Physiotherapy assessment report after ACL reconstruction: template and example

A physiotherapy assessment report after ACL reconstruction is the written record of the physiotherapy diagnostic assessment (in France, the bilan diagnostic kinésithérapique or BDK) for a patient whose anterior cruciate ligament has been reconstructed. It describes the knee, sets treatment goals and the rehab plan, and is updated at each stage: initial assessment, interim assessment before the 41st session, and return-to-sport assessment.

You will find the official French framework (HAS, ameli, Légifrance), a complete template to copy and a completed fictional example.

The official framework in France

The Public Health Code

Article R4321-2 of the French Public Health Code (in force since 3 August 2009) states that, within the medical prescription, the physiotherapist draws up an assessment that includes the physiotherapy diagnosis, treatment goals and the choice of procedures and techniques. The assessment is kept available to the prescribing doctor. A synthesis sheet records the treatment. It goes to the doctor after the last session when treatment includes at least ten sessions, and also if treatment must change or a complication occurs.

What ameli says about the BDK

According to the ameli page on the BDK, the assessment must include the initial evaluation of impairments and functional limitations. The summary sheet of the initial BDK goes to the prescribing doctor at the start of treatment, the assessment is enriched as treatment goes on, and a sheet is sent after the last session when treatment includes at least 10 sessions. For treatments under chapters II or III of the NGAP fee schedule, the same page says the next BDK can be billed at the 30th session, then every 20 sessions. Rehabilitation after ACL reconstruction sits in chapter II, article 1 (orthopaedic and rheumatological conditions), as shown in the health insurance booklet on amendment 7 (March 2024, in French).

The ACL guideline: 40 sessions, then prior approval

On the ameli prior approval page, the line for ACL reconstruction shows sessions 1 to 40 without prior approval, then a request from the 41st session. The page adds that you should assess the patient a few sessions before reaching the number set by the guideline. The request uses form S3108d, with the prescription and the medical rationale, and no answer within 15 days counts as approval to continue treatment. We suggest building that rationale on the figures from the interim assessment.

What the HAS recommends

The HAS recommendation of January 2008 on rehabilitation after ACL reconstruction gives no standard programme. It lists what the physiotherapist should receive from the surgeon: the operative report (type of reconstruction, fixation, tourniquet), instructions, the desired range-of-motion calendar and weight-bearing status. Its indicators are pain, effusion, mobility, muscle strength and proprioception, and it cites the Lysholm-Tegner, IKDC, Arpège and Cofras scores.

It also lists signs that call for referral back to the surgeon: fever above 38°C, rest pain that increases, local heat or redness, wound healing problems, knee flexion below 90° at 4 weeks after surgery, a 10° flexion contracture that does not improve, and suspected phlebitis or pulmonary embolism. Following the surgeon's instructions, individual sports may resume if the knee is dry, stable and pain-free, mobility is functional, muscle strength has recovered and the sport does not put shear stress on the graft. This text dates from 2008; the surgeon decides when sport resumes.

Belgium and Switzerland

We have not read an INAMI or Swiss rule specific to this assessment. We suggest the same structure, checking with INAMI or the insurer which documents are needed.

The three assessments, compared

• Initial assessment (first sessions): purpose, set the physiotherapy diagnosis and goals. Key measures, pain, effusion, scars, flexion and extension, active lock, gait. Recipient, summary sheet to the prescribing doctor at the start of treatment.
• Interim assessment (before the 41st session, often around month 4): purpose, measure progress and justify further sessions. Key measures, compared range of motion, strength figures for both sides, single-leg control, questionnaires. Recipient, prescribing doctor; it also supports the prior approval request.
• Return-to-sport or discharge assessment: purpose, record which criteria are met. Key measures, strength and limb symmetry index, hop tests if the surgeon allows them, questionnaires including the ACL-RSI, sport-specific tasks. Recipient, prescribing doctor and surgeon, who decides on return to sport.

