ACL Reconstruction with a Complex Meniscal Repair: Care and Rehabilitation

Before you start: A stationary bike helps smooth knee movement and restore fitness. Start the bike in this version after the end of week six, once the 90-degree ceiling has been lifted and weight-bearing is free. Choose a stable bike with a relatively high saddle. Use support to mount. Adjust the saddle so the knee is nearly straight at the bottom of the pedal stroke and the pelvis stays still.

How to do it:

1. Start with the lowest resistance.
2. Turn the pedals slowly and evenly.
3. If after the end of week six a full revolution is still not possible, rock the pedal forwards and backwards as far as it goes until the range improves; before the end of week six do not get on the bike at all.
4. Keep the pelvis still and the knee tracking forward; the pelvis must not move up and down with each revolution.
5. Slow down gradually, then get off using the support.

Movement tips: Pedal slowly and evenly, breathing normally. Do not stand on the pedals or use heavy resistance. Lower the saddle only within your permitted range and keep the pelvis from shifting each revolution. If a long session is tiring, shorten it and elevate the leg between sessions. Pedalling should be smooth and should not cause next-day swelling.

Amount, repetitions and progression: In the reference rehabilitation protocol, you start at low or zero resistance and at 5 minutes, and raise the time slowly until you reach 20 minutes a session; raising the resistance begins two to three weeks after you start the bike. Pedal once or twice a day. At each step raise only one of the two — time or resistance — never both together. If pain or swelling increases the next day, go back to the previous amount and review the plan with your physiotherapist.

Stop immediately if: you develop sharp pain or knee catching, front-of-knee pain begins, or you move the pelvis up and down to pedal.

Common mistakes: A saddle set too low, heavy resistance from the start, pedalling while standing, and pushing on through front-of-knee pain.

Easier version: The permitted back-and-forth movement, zero resistance, or less time; even a few minutes is an acceptable start.

Before you start: A wall squat strengthens the front-thigh muscles, with the wall helping your balance. Start after weight-bearing is permitted, swelling is controlled and you can walk without a limp; in this version it starts after the end of week six. Wear closed shoes on a non-slip surface and stand against a flat wall, feet hip-width apart and slightly forward, with your back and buttocks touching the wall. Use a ball behind your back only if your physiotherapist recommends it.

How to do it:

1. Share the weight across both whole feet.
2. Slide your back down the wall and lower yourself slowly.
3. Go down only within your permitted range; the knees must not travel past the toes.
4. Keep the knees over the line of the second toe and do not let them fall inward.
5. In the static version of this exercise, instead of going down and up, stay at the permitted depth until you feel mild thigh fatigue, then stand up; repeat this hold 12 times.
6. Press up evenly through both feet, without pushing off with your hands.

Movement tips: Lower only a short distance within your allowed range. Keep the heels down, weight equal on both legs and knees aligned with the feet. Breathe in to lower and out to rise; breathe freely during holds. Stand upright and relax the thighs between sets. You should feel the front-thigh muscles working. Stop if the knee itself hurts or shaking disrupts control.

Amount, repetitions and progression: 12 repetitions, one to three times a day. Keep the depth shallow. The step-by-step plan for gradually deepening the squat in the 2024 international meniscus rehabilitation consensus is written for a vertical tear, not a complex one, so in this version you do not follow such a plan: the depth stays shallow until the end of month four, around 30 to 45 degrees. If the knee swells after exercise, reduce the depth or the repetitions.

Stop immediately if: the knee hurts, the knee gives way, or shaking disrupts your control of the movement.

Common mistakes: Going deeper than permitted, letting the knee travel past the toes, letting the knees fall inward, lifting the heels, and holding the breath in the static version.

Easier version: Less depth or a shorter hold; you can start by going down only a few centimetres and coming straight back up.

Before you start: With a mini squat, you practise sharing weight between both legs. Start once weight-bearing is permitted, swelling is controlled and you walk without a limp; in this version it starts after the end of week six. Wear closed shoes on a dry, non-slip surface and face a fixed counter or rail, with feet hip-width apart and both feet flat.

