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ACL Reconstruction Rehab – Week-by-Week Recovery Guide with Praxis Physio

ACL Reconstruction Rehab – Week-by-Week Recovery Guide with Praxis Physio

by | May 17, 2025 | ACL, Knee, Return to Sport, Sports Injury

Overview

ACL reconstruction surgery marks the beginning of a structured rehabilitation journey. At Praxis Physiotherapy, located in Teneriffe, Carseldine, and Buranda, we provide an evidence-based approach to guide patients from surgery to sport. Backed by over a decade of experience with football teams across Brisbane and collaborative ties with local knee surgeons, our programs are scientifically informed and results-driven.

Research has shown that a phased, criterion-based rehab plan reduces complication rates and improves return-to-sport outcomes (Shelbourne & Nitz, 1990). The following week-by-week overview reflects current best practice from leading ACL rehab literature.

Week-by-Week ACL Rehab Milestones

Prehab: Starting Strong Before Surgery

If you’re waiting for ACL surgery and your knee has no complicating factors like meniscal locking, there’s good evidence that doing some early rehab — before going under the knife — can significantly improve your recovery trajectory. This phase, often called “prehab,” aims to reduce swelling, restore full knee extension, activate the quadriceps, and build general lower limb strength.

Research shows that patients who enter surgery with better quadriceps strength and full range of motion recover faster and regain function more effectively post-operatively (Eitzen et al., 2010). In fact, one study in the British Journal of Sports Medicine found that even just 5 sessions of targeted prehab improved early post-op outcomes like walking speed, strength, and self-reported function (Failla et al., 2016).

Weeks 0–2: Pain, Protection, and Range

Early rehabilitation begins with swelling and pain management, protection of the graft, and restoration of knee extension. Controlled range-of-motion (ROM) exercises and quadriceps activation, particularly of the vastus medialis, are prioritised. Patients often use crutches to maintain safe gait patterns. Early introduction of blood flow restriction (BFR) training supports muscle maintenance without joint overload (Zazirnyi et al., 2020).

Checkpoint: Achieve full extension and minimal swelling by Week 2.

Weeks 2–6: Regain Motion and Begin Strength

Once inflammation is controlled, attention shifts to regaining full ROM, normalising walking gait, and initiating basic strength exercises such as mini-squats and heel raises. Use of closed kinetic chain exercises is supported for their functional benefit and reduced joint stress (Awad et al., 2017).

Checkpoint: Full ROM with independent walking and neuromuscular control.

Weeks 6–12: Strength Foundation

Patients now begin progressive resistance training using clinic gym equipment, including leg presses, Romanian deadlifts, and lunges. Core strength and dynamic control are emphasised. Light cardio via cycling or elliptical may be introduced. Pilates reformers are utilised at Praxis for controlled joint loading and core development.

Checkpoint: Strength symmetry reaching 70% of non-injured leg; competent single-leg stance.

Weeks 12–20: Power and Plyometric Preparation

This phase involves development of reactive strength and neuromuscular readiness. Jump landing, eccentric hamstring training, and lateral movement patterns are introduced. Key focus is on building capacity for eventual cutting and pivoting movements.

Checkpoint: Successful hop tests, 80% limb symmetry, and controlled change-of-direction drills.

Weeks 20–36: Agility and Functional Sport Movements

Higher-level drills simulate sport-specific movements. Patients perform acceleration/deceleration tasks, direction changes, and reactive decision-making. Plyometrics are progressed in intensity and volume. According to Damian & Damian (2018), phase-specific drills improve psychological readiness and functional return to play (Damian & Damian, 2018).

Checkpoint: Limb symmetry >90% in strength and hop metrics.

Months 9–12: Return-to-Sport Preparation

This stage addresses psychological readiness and simulates sport-specific loading. Functional and fatigue testing are conducted, often including contact drills. Clearance depends on achieving objective strength and control measures (Shelbourne & Patel, 1996).

Checkpoint: Refer for return-to-sport testing (detailed in a separate blog).

