
This article covers key points from our Hot Topics Webinar, “Expert ACL Rehab — A Cutting Edge Approach” with Dr. Wesley Wang. For a full breakdown, watch the video above.
The Harsh Reality of ACL Rehab
If you’re a physical therapist or an aspiring PT, you’ve probably seen firsthand how tricky ACL rehab can be.
It’s not just about getting an athlete back on the field or a patient back to their daily life—it’s about making sure they stay there.
Unfortunately, 20-30% of ACL patients suffer a second ACL tear.
This is often due to improper rehabilitation strategies.
In this article, we break down:
- Why retears happen,
- How to optimize rehab, and
- What exercises and strategies truly make a difference.
Why Do ACL Retears Happen?
1) Improper Progression & Premature Return to Sport
- Many patients are eager to return to activity, and some physical therapists clear them too soon.
- Returning to cutting, pivoting, and high-impact movements before the knee is adequately prepared is a recipe for disaster.
2) Strength Deficits & Asymmetries
- Many patients still have quadriceps and hamstring weakness long after their initial surgery.
- If the strength ratio between limbs isn’t addressed, the injured side is at a much higher risk.
3) Poor Neuromuscular Control & Movement Mechanics
- Just because a patient “feels strong” doesn’t mean they move well.
- Faulty landing mechanics, excessive knee valgus, and poor single-leg stability significantly increase the risk of reinjury.
4) Lack of Objective Testing
- Testing must guide return-to-sport decisions. Too many rehab programs rely on subjective assessments instead of structured, measurable strength and biomechanical testing.
The Primary Goals of ACL Rehab
To prevent retears and optimize recovery, ACL rehab should focus on:
- Restoring strength and function gradually
- Ensuring proper neuromuscular control and movement patterns
- Building resilience for return-to-sport or activity
- Using objective criteria to clear patients, not timelines
— Step 1: Set the Foundation Early
Prioritize Full Knee Extension
One of the most overlooked aspects of early ACL rehab is restoring full knee extension.
If a patient doesn’t regain full extension within the first few weeks, it can lead to compensations, gait abnormalities, and long-term issues.
Key exercises:
- Prone hangs
- Quad sets with a towel under the ankle
- Passive stretching and mobilization techniques
Control Swelling & Regain Quadriceps Activation
Swelling inhibits quad activation, so reducing it is crucial in the early phase.
Neuromuscular electrical stimulation (NMES) and isometric contractions should be incorporated early to improve quad function.
— Step 2: Gradually Build Strength & Tolerance
Focus on Isolated Strength Before Dynamic Movements
Patients should master quad, hamstring, and glute strengthening before jumping into dynamic exercises.
Progressive resistance training helps bridge the gap between passive recovery and higher-level activities.
Key exercises:
- Spanish squats for quad engagement
- Romanian deadlifts for posterior chain strength
- Step-ups and Bulgarian split squats for unilateral control
Progressive Loading is Key
Progressive overload is essential. Too often, patients are underloaded for too long, leading to insufficient strength gains. They need to be lifting heavy, safely and progressively.
— Step 3: Address the Details—Don’t Overlook Biomechanics
Strength alone isn’t enough—movement quality matters just as much.
Assess and Correct Movement Patterns
A patient should be able to land, cut, and pivot without excessive knee valgus or poor mechanics. If they struggle with single-leg stability, higher-level movements are unsafe.
What to look for:
- Is the knee collapsing inward during single-leg tasks?
- Does the patient land softly and with control?
- Are they compensating with excessive hip or trunk motion?
Plyometrics and Deceleration Training
Relearning how to decelerate is one of the most crucial phases of ACL rehab.
Key exercises:
- Drop jumps and landing drills
- Lateral hops with controlled stops
- Sprint-to-deceleration drills
— Step 4: Test, Don’t Guess
ACL rehab should be data-driven, not just time-based. Patients must meet objective criteria before being cleared for return to sport.
Key Tests for Return-to-Sport Readiness:
- Isokinetic Strength Testing: Quad strength should be at least 90% of the uninjured side.
- Hop Testing: Single-leg hop distances should be within 90-95% symmetry.
- Drop Jump & Landing Mechanics: Assessing for knee valgus and neuromuscular control.
- Psychological Readiness: Fear and lack of confidence significantly increase reinjury risk.
For more insights on ACL Return to Sport Testing, read our article here: https://thejacksonclinics.com/acl-return-to-sport-testing-physical-therapists
Takeaways for Physical Therapists:
ACL rehab is extremely complex, and not every PT should take on ACL patients.
ACL rehab requires expertise in strength and conditioning, movement biomechanics, and progressive loading principles.
If you’re treating ACL patients, you have a responsibility to keep them safe and set them up for long-term success.
✔ Be methodical and progressive in your approach.
✔ Load the knee appropriately—too little loading is just as dangerous as too much.
✔ Use objective testing—don’t rely on time-based decisions.
✔ Address biomechanics, strength, and psychological readiness before clearing a patient.
Want More ACL Rehab Strategies?
Watch our full video linked below where Dr. Wesley Wang breaks down everything a physical therapist should know about ACL rehabilitation.
Physical Therapy HOT TOPICS: Expert ACL Rehab – A Cutting-edge Approach
Did you find these tips helpful? Let us know! Contact our PT Success Team at ptlighthouse@thejacksonclinics.com
To learn more about The Jackson Clinics and to explore a career with us, please visit thejacksonclinics.com/careers