What the assessment contains, section by section

• Surgery and graft: date, graft type (hamstrings such as a four-strand semitendinosus, patellar tendon, quadriceps tendon), lateral tenodesis, meniscal procedure (repair or partial meniscectomy), fixation, weight-bearing, brace and range-of-motion instructions. A meniscal repair often changes the instructions: write them down as the surgeon wrote them.
• Pain: VAS or NRS at rest and on effort, location (donor site, anterior knee), trend.
• Effusion and skin: patellar tap or sweep test, compared girth, heat, scars.
• Range of motion: active and passive flexion and extension with a goniometer, compared with the other side, flexion contracture, patellar mobility.
• Strength: active lock (extensor lag), then quadriceps and hamstring strength in figures (handheld dynamometer or isokinetic testing), with values for both sides.
• Proprioception and control: single-leg stance, single-leg squat, dynamic valgus, landing quality.
• Function: gait, walking aids, stairs, running, jumps once allowed.
• Questionnaires: the KOOS (Knee injury and Osteoarthritis Outcome Score), copyright Professor Ewa Roos; according to koos.nu, permission is always required, academic use is free, and fees are charged depending on the type of user (healthcare organisations, commercial users). The IKDC, cited by the HAS. The ACL-RSI, 12 items on the psychological impact of returning to sport, validated in French by Bohu et al. (Knee Surgery, Sports Traumatology, Arthroscopy, 2015). Each score is calculated with the tool's official scoring guide; Delta calculates no scores.
• Physiotherapy diagnosis, goals, plan: impairments, limitations, dated and measurable goals, techniques, session frequency, home programme, criteria for the next stage, date of the next assessment.

Report template to copy

Copy the sections you need. For an interim or return-to-sport assessment, keep the same structure and add a "change since last assessment" column.

1. Identification

• Patient: name, date of birth.
• Prescriber: name, prescription date, number of sessions prescribed.
• Surgeon: name, hospital.
• Assessment type: initial / interim / return to sport / discharge. Date. Session number.

2. History

• Injury mechanism and date:
• Sport, level, position, patient's goal and target date:
• Job, knee demands at work:
• History (operated knee, other knee, other):

3. Surgery and instructions

• Surgery date, side:
• Graft: hamstrings / patellar tendon / quadriceps tendon / other. Lateral tenodesis: yes / no.
• Meniscal procedure: none / repair / meniscectomy (location).
• Fixation, tourniquet (from the operative report):
• Instructions: weight-bearing, brace, allowed range and calendar, restrictions:

4. Examination

• Pain: VAS rest / effort, location:
• Effusion: test used, result; girth operated / other side:
• Scars, heat, HAS warning signs checked: present / absent:
• Active and passive flexion, operated / other side:
• Extension, flexion contracture, operated / other side:
• Active lock: extensor lag in degrees:
• Quadriceps and hamstring strength: tool, angle, values operated / other side, symmetry index:
• Control: single-leg stance, single-leg squat, dynamic valgus:
• Gait, walking aids, stairs:
• Hop tests (if allowed): test, values operated / other side, landing quality:
• Questionnaires: tool, date, result calculated with its scoring guide:

5. Physiotherapy diagnosis

• Impairments:
• Activity limitations:
• Participation restrictions (work, sport):

6. Goals and plan

• Short-term goals, dated and measurable:
• Medium-term goals:
• Techniques and exercises, session frequency:
• Home programme given (yes / no, date):
• Criteria to move to the next stage:
• Next assessment planned (date, session number):

7. Communication

• Summary sent to: prescribing doctor / surgeon / medical service. Date:
• Prior approval request: not applicable / sent on:

Fully completed fictional example

The patient and all values are fictional, chosen to be plausible. They come from no real record.

