Safe Exercises for Someone with a Pacemaker and ACL Tear
You can safely perform supervised rehabilitation exercises focusing on closed kinetic chain exercises, isometric quadriceps work, and neuromuscular training while avoiding high-impact activities that could affect your pacemaker, with immediate knee mobilization and weight-bearing as tolerated starting within the first week. 1
Immediate Phase (First 4 Weeks)
Safe Exercises to Start Now
Begin isometric quadriceps exercises immediately, including static quadriceps contractions and straight leg raises, which can be safely prescribed during the first 2 postoperative weeks and provide faster recovery of knee range of motion without compromising stability. 1
Start closed kinetic chain exercises early, including wall push-ups with progressive hand elevation, quadruped position exercises, and weight-bearing through controlled positions, as these provide better joint stability and are pacemaker-safe since they avoid upper body strain. 2, 3
Implement immediate knee mobilization within 1 week following your ACL tear, as this approach is recommended across multiple guidelines without ROM restrictions. 1
Progress to immediate full weight-bearing as tolerated, which should be used following ACL injury once specific criteria are fulfilled. 1
Pacemaker-Specific Precautions
Avoid exercises requiring arm elevation above shoulder level or sustained upper extremity work during the first 6-8 weeks, as these could stress pacemaker leads or the implant site, though standard ACL rehabilitation exercises are generally safe.
Monitor for any chest discomfort, palpitations, or dizziness during exercise, which would indicate pacemaker issues requiring immediate medical attention.
Intermediate Phase (4-12 Weeks)
Progressive Strengthening
Advance to both open and closed kinetic chain exercises at 4 weeks, as evidence recommends using both types post-ACL injury for regaining quadriceps strength, with open kinetic chain exercises performed in the 90-45° range. 1
Start leg press exercises at 3 weeks to improve subjective knee function and functional outcomes. 1
Begin isokinetic hamstring strengthening at 3 weeks using a functional pattern similar to a half squat (0°-45°) to improve quadriceps and hamstring strength, while monitoring for anterior knee pain. 1
Consider eccentric cycle ergometer training at 3 weeks, which may result in greater strength gains, better daily activity level, and greater quadriceps muscle hypertrophy, with beneficial effects persisting 1 year after injury, without affecting laxity, pain, or swelling. 1
Neuromuscular and Motor Control Training
Add motor control training including unstable surface work (balance pad or foam roller), backward walking on an inclined treadmill, and single-leg dynamic balance exercises, which significantly improve knee joint proprioception in early and intermediate phases. 1, 3
Implement strength and neuromuscular training together, as the combination should be used in postoperative rehabilitation and both training modules significantly improve quadriceps and hamstring strength. 1
Include core stability exercises starting at 4 weeks, as these improve gait, subjective knee function, and range of motion when added to the usual rehabilitation protocol. 1
Exercise Dosing
Perform strengthening exercises 3-4 times per week with at least 48 hours between sessions targeting the same muscle groups. 2
Progress resistance when you can complete 3 sets of 15 repetitions without pain, effusion, or increased joint temperature. 2
Advanced Phase (12+ Weeks)
Return to Running and Plyometrics
Wait a minimum of 12 weeks before initiating running, using a combination of time-based, clinical, and functional criteria rather than time alone. 1, 3
Add plyometric and agility training after 12 weeks, as these have additional benefit at the advanced rehabilitation phase on subjective function and functional outcomes compared with usual rehabilitation protocol. 1
Begin preparatory plyometric activities at low intensity, such as two-hand ball catches and throws against a wall, and light medicine ball chest passes, gradually progressing to single-arm activities over 2-4 weeks. 2
Implement 8 weeks of plyometric exercise regardless of intensity, as this has positive effects on knee function, knee impairments, and psychosocial status. 1
Consider combining plyometric and eccentric training, which shows significant improvement in balance, subjective function, and functional activities compared to either modality alone. 1
Critical Monitoring Parameters
Knee-Specific Red Flags
Stop exercise immediately if you develop knee effusion, increased pain, swelling, or warmth, as these indicate excessive loading requiring immediate modification. 2, 4
Apply cryotherapy after exercise sessions to decrease pain and swelling, with compressive cryotherapy being more effective than cryotherapy alone. 4
Elevate your limb above heart level when resting to help reduce swelling. 4
Pacemaker Monitoring
Check your pulse before and after exercise to ensure your pacemaker is functioning appropriately, with your target heart rate determined by your cardiologist.
Avoid contact sports or activities with risk of direct chest trauma that could damage the pacemaker device.
Common Pitfalls to Avoid
Never progress exercises if effusion develops, as this is the most critical error and leads to prolonged symptoms. 4
Do not neglect quadriceps strengthening, as a deficit >20% significantly impairs outcomes and predisposes to ongoing symptoms, being the primary determinant of long-term outcomes. 4
Avoid using a postoperative knee brace routinely, as it should not be used following ACL injury according to multiple guidelines. 1
Do not rely solely on time-based criteria for return to activity; combine with functional testing including hop tests, quadriceps and hamstring strength symmetry, and proprioception assessment. 3
Rehabilitation Duration and Expectations
Continue rehabilitation for 9-12 months depending on return-to-sport goals, using criterion-based progression rather than time alone. 4
Expect to return to driving approximately 2-3 weeks after left-sided ACL injury, as brake response time returns to normal values at this timeframe. 1
Understand that only 24% of patients after ACL injury meet the guideline of 10,000 steps per day, and objectively measured physical activity is often lower than self-reported activity scales suggest. 5
Be aware that psychological factors including fear of reinjury influence rehabilitation and should be evaluated objectively, as these affect rehabilitation progress. 2, 4