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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.

FACT OR FICTION FRIDAY || I’m too old to lift weights!

FACT OR FICTION FRIDAY || I’m too old to lift weights!

by | Dec 13, 2019 | Gym and Strength, Osteoarthritis

Answer: FICTION 🙊Progressive strength training in the elderly (>60 years) is efficient, even with higher intensities, to improve bone health, pack on muscle and retain function. And not surprisingly, side effects are rare!Strength training increases muscle strength by increasing muscle mass, and by improving the recruitment of motor units, and increasing their firing rate. This is no different between younger and older gym goers.
Mid Potion Achilles Tendinopathy Location

It all comes down to how you train! Training with higher loads generally provokes marginally larger gains in muscle size. Intensity corresponding above 85% of the individual maximum voluntary strength can also illicit improved rate of force development compared to 60-80%. This is imperative for reducing frailty as we age.

It is now recommended that healthy old people should train 3 or 4 times weekly for the best results; persons with poor performance at the outset can achieve improvement even with less frequent training.

So if you are using age as an excuse – STOP! Don’t let your age be a barrier to trying new things or feeling strong. We are here to help with supervised sessions, a great network of PTs as well as our clinical reformer pilates classes which are a great way to start (or return) to strength training!

To book for a clinical pilates 1:1 session or to chat with a physio about how strength training can help you, head to our booking page or give us a call on (07) 3102 3337

Team Praxis

PREVENT | PREPARE | PERFORM

References:

Mayer, F., Scharhag-Rosenberger, F., Carlsohn, A., Cassel, M., Müller, S., & Scharhag, J. (2011). The intensity and effects of strength training in the elderly. Deutsches Ärzteblatt International, 108(21), 359.

Lopez, P., Pinto, R. S., Radaelli, R., Rech, A., Grazioli, R., Izquierdo, M., & Cadore, E. L. (2018). Benefits of resistance training in physically frail elderly: a systematic review. Aging clinical and experimental research, 30(8), 889-899.

Sporting Injuries

Sporting Injuries

by | Dec 3, 2019 | Pain, Return to Sport, Sports Injury

Are you a weekend warrior who is plagued by injury or an aspiring athlete trying to find that extra 1% or somewhere in between? We know how frustrating it can sitting on the side lines and not being able to be involved in the things that make you happy. All the Praxis team have (or still do) play sport of some description and understand the anguish that goes hand in hand with injuries. That is why we do what we do!

 

Praxis has an expert team who have been fortunate to travel the country and even the world with various sporting teams. Whether it is Stephen with Cricket Australia teams, Cam with the ICONZ Rugby, Zac with Netball or Emma with AFL Praxis has you covered.
Mid Potion Achilles Tendinopathy Location

We separate ourselves from other therapist because we know that specific, personalised and evidence based physiotherapy is the most effective and efficient method to getting you back to what you love doing quicker and better. Combine that with our years of experience in treating all athletes from the elite to the weekend warrior, and there is no sport we can’t help with!

In summary, we believe that specific, personalised and evidence based physiotherapy is the most effective and efficient method in

If you are looking to Prevent future dysfunction, Prepare for your activity and Perform at your best, the Praxis Team has you covered and will get you achieving your goals sooner! See one of expert team members today by giving us a call on (07) 3102 3337  emailing admin@praxisphysio.com.au or booking online.

Team Praxis

PREVENT | PREPARE | PERFORM

Is running bad for your knees?

Is running bad for your knees?

by | Nov 28, 2018 | Knee, Pain, Return to Sport, Running Injuries, Sports Injury

Running. Probably one of the most maligned exercises when it comes to knees and overuse injuries. The thought that running ‘wears’ out your knees and causes osteoarthritis (a chronic disease often associated with joint pain and stiffness, reduced mobility and reduced quality of life) is one of the most common comments I hear as a physiotherapist – typically by non-runners. But do we have it right? Is running actually bad for your knees?

I recently attended the University of Queensland Sports Masters presentation day. The keynote speaker was a Dr Jean-Francois Esculier, a Postdoctoral Fellow at the University of British Columbia on the topics of running and knee osteoarthritis. Originally trained as a physiotherapist, Dr Esculier gave us an excellent overview of his latest research his take on whether or not running is detrimental to knee health.

First, there was an acknowledgement that echoed the sentiments in the opening paragraph. A study in which Dr Esculier undertook attempted to ascertain the perception about running and the knee joint health among the public and health care professionals. The results suggested that many non-runners perceived running as detrimental to knee health. Understandably, with no clear guidelines, health care professionals displayed high rates of uncertainty regarding running as a risk factor to develop knee osteoarthritis (KOA), and about the appropriateness of running with pre-existing KOA [1].

Mid Potion Achilles Tendinopathy Location

Osteoarthritis often results in cartilage loss, in bone rubbing on bone, which can cause inflammation, pain, stiffness, reduced mobility and reduced quality of life [7].

