Pop! goes the anterior cruciate ligament. ACL tears are not a rare injury in the athletic world. As an athlete, if you haven’t suffered one yourself, you’re likely terrified of the dreaded ACL tear happening to you one day—and rightfully so. Tearing your ACL, having surgery, and working through the rehabilitation process is no easy venture.
ACL rehabilitation is an all-encompassing process that takes over nearly every aspect of the injured athlete’s life for the year—and then some. So, why is there such a gap in the quality of rehab plans from physical therapists? Why are there such high ACL reinjury rates for athletes?
I tore my ACL in my early 20s during an indoor soccer game, playing on some pretty worn-out turf. Though I played in this adult soccer league for fun, we were losing, and I was frustrated about it—once an athlete, always an athlete. I went in for a sloppy tackle to get the ball, and after winning it, it was all downhill. I did it to myself.
My ACL injury was non-contact, as is the case with many. After winning the ball, I planted my left foot firmly and was shielding the ball from another opponent. Somehow, I twisted in the wrong direction and heard the infamous “pop.” Down I went.
While rehabbing, I got connected with the @theaclclub Instagram community and, shortly after, became their social media manager. It was through my own sub-par physical therapy and seeing the struggles of other ACL patients that I realized just how little is known about this specific rehab process—even with between 100,000 and 200,000 ACL tears suffered yearly in the United States alone.
The Biggest ACL Rehab Misconception
Urgency can be the greatest enemy in ACL rehab. Athletes are the population predominantly dealing with this injury, and they’re eager to get back to playing. Many grab hold of the outdated 6–9-month return-to-sport timeline with a tight fist, and unfortunately, their physical therapists or surgeons may tell them the same.Urgency can be the greatest enemy in ACL rehab. Click To Tweet
At @theaclclub, I have the great pleasure of being connected with some of the most knowledgeable ACL physical therapists around the world. Two of them—Ravi Patel and Tommy Mandala—spoke with me directly to provide additional insights on how to be successful in your ACL rehabilitation process.
“No one should be cleared before nine months post-op, based on the mountains of research and evidence to show that should be our minimum cut-off,” says Ravi Patel, physical therapist, performance coach, and founder of The ACL Athlete. “Time alone will not do anything for us.”
As has been found by Sports Health, delaying return to sport to align with ACL graft integration and maturation decreases reinjury risk, which is why it’s recommended to wait until 9 to 12 months after surgery. But even that timeline can be too soon if the athlete is not engaging in an ACL rehab plan that will fully prepare them to return to sport.
Where the ACL Rehab Process Falls Short
“One of the biggest challenges faced by ACL patients is the tendency for their physical therapist to underload them early in the process and then rapidly overload them in the middle- to late-phase,” said Tommy Mandala, physical therapist and founder of All in ACL.
Mandala continued, “Early in their rehab, many ACL patients are given low-level exercises, like leg lifts, bridges, clamshells, and band walks—which do very little to prepare them for higher-level activities.”
It’s true. Aside from the hamstring curl, leg press, and knee extension machines, I didn’t utilize weights at all in my early rehab. Most of the exercises I saw included what Mandala mentioned, as well as indoor biking and bodyweight squats. By the time I hit three months post-op, I was starting to run on the treadmill without ever performing a strength test. It’s no wonder I felt so weak and unstable, but I didn’t know any better.
Video 1. Performing leg raises post-surgery.
And similar to my experience, when the “standard ACL timeline” allows, athletes are rapidly overloaded with more complex moves like lunges, jumping, running, and even returning to sport. The struggle is that most ACL patients don’t know any better and are doing their best with the resources they have available to them.
“Early progressive overload and continued patience as you rebuild strength symmetry before getting into those more dynamic movements are the key to success in ACL rehab,” Mandala concluded.
Progressive overload—just like in weightlifting. An ACL tear is a significant injury, and it requires you to rebuild gradually. After surgery, muscle atrophy in the injured leg hits quickly. Graduating from low-level bodyweight movements straight into running on that depleted leg is a huge leap. If you take that same drastic leap too soon onto the pitch, you won’t be adequately prepared for the chaos of a full-speed competitive game.Graduating from low-level bodyweight movements straight into running on that depleted leg is a huge leap…It’s these huge leaps that lead to high reinjury rates in the first place. Click To Tweet
It’s these huge leaps that lead to high reinjury rates in the first place.
Another significant problem lies in the lack of proper strength testing from physical therapists. In fact, many athletes go through physical therapy without ever receiving an actual strength test, which measures muscular strength and compares symmetry in each leg.
“Studies show that successfully passing a series of single-leg hop tests, along with a series of strength tests for your quad and hamstring, all with symmetry of 90% matching the other side, reduces risk of reinjury by 84% when returning to sport,” added Mandala.
Don’t make the mistake of letting time be the be-all and end-all measurement of progress or the next steps in your ACL rehab. One day, around four months post-op, my physical therapist said, “Congratulations! It’s your rehab graduation day,” and sent me on my way without any strength testing. I only ever realized I needed a strength test from managing the @theaclclub Instagram account.
“Imagine if I got my doctorate solely based on doing three years of grad school, with no testing. That’s how much of ACL rehab is done. Often, after six months, athletes are cleared to return to sport. No testing or criteria has been met, but rather, it’s because they’ve reached a six-month point with their surgeon or rehab professional,” Patel told me.
It’s what is accomplished from both a physical and mental preparation standpoint, criteria-based testing, rehab, and training during this time—and beyond—that will ultimately influence successful return to sport and activities.
