Returning to Activity and Sport following an ACL injury


Physiotherapy can be very helpful when returning to activity and sport following an ACL injury!


What is the ACL and what does it do?

  • The ACL or Anterior Cruciate Ligament provides stability for your knee in two main directions – prevents forward movement of the tibia and external rotation (outward rotation) of the tibia. ACL injuries occur most commonly via a non-contact mechanism where an individual’s knee buckles and rotates inwards often during a quick cutting movement or change of direction. The ages at which individuals are most likely to experience a torn ACL are for males 19-25 yrs and for females 14-18yrs and 40+.


Following a torn ACL the main management strategies are:

  • Surgical repair: Individuals who undergo surgery will have a graft, taken from their hamstring or quadricep tendon. With an graduated physiotherapy rehab program a return to sport can be expected at 9-12 months – 9 months for elite sportspeople, 12 months for the general population
  • Conservative – A no surgery approach is possible and generally results in a return to sport at around 9 months however may be quicker for suitable patients. This approach is not suitable for everyone, and specific criteria need to be met for a person to follow a conservative approach – a physiotherapist will be able to determine the appropriateness of each patient.
  • Research is currently being conducted into the potential for ACL’s to regrow, a concept that could revolutionize the concept of ACL rehab and our general reliance on surgical approaches for return to sport and function so watch this space!


Regardless of if an individual is going to undergo surgical repair, they should undergo ‘prehab’ or pre-surgical rehab to optimise their functional ability, strength and range of motion prior to their surgery. Primary goals of prehab are as follows:

  • Eliminate swelling
  • Regain full range of motion 
  • Regain a minimum of 90% of the strength in the quads and hamstrings when compared to the opposite side


Whilst each individual and their rehab journey is different a general guide and checklist for ACL rehabilitation post surgery involves:


Stage 1 – Recovery from surgery

During the initial phase of recovering from ACL repair surgery the three most important goals are:

  • Regaining full extension range of motion – getting your knee straight again 
  • Reducing swelling down to low levels
  • Begin reactivating the quadriceps


Stage 2 – Rebuilding strength and control 

The second phase of rehabilitation focuses on regaining your muscular strength, balance and co-ordination. Exercises in this phase tend to begin with easy body weight exercises and subsequently progress to developing an individualized and progress gym based program. 

During this phase it is not uncommon for patients to have occasional increases in swelling and minor discomfort – these are signs that the knee is not quite ready to tolerate the workload and so exercises should be temporarily regressed

The three most important goals of this phase are: 

  • Regaining single leg balance
  • Regain significant single leg strength
  • Being able to do single leg squats with good technique


Stage 3 – Return to running, agility and landing:

Generally occurring roughly around the 12 week mark (provided the following criteria are met) stage 3 and a return to running and jumping is often an encouraging landmark for individuals recovery from ACL injuries, particularly those with sporting backgrounds. The core requirements of this stage are: 

  • Developing a single leg hop power and technique that is excellent and meets specific criteria (listed below)
  • Progressing successfully through an agility and game play program 
  • Regaining full strength and balance


Important landmarks to begin a return to running program include:

  • Able to bend your knee to 120 degrees and fully straighten your knee
  • Minimal to no swelling
  • No more than 2/10 pain at rest
  • Have regained at least 70% of your quads and hamstring strength compared to your unaffected side – quad strength must equal at least 60% of your body weight
  • Be able to hop 15x on the spot, 15 forward consecutively, and have a max hop distance that is at least 70% of your unaffected leg and 60% of your height


Stage 4 – Return to training and sport:

Return to sport tends to be considered around the 9 month mark and once again landmarks in rehabilitation need to be met to progress to this stage. The primary goals that must be met for return to sport include:

  • Regain at least 80% of quad and hamstring strength (90% preferred)
  • Achieve at least 80% on hop tests
  • Be able to tolerate running, controlled change of direction and jumping/hopping/landing drills without aggravating knee
  • Be able to tolerate low level sport specific skills
  • Be mentally ready and confident in knee to allow return to sport

Following a return to training at least one month of progressively more involved training should be completed before a full unrestricted return to the sport and gameplay is allowed. During this month involvement in facets of training that are less controllable and more reactive and dynamic are increased. During this time if the knee begins to flare or swell then a small regression of allowed activities should be applied until the knee has settled and is able to tolerate increased activity.


Are you needing to start ACL prehab or rehab, click here to book your Assessment Consultation today!


Blog written by Physiotherapist, Joe Herrmann.

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