What rehabilitation and exercise approach is recommended after knee Anterior Cruciate Ligament (ACL) reconstruction and Meniscus repair surgery?

Rehabilitation Protocol After ACL Reconstruction and Meniscus Repair Surgery

Following ACL reconstruction and meniscus repair surgery, rehabilitation should follow a comprehensive, progressive program lasting 9-12 months with combined strength and neuromuscular training to optimize outcomes and prevent reinjury. 1, 2

Early Phase (0-4 weeks)

• Immediate knee mobilization

  • Begin within first week to increase range of motion and prevent extension deficit 1, 2
  • Aim for full extension and progressive flexion
  • No continuous passive motion devices (not recommended) 1

• Weight bearing

  • Immediate weight bearing as tolerated if correct gait pattern can be maintained 1
  • Use crutches initially if needed to maintain proper gait mechanics
  • Progress to full weight bearing based on pain and swelling response 1, 2

• Pain and swelling management

  • Apply cryotherapy in first postoperative week 1, 2
  • Monitor for effusion and adjust exercise intensity accordingly

• Initial strengthening

  • Begin isometric quadriceps exercises in first week if pain-free 1, 2
  • Consider neuromuscular electrical stimulation for quadriceps activation 1, 3
  • Prioritize closed kinetic chain (CKC) exercises from week 2 1, 2
  • Avoid open kinetic chain (OKC) exercises until week 4 1

Intermediate Phase (4-12 weeks)

• Progressive strengthening

  • Introduce OKC exercises at week 4 with restricted range of motion (90°-45°) 1, 2
  • For hamstring grafts: avoid adding extra weight to OKC exercises for first 12 weeks 1
  • Progress ROM for OKC exercises: 90°-30° in week 5,90°-20° in week 6,90°-10° in week 7, full ROM in week 8 1
  • Add concentric and eccentric exercises when quadriceps is reactivated 1

• Neuromuscular training

  • Add balance and proprioception exercises to strength training 1, 2
  • Focus on quality of movement patterns 1
  • Include core stability exercises to improve gait and knee function 1, 2

• Functional progression

  • Evaluate readiness for running (typically around 12 weeks) 1
  • Use combination of time-based, clinical and functional criteria for running progression 1
  • Monitor for pain, swelling, or mechanical symptoms during activity progression

Advanced Phase (12-24 weeks)

• Sport-specific training

  • Introduce plyometric and agility training 1, 2
  • Begin with low-intensity plyometrics and progress as tolerated 1
  • Add sport-specific movement patterns and drills 2

• Progressive functional activities

  • Implement gradual return to running program
  • Progress to cutting, pivoting, and jumping activities based on functional testing and strength criteria
  • Monitor for proper biomechanics during all activities 1

Return to Sport Phase (24+ weeks)

• Comprehensive testing criteria

  • No pain or swelling 2
  • Full knee range of motion 2
  • Limb Symmetry Index (LSI) >90% for strength and hop tests (100% recommended for pivoting/contact sports) 1, 2
  • Stable knee on clinical examination 2
  • Normalized patient-reported outcomes 1, 2
  • Psychological readiness for return to sport 1

• Gradual sport reintegration

  • Begin with skill drills before full competitive activities 2
  • Continue maintenance strength program 2
  • Consider continued use of preventive neuromuscular training

Special Considerations for Meniscus Repair

The rehabilitation protocol following combined ACL reconstruction and meniscus repair does not need significant modification compared to isolated ACL reconstruction 4, 5. Research shows:

• Weightbearing and range of motion restrictions associated with meniscus repair do not result in worse outcomes at 6 months 4
• Success rates for meniscus healing are actually higher (92%) when performed with concurrent ACL reconstruction compared to isolated meniscus repairs (67%) 5

Common Pitfalls to Avoid

1. Delaying mobilization - immediate knee mobilization is critical to prevent complications 2
2. Neglecting quadriceps strengthening - quadriceps strength deficits >20% have significant negative consequences for long-term outcomes 1, 2
3. Focusing only on strength without neuromuscular control - both components are essential 1, 2
4. Using time alone for progression - use functional criteria and quality of movement 1, 2
5. Returning to sport too early - incomplete rehabilitation increases reinjury risk 1
6. Neglecting psychological factors - fear of reinjury can impact rehabilitation outcomes 1

Monitoring and Progression

• Use objective measures to track progress throughout rehabilitation 1
• Evaluate both quantity (strength, ROM) and quality of movement 1
• Adjust program based on individual response (pain, swelling, progress) 2
• Continue rehabilitation for 9-12 months depending on return-to-work or play goals 1