Pre-Op ACL Physical Therapy Exercises


If you have an anterior cruciate ligament (ACL) tear and are considering surgery, you may benefit from physical therapy exercises prior to surgery. Preparing for your surgery with your physical therapist has been shown to improve overall outcomes with your knee after your ACL repair.

An ACL sprain can cause a variety of symptoms, and your physical therapist can help you get back to optimal function after the injury. Symptoms of an ACL sprain may include:

  • Knee pain
  • Knee swelling 
  • Limited knee range of motion (ROM)
  • Loss of strength in your quadriceps or hamstring muscles
  • Feeling of instability around your knee joint
  • Difficulty performing basic functional tasks like climbing stairs, walking or running

If you suspect you have an ACL tear, you should visit your healthcare provider to get an accurate diagnosis. Your healthcare provider will likely perform special tests to determine if you have an ACL tear and may order an MRI to confirm the suspected diagnosis.

If you do have an ACL tear, surgery may be recommended. Physical therapy (PT) prior to ACL repair surgery has been shown to improve your overall outcome with the procedure.

Goals of PT prior to ACL surgery may include:

  • Restore normal knee ROM
  • Improve quadriceps and hamstring strength
  • Improve hip strength and stability
  • Maximize balance and proprioception
  • Control pain and swelling in your knee

Your physical therapist may use various modalities to help control your knee pain and swelling and to improve muscular function as part of your ACL prehab. But exercise is your main tool in maximizing knee function prior to ACL surgery.

Here is a sample exercise program that your physical therapist may prescribe for you to do prior to your ACL surgery. Your PT can show you how to do the exercise properly.

Be sure to check in with your healthcare provider before starting this, or any other, exercise program for your knee.


Quad Sets and Short Arc Quads


After an ACL injury, you may find the quadriceps muscle on the front of your thigh isn’t functioning properly. One of the primary goals of pre-op ACL therapy is to restore normal function and strength to your quad muscle so that it supports your knee properly.

Exercises that your PT may prescribe to improve quad function may include:

  • Quad setting exercises: Lie on your back and place a small towel under your knee. Tighten your quads by pressing the back of your knee into the towel. Hold for 5 seconds, and then relax.
  • Short arc quads (SAQ): Lie on your back and place a ball underneath your knee. Straighten your knee fully, keeping the back of your knee against the ball.
  • Straight leg raises: Tighten your quad muscle on the top of your thigh and then slowly lift your straight leg up about 12 to 15 inches. Hold for 2 seconds, and then slowly lower your leg down.

Exercises should be performed in a pain-free motion; stop any exercises that cause increased pain in your knee.


Knee Range of Motion

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Restoring knee range of motion should be one of your primary goals prior to ACL surgery. If your knee is bending and straightening fully before surgery, it is likely to quickly recover full ROM after surgery. Exercises that may be done may include:

  • Heel slides: Lie on your back and slowly bend your knee and slide your heel up towards your buttocks.
  • Prone hang for knee extension: Lie on your stomach and hang your leg over the edge of a bed, allowing your knee to hang in a fully straightened position.
  • Stationary bicycling: Use a bike at the gym or PT clinic to gently get your knee bending and straightening.

Be sure to move your knee with control and slowly and purposefully, and stop the exercise if you feel pain.


Hamstring Strengthening

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Your ACL helps to stabilize your knee by preventing forward slippage of your shin bone underneath your thigh bone. Your hamstrings, by nature of their attachment points behind your thigh and knee, can also help to add stability to your knee joint.

Your physical therapist may prescribe hamstring strengthening exercises during your ACL prehab. Hamstring exercises may include:

  • Hamstring sets: Lie on your back with your knee bent. Slowly press your heel into the floor, tightening your hamstring as you do so. Hold the position tight for 5 seconds, and then relax.
  • Prone knee bends: Lie on your stomach and slowly bend your injured knee up, using your hamstring on the back of your thigh.
  • Seated hamstring curls with a resistance band: Sit in a chair with the band around your ankle of your injured leg. Attach the other end to a doorknob or have someone hold it. Slowly bend your knee while the band provides resistance. Hold it bent for a few seconds, then slowly return to the starting position.

