ACL Hamstring Autograft Rehab Protocol

ACL Hamstring Autograft Rehab Protocol

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The goal of this protocol is to provide a clinical guideline for the post-surgical course of physical therapy for a patient who has had a hamstring tendon allograft Anterior Cruciate Ligament (ACL) reconstruction.  This is not intended to substitute clinical decision making regarding the patient’s proper progression based on evaluation findings, individual progress, and if/when post-operative complications arise.  If a clinician requires assistance in the progression of a post-surgical patient the surgeon should be consulted. 


  • Protection of the graft during the primary re-vascularization phase (8 weeks) and graft fixation phase (8-12 weeks)
  • Continuous passive motion machine not commonly used
  • For ACL reconstruction, with associated meniscus repair, defer to ROM and weight bearing precautions outlined in the meniscus repair protocol 
  • The physician may change the time guidelines for braces and crutches
  • Supervised physical therapy takes place for 4-7 months
  • Use caution with hamstring stretching/strengthening; based on donor site morbidity and with meniscus repair.


  • No bathing/showering until after suture removal.  Sponge bath only.  Brace may be removed for bathing/showering.
  • Sleep with brace locked in extension for 1 week or as directed by PT/MD for maintenance of full extension.
  • Driving:
    • 1 week for automatic cars, left leg surgery
    • 2-4 weeks for standard cars, or right leg surgery
  • Post-op brace:
    • Week 0-1: Locked in full extension for ambulation and sleeping
    • Week 2-3: Unlock brace (< 90°) as quad control improves
    • Week 3-4: Wean off brace if patient demonstrates good quad control and normal gait
  • Use of crutches/brace for 4 weeks with adequate quad function
  • Partial weight bearing (PWB)  for 0-1 weeks with crutches and brace
  • Pass VTFC Knee Functional Performance Test 1 at 3 months
  • Pass VTFC Knee Functional Performance Test 2 at 6 months
  • Return to work as directed by PT/MD based on work demands

Rehabilitation Progression

PHASE I: Week 0 – 4:


  • Protect graft and graft fixation with use of brace and specific exercises
  • Minimize effects of immobilization
  • Promote an optimal healing environment and control inflammation and swelling
  • Full active and passive extension/hyperextension ROM.  Caution: avoid hyperextension > 10°
  • Educate patient on rehabilitation progression
  • Flexion to 90° only in order to protect graft fixation
  • Facilitate quadriceps control to minimize quad lag
  • Restore normal gait on level surfaces


  • Week 0-1: Brace locked in full extension for ambulation and sleeping
  • Week 1-4: Unlock brace (< 90°) and wean from brace as quad control allows and normal gait.
  • Week 4-8: Only use brace in vulnerable situations (ie. crowds, uneven terrain, etc)

Weight Bearing Status:

  • Week 0-1: As able. May require 2 crutches for partial weight bearing based on post-op instructions
  • Week 1-4: As able. May require PWB to full weight bearing with normal gait mechanics 
  • > Week 4: Wean from brace/crutches by 4 weeks as patient demonstrates normal gait mechanics and good quad control with no quadriceps/extension lag


  • Active-assisted leg curls (0-1 week)
    • Progress to active as tolerated after 1 week.  Delay strengthening for 12 weeks. 
  • Knee ROM:  Bike – no resistance (PRN) with rock and roll. Heel slides to 90°
  • Quad sets (Consider NMES for poor quad control)
  • Gastroc/Soleus strengthening
  • Gentle hamstring stretching at 1 week, Calf stretches non-weight bearing
  • Initiate Closed Kinetic Chain quad strengthening and progress as tolerated (wall sits, step-ups, mini-squats, Leg Press 90°-30°, multi-directional lunges slides,  lunges, mini step-down heel touches)
  • SLR, all planes, with brace in full extension until quadriceps strength sufficient to prevent extension lag.
    • Add weight as tolerated to hip abduction, hip adduction, and extension
  • Quadriceps isometrics 60° and 90° (resistance proximal and not distal to protect graft fixation)
  • Limited Range Seated Quadriceps Extension with ankle weight (90° – 40° extension)
  • If available, aquatic therapy (once sutures removed) for normalized gait, weight bearing strengthening, deep water aqua jogging for ROM and swelling. 

