Pilates guide
Pilates can help after an anterior cruciate ligament (ACL) reconstruction, as an addition to your rehabilitation, never instead of it. No trial has tested Pilates after ACL surgery, but its basics, such as quad sets, straight-leg raises, bridges, side-lying leg work and single-leg balance, are moves rehabilitation already uses, and guideline groups say trunk (core) exercises can be added, on low-certainty evidence.
Your surgeon and physiotherapist set the timeline, and their restrictions come first. The main changes are about your graft, kneeling and deep bending: after a hamstring graft, resisted knee bending and deep hamstring stretches often wait about 12 weeks, and kneeling can be sore for a while, especially after a patellar tendon graft.
This guide covers when to start, the reformer exercise by exercise, the trunk and hips, balance and the road back to sport, what a strong core can and can't prevent, and the warning signs, with a staged 25-minute class. Our ACL surgery guide covers the full rehabilitation stages and the return-to-sport tests.
Guidelines run rehabilitation in stages, moving on when you pass checks, for 9 to 12 months or more, and say exercise should be "the mainstay" of it. Pilates can add to your programme once your team agrees.
One small trial found mat Pilates improved thigh strength after a partial ACL tear without surgery, against no treatment, and two people did Pilates-based exercise before surgery. None of the three NHS ACL leaflets we read mentions Pilates.
Two guideline groups say core exercises can be added to rehabilitation, each on two weak studies. Small trials found better knee scores, hop tests and landing mechanics, not less pain or fewer injuries.
After a hamstring graft, resisted knee bending and deep hamstring stretches often wait about 12 weeks. After a patellar tendon graft, kneeling is more often sore. Seated knee extensions follow graft-specific rules too.
Prevention programmes halve ACL injuries, but adding core strengthening didn't make them work any better, and trunk and balance measures didn't predict ACL injuries in large studies of elite players.
About 1 in 4 under-25s who go back to sport injure an ACL again, the other knee about as often as the graft. Keep your team's prevention warm-up going for as long as you play.
The ACL is a band of tissue in the middle of the knee that helps it move and stay stable. In a reconstruction, the surgeon replaces it with a graft, usually from your hamstring, through keyhole surgery taking 1 to 3 hours, often as a day case; the screws or staples "will be left inside your knee permanently". Not every torn ACL needs surgery: our ACL injury guide covers that decision.
The NHS: "It may take several months or longer to recover", and "it can take up to a year to be able to play sport again". Most people go back to work after about 4 to 6 weeks. One NHS trust's patient passport says "There are no set timescales as rehabilitation is symptom and goal-based".
First, a fully straight knee, the swelling down and the thigh switched on; the NHS asks you to avoid twisting your knee, bending down and reaching up as much as possible at first, and never to rest with a pillow under the knee. Then strength and control, then running, hopping and landing, then sport. Experts stress getting the knee straight and the thigh working early.
Lying, side-lying and standing Pilates work trains the thigh, the hips and the trunk, and single-leg balance; one NHS trust's weeks 6 to 12 list includes bridges, single-leg bridges, hip work and balance. Kneeling, deep bending, twisting on the knee and jumping wait. Pilates becomes an add-on to the strength, running and landing work in your plan, not the plan itself.
No Pilates trial after ACL reconstruction; small trials of trunk and hip work added to rehabilitation.
Our searches found no Pilates trial after ACL surgery, only single case descriptions (a dancer rehabilitated on the reformer; one woman with reconstructed knees who did Pilates for 15 years). A 2025 review of 18 exercise trials after ACL injury found single studies with very uncertain benefit of tai chi and Pilates over no treatment, and that "no exercise was likely more beneficial than another".
In a Turkish trial, 50 adults aged 20 to 45 with a partial ACL tear did mat Pilates 3 times a week for 12 weeks or had no treatment. Thigh strength was better after Pilates, and that group felt more satisfied with their knee's stability. It wasn't after surgery, and it shows Pilates beats doing nothing, not that it beats physiotherapy.
In a Canadian case series of 2 people, 6 weeks of Pilates-based exercise before reconstruction went with a settled knee and better thigh strength and knee function. It's a student project summary, never published in a journal.
