ACL rehabilitation in children and teens

For children, teens and young adults who are having ACL reconstruction surgery to repair a torn ACL, there are many steps you can take that can help make your surgery and recovery go as smoothly as possible.

This may seem overwhelming, but your Children’s Hospital of Philadelphia (CHOP) care team is here to help every step of the way during your ACL rehab.

The following guide includes appointment schedules, common milestones, exercises for ACL rehab, and other important patient information to guide patients and families along the way in the process of recovering from an ACL reconstruction.

Appointment schedules at a glance

After your surgery, you can expect to have milestone follow-up visits with your surgeon about every three to four months:

3 months
6 months
9 months

Before or after each of these visits, you will also have a minimum of 3 sessions of strength and functional testing with CHOP Physical Therapy (PT). If you’re receiving PT outside of CHOP, these will be additional visits you’ll need to schedule with the CHOP PT team.

Pre-operative phase: Before ACL surgery

After discussing surgical options for your ACL injury, you will begin the pre-operative process. The orthopedic surgical team will discuss scheduling for your surgery and provide information about things such as crutch training, education on post-op bracing and any other restrictions specific to your current injury.

You will review these educational materials with your physical therapy team at your pre-op crutch training session. This appointment can be made at any Sports Medicine and Performance Center location. They’ll answer any questions you have to make sure you feel prepared for your ACL surgery and what to expect before and after.

Hinged Knee Brace – After knee surgery, your child’s surgeon may suggest wearing a knee brace to protect their knee. Questions about your hinged knee brace can be answered by your child’s surgeon or physical therapist at the pre-op crutch training session.
Crutch Walking – These instructions will help you be prepared to use your crutches safely.
Post-Op ACL Home Exercise Program – These instructions cover stretching and strengthening exercises you can do at home under guidance of your care team.
Anterior Cruciate Ligament (ACL) Reconstruction Physical Therapy Protocol – This protocol covers basic criteria and timeframes that your care team uses to help determine when a patient is ready to advance to the next level of activity during recovery. It’s important to follow your care team’s instructions for each unique case.

Acute post-op phase

The acute post-op phase begins after your immediate post-operative visit with your surgeon.

The first step will be to schedule a physical therapy (PT) evaluation at a Sports Medicine and Performance Center location that is convenient for you. This first appointment is generally scheduled within the first 7 to 10 days after surgery.

This phase will include the following:

Incision Care – Generally steri-strips are used to close the skin around your incision. The steri-strips should fall off on their own around 2 weeks post-op.
- They may curl up on their own, feel free to trim them as this happens. If they have not fallen off by week 3, you may remove them yourself.
- If you remove yourself after 3 weeks, make sure to not remove the scab over your incisions. Your PT may also assist with this.
- Do not submerge your knee in water until the steri-strips are removed and all wounds are closed.
Hinged Knee Brace – During your post-op visits, you’ll learn more about when to wear the brace to protect your knee, how it should fit, and how to adjust the brace. The hinged knee brace is typically worn for about six weeks.
Crutch Walking – These instructions will help you continue to use your crutches safely as you recover.
Post-Op ACL Home Exercise Program – These instructions cover stretching and strengthening exercises you can do at home under guidance of your care team.
Neuromuscular Electrical Stimulation (NMES) – Depending on your insurance coverage a NMES device may be delivered to your home. This device helps wake up your muscles after surgery. If your insurance does not cover a NMES machine, that’s okay. It is not mandatory and your therapist will provide other exercises to work on at home instead.
Continuous Passive Motion (CPM) Machine – Depending on your insurance coverage, you may have a CPM machine delivered to your house in the first few days after surgery. The machine works by gently bending and straightening your knee. If your insurance does not cover a CPM machine, that’s okay. It is not mandatory and we will still provide you with lower extremity exercises to work on at home.
- Before using the CPM machine:
  - Unlock or remove your knee brace
  - Set the dial on the machine to bend the knee (flexion) to 30 degrees. This number should increase up to 10 degrees every day as tolerated, but should never go past 90 degrees.
- You will use the CPM machine 2 hours ON and 2 hours OFF (with a goal of 6-8 hours a day) for the first 2 weeks after surgery.
- You should not stay in the CPM to sleep at night.
- The CPM machine should be used in addition to your post-op ACL exercises.
- Between 3-4 weeks post-op, the CPM machine will be picked up by the distributor.
Functional Testing – Functional testing is a formal evaluation of progress following surgery. It makes sure patients are safe to advance to the next phase of rehab and to progress back to sports when cleared. The timing for the early set of functional testing will be made by your surgeon and your physical therapist at about three months post-op.