Practical Insights for Patients

ACL rehab can be a long and often isolating journey. Many patients report psychological challenges, especially during the early and middle stages when progress may feel slow. At Praxis, we recognise that motivation is a vital part of recovery. Our goal isn’t just to return you to pre-injury levels — it’s to help you become a more resilient, stronger athlete than before. Many ACL injuries stem from non-contact mechanisms linked to strength, control, and movement quality. By targeting these factors throughout rehab, we aim to reduce reinjury risk and elevate athletic performance in the long term.

ACL rehabilitation is about restoring whole-body function, not just healing a ligament. At Praxis Physiotherapy, we use a combination of BFR, Pilates reformers, and in-house rehab gyms to deliver tailored and progressive programs. Our partnerships with Brisbane’s knee specialists ensure timely updates and coordinated care transitions.

Why Brisbane Athletes Choose Praxis Physiotherapy

  • Proven protocols developed with elite Brisbane football teams
  • Direct lines of communication with top knee surgeons
  • BFR and Pilates integrated into post-op care
  • Ongoing strength and functional assessments across all phases

Conclusion

A structured, evidence-backed approach to ACL rehab dramatically improves recovery outcomes. At Praxis Physiotherapy, we offer a seamless, week-by-week program from day one post-op through to full sport readiness. Our comprehensive model ensures that Brisbane athletes receive the highest standard of care at every stage. If you’re ready to get your rehab underway, book with us! 

Until next time – Praxis What You Preach

📍 Clinics in Teneriffe, Buranda, and Carseldine

💪 Trusted by athletes. Backed by evidence. Here for everyone.

References

  1. Shelbourne, K.D., & Nitz, P. (1990). Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med.
  2. Zazirnyi, I.M., et al. (2020). Our Point of View at Rehabilitation After ACL Reconstruction. Feofaniya Hospital.
  3. Damian, C. & Damian, M. (2018). Futsal Player Rehabilitation after ACL Reconstruction. Revista Românească.
  4. Awad, O.B. et al. (2017). A Systematic Review of ACL Reconstruction Rehabilitation. Egyptian Journal of Hospital Medicine.
  5. Shelbourne, K.D., & Patel, D.V. (1996). Rehabilitation after autogenous bone-patellar tendon-bone ACL reconstruction. JBJS Am.

ACL Rehabilitation: The Role of Physiotherapy in Returning to Life, Activity, and Sport

ACL Rehabilitation: The Role of Physiotherapy in Returning to Life, Activity, and Sport

by | Apr 22, 2025 | ACL, Gym and Strength, Knee, Return to Sport, Running Injuries

On today’s Praxis what you Preach, we cover a very common injury here in Australia – the Anterior Cruciate ligament (ACL) injury. At Praxis Physiotherapy, we understand that recovering from ACL reconstruction is more than just healing a knee — it’s about restoring confidence, movement, and returning to the activities and lifestyle that matter most to each person. Physiotherapists are uniquely placed to guide this journey from surgery through to return to everyday function, recreation, and sport.

What is an ACL Rupture?

The ACL is one of the key stabilising ligaments of the knee, crucial for controlling rotation and forward movement of the tibia. An ACL rupture typically occurs during sudden changes in direction, pivoting, or awkward landings — common in sports like AFL, soccer, basketball, and netball. It most often affects young, active individuals, particularly females, due to biomechanical and hormonal factors. While not all ACL injuries require surgery, those with complete ruptures who wish to return to cutting or pivoting sports usually undergo ACL reconstruction. Regardless of the surgical decision, structured rehabilitation guided by a physiotherapist is essential for a successful recovery and long-term knee health.

The Importance of Physiotherapy in ACL Rehab

Research shows that while around 80% of individuals return to some form of sport after ACL reconstruction, only 65% return to their preinjury level and just 55% to competitive levels (Andrade et al. 2020). Physiotherapy plays a vital role in improving these outcomes by guiding progressive rehabilitation and using structured criteria-based progressions.

