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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.

Osgood Schlatters Disease – More than just growing pains in the adolescent knee

Osgood Schlatters Disease – More than just growing pains in the adolescent knee

by | Aug 3, 2023 | Knee, Return to Sport, Running Injuries

Osgood-Schlatter disease (OSD) (or tibial tuberosity traction apophysitis) is a common condition that affects the knee, primarily in adolescents and young athletes. OSD is more frequently experienced in males 12-15 years old who are involved in activities that require frequent running, jumping, kicking and decelerating, like football (Bezuglov et al 2022). The condition manifests as pain, swelling, and tenderness just below the knee, where the patellar tendon attaches to the tibial tuberosity. Discomfort and potential disruption of daily activities and sports participation is often the result.

A prerequisite for this condition is high loading. The repetitive stress placed on this area during physical activities leads to microtrauma and inflammation, causing symptoms. While the condition is generally self-limiting and tends to resolve as the affected individual completes the growth spurt, physiotherapy plays a pivotal role in effectively managing symptoms, promoting healing, and aiding in a smooth return to physical activities. Various conservative approaches have been studied and recommended in the scientific literature to manage symptoms and aid in the healing process. Interestingly, the condition is strongly associated with Sever’s disease, another growth and loading related injury associated with active young people (Schultz et al 2022). Read on for a general overview of the treatment options supported by scientific research.

Rest and Activity Modification

Rest is often a key component of initial treatment. Reducing or modifying activities that aggravate symptoms, such as avoiding high-impact sports or exercises, can help alleviate strain on the affected area and promote healing. According to a study published in the “Journal of Pediatric Orthopaedics,” activity modification was found to be an effective strategy in managing Osgood-Schlatter Disease, with a significant reduction in pain reported by participants who adhered to activity restrictions.

Physical Therapy and Stretching Exercises

Physical therapy plays a vital role in managing Osgood-Schlatter Disease. A study published in the “Journal of Orthopaedic & Sports Physical Therapy” emphasized the importance of a structured physical therapy program involving stretching exercises for the quadriceps, hamstrings, and calf muscles. These exercises aim to improve muscle flexibility, reduce tension around the knee, and address any muscle imbalances that might contribute to the condition.

Strengthening Exercises

Strengthening exercises focused on the quadriceps and surrounding muscles can help improve biomechanics and stabilize the knee joint. Research published in the American Journal of Sports Medicine highlighted the positive effects of a quadriceps-strengthening program in reducing pain and improving function in individuals with Osgood-Schlatter Disease.

Ice Therapy

Cold therapy, such as applying ice to the affected area, can help reduce inflammation and provide pain relief. A study published in the “Journal of Orthopaedic & Sports Physical Therapy” suggested that ice therapy can be beneficial when used in combination with other conservative treatments.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs, such as ibuprofen, are commonly used to manage pain and inflammation associated with Osgood-Schlatter Disease. However, their use should be supervised by a healthcare professional such as your GP or pharmacist, and long-term or excessive use should be avoided.

Bracing and Taping

Some studies have explored the use of knee braces or taping techniques to offload the patellar tendon and reduce strain on the tibial tuberosity. While research on this aspect is limited, these approaches might offer temporary relief during activities. This can be trial and error as to which technique works best however compression over the tibial tuberosity seems to be the most common strategy.

Education and Activity Guidance

Educating patients and their parents about the condition, its natural history, and appropriate activity modification is crucial. A study in the “Journal of Pediatric Orthopaedics” emphasized the significance of patient education in improving adherence to treatment recommendations and facilitating symptom management.

It’s important to note that each individual’s response to treatment can vary, and a tailored approach is often necessary. In cases where conservative treatments do not provide sufficient relief, and severe pain or functional limitations persist, consultation with a Sports Physician or Orthopaedic surgeon may be warranted. Surgical intervention is rarely indicated and is typically considered only when symptoms are severe, long-lasting, and significantly affecting an individual’s quality of life.

In summary, Osgood-Schlatter Disease can pose significant challenges for adolescents and young athletes, affecting their quality of life and participation in sports. While the condition typically resolves with time and growth plate maturation, the discomfort and limitations it presents can be effectively managed and alleviated with the help of physiotherapy. If you or someone you know is dealing with this condition, get help from our friendly and qualified Praxis physios to individualise an appropriate rehabilitation plan.