How to do it:

1. Rest your hands lightly on the support; do not hang from it.
2. Take the hips back slightly, as if you were about to sit.
3. Bend the knees only within the permitted range.
4. Keep the knees in line with the toes and the weight on both legs.
5. Press up slowly and evenly through both feet.

Movement tips: Keep the movement shallow and within your plan, with a level pelvis, heels down and similar pressure through both feet. Lower slowly while breathing in and rise slowly while breathing out. Stand upright between sets. Mild thigh fatigue is expected, but rest if shaking disrupts control.

Amount, repetitions and progression: 12 repetitions, one to three times a day. The depth at this stage is up to 30 degrees, that is, the knee bends only slightly. If the knee swells the next day, reduce the depth or the repetitions.

Stop immediately if: you develop sharp knee pain, a sensation of the knee giving way, or shaking disrupts your control of the movement.

Common mistakes: The knee falling inward, shifting weight to the sound leg, hanging on the hands, and lifting the heels.

Easier version: Use less range or take more support from your hands, but still do not hang from the support; you can start by practising the weight shift alone, without bending the knees.

Before you start: Stepping up trains the front-thigh muscle and knee control. Once you walk without an obvious limp and perform a mini squat correctly, start with a permitted low step. It must be stable, non-slip and beside a rail; wear closed shoes. Face the step, place the entire operated foot on it and keep a hand near the rail.

How to do it:

1. Transfer the weight gradually onto the operated leg.
2. Keep the knee pointing in the same direction as the toes and do not let it fall inward.
3. Press through the whole foot and come up without any hop.
4. At the top, level the pelvis and stand still for a moment.
5. To come down, lower the healthy leg to the floor first and slowly; the operated leg stays on the step and controls the descent until that foot touches down.

Movement tips: The step must not be high enough to cause pain or the knee to fall inward. Keep the pelvis facing forward and level. The back leg should help balance without pushing you up. Breathe out to rise and in to lower more slowly. Stand or sit between sets to let the thigh relax.

Amount, repetitions and progression: In the reference rehabilitation protocol, 12 repetitions on each leg, one to three times a day. Start with the lowest step you have and, once you go up and down smoothly without using your hands, move to an ordinary stair step. If the knee swells after exercise, reduce the height or the repetitions.

Stop immediately if: the knee gives way or you develop sharp pain.

Common mistakes: Hopping off the back leg, placing only half the foot on the step, letting the knee fall inward, and coming down by suddenly releasing the weight.

Easier version: Choose a lower step or take more help from the rail; you can start by practising only the weight transfer onto the step.

Before you start: This exercise practises awareness of knee position and balance control. Start on a flat, non-slip surface once loading the operated leg is permitted and safe and you walk without a limp. Wear suitable shoes and stand beside a firm counter or rail, with the operated foot under the hip and the knee unlocked.

How to do it:

1. Transfer the weight slowly onto the operated leg.
2. Lift the other foot slightly off the floor.
3. Keep the standing knee slightly bent and the pelvis level.
4. Look at a fixed point in front of you.
5. Put the foot down when you can no longer keep the hip and knee in the correct position.

Movement tips: For now, stay on a stable surface and breathe freely. Keep the pelvis level and rest the hand only lightly on the support. Small balance adjustments are expected, but large sways are not; if the sway becomes large, put the foot down and do the next repetition with more weight resting on the support. Stand on both feet between repetitions to relax the thigh and calf. Mild fatigue in the calf and sole may occur.

Amount, repetitions and progression: Several sessions on each leg, one to three times a day; quality matters more than duration. Once you can stand without your hand touching the support and without wobbling, the next step is the same balance on an unstable surface: a balance board, or a half foam roller (a foam roller cut in half along its length). In the reference rehabilitation protocol, single-leg balance work on a balance board sits at weeks four to eight; in this version no weight goes on the operated leg until the end of week six, so this exercise does not start before then.

