ACL reconstruction with meniscal repair
Combined protocol: on top of the ACL progression sit the loading, deep-flexion and rotation restrictions required for healing of the repaired meniscus.
Typically 4-8 weeks longer than isolated ACL; return to sport at 9-12 months
This protocol is part of the post-operative pathway and must be adapted to the surgeon’s instructions and to the individual clinical response.
These documents are protocol templates for information and education only: they do not replace the rehabilitation prescription for the individual case. Timing, loading and progressions must always be adapted to the patient, the lesion pattern, the surgical technique used and the clinical course, in collaboration between orthopaedic surgeon, physiotherapist and, where appropriate, physiatrist. Progression is driven by objective criteria, not by the calendar alone.
At a glance
- Weight bearing
- Peripheral longitudinal tears: touch-down/partial weight bearing for 2-4 weeks. Radial, complex or root repairs: partial weight bearing for 4-6 weeks.
- ROM
- Usually 0-90° for 4-6 weeks in complex repairs; flexion beyond 90° only unloaded and without rotation.
- Loaded deep flexion
- Deep squatting and kneeling avoided for 8-12 weeks.
- Rotation / pivot
- Avoided with the knee flexed until at least 8-12 weeks after repair.
- Running
- Usually delayed 4-8 weeks compared with isolated ACL (roughly months 4-5).
- Return to sport
- 9-12 months, also conditional on absence of mechanical symptoms and joint-line pain.
- Weeks 0-4Flexion limited to 90°, meniscus-protocol weight bearing
- 6 weeksFlexion released, full weight bearing
- Months 3-4Straight-line running
- Month 6Plyometrics and agility
- Months 9-12Return to pivoting sport
When ACL reconstruction is combined with meniscal repair, the protocol is not simply the sum of the two: the more conservative restriction always prevails, because the repaired meniscus is vulnerable to the combination of load, deep flexion and rotation.
Step by step
Each phase lists the goals, what to do and the exercises for that exact moment: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
Before surgery — Preoperative preparation (prehabilitation)
Indicatively 2-6 weeks, but only if the meniscal lesion allows it: with a locked knee or early indication there is no rigid target of completing weeks of prehabilitation.
When it applies
- •The preoperative phase can resemble that of isolated ACL reconstruction, but must respect pain, any joint locking and the meniscal tear pattern.
- •With a bucket-handle tear, mechanical locking or an indication for early repair, surgery takes priority.
- •Exercises must be filtered by the physiotherapist: deep loaded flexion and twisting are avoided.
Goals before surgery
- •Full extension, or symmetrical to the uninjured knee.
- •Near-full flexion.
- •Minimal effusion (a "dry" knee).
- •Walking without significant limp, ideally without crutches.
- •Good voluntary quadriceps control and activation, with no extension lag.
- •Strength recovery compatible with the clinical picture of the injured limb.
- •Education on brace, crutches, allowed weight bearing and the early post-operative phases.
Activities
- •Effusion and pain control (ice, elevation, load management).
- •Practical education on brace, crutches, allowed weight bearing and the goals of the first weeks.
- •Daily home programme, alongside physiotherapy sessions.
Preoperative exercises
Quadriceps isometric contraction (quad set)
- •Lying down, knee straight in a neutral position on the surface; if proprioceptive feedback helps, place a small rolled towel under the knee.
- •Contract the quadriceps pushing the back of the knee toward the surface, hold, then release slowly.
- •Aim for a visible, global quadriceps contraction, without breath holding.
Dosage: Indicative: 10 contractions of 5 seconds, 2-3 times a day. To be adapted with the physiotherapist.
Straight leg raise (only if there is no extension lag)
- •First contract the quadriceps and lock the knee in full extension.
- •Lift the straight leg about 30 cm keeping the knee straight, then lower it slowly.
- •If the knee drops into flexion during the lift (extension lag), stop and work on quad sets first.
Dosage: Indicative: 2-3 sets of 8-10 repetitions. To be adapted with the physiotherapist.
Extension recovery with the heel supported
- •Lying down, rest only the heel on a low support leaving the knee unsupported.
- •Let the knee drop under gravity with the thigh relaxed; a gentle quadriceps contraction can be added.
- •Do not force and do not push abruptly on the knee: extension returns with time and relaxation.
Dosage: Indicative: 3-5 minutes, several times a day if well tolerated.
Heel slides / active-assisted flexion
- •Lying down, slide the heel toward the buttock keeping the foot in contact with the surface.
- •You may assist with your hands or a towel around the leg, staying within the pain-free range.
- •Return slowly to the start position, regaining full extension.
Dosage: Indicative: 10-15 repetitions, 2-3 times a day.
Bridge
- •Supine, knees bent and feet hip-width apart on the floor.
- •Lift the pelvis squeezing the glutes, without arching the back, then lower slowly.
Dosage: Indicative: 2-3 sets of 10-12 repetitions.
Stationary bike
- •To be introduced when range of motion and pain allow: raise the saddle if flexion is still limited.
