ACL and lower limb rehab Part 3 : Return to running, End stage rehab and return to play.

ACL & lower limb rehab | Arana Hills Physiotherapy

In our last 2 posts in this series we looked at;

In this instalment we are looking at what we need to do at the 3 month post operative stage if you’ve successfully completed the first two stages;

  • return to running.
  • end stage rehab, jumping, cutting and sport specific exercise
  • return to play.

At what stage can i run again after ACL reconstruction ?

Interestingly there is not a lot of research to determine when you can return to running post ACL surgery.

Historically its been a time dependant criteria after surgery has been done to ensure that the new graft is strong enough to tolerate running and that you have done the work in the gym. Usually we would look at a three month post surgery date at when we should consider this.

However it’s important that you have reached certain physical competencies before you start pounding the track, streets or trails. The criteria we want to achieve before running are:

Full range of movement in a pain free, no swelling at the knee.

  • 10 single leg dips of 20 cm box.
  • 10 single leg squats from a bench.
  • 20 single leg hamstring bridges off a bench.
  • 30 second bridge.
  • 20 calf raises on operated side.
  • Single leg balance 45 seconds.
  • 3 x spilt squat at 30-50% bodyweight.

If you can achieve these and be within 85% of the non operated side then you should be good to go .

(These criteria are based on the Melbourne ACL guide by Mick Hughes and Randall Cooper, as well as the work of Enda King)

How do i progress my ACL rehab from the previous stage ?

I think the biggest mistake that can be made here is over complicating the gym based rehab and trying to change every component of it. Keep it simple and it will be effective and achievable, make it complicated and it likely won’t get done.

So what needs to be done is;

  1. what has been done to date.
  2. what the tests showed.
  3. what the end or next goal is.

How to alter what has been done to date

Exercise selection:

Primary movements.
These are the big lower limb exercises to choose from. I d suggest pick 4 and do 2 per session.

Secondary movements.
These are the accessory or functional movements. Pick 4-6 exercises to do over 2 sessions.

Specific strength.
These are exercises that are specific to your sport , activity or deficits found in your testing.

Core strength:
A major factor in lower limb injuries in sport is stop the body from moving in an uncontrolled fashion over the supporting leg. A such core strength plays a significant role in the reduction of lower limb injuries in sport as well as enhancing performance. Read more here to get some ideas of what we do.


This can be used to help strengthen the new ligament by recruiting appropriate growth factors that are released under high intensity / lactate based sessions.

It also helps build and maintain the fitness you require for your chosen sport / activity as well as making you more fatigue resistant.

This will help reduce the injury rate further by giving you an endurance aspect to performing skills when playing sport.

Sets and reps
To see real progress the magic number is to be working at 70-85% of your maximum capability. This is where tendon, ligament and muscle starts to really adapt and get stronger.

This can be based off your testing or from a simple visual analogue scale such as the OMNI resistance scale.

7/10 -8/10 intensity is where we want to be working at in the major compound lifts. The specific strength /accessory may be done at a slightly lower intensity.

Here’s a guide to intensity, rep and set selection.

return to play diagram | Arana Hills Physiotherapy

Rest and recovery.
I’m a big fan of 60-90 second rest between sets for my tendon based rehab. Why you ask ? Well it creates the best enviroment for the tendon to get stronger by accessing your own growth factors.

I need to jump and land, what should i do ?

The best way to get better at jumping and landing is to train it. Here’s our heirarchy on improving this physical skill.

  1. skipping.
  2. Low level plyometrics .
  3. mid level plyometrics.
  4. High level plyometrics.

I need to accelerate and change direction what should i do ?

As with jumping if you want to get better at it you need to train it .

  1. Agility drills
  2. running drills
  3. Court based change of direction drills.

When can i get back on the pitch ?

The million dollar question, this should be criteria based, sport dependant and time dependant.

As a rule it should be about 12 months before return to contact sports or those that require the ability to pivot.

At the 3 month post operative point most individuals who have had an ACL reconstruction are not able to perform activities such as running, jumping and landing never mind sudden change in direction and acceleration.

It makes sense as there will be a deconditioning effect on the body to these activities following surgery and these deficits may be present for anywhere up to 6 months or longer. It is highly likely that this affects the non -injured both leg as well.

This is why testing the unaffected lower limb pre-surgery is a valuable tool. It gives us a bench mark of what was your normal was before hand and a standard that we are looking to achieve if not exceed before returning to running or sport.

As such the following physical criteria should be met before return to sport:

  • Completed your rehab program and advanced through all the stages.
  • EPIC Standards : Quad Strength: Using the split squat to establish quald strength: Injured Leg strength, (6 months post-op) / Uninjured Leg (Pre-op; 1.5 months post-injury) x 100.
  • Hop Tests: Injured Leg (6 months post-op) / Uninjured Leg (Pre-op; 2 months post-injury) x 100.
  • Dynamic testing and strength tests as described here

If you want an outstanding result from a knee or sports related injury book here to see one of our team.


Wellsandt, Failla & Snyder-Mackler (2017). Limb symmetry index can over-estimate knee function after ACL injury. Journal of Orthopedic Sports Physical Therapy: 47 (5), 334-338

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