torn ACL with a graft. The surgery is performed under general anaesthesia and typically takes 1–2 hours. Post-surgery, the graft will serve as a scaffold for the body to rebuild a new ligament over time.
Early Post-Operative Rehab (Weeks 1–3)
Goals:
- Reduce swelling
- Prevent joint stiffness and arthrofibrosis
- Activate the quadriceps
- Normalize gait
Early Rehab Outcome Measures:
| Outcome | Test Description | Expected Goal |
|---|---|---|
| Swelling | Sweep test, girth measurements | 1+ or less, symmetry between legs |
| Prevent Joint Stiffness | Full extension and hyperextension measured with a long arm goniometer | 0° or equal to uninjured side |
| | Full flexion measured with a long arm goniometer | 125° or more |
| Quadriceps Activation | Straight leg raise (SLR) with no lag | Full extension and no lag |
| Normalized Gait | Gait assessment | Full weight-bearing, reciprocal gait |
| Patient Feedback | KOOS score (Knee Injury and Osteoarthritis Outcome Score) | Marker of progress through rehab |
- Improvement in extension
- 125°+ flexion
- Minimal swelling (1+ or less)
- Minimal pain (0–3 on pain scale)
Criteria to Progress to Mid-Stage Rehab
Improvement in extension | 125°+ flexion | Minimal swelling (1+ or less) | Minimal pain (0–3 on pain scale)
Mid-Stage Rehab (Weeks 4–18)
During this phase, the focus is on regaining strength, restoring full knee motion, and preparing for functional activities.
Closed Kinetic Chain (CKC) Exercises (Weeks 4–18)
- Leg Press (90° to 0° range, progress as comfortable)
- Single-Leg Deadlifts (SLD)
- Squats (Progress from 0–45° to 0–90°)
- Lunges (Progress from 0–45° to 0–90°)
- Step Downs
Quadriceps Strength Goal: 80% limb symmetry index (LSI) by week 18.
Quadriceps Strength Goal:
80% limb symmetry index (LSI) by week 18.
Hamstring Exercises (Weeks 4–18):
- Weeks 4–12: Isometric and isokinetic curls, hip extensions, bridges
- Weeks 12–18: Straight leg bridges, Nordic curls, Romanian deadlifts (RDL)
Hamstring Strength Goal:
80% LSI by week 18.
Open Kinetic Chain (OKC) Exercises (Week 6–8+):
- Begin with light-resistance leg extensions at 45°–90°.
- Gradually progress to full ROM leg extensions by week 8+.
Criteria for Progressing: Able to squat 0–90° comfortably, full ROM, and no discomfort during leg extensions.
Plyometric Training (Weeks 18–35)
This phase introduces plyometric exercises to develop explosive strength and prepare for return to sports.
Plyometric Stage 1 (Weeks 18–22): Focus on jumping and landing mechanics, force absorption.
Plyometric Stage 2 (Weeks 22–35): Progress to more reactive exercises, focusing on eccentric and concentric force development in all planes of movement.
Criteria to Progress to Next Stage:
- Vertical jump LSI ≥85%
- Triple hop LSI ≥87%
- Cross-over hop LSI ≥90%
Return to Play – The Control to Chaos Continuum (Weeks 36–52+)
Goals:
- Introduce high-speed running and direction changes
- Enhance aerobic and anaerobic conditioning
- Maximise agility, acceleration, and deceleration
- Return to sport-specific drills
Return-to-Play Outcome Measures:
- Single-Leg Vertical Jump: 85% LSI
- Triple Hop for Distance: 87% LSI
- Crossover Hop for Distance: 90% LSI
- Quadriceps and Hamstring Strength: ≥90–95% LSI
Long-Term Recovery
A full return to sport is typically achieved within 9–12 months, depending on adherence to rehab protocols and progress.
Meniscal Repair Rehabilitation Protocol
Phase 1: 0-2 Weeks (Protection Phase)
Goal
Protect the repair, manage pain, and prevent stiffness.