Source 6
The Aspetar guideline says "Core stability exercises might improve functional outcomes and subjective knee function and can be used as an addition to the rehabilitation protocol", on very low certainty evidence from 2 studies. The German Knee Society's 2026 consensus agrees, on low-certainty evidence from 2 studies.
In 26 male athletes about 8.5 months after surgery, 8 weeks of core exercise improved core endurance, hip strength and single-leg landing more than no added training, with no injury outcomes. A 2025 review of 10 trials found better knee scores and hop tests but not less pain, and its full text rates the trials at high risk of bias. Hip strengthening added in the first 12 weeks changed a balance test but not knee scores; adding clamshells helped knee straightening in 40 people 1 to 3 years after surgery.
Across 11 trials (552 people), adding specific exercise to conventional rehabilitation eased pain a little and improved strength and function, with differences between trials that couldn't be explained. Other reviews rank water-based work highly for thigh strength and call strategies for movement control limited but promising.
Guidelines combine strength work with movement control, move people on by checks rather than dates, and say purely time-based decisions about returning to sport should be abandoned. Pilates fits inside the control part, alongside the strength work.
Balance and proprioception training improved knee function and hopping modestly across 13 trials (529 people). Of people who don't return to sport, about two-thirds give a psychological reason, most often fear of another injury, and psychological approaches eased pain and fear of movement in 11 small trials. A calm, graded class may help confidence, which no trial has tested.
Our synthesis of the guidelines and NHS leaflets, not a tested plan. Protocols vary: each step is when your team says so.
Your own team's plan comes first, and a meniscus repair at the same time slows the early stages.
The site's ACL surgery guide uses a working limit: keep pain during and after exercise at 3 out of 10 or less, and ease off any move after which the knee is warmer, more swollen or more painful. The NHS suggests an ice pack wrapped in a tea towel and raising the leg to ease swelling.
Source 24
A US rehabilitation protocol: "If a hamstring autograft is used, resisted hamstring activities are not performed for 12 weeks after surgery." Guidelines that protect the donor site mainly limit resisted knee bending and avoid hamstring stretching, but a 2025 review says the reasons are "largely based on other clinical guidelines, anecdotal observations or basic biomechanics", and one NHS trust lists leg curls from week 6. Follow your own team.
In Pilates terms: feet-in-straps work on the reformer, hamstring curls against a band, long single-leg bridges and deep hamstring stretches (the saw, the spine stretch forward, the single straight-leg stretch) wait for your team's go-ahead (our reading). The tendon regrows in most people, and deep knee-bending strength is the slowest to come back.
A Cochrane review of 19 trials found patellar tendon grafts caused "more anterior knee problems, especially with kneeling", and in a Norwegian registry of 10,329 people, hamstring grafts had lower odds of kneeling difficulty at 5 years. But in a trial of 330 people followed for 10 years, kneeling pain was uncommon whatever the graft (4% to 7%) and didn't differ. So kneeling may be sore for a while; pad it, keep it short and use non-kneeling versions until it's comfortable.
One NHS trust allows leg extensions without resistance from week 4 between 90 and 45 degrees of bend, but no resistance until 12 weeks after a hamstring graft. Seated knee extensions in a Pilates or chair class follow the same rule.
Exercises with the foot pushing against something (closed chain, like a leg press or reformer footwork) and with the foot free (open chain, like a seated knee extension) gave similar knee looseness, strength and function across 10 studies; another review found open-chain work built thigh strength better at 3 to 4 months, at low certainty. Studies started open-chain work at a median of day 15, few with set criteria.
A 2025 European and US consensus says after a meniscus repair "Deep squatting, jumping (deep loaded flexion) and rotational knee movements activities should be avoided for a minimum of 4 months" (expert opinion), with squats built up gradually. Your surgeon's plan for the repair comes first.
No guideline gives a kneeling timeline, and none of the three NHS ACL leaflets we read mentions kneeling. Kneel in class only once it's comfortable and your team agrees, then on a folded mat or cushion, and keep it short (our suggestion).