Stop immediately if: the knee gives way, you feel dizzy or you cannot stand safely.

Common mistakes: Locking the standing knee, letting the pelvis drop to one side, leaning heavily on the hand, and moving to an unstable surface too soon.

Easier version: Take more help from the support, or keep both toes on the floor and practise only the weight shift.

Before you start: Controlled sitting and standing trains strength in both legs. Once you have mastered the mini squat without increased pain or swelling, place a firm chair without wheels against a wall. Wear closed shoes on a non-slip surface and stand with your back to the chair, feet hip-width apart and weight through the whole of both feet.

How to do it:

1. Share the weight across both whole feet.
2. Take the hips back and let the trunk come slightly forward.
3. Keep the knees in line with the toes and lower within the permitted range.
4. Make light contact with the chair; do not drop onto it.
5. Press up evenly through both feet.

Movement tips: The chair must be high enough to sit within your permitted range. Keep the heels down and weight equal on both legs, touching the chair gently. Breathe in as you lower slowly and out as you stand. Sit or stand between sessions and relax the thighs. Do not continue when fatigue reduces control.

Amount, repetitions and progression: 12 repetitions, one to three times a day. In this version work with a chair higher than the knee until the end of month four and do not go deeper; after month four, once you can do 12 repetitions without dropping onto the chair and without using your hands, use a lower chair. If the knee swells after exercise, reduce the depth or the repetitions.

Stop immediately if: you develop sharp knee pain, the knee gives way, or fatigue reduces your control of the movement.

Common mistakes: Dropping suddenly onto the chair, the knees collapsing inward, shifting weight to the healthy leg, and lifting the heels.

Easier version: Use a higher chair, or rest a hand lightly on a counter so the path stays controlled.

Before you start: Sideways steps with a band train the side-hip muscles. Start after mastering single-leg balance and shallow squats with correct alignment. Place the band above the knees and start with the lightest resistance; placing it around the ankles loads the knee more and belongs to later stages. On a flat, clear path, keep the feet parallel and hip-width apart, knees slightly bent and band lightly stretched.

How to do it:

1. Keep the band under slight tension so there is resistance the whole way.
2. Take the hips back a little and keep the trunk still.
3. Take a short step sideways.
4. Bring the second foot in without letting the band go completely slack.
5. Keep the toes and kneecaps pointing forward throughout.

Movement tips: Take short, equal steps in both directions. Keep the trunk from rotating or leaning sideways and the knees aligned with the feet. Breathe normally and move without bouncing. Release the band and stand upright between sessions. Mild fatigue or burning at the side of the hip is expected, but if this burning turns into pain, stop the exercise.

Amount, repetitions and progression: 12 steps in each direction, one to three times a day. Start with the lightest band and, once you can take 12 steps with the knee in line with the toes and the trunk steady, move to a firmer band. If the knee or the side of the hip swells or hurts after exercise, reduce the distance or the resistance.

Stop immediately if: the knee or side of the hip hurts, the knee gives way, or your body position changes clearly, for example if the toes turn or the trunk leans.

Common mistakes: Dragging the foot along the floor, taking long steps, letting the toes turn out, and leaning the trunk sideways to compensate.

Easier version: Use a lighter band, keep it above the knees rather than moving it to the ankles, and take shorter steps. Coordinate this change with your physiotherapist.

Before you start: This exercise improves the front-thigh muscle's ability to control lowering your body. Start after mastering pain-free step-ups and squats with correct alignment. Wear closed shoes and stand on a low, stable step beside a rail, with the entire operated foot on the step, pelvis facing forward and a hand near the rail.

How to do it:

1. Keep the weight on the operated leg.
2. Keep the pelvis level and guide the knee of the operated leg in line with the toes.
3. Bend the operated knee slowly so the other foot travels down.
4. Let only the heel of the other foot touch the floor lightly; do not put weight on it.
5. Return up by pressing through the operated leg, without any hop.