- •Continuous pedalling at low resistance, pain-free and without increased swelling in the following hours.
Dosage: Indicative: 10-20 minutes, as tolerated.
Crutch and weight-bearing training
- •Try the crutches before surgery, with correct height and the weight-bearing status set by the surgeon.
- •Practise on level ground, stairs and the entrance to your home, with someone assisting.
- •Also practise sitting, standing and moving in the bathroom while respecting the planned loading restrictions.
Dosage: At least one training session before admission; repeat until the technique is safe.
Readiness criteria for surgery
- ☐Full or symmetrical extension and near-full flexion.
- ☐A dry knee, or a stable minimal effusion.
- ☐Smooth gait, without antalgic limp.
- ☐Effective quadriceps contraction, with no extension lag on straight leg raise.
- ☐The young patient and family can use crutches and brace and understand the first post-operative weeks.
When surgery must not be delayed
- •Mechanical locking or a reducible bucket-handle tear: early treatment, without delaying to complete prehabilitation.
- •Meniscal tear with an indication for early repair, where delay reduces reparability.
- •Associated chondral or osteochondral lesions requiring timely treatment.
What to prepare at home and school
- •Organise movement at home: clear pathways, remove rugs, keep useful items within reach.
- •Prepare ice, a support for the heel, comfortable clothing and crutches already adjusted.
- •Inform school or the sports club: plan the absence, temporary exemption and gradual return.
- •Agree the first post-operative physiotherapy session in advance.
Preoperative preparation may improve pre-surgical strength and function and support early recovery after reconstruction. It is not a guarantee of the final outcome: the post-operative pathway remains decisive. Dosages and duration are indicative and must be adapted by the physiotherapist.
Phase 1 — Protecting the repair
Indicative timing: Weeks 0-6
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Full knee extension
- •Effusion control
- •Quadriceps activation without extension lag
What to do
- •Quadriceps isometrics, straight leg raise, patellar mobilisations
- •Assisted ROM within the allowed range (typically 0-90°)
- •Weight bearing according to tear pattern and surgical prescription, with crutches
- •Hip, core and contralateral limb work
Restrictions and precautions
- •No flexion beyond the allowed range, no loaded deep flexion
- •No rotation of the flexed knee, no trunk twisting with a planted foot
- •Avoid squatting and reciprocal stair descent
Exercises for this phase
1. Quadriceps isometric contraction (quad set)From day 1
- •Lie on your back with the leg straight and a rolled towel under the ankle.
- •Push the knee down by tightening the thigh, as if flattening the bed.
- •The heel lifts slightly: that means you are reaching full extension.
Dosage: 10 contractions of 5 seconds, 4-6 times a day
2. Straight-leg raiseFrom day 1-2
- •Lying on your back, first tighten the thigh until the knee locks straight.
- •Lift the straight leg about 30 cm, hold 3 seconds and lower slowly.
- •If the knee bends while lifting, the quadriceps is not ready yet: go back to quad sets.
Dosage: 3 sets of 10, twice a day
Ready for the next phase when
- ☐Passive extension 0°, flexion to the allowed limit without joint-line pain
- ☐Decreasing effusion
- ☐Effective quad set without lag
Note for the physiotherapist
Joint-line pain is not a specific sign of repair failure. Even so, new or increasing pain during assisted flexion — particularly with reactive effusion or mechanical symptoms — is a reason to reduce range and load and reassess rather than pushing through.
Phase 2 — Restoring loading and strength
Indicative timing: Weeks 6-16
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Full weight bearing and symmetrical gait
- •Full ROM, achieved progressively
- •Strength and neuromuscular control
What to do
- •Weaning from crutches, gait re-education
- •Protected-range closed kinetic chain: mini squat, leg press, step up, progressing to step down
- •High-saddle cycling, walking in water, gluteal and core strengthening
- •Double-leg then single-leg proprioception
Restrictions and precautions
- •Deep squat, deep lunge and kneeling not before 8-12 weeks
- •No pivoting, no loaded rotational movements
Exercises for this phase
3. Glute bridgeFrom week 2
- •Lie on your back, knees bent, feet flat on the floor.
- •Lift the pelvis by squeezing the glutes until shoulders, hip and knee are aligned.
- •Lower slowly without arching the back.
Dosage: 3 sets of 12-15, on alternate days
4. Mini-squat 0-45°From the full weight-bearing phase
- •Standing, feet hip-width apart, weight evenly distributed.
- •Bend the knees to about 45°, keeping the knees aligned over the feet.
- •Rise by pushing through the heels, without letting the knee collapse inwards.
Dosage: 3 sets of 12, 3-4 times a week
Ready for the next phase when
- ☐Full ROM without joint-line pain
- ☐No effusion after sessions
- ☐Controlled single leg squat without dynamic valgus
- ☐Quadriceps strength ≥70-80% of the contralateral side
Phase 3 — Running, plyometrics and agility
Indicative timing: Months 4-5 to 8
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Resume running and conditioning
- •Quality jumping and landing
- •Strength symmetry
What to do
- •Straight-line running, then progressively tighter curves
- •Progressive plyometrics on increasingly firm surfaces
- •Progressive heavy strengthening, introducing deep flexion only if asymptomatic
Restrictions and precautions
- •Stop and reassess if joint-line pain or effusion appears after loaded flexion
Exercises for this phase
5. Single-leg balanceFrom the full weight-bearing phase
- •Stand on one leg, knee slightly bent, looking ahead.