Intermediate post-op phase

The intermediate post-op phase after ACL reconstruction begins no sooner than 3 months have passed from your date of surgery and can only begin once the early functional testing goals have been met.

To determine if you’re ready to proceed to the intermediate phase, you’ll complete functional testing with a CHOP sports physical therapist. You will review the results with your surgical team to get clearance to move forward.

Once you’re cleared to begin the intermediate phase, you’ll set up the intensity of exercises with your PT team.

This phase will include the following:

Beginner Plyometrics – You may begin the beginner plyometric phase once cleared by your physical therapist/care team.
Intermediate Plyometrics – You may begin the intermediate plyometric phase once cleared by your physical therapist/care team and after completing the beginner phase with proper form and without pain or swelling in your injured area.
Strength Training: Quadriceps – These exercises focus on increasing quadriceps strength while keeping good form and not increasing pain.

Late post-op phase

The late post-op phase after ACL reconstruction begins no sooner than six months have passed from your date of surgery and can only begin once the intermediate functional testing goals have been met.

To determine if you’re ready to proceed to the late post-op phase, you’ll complete an additional functional testing visit with a CHOP sports physical therapist. You will review the results with your surgical team to get clearance to move forward.

Once you’re cleared to begin the late post-op phase, you’ll set up your next series of post-op visits with your PT team.

This phase will include the following:

Intermediate Plyometrics – You may begin the intermediate plyometric phase once cleared by your physical therapist/care team and after completing the beginner phase with proper form and without pain or swelling in your injured area.
Advanced Plyometrics – You may begin the advanced plyometric phase once cleared by your physical therapist/care team and after completing the intermediate phase with proper form and without pain or swelling in your injured area.
Strength Training Exercises – These exercises focus on increasing the strength of certain muscle groups while keeping good form and not increasing pain.
Agility Training

Return to sport phase

The return to sport phase after ACL surgery begins no sooner than nine to 12 months have passed from your date of surgery and can begin once the functional testing goals have been met.

To determine if you’re ready to proceed to the return to sport phase, you’ll again complete a functional testing visit with a CHOP sports physical therapist. You will review the results with your surgical team to get clearance to move forward.

Once you’re cleared to begin the return to sport phase, you’ll set up your next series of post-op visits with your PT team. This phase will include the following:

Return to Sport Progression – This program will help you and your family design a program to slowly get back into sports. This is a process that usually takes two to three months until you will be fully participating in sports.
Ready, Set, Prevent – A maintenance-based lower extremity injury prevention program designed to reduce injuries, while also improving athletic performance will be incorporated into your workout plan. Designed as a warm-up routine, these programs should be performed in the first few minutes of practice and overseen by a coach or trainer. Many programs show good results and you are free to use whatever program you and your therapist decide on. CHOP has a program you can use as well:
- Video series demonstrates warm up activities, dynamic stretching, strengthening and plyometrics
- Program outline
- Field tip sheet with photos
Strength Training Exercises – These exercises focus on increasing the strength of certain muscle groups while keeping good form and not increasing pain.

Remember, a return to sports doesn’t mean playing a game your first week back! You must begin with practices and follow the structured progression schedule guided by your physical therapist.

For your first season back, you must choose only one sport for unrestricted participation unless your surgeon approves otherwise.