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.
The pathway respects both repairs; pivoting sport resumes only after the ACL timing and criteria are met.
Prepare the visit handout
Use the condition and phase indicated by your clinician. You can leave out individual exercises; instructions, illustrations and safety advice remain together.
Changing phase restores its full exercise list. Timing alone does not determine the phase.
Exclude exercises if needed
15 of 15 exercise cards included
The full web page remains available. Your selection is not saved or shared.
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 — the full pathway
- Weight bearing and ROM: stable vertical tear
- Early weight bearing may be allowed; movement limits depend on repair stability and associated procedures.
- Weight bearing and ROM: complete radial or root tear
- Complete radial tear: non-weight bearing for 4-6 weeks; root tear: non-weight bearing for 6 weeks. Flexion is initially protected, often within 90°; the surgeon must specify duration and brace use.
- Complex or horizontal tears and associated procedures
- Use the specific prescription. Do not extend the early loading of a vertical repair to other patterns; the most restrictive requirement takes precedence.
- Deep flexion, jumping and rotation
- Avoid deep squats, jumping and knee rotation for at least 4 months and until cleared. Partial squats require a specifically permitted range.
- Running and sport
- Elapsed weeks alone do not provide clearance: adequate healing, no pain or effusion, recovered strength and control, and authorisation are required.
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 offers exercise options: perform only those selected by your clinician, without bringing later phases forward or automatically adding earlier exercises. Dosage, frequency and rests are individualised; the complete catalogue is not a single session.
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)After entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Lie on your back with the leg supported and the knee within the authorised extension range.
- •Tighten the front of the thigh without lifting the leg or forcing the knee. Use a small support under the knee only if demonstrated by your physiotherapist.
- •Hold briefly and relax. Lifting the heel is neither a target nor proof of full extension.
Dosage: 10 contractions of 5 seconds, 4-6 times a day
2. Straight-leg raiseAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •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
- •Progressive strengthening in the range permitted for the repair; no default squat depth or step progression
- •High-saddle cycling, walking in water, gluteal and core strengthening
- •Double-leg then single-leg proprioception
Restrictions and precautions
- •No deep loaded flexion or jumping for at least 4 months and until cleared
- •No pivoting, no loaded rotational movements
Exercises for this phase
3. Glute bridgeAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •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°After entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •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
5. Single-leg balanceAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Stand on one leg with the knee slightly bent and look ahead, after clearance for weight bearing.
- •Keep your eyes open on firm ground near a stable support; an adult must be able to assist the child.
- •Aim to keep your pelvis steady. If it tilts or you lose balance, put the other foot down, reduce the difficulty and ask your physiotherapist to check the movement.
Dosage: 3 x 30 seconds per side, daily
6. Controlled step-downAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •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
7. Low-impact conditioningAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Stationary bike with high saddle and minimal resistance, swimming (avoiding breaststroke early), elliptical.
- •Select cycling, pool exercise or other low-impact activity with your physiotherapist within the permitted load, range and resistance. Low impact does not mean no compression of 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
- ☐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 strengthening; deep flexion only after at least 4 months and specific clearance
Restrictions and precautions
- •Stop and reassess if joint-line pain or effusion appears after loaded flexion
Exercises for this phase
8. Progressive plyometricsAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Only after clearance for impact and demonstration by your physiotherapist, start with small two-foot hops on a stable surface.
- •Increase direction, height or single-leg work only within the agreed progression; do not add several challenges at once.
- •Aim for a controlled landing with knees and feet aligned. Stop for pain, giving way or loss of control; report swelling or worsening symptoms afterwards. Landing noise alone does not measure movement safety.
Dosage: 2-3 sets of 10-20 contacts, 2-3 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
No additional exercise cards are assigned here. Follow this phase’s indications and the programme selected by your physiotherapist; do not automatically continue or progress every previous exercise.
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, stop progression and contact the treating clinician or physiotherapist to review the programme. Seek prompt assessment for the red flags below. This document does not replace individual clinical assessment.
Return to sport / full activity
Respect both meniscal healing and the ACL return-to-sport criteria and timing; no automatic additional number of weeks.
- ☐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
Author: Dott. Daniele Priano, Paediatric Orthopaedics. Content version: 9 September 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the treating clinician’s instructions.
Full introduction and 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.
Latest online versionThis protocol may be used and shared for clinical and informational purposes provided that attribution to the author and to the original source is kept intact. Republishing or distributing it as one’s own work is not allowed.
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Email: daniele.priano@ortopediaevolutiva.com