Do the side kick lying down instead of kneeling, the dead bug instead of the bird dog, and cat-cow sitting on a chair. Leave the knee hover, the kneeling side kick and the reformer's knee stretches until kneeling is easy (our suggestion).
Source 14
Rolling like a ball, the seal, rocking and child's pose need a deep knee bend. Leave them until bending is back and comfortable, and longer after a meniscus repair.
Our reading of the classical reformer order against the rehabilitation guidelines, not evidence: no reformer trial after ACL surgery exists.
Reformer footwork opens the classical order and is a lying leg press against springs. The Aspetar guideline starts the leg press at about 3 weeks after a hamstring graft in a half-squat range (0 to 45 degrees of bend), so set the footbar and the stopper so your knee bends only as far as your team allows, with moderate springs (our reading; timings vary, so start when your team says so).
Running and the tendon stretch are calf work on the footbar, and the pelvic lift is a bridge with your feet on the bar; these fit the middle stage (our reading).
Source 54
Leg circles and frogs move the knee against springs, and pulling down against the straps works the hamstrings, so after a hamstring graft leave them until your team allows loaded hamstring work (our reading).
The knee stretch series and the elephant kneel or stand on the moving carriage, so they wait until kneeling is comfortable. The jump board is jumping, so it waits for the same clearance as hopping. One protocol for a different, faster operation (an ACL repair with internal bracing) used the reformer's leg press and jump board early, which doesn't apply to a reconstruction.
As your team allows. Use the ACL surgery guide's doses, which come from NHS leaflets: quad sets, hold 5 seconds building to 30, 3 sets of 10, 3 times a day; straight-leg raises, hold 5 seconds, 3 sets of 10, 3 times a day; heel slides, 10 slides, 4 to 5 times a day, as far as is comfortable; ankle pumps, 10 times, 4 to 5 times a day. Lateral breathing: the move page's dose, "5 to 8 breaths at the start of every session". Never rest with a pillow under the knee.
From about 2 weeks, as your team allows; 2 or 3 times a week. Side kick: the move page's dose, "8 to 10 each side". Wall side leg lift, standing on the operated leg: the move page's dose, "10 to 12 each side". Bridge and sit to stand: 2 to 3 sets of 8 to 12 (the ACL guide's NHS trust dose). Single-leg stand: 3 holds of up to 30 seconds on each leg, near a support (the ACL guide's dose). Side-lying leg raise, clam and dead bug: 2 sets of 8 to 10 each side; leg circles: 5 small circles each way (our editorial starting points). Seated knee extension: the move page's dose, "3 sets of 10 to 15 each leg, 2 to 3 days a week", in the range your team allows, without resistance until 12 weeks after a hamstring graft in one NHS trust's plan.
3D demoSide kick (Pilates side kick series)Beginner · No equipment
3D demoSide-lying leg raiseBeginner · No equipment
3D demoClamshellBeginner · No equipment
3D demoGlute bridgeBeginner · No equipment
3D demoDead bug heel tapsBeginner · No equipment
3D demoSingle-leg circle (Pilates one leg circle)Beginner · No equipment
3D demoSit to stand from a chairBeginner · A bench or box
3D demoSingle-leg standBeginner · A wall
3D demoWall side leg lift (standing side kick at the wall)Beginner · A wall
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weightFrom about 6 to 12 weeks, as your team allows. Step-down: 3 sets of 8 to 10 each leg; split squat and single-leg Romanian deadlift: 3 sets of 8 to 12 each leg, holding a support (the ACL guide's doses). Single-leg bridge: 2 sets of 6 to 10 each side (our editorial starting point), after a hamstring graft only once loaded hamstring work is allowed. Single-leg kick: the move page's dose, "6 to 8 each leg (the classical sequence uses 6)", once bending past a right angle is comfortable. Leg pull front: the move page's dose, "3 to 5 each side (the classical sequence uses 3)", once kneeling and full planks are comfortable.
