ACL Recovery: Don’t Just Return —Return Ready

A Smarter Approach to ACL Rehab and Return to Play

By Justin Mitchell, PT, DPT, MS, OSS Powder Mill

An ACL injury can sideline even the toughest athletes — from weekend warriors to pros. The road back is long, often involving surgery and months of rehab. But the goal isn’t just to get back on the field — it’s to come back ready.

While the knee may feel strong a few months after surgery, real readiness takes time. Understanding the “why” behind each stage of rehab helps make that process clearer — and more successful.

Surgery: More Than One Way to Rebuild

Traditionally, ACL reconstruction uses an autograft — tissue from your own body. Common graft options include:

Quadriceps tendon graft (front of the thigh)
Patellar tendon graft (below the kneecap)
Hamstring tendon graft (back of thigh)

In recent years, a new option — the BEAR implant (Bridge-Enhanced ACL Restoration) — has gained attention. Instead of replacing the ligament with a graft, BEAR uses the body’s natural healing response to regrow the ACL. This innovative technique is changing how many athletes approach recovery and rehab.

Rehab: The Real Work Begins

No matter the surgical method, rehab is the heart of recovery. It’s a demanding process that calls for consistency, patience, and a great support team.

A strong rehab plan should do more than check boxes — it should help you understand what’s happening and why. Your therapist’s role is to guide you through each milestone, measure progress objectively, and keep you mentally engaged when the road feels long.

Because the truth is: the goal isn’t just to return to sport — it’s to return stronger, more resilient, and more confident than before.

The Power of the Quads

When it comes to safe return-to-play decisions, quadriceps strength is one of the best predictors of success. Strong quads help protect the knee, absorb force, and stabilize movement — all essential for cutting, sprinting, and landing.

Here’s what your rehab team should measure along the way:

Crutch/Brace Discharge: 10 straight leg raises with good control.
Running Readiness: At least 80% quadriceps limb symmetry index (LSI) comparing strength of the surgical leg to the non-surgical leg.
Return to Sport: 90–95% strength LSI before returning to field or court activities.

Why it matters: Every 1% increase over 90% limb symmetry is linked to a roughly 10% decrease in re-injury risk.

Even when an athlete feels strong, objective testing often reveals lingering deficits. And those deficits can make a big difference when the game gets fast and unpredictable.

And while the quads are key, don’t forget the supporting cast: glutes, hamstrings, and the strength balance between them all are additional factors that help predict an athlete’s overall readiness to return to play.

Functional Testing: More Than Just Strength

As an athlete progresses through rehab and achieves key milestones—such as running, jumping, and introducing cutting and pivoting drills—the next big question naturally arises:

“When can I play again?”

As we’ve already discussed, strength is one of the most important factors in making that determination. However, strength alone doesn’t fully capture an athlete’s ability to create, accept, and control forces in real-world game scenarios. That’s where functional testing comes in — assessing how your leg handles real-world movement, balance, and power.

Hop Testing

Measures how well the leg can absorb force, control movement, and generate power
Single hop, triple hop, crossover hop, and 6-meter timed hop
Goal: At least 90% limb symmetry with good landing control

Vertical Power Testing

Measures explosive jump performance
Goal: Less than 10% difference between legs

Y-Balance Testing

Evaluates single-leg control in multiple directions
This is important because poor balance can predict future injury in athletes involved in cutting, pivoting, or contact sports
Goal: 90% or better overall symmetry

Movement Quality Screening

Looks at how you move, not just how much you can do; poor mechanics can significantly increase the risk of re-injury.
Clinicians assess for knee collapse, trunk instability, and asymmetrical loading

Each test gives insight into whether your body can handle the unpredictable demands of your sport — safely and efficiently.

Don’t Forget the Mental Game

Physical readiness is only half the picture. Many athletes struggle with fear or hesitation, even after passing every physical test.

Tools like the ACL-RSI questionnaire help gauge psychological readiness — because confidence matters just as much as strength. If you’re not mentally ready to trust your knee, your body will show it.

This is where communication with your rehab team is essential. Honest conversations about fear, frustration, or uncertainty can lead to targeted strategies that rebuild confidence — one step, one drill, one success at a time.

Small Steps, Big Impact

If you’re recovering from an ACL injury or supporting an athlete who is, keep these key reminders in mind:

Progress isn’t a timeline — it’s a checklist. Rehab should move forward based on readiness, not the calendar.
Stay consistent with strength work. Even when pain is gone, keep training those quads and glutes.
Ask questions. Your therapist should clearly explain every phase and the purpose behind it.
Rebuild confidence gradually. Slow, structured exposure leads to long-term success.

Clearing a return-to-play test isn’t the finish line — it’s the bridge to performance.

The Takeaway

Returning to your sport after an ACL injury is about proving you’re truly ready — physically, mentally, and functionally. With a structured physical therapy program, functional testing, and the support of a knowledgeable team, athletes can return to the field safer, stronger, and better prepared for the demands of their sport.

Don’t just return. Return ready.