running knee pain Archives - Praxis Physiotherapy

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

by Stephen Timms | 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.

Capping kneecap pain – Your guide to Anterior Knee Pain (Patellofemoral Pain Syndrome)

by Stephen Timms | Jul 11, 2023 | Knee, Return to Sport, Running Injuries

Patellofemoral Pain Syndrome (PFPS) is a common condition that affects the knee joint, particularly the area where the kneecap (patella) meets the thigh bone (femur). It is a prevalent issue among athletes, active individuals, and people with certain anatomical factors. In this Praxis What You Preach article, we will explore PFPS, its causes, symptoms, and available treatment options, shedding light on how physiotherapy can effectively manage and alleviate this condition.

What is PFPS?

Patellofemoral Pain Syndrome, also known as runner’s knee or anterior knee pain, occurs when the patella fails to glide smoothly over the femoral groove during knee movement. This causes irritation and inflammation in the patellofemoral joint, specifically the underlying bone, leading to pain, discomfort, loss of function and even swelling. PFPS can be triggered by multiple factors, such as overuse, muscle imbalances, poor biomechanics, weak hip and thigh muscles, improper footwear, and previous knee injuries. Essentially though it is the kneecap joints’ in ability to tolerate the load of the activities being undertaken.

Symptoms and Diagnosis

Common symptoms of PFPS include pain around or behind the patella, especially during activities that involve knee squatting, lunging, bending, climbing / descending stairs, or sitting for extended periods with knees bent (commonly called movie goers knee). These typically can occur when workloads have increased with activities such as running, cycling or weightlifting. Patients may also experience swelling, grinding or even stabbing sensations, and occasionally a feeling of knee instability. A physiotherapist will perform a comprehensive evaluation, considering the patient’s medical history, conducting a physical examination, and possibly using imaging tests, to accurately diagnose PFPS and rule out other potential causes of knee pain.

Treatment and Management

Physiotherapy plays a crucial role in managing and treating PFPS. The primary goal of physiotherapy is to exclude differential diagnoses, alleviate pain, improve knee function, manage aggravating workloads and prevent the recurrence of symptoms. Treatment plans are tailored after a comprehensive history taking and examination to the individual’s specific needs and should include the following components:

Pain Management: Initially, pain and inflammation may be managed through ice therapy, massage, stretching and non-steroidal anti-inflammatory drugs (NSAIDs).
Strengthening Exercises: Targeted exercises aim to strengthen the hip, thigh, and trunk muscles, which can help correct muscle imbalances and improve knee alignment and load tolerance.

Stretching and Flexibility: Stretching exercises can help improve flexibility in the muscles surrounding the knee joint, reducing strain on the patellofemoral joint.
Biomechanical Analysis: A physiotherapist may evaluate the patient’s movement patterns during functional activities such as jumping and running to identify any obvious faulty mechanics that contribute to PFPS. Corrective techniques, gait retraining may be employed.
Activity Modification and Rehabilitation: A gradual return to activities while maintaining a balance between rest and exercise is important to ensure proper healing and prevent re-injury.
Taping: taping has been shown to acutely help reduce symptoms by aiding in the improvement of kneecap tracking through the femoral trochlea (groove where the kneecap runs)

Prevention Strategies

To prevent the onset or recurrence of PFPS, individuals can incorporate the following strategies:

Regular strength and conditioning exercises to maintain muscle balance and strength of the lower limbs and trunk musculature.
Proper warm-up and cool-down routines before and after physical activities.
Gradual progression of activity levels and intensities to avoid overuse injuries.
Being aware of the early signs and symptoms and addressing them promptly.

Is my knee pain osteoarthritis?

In short, No. Patellofemoral Pain Syndrome (PFPS) is not the same as Patellofemoral Joint (PFJ) Osteoarthritis (OA). While both conditions involve the patellofemoral joint, they are distinct entities with different causes and characteristics. As mentioned, PFPS primarily involves pain and dysfunction in the patellofemoral joint, often caused by factors such as overuse, muscle imbalances, or poor biomechanics. It is commonly seen in younger athletes and active individuals. PFPS is characterized by pain around or behind the patella, especially during activities that involve knee bending or loading such as running.

On the other hand, PFJ OA refers to the degeneration and wearing down of the cartilage within the patellofemoral joint. This condition typically occurs in older individuals and is more common in those with a history of knee injuries or conditions such as patellar instability. The primary symptom of patellofemoral joint osteoarthritis is joint pain, stiffness, and swelling, which worsen over time. This pain can be at rest.

While both conditions can cause knee pain and affect the patellofemoral joint, the underlying mechanisms and treatment approaches differ. Physiotherapy plays a crucial role in managing both conditions, but the specific treatment plans and exercises may vary based on the individual’s diagnosis, symptoms, and physical examination findings.

In summary, Patellofemoral Pain Syndrome is a common knee condition that can significantly impact an individual’s daily activities. With a comprehensive physiotherapy approach involving pain management, strengthening exercises, and biomechanical analysis, PFPS can be effectively managed and treated, allowing individuals to regain pain-free movement and engage in their desired activities. If your knee cap pain prevents you from doing the things you want to do, book in with of our expert Praxis team members to discuss getting you back to function!

Until next time,

Praxis What You Preach

Team Praxis