Strengthening your hamstrings should not cause any pain; if you feel pain during the exercise, stop it and check in with your PT.


Hip Strengthening

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Research indicates that your hips control the position of your knees when walking, running, and jumping. Keeping your hips—especially your gluteus medius muscles—strong can keep your knees in the best position during activity and minimize stress to your knee and ACL.

Hip strengthening exercises may start with straight leg raises, but some other exercises your PT may prescribe as part of your pre-op ACL program may include:

  • Lateral band walks: Place an elastic band around your ankles and slowly walk sideways across the room.
  • Hip hikers: Stand with one leg on a step and the other leg hanging freely down, and then slowly lower your pelvis down, being sure the motions come from your knee.
  • Single leg bridges: Perform a bridge exercise with one knee bent and one knee out straight and lifted off the floor.

By working to keep your hips strong prior to your ACL surgery, you may be able to maximize hip strength after your surgery.


Balance and Proprioception

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Proprioception is a term that describes your body’s ability to understand where it is in your environment.

Good balance and proprioception are essential to keeping your knees in the correct alignment when running and jumping, and this can help keep stress and strain off your ACL.

Working on your proprioception will likely be a major component of your rehab after surgery, so making it a part of your ACL prehab may be a good idea.

Your PT may have you perform various balance and proprioception exercises to help you prepare for your ACL surgery. These may include:

  • Single leg standing: Simply stand on one leg and try to hold your balance for 30 to 60 seconds.
  • BOSU exercises: Use a BOSU ball to stand upon it to challenge your balance.
  • BAPS board: Your PT may have you use a device called a BAPS board to challenge your proprioception and balance.
  • The T-Stance exercise: Stand on one leg with your other leg out behind you. Hold both arms out to the side, like a letter “T,” and slowly bend forward at the waist, maintaining a stable balance.

Remember, to improve your balance you need to challenge your balance. This may be difficult for an ACL-deficient knee prior to surgery, so be careful when selecting the balance and proprioception exercises that you do.

Your physical therapist can help determine the best balance exercises for you to do while preparing for your ACL surgery.


Neuromuscular Training

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Neuromuscular training is performing specific motions designed to improve the way your body moves and responds to various forces that are placed upon it.

After an ACL tear, research shows that performing neuromuscular training exercises can help improve overall knee function and may reduce the chance of a future ACL problem.

Exercises that your PT may prescribe for neuromuscular training may include:

  • The drop jump exercise: Stand on a 12 to 18-inch stool, and jump down, landing with your knees bent. Then, immediately jump back up as high as possible.
  • Learning to jump and land correctly: Practice jumping up and landing on your feet shoulder-width apart and your knees directly over your ankles. Land softly by bending your knees as you come down from your jump.
  • Single leg hopping: Stand on one foot and hop forward for three hops. Be sure to land with your knee slightly bent and directly over your ankle and foot.

These motions and exercises are challenging, and they may be difficult to perform with your ACL-deficient knee. The key to these exercises is to ensure that your knees are in the proper alignment when performing them.

Be sure to check in with your physical therapist to be sure that this type of training is right for you and your specific condition.


Putting It All Together

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An anterior cruciate ligament sprain can be a devastating injury that sidelines you for months. Choosing to have surgery can help you restore normal motion and function to your injured knee.

Engaging in pre-operative physical therapy when preparing for your ACL repair surgery can have positive impacts on your overall recovery. Your prehab should focus on the basics first—restoring normal knee range of motion and optimal quad and hamstring strength.

Once your knee is moving well, adding in advanced balance and proprioception exercise and neuromuscular training can help you feel fully prepared for your ACL surgery.

Working with your healthcare provider and PT is the best way to learn how to prepare for your ACL surgery. They’ll guide you through your exercise program, which ensures your knee is ready when surgery arrives and maximizes your chances of a full and rapid recovery.

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