PHASE II: Weeks 4-12:

Criteria to advance to Phase II:

  • Full extension
  • Good quad set, SLR, without extension lag
  • Flexion to 90°
  • Minimal swelling/inflammation
  • Normal gait on level surfaces


  • Restore normal gait with stair climbing
  • Maintain full extension, progress toward full flexion ROM
  • Protect graft and graft fixation
  • Increase hip, quadriceps, and calf strength
  • Increase proprioception
  • Pass VTFC Knee Functional Performance Test I

Brace/Weight Bearing Status:

  • Full weight bearing, no brace


  • Complete VTFC Knee Functional Performance Test 1
  • Continue with ROM/flexibility exercises as appropriate 
  • Progressive hip, hamstring, calf strengthening.
    • Week 12:  Gradually add resistance to open chain hamstring exercises 
  • Continue hamstring, gastroc/soleus stretches
  • Stairmaster (begin with short steps, avoid hyperextension)
  • Conditioning:  Elliptical machine / Nordic Trac / Stationary bike (progressive time and resistance)
  • Single leg balance/proprioception work
  • Week 8-12: Jogging/running intervals in aquatic treadmill

Phase III:  Week 12 to 18 – 20 (4.5 – 5 months):

Criteria to advance to Phase III:

  • No patellofemoral pain
  • Minimum of 120° of flexion
  • Sufficient strength and proprioception to initiate running (unweighted or in pool)
  • Minimal swelling/inflammation
  • Pass VTFC Knee Functional Performance Test 1


  • Full ROM (comparable to uninvolved side, if normal)
  • Improve strength, endurance, and proprioception of the lower extremity to prepare for sports 
  • Isokinetics (with anti-shear device)
  • Begin with mid-range speeds (120°/sec – 240°/sec)
  • Progress towards full weight bearing running at about 16 weeks
  • Knee Extensions
  • Begin swimming if desired
  • Recommend isokinetic test with anti-shear device at 14-16 weeks to guide continued strengthening
  • Progressive hip, quad, hamstring, and calf strengthening
  • Cardiovascular endurance training via stairmaster, versaclimber, elliptical, bike
  • Advance proprioceptive training activities

Phase IV:  4.5–5 months through 6-7 months:

Criteria for advancement to Phase IV:

  • No significant swelling/inflammation
  • Full, pain-free ROM
  • No evidence of patellofemoral joint irritation
  • Strength approximately 70% of uninvolved lower extremity per isokinetic evaluation
  • Sufficient strength and proprioception to initiate agility activities
  • Normal running gait


  • Symmetric performance of basic and sport specific agility drills
  • Single hop and three hop tests 85% of uninvolved leg
  • Quadriceps and hamstrings strength at least 85% of uninvolved lower extremity per testing


  • Complete VTFC Knee Functional Performance Test 2
  • Continue and progress flexibility and strengthening program based on individual needs and deficits
  • Initiate plyometric program as appropriate for patient’s athletic goals
  • Agility progression including, but not limited to:
  • Side steps, Crossovers, Figure 8 running, Shuttle running
  • One leg and two leg jumping
  • Broad jumps while sticking landing, 3 hop jumps
  • Two legged 90° turns with landing (cw/ccw turns), progressing to single leg 
  • Cutting
  • Acceleration/deceleration springs
  • Agility ladder drills
  • Continue progression of running distance based on patient needs
  • Initiate sport-specific drills as appropriate for patient

Phase V:  Begins at post-operative months 6-7:

Criteria for advancement to Phase V:

  • No patellofemoral pain or soft tissue complaints
  • Necessary joint ROM, strength, endurance, and proprioception to safely return to work/athletics
  • Physician clearance to resume partial or full activity
  • Pass VTFC Knee Functional Performance Test 2


  • Safe return to athletics/work
  • Maintenance of strength, endurance, and proprioception
  • Patient education with regards to any possible limitations


  • Gradual return to sports participation
  • Maintenance program for strength, endurance


  • Functional brace generally not used, but may be recommended by the physician on an individual basis