ACL Rehab in Sydney: Phases, Milestones and Running

ACL Rehab in Sydney: Phases, Milestones and Running

Most people searching for ACL rehab in Sydney have already had the scan, already met the surgeon, and want to know what the next nine to twelve months actually look like. The short answer is that ACL rehabilitation is a long, structured strength programme with running placed in the middle of it, not at the start. The longer answer is worth reading if you play football, netball, basketball, touch or any sport that asks you to cut and land.

This applies whether you had a hamstring graft, a patellar tendon graft, a quad tendon graft, or you are managing the knee without surgery.

Weeks 0 to 6: quiet work that decides everything later

The early phase looks unimpressive and matters enormously. Three things get priority.

Full passive knee extension, matching the other side. If the knee will not straighten by around two weeks, everything downstream gets harder, including gait and quad activation.

Swelling control. We use the stroke test to grade effusion. A knee that keeps refilling after sessions is telling you the load was too much, and persistent effusion inhibits the quadriceps directly.

Quadriceps activation. Many people cannot contract the quad properly for several weeks after surgery. Straight leg raise without a lag, isometric holds, blood flow restriction work in some cases, and a lot of repetition.

Crutches usually come off once you can walk without a limp, commonly in the first two weeks, though hamstring graft patients often feel the posterior thigh for longer.

Weeks 6 to 16: building the strength you will need for running

This block is gym work. Leg press, split squats, step-downs, calf raises, hamstring curls and Nordic variations if the graft site allows, plus hip work. The target is a quadriceps strength limb symmetry index around 80% before running is introduced, measured on a dynamometer or with a repetition-based estimate rather than by feel.

Calf capacity gets neglected here and shows up later. A single-leg calf raise test to fatigue, comparing sides, is a quick way to find the gap. Runners land through the calf and Achilles complex, and a knee that is strong with a calf that is not will still produce a poor running pattern.

We also start low-level plyometrics near the end of this phase: double-leg pogos, drop-and-stick landings, then single-leg versions. Landing mechanics are trained before speed and change of direction, because those are the positions that stress the graft.

Running is a criterion, not a date

Running after ACL reconstruction commonly begins somewhere between 12 and 16 weeks, but the date is the least useful part of that sentence. The criteria we look for before a first running session include a settled knee with minimal effusion, full extension, quad symmetry around 80%, the ability to perform 10 controlled single-leg squats to about 60 degrees, and a tolerable single-leg hop with a controlled landing.

Surgeons vary in their protocols. If yours has given a specific timeframe or restriction, that takes precedence and we build the programme around it.

Where body-weight-supported running fits

An anti-gravity treadmill lets you run at a set percentage of your body weight, adjustable in 1% steps from around 20% upward. Reducing body weight reduces the vertical load going through the leg with each step, roughly in proportion. For an ACL knee, that means you can practise running mechanics and accumulate running minutes at a load the knee tolerates, then increase the percentage over subsequent weeks as strength and swelling responses allow.

It suits the first four to six weeks of running in particular, when the knee often manages the movement but not the volume. Sessions are short. A typical early one might be 8 to 12 minutes at 70% body weight at an easy pace, with the response over the following 24 hours guiding the next step. We also use the camera and mirror feedback to look for the asymmetries that show up under fatigue, especially a shortened stance time on the operated side.

Testing before return to sport

Before returning to training with contact or pivoting, a return-to-sport battery usually includes isokinetic or handheld dynamometer quad and hamstring strength, a hop test series (single, triple, crossover, six-metre timed), landing assessment, and a discussion about psychological readiness using a questionnaire such as the ACL-RSI.

Grindem and colleagues, in a 2016 British Journal of Sports Medicine paper following Norwegian athletes, reported lower reinjury rates in those who delayed return to pivoting sport until nine months and who passed strength and hop criteria before returning. That research informs how we set milestones, though every knee and every sport is different.

When to get assessed

Book early rather than late. A pre-operative block of rehab to restore extension and quad strength is standard practice and shapes the first three months after surgery. If you are already six months post-op and unsure whether you are on track, a single assessment session with strength and hop testing gives you numbers instead of guesswork.

Come in shorts. The assessment involves knee range of motion, effusion grading, strength testing, single-leg control tasks and, if you are running, a treadmill gait look.

If you would like your ACL rehab reviewed or want to start the running phase with a structured plan, you are welcome to book an assessment at our Inner West clinic.