The paucity of clear training parameters for runners also has a knock on effect with a staggering 75% of runners report being injured whilst running each year with the knee being the most common region of complaint [2]. From my experience as a clinician, the factor that is most often associated with an injury are training errors. Too much too quick. Boom bust. No physical preparation. No listening to your body or allowing adequate recovery time. No periodisation or plan – just run and run.

The remainder of the talk that covered many interesting relatable topics (that will likely be areas for future blogs) but the information that most interested me and should answer the question as to whether running is bad for your knees was the following:

Cartilage change with running:

With the improvements in MRI scanning, more papers are looking at the cartilage volume of knees immediately after a long distance run. According to current evidence [3], cartilage may exhibit short-term decreases in thickness, volume and cartilage water flow (T2 relaxation time) secondary to temporary loss of fluid following repeated compressions associated with running. However, cartilage size tends to return to baseline within hours suggesting that cartilage may well tolerate mechanical loading sustained during running and adapt to repeated exposure.

The response of cartilage to longitudinal load is exactly what Van Ginckel et al [4] investigated. After providing a 10 week “Start To Run” program to novice runners, the reserachers looked at the glycosaminoglycan (GAG) content before and after the running intervention and compared to sedentary controls, who did no running. For those of you (like me) who had no idea what glycosaminoglycan / GAG content is, it is essentially a surrogate marker for cartilage quality (specifically, GAG is an important structural matrix compound in regulating the cartilage tissue’s endosmotic swelling pressure and thus, the tissue’s compressive strength).

The results suggested that a gradually built up running scheme appears to positively effect GAG content, and thus cartilage quality. In fact, running appears to be a chondroprotective effect on the knee when compared to a sedentary lifestyle in a female asymptomatic subjects. The author’s went onto say that running schemes like this might be considered a valuable tool in osteoarthritis prevention strategies [4].

Osteoarthritis (OA) rates in competitive vs recreational vs non-runners:

The body’s ability to adapt to considered and appropriate load is likely explanation as to why when we look at the rates of lower limb osteoarthritis (OA) across the population, we find some interesting results. A systematic review [5] of the literature looked at the association of recreational and competitive running with hip and knee OA. The overall prevalence of hip and knee OA was 13.3% in competitive runners, 3.5% in recreational runners, and 10.2% in controls. Exposure to running of less than 15 years was associated with a lower association with hip and/or knee OA compared with non-runners.

Recreational runners had a lower occurrence of OA compared with competitive runners and controls. These results indicated that a more sedentary lifestyle or long exposure to high-volume and/or high-intensity running are both associated with hip and/or knee OA. However, it was not possible to determine whether these associations were causative or confounded by other risk factors, such as previous injury [5].

SUMMARY

Running appears not to cause osteoarthritis in your knees unless you are a competitive long distance runner. Even then, you are only slightly above the average for non-runners but enjoy the myriad of other benefits that exercise brings. Further, increased mileage in recreational runners appears to be actually protective for your knees and reduces your risk of needing a knee replacement [6]. Caution however must be taken to monitor detailed training parameters such as frequency, speed and distance, so that an optimal dosage for knee joint health tailored to the individual patients with knee osteoarthritis.

So the next time someone tells you that you shouldn’t be running because you’ll get OA, or if your health expert recommends to stop all activity because you have been diagnosed with mild / moderate osteoarthritis of the knee, we can help! As always, we at Praxis are more than happy to help you navigate your way back to performing – whatever that may look like! Give us a call (07) 3102 3337 or book online www.praxisphysio.com.au today

Until next time, Praxis What You Preach

There is no need to accept knee pain as ‘normal’. Call us now on (07) 3102 3337 or book online to have one of our physios develop a plan to reduce your pain and restore your function!

To read more about how running can help your knees (that’s right – running!) check out our related posts on running written by our published principal physio, Stephen.

Team Praxis,

PREVENT | PREPARE | PERFORM

Private Health Preferred Provider Schemes

Private Health Preferred Provider Schemes

by | Jul 1, 2018 | Uncategorized

PRIVATE HEALTH

Firstly it is important to point out that when seeing a practitioner at Praxis Physiotherapy, you will be able to use your private health insurance (PHI) towards the fee if you have appropriate cover (usually called ‘Extras’). It must be said that we think PHI for physiotherapy is an excellent investment for those that have it as a part of their cover. It must also be stated that whilst we offer HICAPS transactions onsite at all our clinics, we at Praxis Physiotherapy are not currently a member of any preferred provider schemes.

We are often asked why we aren’t so we have done this blog to outline some important information which outlines some things for you to consider before automatically choosing a clinic with a preferred provider status.

What is a preferred provider scheme?

Some PHI companies have created their own list of health providers which they recommend to their members. Preferred provider schemes take several different forms but include the following examples:

  • Bupa / Medibank – Members First Extras / Provider
  • HCF – More for Muscles
  • NIB – Extra Cover Providers

These providers are generally marketed as being ‘preferred’ as though they have achieved this title through clinical excellence but in fact these are just practices who have agreed to sign a contract which allows the PHI to set the fee structure and reimbursements for the practice.