3D demoPatrick step-downIntermediate · A step
3D demoSplit squatIntermediate · No equipment
3D demoSingle-leg Romanian deadliftAdvanced · A dumbbell
3D demoSingle-leg glute bridgeIntermediate · No equipment
3D demoSingle-leg kick (Pilates one leg kick)Beginner · No equipment
3D demoLeg pull front (Pilates leg pull down)Advanced · No equipmentThe kneeling side kick, the knee hover, the bird dog, cat-cow on all fours and the knee plank: wait until kneeling is comfortable and your team agrees, then pad the knee and keep it short.
Rolling like a ball, the seal, rocking, child's pose and side-sitting for the mermaid: leave them until the bend is back and comfortable, longer after a meniscus repair.
Source 51
After a hamstring graft, wait for your team's go-ahead, often about 12 weeks: feet-in-straps work, a band round the heel, long single-leg bridges, the saw, the spine stretch forward and the single straight-leg stretch.
Leave out standing hip circles on one leg, hops and the reformer jump board until your team clears running and hopping, which usually waits for strength and swelling checks at about 3 months.
In 277 college athletes, poorer trunk control predicted knee ligament injuries in women, and in 501 athletes weaker hips predicted non-contact ACL injuries, but both studies had few injuries (25 and 15). In 838 elite Norwegian female players, no balance measure predicted ACL injury; a previous ACL injury did. In 322 elite female footballers, trunk lean on a hop and knee collapse went with injury, but there were only 15 injuries. Across 69 studies of women's team sports, most suggested risk factors weren't linked with injury or the evidence conflicted.
Across 8 meta-analyses, prevention programmes cut ACL injuries by about half, and by about two-thirds for non-contact injuries in women. In young female athletes, "Programs including balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components"; landing practice and leg strength mattered. Programmes change little of the hip and knee movement they target, and a 2026 position statement says direct evidence for strategies aimed at trunk lean and knee collapse "remains limited".
Across 69 studies, 81% went back to some sport, 65% to their previous level and 55% to competitive sport. Experts treat return to sport as a path from training again, to playing, to playing at your old level, decided by your team with tests of strength, hopping and confidence.
Across 19 studies, 15% had a second ACL injury (7% the graft, 8% the other knee), and 23% of under-25s who went back to sport. Over about 10 years, 11% tore the graft and 12% the other knee's ACL. In footballers under 21, the figure was 31.9%.
In 30 young female volleyball players, 8 weeks of Pilates reduced errors on landing tests, which are screening tests, not injuries. In 34 novice runners, 12 weeks of home mat Pilates didn't significantly change how far the knee caved in while running.
Trunk, hip and balance work sits beside your team's strength, running, landing and prevention programme. It can't promise fewer injuries.
Our staged class has no kneeling and keeps loaded hamstring work back until your team allows it; its structure is our own and untested. The knee pain class suits the middle stage (after a hamstring graft, leave out its hamstring stretch until your team agrees). The leg and knee workouts are the ones the ACL guide uses; after a hamstring graft, leave out the knee strengthening workout's slider hamstring curl, and its reverse Nordic until kneeling is comfortable. The knee control warm-up and the netball class suit the later stages. If you'd rather do yoga, our yoga after ACL surgery guide covers it.
A 25-minute Pilates class after ACL surgery in three stages: a straight knee and a working thigh, hips and trunk, then one-leg control, with no kneeling.
25 minBeginner17 movesBench or box, wallA 25-minute Pilates class for sore knees and knee arthritis: lying and side-lying leg work, shallow squats and balance, with no kneeling at all.
25 minBeginner15 movesBench or box, something with weightA gentle leg strength routine with no jumping: sit-to-stands, step-ups, wall sits, bridges and calf raises.
20 minBeginner7 movesBench or box, stepA 25-minute session for knees that don't currently hurt: thigh and hamstring strength, single-leg control, then an optional full-range block with knees over toes.
25 minBeginner14 movesBench or box, wallA 20-minute warm-up that trains your knees to track over your toes: side-hip strength, squats and lunges with alignment practice, balance and quiet landings.
20 minBeginner10 movesWall, bandA 25-minute Pilates class for netball: ankles, the landing leg for quick stops, a trunk that doesn't lean or twist as you land, the hips and the shoulders.
25 minBeginner15 movesWall, bandThis is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Leg pain or swelling with breathlessness or chest pain: call 999 or go to A&E, and do not drive yourself. It can be a blood clot that has reached the lungs.