Initial assessment, session 1, day 12

• Identification: Léa M., 24. Prescribed by Dr P. (sports doctor). Surgeon: Dr R.
• History: right knee sprain during a handball match (landing with rotation), four months ago. Wing player, regional level, 3 training sessions a week. Office administrator, seated work. No history on the left knee. Wants to play next season.
• Surgery: right ACL reconstruction, four-strand hamstring graft, no tenodesis, no meniscal procedure. Full weight-bearing allowed, brace removed on day 8, no range limit.
• Pain: VAS 2/10 at rest, 4/10 after long walks, medial side (donor site).
• Effusion: positive patellar tap; girth 5 cm above the patella, +2 cm on the right. Clean scars, no heat, no HAS warning sign.
• Range of motion: active flexion 85°, passive 95° (left 145°). 5° flexion contracture. Reduced superior patellar glide.
• Strength: 10° extensor lag. Visible but weak quadriceps contraction.
• Function: walks with two crutches, limps, stairs one step at a time.
• Physiotherapy diagnosis: painful, swollen right knee after hamstring-graft ACL reconstruction, with flexion deficit, flexion contracture, poor active lock and limited gait. No work or sport possible at this stage.
• Goals: by week 4, full extension, active lock, flexion beyond 120°, walking without crutches. By week 8, dry knee, reciprocal stairs.
• Plan: 3 sessions a week. Effusion control, mobilisation, lock work, progressive strengthening, gait. Home programme given on day 12.
• Next assessment: around session 35, before prior approval.

Interim assessment, session 35, month 4

• Progress: VAS 0/10 at rest, 2/10 after a heavy session. Dry knee. Flexion 135° (left 145°), full extension.
• Strength: isometric quadriceps at 60° with a handheld dynamometer, 30 kg right and 42 kg left, 71% symmetry. Hamstrings 22 kg right, 25 kg left, 88%.
• Control: eyes-closed single-leg stance held 20 s on the right, 30 s on the left. Dynamic valgus on right single-leg squat.
• Questionnaires: KOOS and ACL-RSI completed by the patient and calculated with their scoring guides. ACL-RSI 55 out of 100. She says she fears changes of direction.
• Physiotherapy diagnosis: quadriceps strength deficit and poor right knee control in single-leg stance, apprehension about pivoting. Running and jumping not resumed.
• Goals: by month 6, quadriceps at least 80% of the left side, single-leg squat without valgus, straight-line running if the surgeon approves.
• Communication: summary sent to Dr P. and Dr R.; prior approval request sent to the medical service, with the prescription and a rationale drawn from this report, to continue beyond session 40.

Common mistakes

• Writing "good progress" with no figures. The medical service and the surgeon need angles, strength values and dates.
• Giving only the symmetry percentage. If the healthy side has lost strength, 90% can hide a deficit. We suggest writing raw values for both sides and the tool used.
• Thinking only in weeks. Record which criteria are met, not only the time since surgery.
• Naming a questionnaire without its version or scoring. Give the version, date and scoring method. For the KOOS, check the terms of use on koos.nu.

Why Delta fits this assessment

After the assessment, you dictate your observations and measurements; Delta writes the report in your structure and vocabulary, learned from your existing assessments, and updates the patient record with the goals being tracked, so you can follow the knee from one assessment to the next. Delta calculates no scores, does no billing coding and does not fill in the prior approval request; data is hosted in France with an HDS-certified host. Learn more about what Delta is and Delta for physiotherapists.

Further reading

• How to write physiotherapy notes
• Physiotherapy software: how to choose
• Clinical document templates by profession

Sources

• HAS, Follow-up criteria in rehabilitation and referral after anterior cruciate ligament reconstruction, recommendations, January 2008 (in French)
• Assurance Maladie (ameli), Prior approval request, physiotherapists, accessed 5 November 2026 (in French)
• Assurance Maladie (ameli), The physiotherapy diagnostic assessment (BDK), accessed 5 November 2026 (in French)
• Légifrance, article R4321-2 of the French Public Health Code, in force since 3 August 2009
• Assurance Maladie du Loiret, amendment 7 booklet for physiotherapists, March 2024 (in French, hosted by the Gard physiotherapy council)