- Brace: Hinge knee brace locked between 0-90° flexion for 6 weeks. Worn at all times except for hygiene and exercises.
- Weight Bearing: Partial weight-bearing (PWB) with crutches (typically 25-50%) unless the surgeon specifies otherwise. Patients should follow surgeon advice regarding progression to full weight-bearing.
- ROM: Limited to 0-90° to prevent stress on the repaired meniscus. ROM beyond 90° can increase shearing forces, especially during weight-bearing.
- Pain Management: Ice, elevation, compression, and analgesia as needed.
Exercises
- Quadriceps Isometrics: 5-second holds, 10 reps, 3 times per day to maintain muscle activation.
- Hamstring and Calf Stretches: Gentle stretching in non-weight-bearing positions to prevent stiffness.
- Straight Leg Raises: In brace to avoid hyperflexion, focusing on quad engagement.
- Passive Knee Extension: (0° flexion) while seated to maintain extension without stressing the meniscus.
- Active-Assisted ROM: Knee flexion within the allowed range (0-90°), performed slowly and pain-free.
Phase 2: 2-6 Weeks (Controlled Motion Phase)
Goal
Begin gentle mobility and controlled strengthening, while protecting the repair.
- Brace: Continue 0-90° locked brace for 6 weeks. Wear during all activities except for passive ROM exercises and showering.
- Weight Bearing: Gradual transition to full weight-bearing (FWB) as tolerated by the end of week 6. Crutches can be reduced after 4 weeks if gait pattern is normal and patient is pain-free.
- ROM: Progress gradually toward full ROM under supervision. Ensure passive ROM does not exceed 90° of flexion before week 6.
Exercises
- Quadriceps Activation Progression:
- Continue isometrics, progress to short arc quads (0-30°), and full arc quad sets as tolerated.
- Add resistance via light weights (0.5-1kg) or bands at 4 weeks for leg extensions in safe ranges.
- Stationary Cycling: No resistance, minimal flexion (≤90°), 5-10 minutes to aid joint mobility.
- Heel Slides: In sitting or supine, 3 x 15-20 reps within pain-free range, do not exceed 90°.
- Closed-Chain Isometrics: Mini squats (30-45° flexion), focusing on co-contraction of quads and hamstrings without knee instability.
- Straight Leg Raises (SLRs): With brace or minimal flexion, avoiding valgus/varus movements.
- Core Stability and Hip Strengthening: Side-lying leg lifts, bridging exercises, focusing on hip abductors to avoid excessive knee strain.
Phase 3: 6-12 Weeks (Strengthening & Controlled Load Phase)
Goal
Gradual progression of strength, balance, and controlled motion.
- Brace: Discontinue brace after 6 weeks unless otherwise advised.
- Weight Bearing: Full weight-bearing without crutches if gait is normal, pain-free, and knee is stable.
- ROM: Achieve full ROM by week 12 (0-135° flexion). Avoid forced ROM.
Exercises
- Progressive Strengthening:
- Open Chain Quad Work: Avoid ranges beyond 60° flexion.
- Closed-Chain Work: Begin mini squats, leg presses (0-60°), wall sits, and step-ups with gradual resistance.
- Proprioception and Balance Training:
- Single-leg stance on unstable surfaces (e.g., foam, wobble boards).
- Balance beam walking and controlled lunges.
- Cycling and Swimming (Freestyle): Gentle cycling with progressive resistance. Swimming allowed but avoid breaststroke to minimize valgus stress.
- Gluteal and Core Strengthening: Bridging, side planks, and dynamic core exercises to reduce stress on the knee.
Phase 4: 12-16 Weeks (Advanced Strength & Endurance)
Goal
Restore functional strength and dynamic control.
- ROM: Full ROM without restrictions.
- Weight Bearing: Full.
- Functional Movements: Introduce higher-load, multi-joint exercises.
Exercises
- Advanced Closed-Chain Strengthening:
- Single-leg squats, lunges, and step-downs. Focus on form and knee alignment.