Until next time, PREVENT PREPARE PERFORM

Team Praxis

References:

Bezuglov, E., Pirmakhanov, B., Ussatayeva, G., Emanov, A., Valova, Y., Kletsovskiy, A., … & Morgans, R. (2022). The mid-term effect of Osgood-Schlatter disease on knee function in young players from elite soccer academies. ThePhysicianandSportsmedicine, 1-6.

Ciatawi, K., & Dusak, I. W. S. (2022). Osgood-Schlatter disease: A review of current diagnosis and management. CurrentOrthopaedicPractice, 33(3), 294-298.

Schultz, M., Tol, J. L., Veltman, L., & Reurink, G. (2022). Osgood-Schlatter Disease in youth elite football: Minimal time-loss and no association with clinical and ultrasonographic factors. PhysicalTherapyinSport, 55, 98-

Understanding Sever’s Disease: A Common Foot Condition in Active Growing Children

Understanding Sever’s Disease: A Common Foot Condition in Active Growing Children

by | May 16, 2023 | Ankle and Foot, Return to Sport, Running Injuries

Understanding Sever’s Disease in Growing Children

Sever’s disease — medically known as calcaneal apophysitis — is a common heel condition affecting active children, especially during growth spurts. Despite its name, it’s not a “disease” in the traditional sense, but an overuse injury of the growth plate at the back of the heel.

What Causes Sever’s Disease?

Sever’s disease develops when repetitive stress irritates the growth plate in the heel bone (the calcaneal apophysis). During adolescence, especially between ages 8–15, the heel bone may grow faster than the surrounding muscles and tendons, causing excessive tension at the Achilles insertion site. When coupled with repetitive impact — such as running, jumping, or playing on hard surfaces — this mechanical overload leads to inflammation and pain.

It’s especially common in sports like soccer, basketball, AFL, netball, and gymnastics. Kids going through growth spurts, or who are highly active without sufficient recovery, are most at risk. Tight calf muscles, poor footwear, and biomechanical factors like flat feet or poor shock absorption may also contribute.

Common Symptoms

The main symptom is heel pain that worsens during physical activity and settles with rest. Children may complain of:

  • Pain or tenderness at the back or underside of the heel

  • Limping or toe-walking, particularly after sport

  • Discomfort when pressing on the heel or squeezing it from both sides

  • Stiffness first thing in the morning or after periods of inactivity

Symptoms are usually one-sided but can be bilateral. If left unaddressed, the pain can start to interfere with participation in sport and physical education at school.

Diagnosis

A diagnosis is usually made through clinical history and physical examination by a physiotherapist. Key indicators include heel pain during activity, recent growth, and tenderness at the posterior heel. The “squeeze test” — applying gentle pressure to both sides of the heel — is often positive.

Imaging (X-ray or MRI) is rarely needed unless symptoms persist longer than expected, or there is suspicion of another diagnosis. Importantly, a visible growth plate on X-ray in this age group is normal and not a reason for concern in itself.

Treatment and Management

Treatment is focused on reducing inflammation, offloading the heel, and supporting the child’s return to normal function. It is important to reassure both child and parent that this is a temporary, self-limiting condition.

Key management strategies include:

  • Load modification: Avoiding or reducing high-impact activity is key, especially sports with frequent jumping or sprinting. Your physio can help create a weekly plan to reduce flare-ups while keeping your child engaged and active.

  • Ice: Icing the heel after sport can reduce inflammation and pain, especially in the early stages.

  • Heel lifts or orthotics: Studies, including the 2016 randomised trial by James et al., show that both orthotic devices and cushioned heel lifts can effectively reduce heel stress. These inserts help absorb shock and reduce Achilles tendon tension.

  • Calf stretching and strengthening: Tight calf muscles increase load on the heel. Scharfbillig et al. (2008) emphasised the role of flexibility programs, particularly eccentric calf training, in improving outcomes.

  • Footwear advice: Supportive, well-fitted athletic shoes are essential. Avoid barefoot running or flat-soled footwear during recovery.

  • Manual therapy and taping: In some cases, hands-on techniques and taping methods may be used to reduce load on the Achilles insertion.

According to the trial by Weert et al. (2016), physical therapy combining load management and exercise-based rehab was just as effective as orthotic devices. This supports a flexible treatment approach tailored to the child’s specific needs and activity level.

Medication: Short courses of anti-inflammatory medication such as ibuprofen can help in more severe cases, especially when pain interferes with sleep or daily function. However, these should always be used under medical advice.