Physiotherapy-led rehabilitation should begin early, with emphasis on knee mobilisation, weight-bearing as tolerated, and initiation of neuromuscular training (Andrade et al. 2020). The BJSM systematic review of clinical guidelines for ACL rehab supports early kinetic chain exercises (both open and closed), strength training, cryotherapy, and neuromuscular stimulation when indicated (Andrade et al. 2020).

From Healing to Performance: A Continuum

Recovery after ACL surgery should follow a continuum from impairment-based care to performance restoration. This includes early pain and swelling control, progressive strength and range of motion restoration, motor control retraining, and sport-specific preparation. At Praxis, we follow a phase-based rehabilitation model tailored to individual needs. These needs may include the type of surgical graft used, concurrent injury (e.g meniscus / MCL), the operating surgeon’s post-op protocols, the patient’s goals, sport-specific demands, timelines for return to competition, and previous levels of function — all of which require thoughtful and collaborative clinical decision-making.

Unfortunately, studies show that many patients are discharged before meeting strength or performance benchmarks — particularly in strength-focused exercises like the split squat, squat, or deadlift, which play a vital role in ACL rehab progression. For example, performing around 22 single-leg sit-to-stands is one such late-stage benchmark that reflects adequate quadriceps strength and control before return to sport (Welling et al 2018). Nichols et al. (2021) found that most published rehabilitation protocols emphasize endurance and hypertrophy without progressing to the strength or power needed to reduce reinjury risk. This underlines the need for physiotherapists to include high-intensity, sports specific strength training and late-stage performance metrics as patients near return to sport.

Addressing Muscle Atrophy and Weakness

Quadriceps atrophy remains a key barrier to recovery post-ACL reconstruction. Evidence supports adjunct interventions such as neuromuscular electrical stimulation and blood flow restriction (BFR) training to combat muscle loss, particularly in the early post-operative period (Charles et al. 2020). BFR combined with low-load resistance exercise has been shown to reduce muscle wasting and promote strength gains when higher loads are contraindicated — we explore this more in our Blood Flow Restriction Training blog. We use this frequently at Praxis Physiotherapy in both reformer pilates and early gym based settings. 

The Role of the Physio: More Than Just Exercise

Our job as physiotherapists goes beyond prescribing exercises. We support patients through the emotional and motivational challenges of recovery, address fear of re-injury, and help them develop the confidence to return to sport or physically demanding jobs. We tailor plans based on functional goals, sport-specific needs, and personal circumstances.

At Praxis, this also means working closely with coaches, GPs, surgeons, and families to ensure clear communication and aligned expectations. For sporting patients, this might include on-field rehab or comprehensive return-to-play assessments in collaboration with clubs and teams.

A Collaborative, High-Performance Rehabilitation Environment

At Praxis Physiotherapy, we bring high-performance rehab principles to all patients — not just elite athletes. Our team has provided physiotherapy services to the Aspley Hornets AFL Club since 2014, giving us deep insight into the physical and mental demands of competitive sport. We apply this same standard of care to everyday athletes, weekend warriors, and anyone seeking to return to an active lifestyle.

We also work closely with orthopaedic knee and shoulder surgeon Dr. Kelly Macgroarty, including in-room triage consulting, ensuring a seamlessly integrated, evidence-informed rehabilitation pathway. This collaboration allows us to align surgical timelines, post-op considerations, and physiotherapy progressions — from day one to return to sport.

Our clinical culture is shaped by exposure to elite-level sports environments, including AFL, representative athletics, and professional national cricket programs. But rather than highlight individual accolades, we’re most proud of the high clinical standards and systems-based approach that ensure our entire team delivers the same quality of care — no matter who walks through the door.

Each of our Brisbane based clinics includes access to gym facilities and reformer Pilates equipment, allowing for real-world, function-driven exercise. These resources support patients to not only recover structurally but also return to high levels of strength, coordination, and performance in line with the latest evidence-based guidelines.