- Increase resistance in leg presses, squats (0-90°), and step-ups.
- Plyometric Progression: Gentle hopping, controlled jumps with soft landings. Focus on proprioception.
- Endurance: Low-impact cardio (elliptical, cycling, rowing). Avoid high-impact activities like running until late in this phase and only if the patient is pain-free and has adequate strength.
- Neuromuscular Control: Agility drills, ladder drills, and pivoting exercises with close monitoring of knee stability and alignment.
Phase 5: 16+ Weeks (Return to Sport and High-Level Function)
Goal
Full return to activity and sport-specific drills.
- ROM: Full, functional ROM.
- Functional Movements: Advanced strengthening, agility, and coordination training.
Exercises
- Plyometrics & Jump Training: Box jumps, bounding, and lateral agility drills, ensuring control with take-off and landing.
- Sport-Specific Drills: Progressive return to running, pivoting, and cutting. Sports drills (e.g., soccer, basketball) can begin with gradual increases in intensity.
- Strength Maintenance: Continue with multi-joint, functional exercises (e.g., deadlifts, single-leg squats) with a focus on balanced loading.
- Running Progression: Gradual return to running, beginning with treadmill work, progressing to outdoor running, focusing on form and minimizing knee valgus during acceleration/deceleration.
Important Considerations
Avoid Deep Flexion
Avoid exercises that require more than 90° of flexion, such as deep squats, until late in rehabilitation.
Return to Impact Activities
Running, jumping, and high-intensity activities are typically introduced no earlier than 12-16 weeks, depending on patient progress.
Monitor for Pain/Swelling
Any increase in pain or swelling should be addressed with rest and modification of activity.
Surgeon Guidance
Always adhere to specific instructions from the surgeon, especially if there were additional procedures during surgery (e.g., ACL reconstruction).
Knee Arthroscopy Rehabilitation Protocol
Phase 1: Immediate Post-Surgery (Week 0-2)
- Goals: Control swelling, prevent stiffness, initiate weight-bearing.
- Actions: Follow RICE protocol (Rest, Ice, Compression, Elevation). Perform heel slides, quadriceps activation exercises, and focus on achieving full knee extension.
- Weight-bearing: Weight Bearing As Tolerated (WBAT) with crutches.
Phase 2: Early Recovery (Week 2-4)
- Goals: Restore range of motion and improve walking.
- Actions: Engage in gentle cycling, gait training, and strengthening exercises (quad sets and straight leg raises).
Phase 3: Strength & Mobility (Week 4-6)
- Goals: Increase strength and mobility.
- Actions: Incorporate closed-chain exercises, leg presses, and balance exercises.
Phase 4: Return to Activity (Week 6+)
- Goals: Achieve full recovery of knee function.
- Actions: Begin plyometric exercises, sport-specific drills, and non-impact activities such as swimming.
Progression Criteria: Individualize based on pain-free motion, strength return, and ability to bear weight fully.
For a more tailored recovery plan, consult your physiotherapist.
PCL Reconstruction Rehabilitation Protocol
Week 0–2: Early Post-Operative Phase
- Walking:
- WBAT (Weight Bearing As Tolerated) unless otherwise directed.
- Use of crutches with brace support (E/C).
- Walking:
- Range of Movement:
- Remain in full extension.
- Passive Range of Motion (PROM) 0–90° in prone position (with assistance from physio or opposite leg).
- Patella mobilizations to avoid patella-femoral stiffness.
- Education on wearing brace 24/7. - Swelling:
- Ice and elevation to reduce swelling.
- Strength:
- In brace exercises:
-- Quadriceps setting (squats).
-- Straight leg raises (SLR).
-- Hip abduction/adduction exercises.- Femoral overpressure if extension is not achieved to 0°.
Week 2–4: Early Movement Phase
- Walking:
- WBAT, weaning off crutches as tolerated. - Range of Movement:
- Continue to wear brace set to 0–90°.