- •Progress: eyes open → eyes closed → soft surface → catching a ball.
- •The pelvis must stay level: if it drops on one side, the gluteus medius is weak.
Dosage: 3 x 30 seconds per side, daily
6. Controlled step-downStrength phase (from month 3)
- •Stand on a 15-20 cm step on the operated leg.
- •Lower slowly with the other foot, touching the floor with the heel, over 3 seconds.
- •The standing knee must stay aligned over the foot: if it collapses inwards, lower the step.
Dosage: 3 sets of 8-10 per side, 3 times a week
Ready for the next phase when
- ☐No mechanical symptoms (locking, painful catching)
- ☐Hop tests with LSI ≥85-90%
- ☐No persistent joint-line pain and no reactive effusion
- ☐Good tolerance of progressive loaded flexion
Phase 4 — Sport-specific work and return to sport
Indicative timing: From month 8
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Sport-specific technical skills
- •Progressive team reintegration
- •Psychological readiness
What to do
- •Progressive individual sessions, then partial and full team training
- •Integrated prevention programme (FIFA 11+)
- •Isokinetic test before the outpatient review
Exercises for this phase
7. Progressive plyometricsImpact phase
- •Start with two-foot hops on the spot, landing softly with bent knees.
- •Progress to front-back and lateral hops, then single-leg.
- •Landings must be silent: noise means insufficient shock absorption.
Dosage: 2-3 sets of 10-20 contacts, 2-3 times a week
8. Low-impact conditioningAll intermediate phases
- •Stationary bike with high saddle and minimal resistance, swimming (avoiding breaststroke early), elliptical.
- •These maintain general fitness without compressing the repaired area.
- •The rule is always the same: no swelling the next day.
Dosage: 20-30 minutes, 3-5 times a week
Ready for the next phase when
- ☐Training progression without pain, effusion or mechanical symptoms
- ☐Sport-specific skills performed with good control and without compensation
- ☐Confidence in the knee on the field, without apprehension
- ☐The instrumented tests and scores required for clearance are listed in the return-to-sport section
If symptoms appear after a progression
If persistent pain, effusion or swelling, or loss of movement appears after moving to a new phase or increasing load, temporarily reduce load and volume and have the situation reassessed by the surgeon or physiotherapist before progressing again. This document is informative for families and physiotherapists and does not replace individual clinical assessment.
Return to sport / full activity
9-12 months, usually 4-8 weeks later than isolated ACL reconstruction.
- ☐Hop tests with LSI ≥90% and isokinetic strength with LSI ≥90%
- ☐No mechanical symptoms and no joint-line pain
- ☐No effusion after loaded deep-flexion activity
- ☐IKDC ≥90 and high ACL-RSI
- ☐Full team training without symptoms for at least 2-4 weeks
Surgical instructions specific to the repaired tear pattern always take precedence over this general scheme. The Limb Symmetry Index has known limitations: on its own it is not sufficient, because the uninjured side may also be deconditioned; it should be combined with absolute strength values, movement quality and sport-specific demands.
Red flags: stop and contact us
- •Persistent joint-line pain, especially after loaded flexion
- •Effusion returning after sessions or after load increases
- •Joint locking or inability to fully extend the knee
- •Painful catching or the sensation of something moving inside the joint
- •Giving way or a new twisting injury
- •Fever, redness or wound discharge; calf pain with asymmetric swelling
Written and reviewed by Dott. Daniele Priano, Paediatric Orthopaedics. Last review: August 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the surgeon’s indications.
Frequent questions
Why is rehabilitation slower than for isolated ACL?
Because the meniscal repair dictates the pace: the meniscus heals slowly and its repair is stressed precisely by deep loaded flexion and twisting. Flexion is limited in the first 6 weeks even if the knee seems ready.
Can I squat down to pick something up?
Not in the first 12 weeks: deep squatting compresses and shears the posterior horn of the repaired meniscus. Learn to hinge at the hip keeping the operated knee less flexed, or kneel on the other knee.
Is swelling in the evening normal?
Mild evening swelling in the first weeks is common. It becomes a warning sign when it increases day by day, appears after every session, or does not settle within 24-48 hours with ice and elevation: in that case the weekly load is excessive and should be reduced by one level.
Can I do physiotherapy only once a week?
The physiotherapy session is for setting up, correcting and progressing the programme. The result, however, depends on the exercises performed at home every day: a short daily home programme is worth more than an isolated weekly session.
In-depth content (full introduction, technique comparison, FAQ, references) at ortopediaevolutiva.com/en/rehabilitation/acl-with-meniscal-repair
ACL reconstruction with meniscal repair — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com