ACL Rehabilitation – A step by step approach

An ACL injury is o3D Biomechanics Laboratory at UPMC Sports Surgery Clinicne of the most feared injuries for any athlete playing multi-directional field sports.

Given the long-term rehabilitation required, and the challenges in returning to play it can often stall or derail the most promising of playing careers. Despite the severity of the injury and the length of time laid off, outcomes after ACL reconstruction are extremely successful. The principal indication for having this done is an intention to return to high-level sport, involving twisting, turning, jumping, landing. The main markers for a successful outcome are a return to the same level of sport as participated in prior to injury with little or no symptoms in the knee, and to avoid any re-injury, not only on the operated leg but on the non-operated leg as well.

A huge volume of research has been done and continues to be carried out in the area of operative techniques for ACL reconstruction. The two main and most commonly used techniques are with the patellar tendon graft or hamstring tendon graft. Despite the large volumes of operations that are done on an annual basis, there has been very little definitive research to indicate any major benefit in having one technique versus the other. What is of far greater consequence is the skill of your surgeon, and there is plenty of research to support the fact that the more ACLs your surgeon does, the higher the likelihood is of a successful outcome.

Almost every player will have had a teammate or friend who has undergone ACL injury, and despite this prevalence, there is actually quite a poor understanding of the amount of work that is required to rehabilitate after surgery and also in what a fully rehabilitated knee looks like. It is this lack of clarity and understanding that very often causes issues in terms of ongoing pain and symptoms, but also of disappointment and poor progress during rehabilitation.

It should be very clear from that start that the ACL rehabilitation is actually an opportunity for an athlete to condition themselves back to a level of performance that was equal to, if not better than, what they were at before the injury. However it should also be understood the huge volume of work, commitment and dedication it takes in order to have the most expedient and successful return.  At SSC we sit down and meet with athletes before their surgery when they have been initially diagnosed, as well as immediately after surgery to set goals and expectations and to ensure the athlete is fully physically and mentally prepared for the journey that lies ahead.

The principal message is always that ACL rehabilitation is a step by step process which is focused on criteria based progression as opposed to time-based progression. Far too often in the media and in the general population the discussion around ACL rehabilitation centres on timelines i.e. return in 6 months, return in 7 months, return in 9 months.

However this in no way takes into account the nature of the injury, any concurrent damage to the cartilage or other ligaments in the knee during the initial injury, baseline strength and conditioning levels, athletes adherence and diligence with the rehabilitation programme and the level of sport participation that the athlete is returning to. It is important the rehabilitation is progressed in a step by step fashion with advancement to the next level being achieved when previous criteria have been met in order to avoid re-injury but also to avoid athletes taking longer than necessary by “giving the knee more time” when they are ready to push on.

During early rehabilitation the emphasis centres on restoring normal range of motion to the knee, reducing pain and swelling and minimising any muscle wasting that will have happened after surgery. This is then progressed onto graduated balance and body weight strengthening exercises to improve normal movement and activate the muscles around the knee.

Once the knee is calm and normal range is achieved, a more vigorous strengthening programme can be entered into. This generally happens anytime from 4-8 weeks postoperatively.
The principal landmarks during the ACL rehabilitation are commencing hopping and landing, running, turning, returning to training, and returning to full competitive action.

Each of these criteria or landmarks should only be commenced when certain levels of a range of motion, strength, power and neuromuscular control have been achieved. Not only will this guarantee rapid progress through this phase, but it will also minimise any of the complications of overloading or aggravating the knee or the donor site as well as avoiding any acute re-injuries.

As part of our ACL rehabilitation pathway, SSC offers consultancy reviews during the early stages of rehab, in the middle of rehab and at the end once the athlete has returned to play. These reviews consist of a strength assessment using isokinetic and mid-thigh pull and 3D biomechanical analysis in our Vicon lab including, landing, jumping and cutting tests with and without reacting to external cues.

This data is used to provide accurate feedback to the athlete, their referring physiotherapist and the surgeon as to the progress of their rehabilitation and areas for further improvement.
As the athlete continues to progress through the rehabilitation, the main goal tends to be returning to their first match.  However it should be noted that returning to play your first game is really only about 80% – 85% of the way through the rehabilitation programme process, and although the athlete has returned to play, resolving any residual biomechanical deficits and maintaining strength and power is extremely important in the months after a successful return has been made.
ACL reconstruction and rehabilitation is extremely successful and athletes at every level of sporting performance have made successful returns. A step by step approach and a clear understanding of the work that needs to be done after surgery as well as what the completed rehabilitation looks like will allow for a very efficient and comprehensive rehabilitation allowing the athlete to return to an even greater level of athletic performance than prior to the injury.
Head of Performance Rehabilitation, UPMC Sports Surgery Clinic.
Enda is carrying out his PhD in 3D biomechanics in return to play decision making after ACL reconstruction.
For more information please contact our Physiotherapy Team on +353 1 5262040 or email

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