- PROM 0–90° in prone (with assistance).
- Focus on achieving full extension to 0°. - Swelling:
- Continue regular ice and elevation. - Strength:
- Add in:
-- Gluteus maximus exercises (in prone position).
-- Double leg heel raises. - If not achieving full extension, consider returning for extension stretches and femoral overpressure.
Week 4–6: Controlled Movement Phase
- Walking:
- Gait retraining with/without crutches and brace. - Range of Movement:
- Brace set to 0–90°.
- Active Range of Motion (AROM) 0–90°. - Other:
- Introduce neuromuscular control, proprioception, and balance exercises if weight-bearing is allowed. - Strength:
- Add in:
-- Wall slides (≤ 45° if WB).
-- Inner range quadriceps (IRQ) with tibia block. - Goals by Week 6:
- Full extension to 0°.
- Flexion to 90° in brace.
- SLR with no lag.
- No significant swelling.
Week 6–8: Progression Phase
- Walking:
- Gait retraining in brace. - Range of Movement:
- AROM in brace to full ROM (120°). - Strength:
- Add in:
-- Gluteus medius exercises.
-- Single leg dips.
-- Single leg heel raises.
-- Lunges. - Gym:
-- Stationary bike (low resistance, high seat).
Week 8–12: Brace Weaning Phase
- Walking:
- Wean brace by Week 12.
- Wean off crutches (if still using).
- Aim for a normal gait pattern. - Range of Movement:
- Achieve full AROM.
- Do not force full flexion or hyperextension. - Strength:
- Continue strength exercises.
- Focus on control during knee dips. - Gym:
- Stationary bike (low resistance).
- Cross trainer.
- Stepper.
- Closed chain leg press. - Driving may resume when brace is removed, and patient is comfortable.
Week 12: Strength and Function Focus
- Walking:
- Normal gait pattern with no brace. - Range of Movement:
- Push for full hyperextension (femoral overpressure).
- Increase flexion range. - Strength:
- Start hamstring strengthening:
-- Hamstring curls in prone, mid-range (70–90°).
Week 14: Strength Progression
- Strength:
- Hamstring curls in standing. - Gym:
- Increase bike resistance.
- Cross trainer.
- Stepper.
- Treadmill walking.
- Quads bench exercises at 60°.
Week 16: Functional Strength and Mobility
- Walking:
- Full weight-bearing (FWB).
- No limp during gait. - Range of Movement:
- Achieve full flexion and hyperextension. - Strength:
- Progress hamstring bench exercises.
- Continue increasing open-chain quadriceps strengthening.
Week 18: Plyometric and Strength Testing
- Strength:
- Quads/Hamstring strength testing. - Gym:
- Begin plyometrics and interval jogging if strength testing criteria are met.
- Continue:
-- Quads bench exercises.
-- Hamstring bench exercises.
Week 24+: Return to Sport Prep
- Plyometric Test:
- Pass plyometric test: ≥85% of non-operated leg on 3-hop test. - Strength Test:
- Pass quads/hamstring strength test: ≥95% of non-operated leg. - Running Rehabilitation:
- Start progressive running rehab. - Criteria for Return to Sport:
- Ensure quad/hamstring ratio is over 85% of the same leg (quads > hams).
- No contact or competitive sports until 9–12 months post-op.
Tailored to the clinic, progression is based on pain-free motion, strength return, and full weight-bearing ability.
For further details, consult your physiotherapist for an individualised plan
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Osteotomy Rehabilitation Protocol
Phase 1: Immediate Post-Operative (Weeks 1-2)
- Goals: Manage pain, reduce swelling, and begin gentle range of motion exercises.
- Activities:
- Rest and elevate the leg to minimise swelling.
- Use ice packs for 15-20 minutes every few hours to manage pain.
- Begin passive range of motion exercises as tolerated, avoiding any discomfort.
- Weight-bearing is typically limited; crutches may be necessary initially.
Phase 2: Early Rehabilitation (Weeks 2-6)
- Goals: Restore range of motion and initiate strengthening exercises.
