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
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.
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.
The EU-US meniscus rehabilitation consensus (PAASS framework) recommends modulating loading and ROM according to tear pattern, age, acuity, knee stability and tear size, rather than applying one protocol to all patients. The surgeon’s instructions on weight bearing and ROM override any general scheme.
Meniscal repairs performed together with ACL reconstruction heal better than isolated repairs, thanks to the favourable biological environment created by the bone tunnels: that advantage is lost if loading is progressed too quickly.
Key parameters
- 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.
Milestones at a glance
- 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
Phases of the pathway
Phase 1 — Protecting the repair
Weeks 0-6
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
Criteria to progress
- ☐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 during assisted flexion is the earliest sign of overload on the repair: reduce range and load rather than pushing through.
Phase 2 — Restoring loading and strength
Weeks 6-16
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
Criteria to progress
- ☐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
Months 4-5 to 8
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
Criteria to progress
- ☐No mechanical symptoms (locking, painful catching)
- ☐Hop tests with LSI ≥85-90%
- ☐No joint-line pain on clinical tests (McMurray/Thessaly)
Phase 4 — Sport-specific work and return to sport
From month 8
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
Criteria to progress
- ☐LSI ≥90% on hop tests and isokinetic strength
- ☐IKDC ≥90 and high ACL-RSI
- ☐No mechanical symptoms or effusion with full loaded flexion
- ☐Full team training without symptoms
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.
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
Guidelines and literature
- EU-US Meniscus Rehabilitation Consensus (ESSKA-AOSSM-AASPT), PAASS framework. IJSPT 2025, parts I-II.
- Academy of Orthopaedic Physical Therapy. Clinical Practice Guideline: Knee Pain and Mobility Impairments — Meniscal and Articular Cartilage Lesions. JOSPT.
- Grindem H et al. Br J Sports Med 2016 (regole decisionali per il ritorno allo sport dopo LCA).
- Evidence-based weight-bearing protocols after meniscal repair. J Orthop Surg Res 2025.
Key exercises, step by step
Each exercise belongs to a specific phase: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
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 raise
From 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
3. Glute bridge
From 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
5. Single-leg balance
From 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-down
Strength 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
7. Progressive plyometrics
Impact 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 conditioning
All 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
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.
ACL reconstruction with meniscal repair — Dott. Daniele Priano, Pediatric Orthopaedics · ortopediaevolutiva.com/en/rehabilitation/acl-with-meniscal-repair · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com