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The Problem with Traditional ACL Rehab

Imagine this. You tear your ACL. You’re devastated. You’ve been benched and you can’t play your favorite sport or even exercise the way you’re used to.

You get surgery and start rehab ASAP. You’re dedicated to putting in the work. Then they discharge you at 6 months - even though you don’t feel ready at all. You’re terrified.

Insurance cuts off your visits around 5-6 months. You haven’t gone through proper testing - you don’t have full knee extension, you can’t do a full loaded squat, and you still feel unstable.

You return to sport and re-tear your ACL. Then you retear it—this is an even longer rehab process, as your surgeon has to perform a bone graft, then wait 3 months to secure your new ACL graft. 

THIS IS WAY TOO COMMON!!! The incidence of subsequent knee injury following an initial ACL tear is substantial. Here are a couple of the numbers from the current literature: 

  • Returning to sport too early (before 9 months) increases the risk of retear 7x

  • Post ACL reconstruction, rates of retear, contralateral knee injury, and meniscal injury are estimated to be around 30%. Specifically, the probability of graft retear ranges from 8%-17%, while the risk of contralateral ACL injury can be as high as 24%. (Hadley et al. 2022).

The above  numbers are a touch frightening. But the good news? Quality rehab and robust, functional return to sport testing can make or break your return. 

  • For every month that return to sport was delayed, until 9 months after ACL reconstruction, the rate of knee reinjury was reduced by 51% (Grindem et al. 2017).

  • Studies show an 84% lower knee injury rate in patients who pass return to sport testing, with quadriceps strength and symmetry significantly reducing the risk for reinjury (Grindem 2016). 

Athletes are returning to sport early and unprepared-mentally and physically- but why? We've heard too many stories of people not being tested, not being loaded or challenged approriately, getting cleared way too early, and re-tearing.⁠

The research is VERY clear - return to sport should be after a MINIMUM of 9 months AND after passing functional criteria. So why are people being discharged and sent back to the field at 5 or 6 months without being mentally or physically ready?

We HAVE to do better. ACL rehab has to change. We’re here to elevate the standard. 

Why are Retears and Inadequate Rehab “the norm” after ACL Recontruction?

  • Insurance cuts your visits off too early

  • The research is clear. Return to sport should be at 9 months MINIMUM. If > 9 months is the standard, why is insurance discharging you at 5 months? Along with visits getting cuf off, most ACL rehab just isn’t cutting it. 

  • Traditional rehab lacks sufficient loading and proper objective testing. This could be a fault of clinic space and equipment, yes, but it starts with just geting that quad working and ensuring it’s strong and prepared to absorb and produce force before we say “Now go run, cut, and pivot!!!” At Made 2 Move, we utilize tools like BFR and proper rehab progressions when deciding to increase volume or intensity. 

What Can We Do? 

The current standard has to change. This “norm” is far from ideal and as physical therapists here at Made 2 Move, we believe that we can do better in beginning to change this narrative. Below are a few (by no means an all encompassing list) of the ways we are trying to elevate the standard of ACL rehab: 

  • Conservative rehab after ACL reconstruction for AT LEAST 9 months.

  • Objective testing

  • How can we know your capabilities by just “eyeballing it?” While numbers don’t tell the whole story, they are a good starting point for deciding if an athlete is adequately prepared for the demands of a sport. We will assess….

  • Quad index- How strong is your involved quad compared to your uninvolved quad?

  • Hamstring: Quadriceps Strength Ratio. How strong are your quads in relationship to your hamstrings?

  • These numbers can be compiled into a limb symmetry index or LSI. We shoot for an LSI of AT LEAST 90% , meaning your involved side has at least 90% of the strength of your uninvolved side, before considering return to sport. 

  • Now, we understand (and appreciate) that athletes may not be perfectly symmetrical due to having a dominant side, being a human, etc. But these numbers can give us a ballpark idea of the force you’re able to produce through that lower limb, which is vital for producing and absorbing the forces you face in a sport setting. 

  • Fundamentals and a logical progression back into skills, practice, and games 

  •  88% of injuries occur in games 12% in practice, thus we are going to introduce you to drills before practice before contact before competition. 

  • Return to PLAY  (this can be drills, passing, juggling, dribbling, etc)  is different and should come earlier than a full return to COMPETITION or PERFORMANCE.

  • Subjective tests, assessing an athlete’s feelings of confidence, fear, and overall preparedness (aka you are more than just your quad strength or hop test!): 

  • ACL injuries can be traumatic. There is lots of fear and psychological factors that predict a successful return to sport. That’s why  when we are considering an athlete’s return to sport, we may give athletes an ACL Return to Sport Index (ACL RSI), shooting for above a  77%.  The ACL RSI assesses an athlete’s fear, confidence, preparedness, and overall psychological readiness. 

  • Below 77% on the ACL RSI? We may need to dive into why an athlete doesn’t feel fully confident or prepared in their knee. 

Let’s Do Better

End stage rehab  (all stages of rehab if we’re being frank) and return to sport guidelines have to be better. It HAS to incorporate more than just a few hops, pain-free jogging, sub-par strength testing, and an athlete subjectively feeling “good” about going back to sport. 

Inevitably, not an athlete, surgeon or PT can entirely prevent an ACL injury. However, at Made 2 Move, we can empower you with strength, awareness, exposure, and an enhanced capability to accelerate, decelerate, change directions, and whatever other aspect of athleticism your sport may require. With these tools, you can feel optimally prepared for the demands of your sport. 

Interested in learning more about our ACL Performance Lab? Reach out to to schedule a consult with one of our clinicians!


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