Unfortunately, I see far too many patients following ACL reconstruction in my sports medicine practice. In any given month, I am rehabbing between 10 and 15 patients who have lost their season to this injury. Most of the time it is a non-contact mechanism of injury, often involving additional trauma to the collateral ligaments, menisci and/or cartilage within the joint.

Throughout my career, I have rehabbed several hundred athletes with ACL tears. It has always been an area of interest and passion for me as well as prevention. Blending my background in performance training with rehab, I have fostered through much trial and adjustment what seems to be a very effective approach to rehab and return to sport.  Rehabbing higher level athletes is much like working on a high performance sports cars.


If you own a high performance vehicle, you would prefer to have it serviced at a dealership where the mechanics are experienced working on similar cars, yes? I feel the same care and application is relevant with ACL rehab.  PT that is too aggressive or too conservative can impede progress and negatively impact peak performance.

Over the past 5-10 years, I have seen our profession grow in terms of adding more functional testing (FMS, Y-Balance test, LESS, etc.) as we try to better determine when it is appropriate to allow said athletes to resume their prior activity levels safely. Many times, orthopedic surgeons will “clear” patient to resume activity around 6 months post-op provided their quadriceps looks good and graft stability is acceptable.

In many cases, athletes are simply not ready for competition yet even when rehab goes perfectly.  My concern has been and continues to be the type of rehab the athlete is receiving. Is it progressive, sequential and functional? Does it include key milestones with subjective and objective markers we want the athlete to achieve?  Are we utilizing evidence-based criteria to assess the efficacy of our programs and ensure there is appropriate progression that is patient dependent, not protocol dependent?

I am writing this post after I recently helped revise the ACL protocol used in my organization to ensure that all of my peers and I have a similar lens with which to assess these things, thereby ensuring the patients win and get more standardized care. In the end it does really matter. I will illustrate why using a case study with a female 22 year old high level club soccer player at a D1 institution.

She underwent a BTB autograft ACL reconstruction with a partial lateral meniscectomy on 7-13-16. She had therapy with another clinician up until she was referred to me for “functional rehab” on 1/18/17 (27 weeks post-op).  Upon my assessment I discovered the following:

  • TSK-11 (Tampa Scale for Kinesiophobia) score of 19 where perfect score is 11 and worst score is 44
  • Marked quad atrophy and weakness with single leg squat as well as poor frontal plane control
  • Decreased stride length on involve side and asymmetrical running pattern
  • Single leg hop for distance = 55″ average on uninvolved side and 15.5″ average on involved side for 72% deficit (expectation would be 10% or less at this point for a full hop test battery)
  • Apprehension with landing on affected side
  • Trunk dominant strategy for landing (too upright and shoulders outside the body with lateral movement/deceleration

Based on these findings, it was evident to me that this patient was about 3 months behind schedule based on what my athletes typically look like following surgery.  Why? As I began to review the therapist’s notes it was clear there was no intentional progression of impact training, no real initiation or progression of plyometrics and running form, limited movement training and not aggressive enough strengthening given her sport and desired activity level.

Within 50 minutes of our first session together, the athlete remarked, “Why didn’t they send me to you sooner?”  She now knew what I am talking about in this very blog post – she was the victim of suboptimal rehab. Her progression was less than expected, but it was not her fault.  Things I would have done much sooner in her rehab program were never done at all. Despite the mutual frustration she and I shared on that afternoon, I am pleased to report she is making excellent progress.

On 3/2, I re-assessed her single leg hop for distance and her average distance increased from 15.5″ to 42″ reducing her deficit from 72% to 28%. Below you can see the progression (reduction of deficits) in terms of testing done on 3/2 and 4/4:

  • Single hop: 28% -> 23%
  • Triple hop: 27% -> 11%
  • Crossed hop: 27% -> 13%
  • Timed hop: 5% on both dates

Her single leg hop score did not improve as much in light of jumping further on the uninvolved side, but she is now nearly meeting the 90% threshold on 3 of the 4 hopping maneuvers.  Her most recent TSK-11 on 3/21 went down to a 14 (previously 19) which indicates her apprehension is resolving.  Her FMS score is 16.

This young lady still has some work to do in terms of cleaning up her landing form and reaching the desired functional performance standards I want to see for her, however, she is now looking much better in just the three months we have been working together (1-2x/week). The moral of the story here is the rehab progression, exercise selection and professional guidance do in fact significantly impact the athlete’s performance, confidence and outcome.

Not all athletes can or will progress at the same rate.  With that said, it is imperative that they do work with a skilled clinician who understands how to assess, correct and progress them in order to attain the best recovery and reduce secondary injury risk moving forward.  In my humble opinion, the rehab from day one matters.  The protocol allows for structure and norms, but the clinician must be able to think on the fly and slow things down or speed up on a case-by-case basis.

Hearing the words “you are cleared” by the MD if often never enough, and as a profession we must continue to strive to get better by staying up on the research, being open to change, learning form our peers, critically evaluating our own programs and including the patient, MD, family, ATC, coach and other involved parties in the conversation to deliver the best care possible.