Movement tips: Choose a step low enough to prevent the pelvis dropping or knee falling inward. Breathe in as you lower slowly until the healthy foot touches the floor lightly and quietly; breathe out to return. Relax the thigh between sessions. Stop if fatigue makes alignment difficult to maintain. Raising the step too soon may increase pain at the front of the knee.

Amount, repetitions and progression: 12 repetitions on the operated leg, one to three times a day. Start with the lowest step you have and, once you can do 12 repetitions with the pelvis level and the knee in line with the toes, move to an ordinary stair step. If the knee swells after exercise, reduce the height or the repetitions.

Stop immediately if: the front of the knee hurts, the knee gives way, or fatigue makes keeping the alignment hard.

Common mistakes: The knee falling inward, the free-side pelvis dropping, pushing off with the other foot, and releasing the weight suddenly at the end of the range.

Easier version: A lower step or more help from the rail; you can start by going down only a few centimetres and returning.

Before you start: In this exercise you practise knee control during sideways movement. Start after mastering forward step-ups and step-downs without pain and with correct alignment. Wear closed shoes and stand beside a low, stable step with a rail, operated leg nearest the step, pelvis facing forward and a hand near the rail.

How to do it:

1. Place the whole operated foot on the step.
2. Transfer the weight gradually onto that leg and keep the knee in line with the toes.
3. Without pushing off with the other leg, press through the whole foot and come up.
4. Stand still at the top for a moment and level the pelvis.
5. Bend the operated knee slowly and lower the other leg under control to the floor.

Movement tips: Keep the step low. Do not let the knee fall inward, the free-side pelvis drop or the trunk lean sideways. Breathe out as you rise and breathe in as you lower more slowly. The healthy foot should touch the floor lightly. Relax the thigh and side-hip muscles between sessions so fatigue does not disrupt alignment.

Amount, repetitions and progression: 12 repetitions on each leg, one to three times a day. Start with the same low step. If pain or swelling increases the next day, reduce the repetitions and keep the height as it is. Raise the height only when the pelvis does not drop, the knee does not fall inward, and pain or swelling does not increase the next day.

Stop immediately if: the knee falls inward despite your attempts to correct it, or it gives way or hurts sharply.

Common mistakes: Pushing off with the healthy leg, leaning the trunk sideways, letting the free-side pelvis drop, and choosing a high step from the start.

Easier version: A lower step or more help from the rail; practise only the step-up first and add the step-down later.

Before you start: A lunge practises leg strength and control with one foot forward or to the side. In this guide it follows established single-leg control in the third month; pain-free chair squats and step work must be mastered first. Wear closed shoes and stand near a support in a flat, clear area, feet hip-width apart and trunk upright.

How to do it:

1. For the front lunge, step forward with the operated leg and land heel first; once the repetitions are done, do the same with the sound leg.
2. Bend the front knee only within the permitted range and keep it in line with the toes.
3. Press through the front foot to return to standing.
4. For the side lunge, step sideways with the operated leg and take the hips back while the other leg stays straight; do this on both sides too.
5. Press through the outside foot to return to the starting standing position, keeping the trunk upright throughout.

Movement tips: Keep the step short and the movement shallow. At this stage, the front knee should not pass the toes or fall inward. Do not pivot on a planted foot. Breathe in to lower and out to return slowly without bouncing. Stand upright and relax the thighs between sessions. Return without wobbling and keep the knee aligned.

Amount, repetitions and progression: 12 repetitions on each side, one to three times a day. Take a step the length of a normal walking stride, and at first bend the front knee only to 45 degrees; in this version stay at 45 degrees until the end of month four; after that, if you have trained for several sessions without wobbling and pain or swelling has not increased the next day, go on to 90 degrees. If pain or swelling increases the next day, reduce the depth or the repetitions.

Stop immediately if: the knee falls inward, hurts sharply or gives way, or you are unsure of your balance.

Common mistakes: A long step, the knee falling inward, the trunk folding forward, landing on the toes instead of the heel, and going straight to a deep lunge.

Easier version: A shorter step and less depth, or performing the movement beside a wall with one hand on a support.