7 Best Practices for Successfully Returning to Sport
Seeing such high ACL reinjury rates can feel discouraging for athletes. Of course, full-speed games are unpredictable, and things that are out of your control can always happen. But you have more power over your ACL rehab than you may think. Heed these seven best practices from a pair of physical therapists specializing in ACL RTP for successfully returning to sport.
1. Quad Strength Is Key
The importance of quad strength is severely underlooked in ACL rehab, yet after surgery, this is the spot where you’ll immediately start noticing a difference. As a soccer player, I always prided myself on my strong quads. So, it was completely shocking when my surgical leg went from firm and strong to that of a hot dog within a week’s time. Even just flexing the quad and lifting my leg after surgery felt like mission impossible.The importance of quad strength is severely underlooked in ACL rehab, yet after surgery, this is the spot where you’ll immediately start noticing a difference. Click To Tweet
Atrophy takes over, so regaining quad strength is extremely important. After all, every 1% increase in quad strength is a 3% decrease in risk of a re-tear.
Mandala said, “Gaining strength in this rehab, while maintaining a quiet knee, free of swelling, is the name of the game in successful return to sport.”
2. Vet Your Physical Therapist
Many folks make the mistake of going to their nearest surgeon and the recommended physical therapist and hoping for the best. It’s essential that you vet your ACL care team, including your surgeon and physical therapist. You’re not expected to know everything, but there are important questions to ask your physical therapist before you commit to working with them.
Mandala, amongst many other specialized physical therapists, encourages asking the number one question: “How many ACL patients do you work with per year?”
A physical therapist who sees upward of five ACL patients each year is a good number to aim for. It’s a unique injury, and athletes need to work with someone who helps ACL patients regularly and understands the process. Unfortunately, the traditional healthcare model can limit even the best clinicians.
Here are some other important questions to ask your physical therapist:
- What criteria do you use for return to sport?
- How long should it take to get back to sport? (Watch if they say less than nine months.)
- How heavy can you load me during rehab? (Fifty pounds and heavier needs to be available.)
- How do you measure quad strength or force gauge? (Words to look for: handheld dynamometer or an isokinetic dynamometer/Biodex.)
- What tools do you have access to during rehab? (Helpful items can be blood flow restriction cuffs and electric stimulation.)
- What are your keys for patients during recovery? (Recommendations can include being around teammates, journaling, sports psychologist, nutrition, etc.)
- Will I see more than one provider? (Personal preference is to see the same provider or work with a few different ones within the practice you trust.)
Patel stated, “People assume that their healthcare system is set up to take care of them from start to finish, but it’s not, and you have to be your own advocate—from vetting surgeons to physical therapists to any other professionals involved, as most are not experts in ACL rehabilitation.
Get ahead of this. Do your research and find an ACL expert to guide you on your journey. Don’t assume the system will take care of you, and always be your own advocate. And lastly, choose what is truly needed over what’s available or convenient. I promise you will thank yourself in a year,” he concluded.
3. Understand What You Need to Succeed
Having worked with many ACL patients, Patel advises that ACL patients need three things in this process to return to sport successfully.
- Making sure the patient has solid evidence-based and criteria-driven testing every 4–6 weeks. This includes range of motion, functional positions, quadriceps and hamstring isolated strength, jump, deceleration, and change of direction profiling.
- Appropriate planning and programming for the patient’s specific needs and gaps to help meet the proper criteria being tested and sport demands.
- Having expert support each step of the way.
4. Do Your Homework
Your rehab homework, that is. ACL rehabilitation is like having a full-time job you didn’t ever apply for. Of course, you have to attend your physical therapy sessions with a focused mind and a ready-to-work mentality. But you also have to work on your own time.
“Two physical therapy visits per week for an hour per session is still less than 2% of your week. Your success in ACL rehab is dependent upon what you do with the other 98% of the week!” Mandala declared.
5. Don’t Underestimate the Early Post-Op Days
The early days of ACL rehab are more important than you might think, and their significance is often underestimated. The immediate post-op days can be painful and full of exhaustion. You may even be scared to hurt yourself somehow. But this is where the foundation is built.
“You can easily make this process two times longer if you don’t focus on those basics early, such as getting the knee quiet and strong.” Patel went on. “People assume the knee just needs to heal, which is partially correct. The other part is doing your job to make sure your range of motion is perfect, quads are firing on all cylinders, your walking is normal, and you’ve got your pain and swelling under control.”
Hitting these key points early and over-excelling in the post-op phase will allow you to have an easier mid and late stage.
6. Prioritize Patience
As social media manager for @theaclclub, a community with more than 30,000 followers, I’ve received many messages asking how to speed up the ACL recovery process. Spoiler alert: you can’t, and you shouldn’t. No athlete wants to hear about the importance of patience, but it truly is a virtue that will serve you well in ACL rehab.No athlete wants to hear about the importance of patience, but it truly is a virtue that will serve you well in ACL rehab. Click To Tweet
“Don’t rush trying to get back—play the long game, instead. You can’t rush biology. This recovery takes time not only to heal but also to physically and mentally get back to better than before. Don’t beat yourself up if it takes over a year to feel that. Your older self will also appreciate that you didn’t rush back,” Patel encouraged.
7. Conquer Your ACL Rehab
ACL rehabilitation is a tough battle that can certainly feel overwhelming—especially if it’s your first major injury. There are so many things learned from simply going through it, and we all have different resources available to us. Take your ACL rehab process one step and one day at a time while doing all you can to be your best advocate.
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Mandala, Tommy. All in ACL.
Patel, Ravi. The ACL Athlete.
Friedberg RP and d’Hemecourt PA. “Anterior cruciate ligament injury.” Uptodate. 2023.
Brinlee AW, Dickenson SB, Hunter-Giordano A, and Snyder-Mackler L. “ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline.” Sports Health. 2021;14(5):770–779.