Prevention and Long-Term Outlook

The prognosis for Sever’s disease is excellent. Most children recover fully once the growth plate fuses — typically by age 15 for boys and 13 for girls. The condition does not cause permanent damage, though symptom duration can vary from a few weeks to several months depending on activity levels and adherence to management.

To reduce the risk of recurrence:

  • Encourage a proper warm-up and cool-down routine

  • Ensure sport participation is balanced with adequate rest

  • Maintain calf flexibility and foot strength

  • Use shock-absorbing shoes or orthotics during growth spurts

  • Avoid large increases in training volume or intensity

It’s also helpful to educate kids and parents that some discomfort during growth phases is normal, but persistent pain warrants a review. At Praxis Physiotherapy, our clinicians are experienced in managing growing athletes — and ensuring they don’t miss more game time than necessary.

Summary

Sever’s disease is a common and manageable cause of heel pain in growing children. Early recognition, temporary load reduction, and a guided rehab program can ensure a smooth recovery and quick return to sport. If your child is experiencing heel pain that isn’t improving with rest, book in with the friendly and knowlegable team at Praxis Physiotherapy for a tailored management plan.

Until next time, Praxis What You Preach

📍 Clinics in Teneriffe, Buranda, and Carseldine

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

References

James, A. M., Williams, C. M., & Haines, T. P. (2016). Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12-month factorial randomised trial. British Journal of Sports Medicine, 50(20), 1268–1275. https://doi.org/10.1136/bjsports-2015-094986

Scharfbillig, R. W., Jones, S., & Scutter, S. D. (2008). Sever’s Disease: What Does the Literature Really Tell Us? Journal of the American Podiatric Medical Association, 98(3), 212–223. https://doi.org/10.7547/0980212

Weert, H. C., van Dijk, C. N., & Struijs, P. A. (2016). Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy. Journal of Pediatric Orthopaedics, 36(2), 152–157. https://doi.org/10.1097/BPO.0000000000000417

Fact or Fiction Friday – Lower back Pain and MRI’s

Fact or Fiction Friday – Lower back Pain and MRI’s

by | Nov 8, 2022 | Lower Back, Pain

I need to get an MRI to help with the management of my lower back pain

Answer – FICTION

In a recent narrative review, Wang and colleagues (2018) concluded that MRI imaging in the early stages of lower back pain can have detrimental effects including more pain, less improvement, higher risk of surgery and worse overall health status. In fact, one study reported that patients that received an MRI within the first month had an 8x greater risk for surgery and 5x more medical costs!

If you do NOT present with severe neurological deficits, signs of a serious or specific underlying condition or have persistent pain >6 weeks which is unresponsive to conservative treatment then there likely isn’t a need for further investigation!

To get help with your long standing back pain or even that acute flare up, give us a call on (07) 3102 3337 or book online  so we can sort you out.

#praxiswhatyoupreach #praxisphysio #factorfictionfriday #physioeducation #preventprepareperform #pain #backpain #lowerbackpain #MRI #patienteducation

Wang Y, et al. Informed appropriate imaging for low back pain management: A narrative review. Journal of Orthopaedic Translation. 2018.

FACT OR FICTION FRIDAY || Knee Pain and Scans

FACT OR FICTION FRIDAY || Knee Pain and Scans

by | Dec 6, 2019 | Knee, Osteoarthritis, Pain

Answer: FICTION 🙊

“Osteoarthritis” is a common term that gets used by our patients as an explanation of their knee pain. But is this always the case 🤔?

🔍In a recent systematic review estimates of osteoarthritis feature prevalence on MRI among asymptomatic uninjured knees were up to 14% in adults < 40 years, and up to 43% in adults > 40 years!

Whilst features on MRI imaging such as cartilage defects, meniscal tears and osteophyte lesions can potentially play a role if you have pain, this should always be interpreted in the context of your clinical presentation by a health care professional as these changes can be normal in an asymptomatic population – just like grey hair as we age 👴👵!

If you have knee pain and have resigned yourself to a ‘life sentence’, come and have a chat to one of our physios to ensure you aren’t robbing yourself of a full functioning future 🕺🏃🏌️🏄🏋️🏊🚴🏂🎾! Call 07 3102 3337 or book online 

#kneeoa #praxisphysio #factorfictionfriday #preventprepareperform #kneepain #kneeosteoarthritis #mri #fullfunctionfuture

Reference:

Culvenor AG, Øiestad BE, Hart HF, et al Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis British Journal of Sports Medicine 2019;53:1268-1278.