There are no minimum standards of practice, experience or quality of care required to qualify for these contracts. It is purely an agreement that the practice will charge those patients the amount the insurance company has set.

You might ask why a practice would do this? It is an easy way to gain exposure to many prospective new patients, so it can be an effective way to get your practice up and running or boost numbers.

What’s the problem here?

Although discounting services to get more patients to your business might be good to start with, and also good for the patients who will have a smaller gap to pay, problems occur relatively quickly when there are many patients coming to the clinic who are not paying a normal/typical fee. The cost of providing adequate length appointments with experienced staff generally is too great for the business to sustain.

Practices in these schemes may then be forced to make some difficult decisions about how they run their business, and generally these result in shorter appointment times or using less experienced staff who they can pay less (or both). The combination of these two things is a big concern to the allied health industry as it is likely to be detrimental to the quality of healthcare provided to the patient.

What can you do?

Remember that you have a choice!

If you are concerned about the small contribution your health fund makes for physiotherapy or other allied health, it is important you know that you can shop around for an insurer that better suits your needs. Some funds (usually the smaller not for profits) pay much better rebates for allied health. It is important to note also, that you can have hospital cover with one insurer, and your extras cover with another.

What does the Australian Physiotherapy Association (APA) say about preferred provider schemes?

This information is taken directly from their website:

“The Australian Physiotherapy Association remains concerned that health funds actively divert their members to network providers, regardless of existing therapeutic relationships.

The APA believes the term ‘preferred’ might make a patient think a practice is of a particular standard than those practices that are not preferred. This is not the case. By being a preferred provider, a physiotherapist simply elects to join the scheme and bring their fees in line with what the health funds mandate. We know this is a significant disadvantage to physiotherapists and that keeping fees close to market rates is essential to maintain the financial viability of a physiotherapy business.

We have raised this matter with the ACCC, which has not determined this is a matter for further investigation. We will continue to advocate for change when appropriate.”

In summary…

We at Praxis Physiotherapy believe that schemes such as these do not allow us to sustainably offer the expert services, longer appointment times (60mins for initials / 30mins subsequents), experienced staff and the physical environment that we do. We feel that compromising in any of these areas would not align with the values we set ourselves when we started our clinic. In short, we do not apologise for putting the needs of our patients above the bottom line and believe that in order to help you Prevent. Prepare. Perform, the requisite time, expertise and effort is required from your Praxis therapist.

Until next time…

Prevent. Prepare. Perform.

Team Praxis

Physiological

Changes in parasympathetic activity (as measured by heart rate, blood pressure and heart rate variability) and hormonal levels (as measured by cortisol levels) following massage result in a relaxation response.

Psychological

A reduction in anxiety and an improvement in mood state also cause relaxation, and has been shown prior to sports to help lower performance anxiety.

Ultimately, what the above proposed mechanisms translate into a series of studied benefits on specific conditions. According to the Massage and Myotherapy Australia website, massage has also been shown to help:

  • Back pain
  • Arthritis
  • Insomnia
  • Headaches
  • Depression and anxiety
  • Constipation
  • High blood pressure
  • Chronic pain​

All in all, massage provides good bang for buck when used in the appropriate setting. Our mantra at Praxis is Prevent Prepare Perform and as physiotherapists, we work in tandem with our qualified massage therapists to deliver the best results for a wide variety of conditions. Whilst, physiotherapy is focussed on the diagnosis and treatment of acute or chronic injuries, remedial massage enables a little more hands on time to truly address issues that our physiotherapists may have identified in their sessions. Further, massages offers a great medium for regular ‘tune-ups’ when the rigours of training and working take their toll.

We ensure that your massage experience is not only blissful, but productive for your rehabilitation as well. So if you have been swayed by the evidence, or just looking for that little reward, we are here to help!

BOOK YOUR MASSAGE HERE

Until next time – Prevent. Prepare. Perform

References:

  1. Hopper D, Deacon S, Das S, et al. Dynamic soft tissue mobilization increases hamstring flexibility in healthy male subjects. Br J Sports Med. 2004;39:594–598
  2. Weerapong, P., Hume, P.A. & Kolt, G.S. The mechanisms of massage and effects on performance, muscle recovery and injury prevention. Sports Med 2005; 35: 235
  3. Morelli M, Seaborne DE, Sullivan SJ. Changes in h-reflex amplitude during massage of triceps surae in healthy subjects.J Orthop Sports Phys Ther. 1990;12(2):55-9.
  4. Arroyo-Morales M1, Fernández-Lao C, Ariza-García A, Toro-Velasco C, Winters M, Díaz-Rodríguez L, Cantarero-Villanueva I, Huijbregts P, Fernández-De-las-Peñas C. Psychophysiological effects of preperformance massage before isokinetic exercise. J Strength Cond Res. 2011 Feb;25(2):481-8.

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