ACLR Rehab – We need to do better!

Outcomes following ACLR has been less than desirable with up to 30% of athletes incurring a second ACL injury in addition to 37% of athletes not returning to the same level of sports participation. In my opinion, this is unacceptable and we need to do a better job of rehabilitation.

A big reason for this may be due to the lack of consistency even with our research and protocols. Up to 70% of published studies exclude any form of functional outcome measure in return to play decision-making. Despite being some confusion as to the best return to play protocol, there are enough published studies available for us to achieve at the very least a minimal standard.

Rehabilitation Practice Patterns following Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists.

Greenberg, et al. (2018)

The aim of the study was to understand the current clinical practice of members of the American Physical Therapy Association (APTA) in rehabilitation decision making and the use of objective tests in guiding activity progression following ACLR.


Physical Therapists were recruited through email invitations to members of the APTA Orthopaedic and Sports Sections. In addition, a link was embedded in the newsletter for APTA Private Practice section. This was done to recruit members that are more likely to treat this patient population A total of 1074 responses were recorded.

Survey participants were asked to answer questions based on the following case vignette. “Your patient is a 17-year old female soccer player who underwent ACL reconstruction using a hamstring autograft. There were no concomitant injuries and she is having an uncomplicated postoperative recovery. Her goal is to return to soccer competition at the collegiate level upon full recovery.


  1. Knee strength was reported as a key component of determining readiness for activity progression. However, 56.1% of the participants responded with manual muscle testing as their only method of testing for knee strength. High volume practitioners and certified specialists were more likely to utilize objective strength measures than those who treat fewer post-op ACLRs.
  2. A majority of respondents (89.2%) cited using the single limp hop test to determine readiness for modified sports activity. However, approximately 40% of respondents reported limb symmetry of 75-85% is acceptable for progression!
  3. 40.2% of respondents reported a return to unrestricted sports at 4-8 months!
  4. 88.3% of the respondents indicated a typical duration of supervised rehab lasting less than 8 months.
  5. Approximately 45.3% of respondents used a patient-reported outcome measure for progression to modified sports activity. However, those associated with fear or athletic confidence were less commonly reported (9.7%)
  6. 41.1% of PTs favored the use of functional bracing upon return to sport.

Clinical Implications:

This study really was an eye opener for myself because I couldn’t believe some of the stats shown here. I can go in depth with regards to each point but you can read more on this topic with our previous blogs (and future blogs). This study suggests we need to be better. Way better! With respect to ACL rehab.

Now I don’t know the golden standard to return to play protocol, as this has not been established in research as of yet. However, that is no excuse for some of the findings in this study. What I do know is if you can’t achieve some of the minimal standards, the patient should not be returning to sports.

When I read stats like 40.2% of patients returning back to unrestricted sports between 4-8 months, I can’t help but think most of these patients are at a high risk of re-injury.  When 40% of respondents believe limb symmetry of 75-85% is acceptable for progression, I think to myself again the high risk of re-injury. As a whole in general, we understand the importance of quad strength but I’m sorry to say MMT is absolutely not a reliable measure. To see that ~56% of rehab professionals using MMT as their only way to measure strength is not good enough!

I think we need to reflect as rehab professionals as a whole to do better. Be strict with your return to sports criteria’s and don’t send a patient back to play if they are not ready!

This isn’t a blog to bring down physios’ as there are amazing rehab professionals but this blog is more to stimulate us to think and reflect whether we are doing enough. Can we do better?

Please read our past blog on a few key indicators I believe should be met at a bare minimum to even think about a return to sport.


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