Use your team's rule first. The ACL surgery guide's working limit is pain of 3 out of 10 or less during and after exercise; ease off any move after which the knee is warmer, more swollen or more painful, use ice and raise the leg, and avoid twisting on the knee (our suggestion, from the NHS recovery advice). Our knee pain after Pilates guide covers kneeling, reformer footwork and deep bends.
Source 24
Call 999 if:
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
Source 76
You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
Source 77
No trial has tested Pilates after reconstruction, and guidelines put progressive strength, movement control, running, landing and return-to-sport testing at the centre for 9 to 12 months. Pilates is an addition.
Prevention programmes work, but adding core strengthening didn't make them more effective, and trunk and balance measures didn't predict ACL injuries in large studies. Landing practice and leg strength mattered more.
We found no study showing it. Kneeling is often uncomfortable for a while, more often after a patellar tendon graft, and kneeling pain was uncommon 10 years on in one trial. Wait until it's comfortable and your team agrees.
The Pilates trial in partial ACL tears used mat work. Reformer footwork is a leg press, which a leg press machine, bridges and sit-to-stands also train.
Returning to pivoting sport depends on strength, hop and movement tests, confidence and time, and about 1 in 4 young athletes who go back injure an ACL again.
Yes, as an addition to your rehabilitation once your team agrees. No trial has tested Pilates after ACL surgery, but quad sets, straight-leg raises, bridges, side-lying leg work and balance are moves rehabilitation already uses, and guideline groups say core exercises can be added. Your physiotherapist's plan comes first.
The lying moves are part of your first weeks at home. Side-lying hip work and bridges often come from about 2 weeks, single-leg work from about 6 to 12 weeks, and one NHS trust may refer you to an ACL class in weeks 6 to 12. That's our summary, and protocols vary, so start when your team says so.
Ask your physiotherapist. Lying footwork is a leg press, which one guideline starts at about 3 weeks after a hamstring graft in a small range, so set the stopper and keep the springs moderate. The kneeling knee stretches and the jump board wait until kneeling and hopping are cleared. This is our reading of the method, not tested evidence.
Only once kneeling is comfortable and your team agrees; then pad the knee and keep it short. A Cochrane review found more kneeling problems after a patellar tendon graft, though a 10-year trial found kneeling pain uncommon by then whatever the graft.
Early on, leave out kneeling moves, deep knee bends such as rolling like a ball and child's pose, twisting on a planted foot and jumping. After a hamstring graft, wait for your team before resisted knee bending and deep hamstring stretches, and after a meniscus repair deep bending waits at least 4 months.
Yes, with changes: leave out resisted knee bending (feet in straps, band curls, long single-leg bridges) and deep hamstring stretches until your team allows them, often about 12 weeks. A US protocol advises that wait; reviews say the reasons rest mostly on habit and biomechanics, and one NHS trust lists leg curls from week 6, so follow your own team.
It hasn't been shown to. Prevention programmes cut ACL injuries by about half, but adding core strengthening didn't make them work better; landing practice and leg strength matter most. Keep your team's prevention warm-up going.
No. Guidelines centre rehabilitation on progressive strength and movement control for 9 to 12 months or more, then running, landing and return-to-sport tests. Pilates adds trunk, hip and balance work.
Often yes, with your physiotherapist's guidance. In one trial, 12 weeks of mat Pilates improved thigh strength in adults with a partial tear, against no treatment. Our ACL injury guide covers rehab first against surgery.
Possibly. Fear of another injury is the commonest reason people don't return to sport, and psychological approaches eased fear of movement in small trials. A calm, graded class may help, though no trial has tested Pilates for this.
Usually, with the same care. After a meniscus repair, deep bending waits longer, and after a knee replacement our Pilates after a knee replacement guide applies.
Leg pain or swelling with breathlessness or chest pain needs 999. Throbbing or cramping leg pain, a high temperature, oozing or pus from the wound, or a knee getting more tender, swollen, painful or red needs an urgent GP appointment or NHS 111. A knee that gives way, locks or swells quickly needs checking.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