A Message to Our Patients

Whether you’re an athlete aiming for competitive return or someone wanting to run after your kids again, we bring the same level of care and attention to your ACL rehab. Recovery is not just about timelines — it’s about building back strength, movement, and trust in your knee. Ready to get started with your own recovery plan? Explore the ACL physiotherapy services at Praxis and book an appointment today.

Until next time, Praxis What You Preach…

📍 Clinics in Teneriffe, Buranda, and Carseldine
💪 Trusted by athletes. Backed by evidence. Here for everyone.

For more insights into long-term knee health, including non-surgical rehab, check out our Knee Osteoarthritis blog.

References

Andrade R, et al. (2020). How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines. Br J Sports Med, 54(9), 512–519.

Kochman M, et al. (2022). ACL Reconstruction: Which Additional Physiotherapy Interventions Improve Early-Stage Rehabilitation? Int J Environ Res Public Health, 19(23), 15893.

Charles D, et al. (2020). A systematic review of the effects of blood flow restriction training on quadriceps muscle atrophy and circumference post ACL reconstruction. Int J Sports Phys Ther, 15(6), 882–889.

Nichols ZW, et al. (2021). Is resistance training intensity adequately prescribed to meet the demands of returning to sport following ACL repair? A systematic review. BMJ Open Sport Exerc Med, 7(1), e001144.

Welling W, Benjaminse A, Gokeler A, Otten E, & Seil R. (2018). Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatol Arthrosc, 26(12), 3636–3644.

Blood Flow Restriction – more than just a gimmick?

Blood Flow Restriction – more than just a gimmick?

by | Oct 11, 2022 | ACL, Gym and Strength, Knee, Reformer Pilates, Return to Sport

Summary:

  • Restriction of blood flow purportedly creates an internal environment of greater stress, thus greater adaptation
  • Importantly, the greater adaptation can occur with less absolute load to damaged or painful tissues
  • Started in healthy population to build muscles but the principles are transferable to rehabilitation
  • Best suited persons who are unable to tolerate normal load
  • Post surgery, tendinopathies and people needing to arrest atrophy or build muscle fast are best candidates

Blood flow restriction (BFR) training is becoming increasingly popular in rehabilitation and conditioning settings. As the name suggests, BFR training incorporates a restriction of blood to an area paired with low resistance training (20-50% of 1 rep maximum). The principle is to achieve greater muscle strength and hypertrophy gains for healthy and load-compromised populations with the same or less load than without a cuff. Essentially – more bang for your buck in the early phases of rehabilitation!

Benefits of BFR include; prevention of muscle mass in early post-operative periods, similar benefits of muscle mass and strength as heavier resistance training in achilles tendinopathies (>70% 1RM) (Centner et al, 2019), and improvement in maximum voluntary torque.

 

Whilst research is still being developed, multiple studies have been conducted recently showing the benefits of BFR training in post-operative populations ie. ACLR, patella / achilles tendinopathies, as well as knee osteoarthritis and patellofemoral pain syndrome.

Here at Praxis Physiotherapy, we have used a BFR cuff paired with low-resistance training on the reformer pilates and in the gym to optimise the distal quadriceps strength post ACL surgery. As you can see we are putting to the distal quadriceps to fatigue under a small amount of load, thus preventing muscle loss (Prue, et al. 2022) which can be common postoperatively.

General prescription guidelines according to the Australian Institute of Sport recommend that “the application of BFR should be limited to less than 20 minutes for lower limb, and 15 minutes for upper limb, before allowing adequate time for reperfusion of tissues (3 min).” (AIS, 2022).

In summary, this is an exciting new area of research that we are investigating clinically. Anecdotally, we hear from patients that they fatigue earlier in the desired muscle groups. We as a Praxis Team are embarking on some in clinic research in the area and hoping to provide feedback on our experiences so keep your eyes peeled. In the meantime, if you are pre or post your operation and are looking to maximise your recovery, come and have a chat with us about whether BFR is suitable for you!

Until next time,

Prevent | Prepare | Perform

Team Praxis