May 9, 2016
Returning from an ACL Tear

The long and difficult process of rehabbing from an ACL injury takes patience, persistence, and attention to detail.


A men’s lacrosse player falls to the ground following a cutting move towards the goal, dropping his stick and clutching his knee. Thus starts a journey for the athlete, one that is challenging and at times painful.

I have been in the above situation with dozens of student-athletes, male and female, during my nearly 40-year career as a certified athletic trainer. The approach I use is to ensure the athlete recovers not only to effectively return to play, but also to minimize any impact to their long-term well-being so they may go on to an active lifestyle later in life.

In addition to the physical effort put forth in rehab, the athlete must also be educated and monitored on the importance of psychological health. I always meet with the athlete and map out the overall plan, explaining that discomfort and setbacks are often part of the process.

From there, the first step after a diagnosis of an ACL tear is to care for the initial inflammation. This ensures that the knee doesn’t go into a surgical procedure in an active state of inflammation, which can negatively affect healing. I utilize cold whirlpools, intermittent compression units, and electrical stimulation to reduce swelling and pain.

Once out of the acute inflammation phase and into the pre-surgical phase, I have the athlete start strengthening the quad and hamstring (if no other injuries were present that would preclude such exercises) on leg machines such as knee extensions and flexion, and leg press. Usually I have the athlete spend this thee to four week period working at 50 to 75 percent of their total strength. During this stage, I would also have the athlete stretch his or her calves and do toe raises, along with multi hip exercises on a four-way hip machine.

The initial seven to 14 days following surgery is the hardest part for the athlete. They are very uncomfortable, and the effects of surgery can throw the athlete into dehydration, anorexia, and for some, anxiety and depression. At this point, I have the athlete use an intermittent compression device, electrical stimulation for pain, and per the surgeon’s orders, a passive motion machine to keep the knee moving throughout the day. Band work for ankle plantar flexion and dorsiflexion are also used.

The initial stage of range of motion and toning has the athlete working on their passive, active-assisted, and finally, active range of motion. Utilizing electrical stimulation (Russian mode) to help the athlete fully contract their muscles through the range of motion is beneficial. It is during this phase that band work for the quads can be incorporated, along with hip and lower leg exercises. Using a regular or recumbent bike to aid in range of motion and warming up the muscles for exercise is recommended. Using a warm whirlpool and/or hot packs prior to the bike is also beneficial.

Checking patellar mobility is important at this stage. If there are any adhesions developing around the patella-femoral area, using ultrasound to help make the adhesion more pliable before mobilization is recommended. Utilizing small step boards to help in initiating range of motion into full extension can be used, along with starting balance work on a balance board. It is during this time that the athlete may start underwater walking if the wounds on the surgical scar are healed.

Once the range of motion is complete, leg tone has been established, and no swelling or pain is present, per the surgeon’s timeline based on the repair used, strengthening exercises can be initiated. Depending on the repair, work can begin using a leg extension machine and leg knee flexion machine, and leg press work can be initiated. These exercises, along with closed chain work, can start to build strength. In time, once the muscles are building strength, an isokinetic machine can then be used to top off the strength and then re-calibrated for power and endurance. Once the muscle groups are testing out at 75-80 percent of the uninjured knee, adding once a week girth building exercises, especially eccentric strengthening, is recommended.

During the functional stage, functional movement equipment such as a rope ladder and mini hurdles for lateral movement are used. The athlete, once reaching 85 percent or more of strength and without pain or swelling, may start running. Wearing a functional brace to protect the knee during activity is recommended. Starting the running program on a treadmill or in a pool is suggested to lessen the overall impact on the knee.

Working in collaboration with the strength coach, the athlete can start working on sport specific activity while wearing their brace. Various athletic equipment per the player’s sport can be used. In the case of the lacrosse player, running and cutting while passing and catching could be incorporated, for example.

Finally, the lacrosse player would return to full participation on a gradual basis. This would entail increasing intensity to monitor for any pain or swelling that may occur. Utilizing hot therapies such as hot whirlpool or moist heat packs prior to practice, and cold therapies such as ice, cold whirlpool, or cold compression devices to minimize any post-practice swelling is recommended.

The journey following an ACL injury can be an arduous one for the athlete, as it can take 8 to 12 months to fully recover. Accompanied and assisted by a certified athletic trainer well versed in rehabilitation techniques, psychological well-being methods, and the use of a multitude of modalities and rehabilitation equipment will help. The goal should always be twofold–to return the athlete to his or her sport and to make sure the recovery is full so he or she can lead an active life long after the rehab ends.

Timothy Neal, MS, ATC, is President of TLN Consulting and an Assistant Professor of Health and Human Performance at Concordia University-Ann Arbor.

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