ACL Injury: Whats Next?

May 24, 2021

Confirm Diagnosis

First things first, you need a thorough assessment to ascertain the level of injury and any concurrent injuries (E.g. MCL/ Meniscal etc.)  Book an appointment with a physiotherapist, if they feel it is warranted, they will refer you onwards for imaging or orthopaedic opinion as required.  

Surgery or no surgery?

When you have confirmation of the extent of your injury, in consultation with your physio and your consultant, you will decide on whether you will have surgery, or you will be managed conservatively. The vast majority of the athletic population usually opt for surgery, but it is possible to do without, particularly if you aren’t aiming to return to sport. This is a decision that will be weighed up taking into consideration many factors such as age, injury history, sport played and many more. If you are returning to a sport which involves change of direction, then surgery at the moment is usually the preferred option to give you the best chance of a successful return to play and more importantly a return to performance.   

Surgical Repair

For the purpose of this post we will delve into the details of a surgical repair for the athletic population but if you don’t fall into this bracke,t feel free to contact us for more information in regard to your individual case. If the decision has been made to go ahead with surgery, the next decision is what type of graft will be used in the repair. The two most popular grafts are a hamstring graft or a patellar tendon graft, although there are other potential options. This decision will usually come down to the consultant’s personal technique preference and your injury history.

In the meantime, whilst you are waiting on your surgery it is vitally important that you begin some pre-operative training, often referred to as the prehab phase to allow for optimal success post-surgery. The main aims of this prehab phase are to restore range of motion, increase muscle strength, maintain muscle bulk & maintain proprioceptive qualities. This program will vary depending on the length of time to surgery & will be provided by your physiotherapist. The more work done in this period can help make the post-operative phase that bit easier.

Next up is the surgery itself, where your chosen surgeon will perform your ACL repair. This will be done under general anaesthetic and post-operative management will usually involve an overnight night stay. The next day you will see the resident physiotherapists who will guide you on your immediate post-operative rehab and it is here that your rehab journey begins. After this you will then be discharged from hospital & returned to the care of your physiotherapist.


ACL rehabilitation can then be split into 7 phases which we will explore below. All of these phases will be led by your physiotherapist. Here at PhysioFocus we guide all our athletes through each stage & we are launching our new ACL service which will include two supervised gym-based sessions per week & one pitch based supervised session per week, these can be completed in house, or our physiotherapists programme these for you to complete remotely.

Phase 1 – Protection

The first phase post ACL repair involves the protection of the wound, respecting the healing process & beginning range of motion-based exercises. On discharge from hospital you will be on two elbow crutches & a main aim from this phase is to wean you off this & return to a normal gait pattern. In this stage your early exercises can be bed based but as soon as possible we want to get you doing some exercises in a weight bearing position.

Phase 2 – Load Introduction

The second phase involves introducing load to the operated limb whilst still respecting the healing process which is taking place. Here the aims are full extension of the knee, at least 120 degrees of flexion, minimal joint effusion, wound fully healed & a normal pain free gait pattern. At this point we are for you to have started your gym-based rehab and be comfortable in your main lower limb movement patterns of squatting & hinging. In this phase we have a great opportunity to strengthening important areas such as the lateral hip, the calf’s & the trunk area with exercises such as calf raises, hip hitching & side planks to a high level so that when we begin our more complex loading of the knee area we have required strength & stability from surrounding muscle groups. At this stage we like our athletes to complete rehab at least 5 times per week.

Phase 3 – Early Stage Gym & Pitch based Rehab

The third phase is where the fun starts & a return to more ‘normal’ training types, here our aim is to accumulate strength, regain muscle bulk, improve balance & proprioception, work on running mechanics and load both on two legs and on one leg and to begin some energy systems development work. At this stage we can now put ore load through the knee joint, the quads & hamstrings & exercises may include hamstring bridges, single leg squats and non-counter movement jumps to start on the plyometric continuum. Straight line running can usually begin at this stage. At this stage we like our athletes to rehab a minimum of 4 days per week. Here at PhysioFocus we have a robust testing system which dictates your ability to move from phase to phase. At this phase you will be required to pass a series of isometric muscle strength tests, endurances tests and a jumping & hopping assessment.

Phase 4 – Mid Stage – Gym & Pitch based Rehab

Phase four we really start to challenge our clients as we aim to integrate back in training & sports specific attributes working on running mechanics, continuing to build strength and power, progressing along the plyometric continuum, begin change of direction tasks, improve overall fitness & importantly improve your confidence in your affected limb. Exercises at this stage include change of direction mechanics & strength exercises in different lanes of motion. At this stage we like our athletes to continue with a minimum of four sessions per week. To progress from this phase with us you will be required to come through a robust testing assessment including several strength tests, several jumping and hopping tests along with the use of our Vald Performance testing kit including Forcedecks, Nordboard & Forceframe.

Phase 5 – End – Gym & Pitch based Rehab

Phase five is about return to play & ultimately aiming for return to performance, at this stage we will progress you further along the plyometric continuum, continue to develop strength and power, move to end stage change of direction drills which will involve a return to non-contact training followed by a return to partial contact training & then full contact training. At this point your pitch-based training will aim to mimic the demands of your sport & your gym-based exercises will continue to build a robust athlete to the demands of your sport through extensive plyometrics alongside the continuation of strength and power-based exercises. At this stage with our athletes reintegrating into a team environment up to 3 days per week we like them to also carry out at least two individualised sessions per week.  At this stage we have two separate testing systems, one of which is gym based & one of which is pitch based. Gym based is a progression from our phase 4 testing & our pitch-based testing will include assessments on acceleration, deceleration, absolute speed, fitness, agility, reactive agility & a comparison between agility versus reactive agility to allow for a return to sport. 

Phase 6 – Return to Play

By this stage you will have progressed through our robust testing system and your physiotherapist will have cleared you for return to play. At this stage it is our aim that you have full confidence in your knee & overall athletic abilities. However, your ACL journey does not end here, it is vitally important that you continue to train in both the gym & the pitch in a manner which minimises the risk of reinjury. At this point you will fully re-join team training and you will continue to complete at least two gym-based sessions per week. After completing your rehab journey with us it is our aim that our clients will be educated enough to be autonomous in their training & recovery.

Phase 7 – Return to Performance & Maintenance 

The final part of your rehabilitation journey is one which is often neglected is return to performance. This stage will be largely down to getting match play under your belt & honing your skills. This requires good communication between team management and your physiotherapist to manage your training load & gradually build up to the level you require. An ACL injury and rehab process does not end after 9 months or a year, the journey is forever ongoing but with the right care and commitment you can still achieve your goals.

Any queries please feel free to contact us & we will be more than happy to help.