- Activities:
- Gradually increase weight-bearing as guided by the surgeon or physiotherapist.
- Start physical therapy sessions focused on gentle active range of motion and strengthening exercises for the quadriceps and hamstrings.
- Introduce low-impact activities, such as stationary cycling, as tolerated to improve mobility.
Phase 3: Strengthening and Functional Training (Weeks 6-12)
- Goals: Enhance muscle strength and improve functional mobility.
- Activities:
- Continue physical therapy, focusing on strengthening exercises for the lower extremities, core stability, and balance.
- Gradually progress to more functional movements, including squats, lunges, and gait training.
- Start incorporating sport-specific movements as advised by the physiotherapist.
Phase 4: Return to Sports and Activity (Months 3-6)
- Goals: Prepare for a safe return to sports and high-impact activities.
- Activities:
- Continue with advanced rehabilitation exercises, focusing on strength, agility, and proprioception.
- Gradual reintroduction to sport-specific drills and exercises.
- Evaluate readiness for full participation in sports through functional testing and assessments.
Postoperative Rehabilitation Protocol for Total Knee Replacement
Phase 1: Immediate Post-Operative (Weeks 1-2)
- Goals:
- Manage pain and swelling
- Begin gentle range of motion (ROM)
- Initiate weight-bearing as tolerated
- Activities:
- Rest and ice the knee, applying ice packs for 15-20 minutes every few hours.
- Elevate the leg to reduce swelling.
- Begin passive and active-assisted ROM exercises.
- Engage in quadriceps and hamstring exercise.
- Start full weight-bearing with crutches or a walker.
Phase 2: Early Rehabilitation (Weeks 2-6)
- Goals:
- Improve ROM and strength
- Activities:
- Attend regular physiotherapy sessions focused on active ROM and strengthening exercises.
- Practice gait training and begin using a stationary bike.
- Start stair climbing with assistance.
Phase 3: Strengthening and Functional Training (Weeks 6-12)
- Goals:
- Enhance muscle strength
- Improve functional mobility
- Activities:
- Continue physiotherapy with a focus on strength and balance training.
- Incorporate low-impact activities and functional movements.
Phase 4: Return to normal Activity (Months 3)
- Goals:
- Prepare for a safe return to normal daily activities
- Activities:
- Engage in advanced rehabilitation exercises.
- Evaluate readiness for full participation through functional testing.
Patellar Instability Surgery Rehabilitation Protocol
Weeks 1–2: Early Recovery
- Goals: Manage pain and swelling, achieve full knee extension, initiate gentle ROM exercises.
- Activities:
- Passive and active knee flexion.
- Full weight-bearing with crutches as tolerated.
- Early quadriceps activation (e.g., straight leg raises).
- Begin gentle balance and proprioception training.
Weeks 2–6: Strengthening Phase
- Goals: Achieve full extension and near-full flexion, improve quadriceps control, and wean off crutches.
- Activities:
- Continue swelling management, progress to closed-chain quadriceps exercises (mini squats, lunges).
- Cycling on a stationary bike once 100° knee flexion is reached.
- Initiate gentle resistance exercises for quadriceps and hamstrings.
Weeks 6–12: Intermediate Rehabilitation
- Goals: Full ROM, increased strength, and improved balance.
- Activities:
- Progress to functional movements such as squats, lunges, and controlled rotational exercises.
- Focus on VMO strengthening for better patella tracking.
- Continue advanced proprioception and coordination exercises.
Months 3–6: Return to Activity
- Goals: Build strength and stability for a return to sports.
- Activities:
- Progress to running, jumping, cutting, and pivoting drills.
- Sport-specific exercises and agility drills.
- Regular testing of strength and function to assess readiness for sports.
Months 6+: Return to Sport
- Goals: Full return to non-contact and contact sports.
- Activities:
- Gradual reintroduction to sports with a focus on functional performance, starting with non-contact drills and progressing to full training.
