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ACL Rehabilitation Brisbane

ACL Rehabilitation

Anterior cruciate ligament (ACL) injuries are becoming more and more common, particularly in our younger athletes. Alas, even after all the research and surgeries performed, we aren’t significantly changing the number of re-injuries that are occurring. ACL rehabilitation and optimising the return to sport process through a criteria-based progression and program is currently the best evidenced based practice. At PRP Physio, I have developed an ACL rehabilitation program that takes you from initial injury management through to return to sport inclusive of an ongoing injury prevention program. I genuinely believe that physiotherapy is the best sports medicine to accelerate an athlete’s recovery and maximise their performance on returning to sport.

ACL injuries occur often in many Australian sports like soccer, AFL, netball, rugby league and rugby union. The common factor between these sports is that they are multi-directional 360-degree games. Preparing an athlete to return to their prior level of performance and reducing their risk of another knee injury takes exposure to specific sports physical therapy and patterns. I believe in an early loading program that develops early strength improvements and allows for exposure to basic sport-specific movements to develop confidence in the knee.

I specifically designed the program for an athlete who desires to not only return to sport, but to exceed the level of performance they were previously at. My goal is to make each athlete more robust and complete than they were prior to their injury.

What is an ACL tear?

A torn ACL is an injury to the anterior cruciate ligament (ACL), which is one of the four main ligaments that stabilises the knee joint along with the posterior cruciate ligament (PCL) and the medial and lateral collateral ligaments (MCL and LCL). The ACL connects the thigh bone (femur) to the shin bone (tibia) and prevents the shin bone from sliding forward too much. The ACL also helps control the rotation of the knee.

ACL injuries vary in severity, from mild sprains (Grade 1) to partial tears (Grade 2) to complete tears (Grade 3). A partial ACL tear refers to damage to only a portion of the ligament without completely severing it. This typically occurs when the ligament is stretched and becomes loose, but still maintains some continuity and passive strength. A complete ACL tear involves a total rupture of the ligament. This means that the ACL has been severed into two separate ends, often resulting in a significant loss of knee stability.

An ACL tear can happen when the knee is twisted or bent unnaturally, such as during a sudden change of direction, landing from a jump, or a direct blow to the knee. When the ACL is torn, it can cause a popping sound or sensation in the knee, and it is often followed by pain, swelling, and instability.

The ACL is most commonly injured during knee flexion, which is when the knee is bent. This reduces the space between the thigh bone and the shin bone, which increases the tension on the ACL. When the knee is straightened (knee extension), the space between the bones increases and the tension on the ACL decreases.
Physiotherapist massaging a client's calf
Physiotherapist assessing a client's knee
Physiotherapist treating the muscles around a client's knee

The anatomy of the knee

First, we will explore the anatomy of the knee, it is composed of four main ligaments, menisci and other joint related structures and the surrounding muscles. To begin, we will look at the ligaments. On either side of the knee are the medial (inside) and lateral (outside) collateral ligaments. These ligaments provide support to the knee in either a valgus (bowing in) or a varus (bowing out) force. Lateral collateral ligament (LCL) injuries aren’t commonly seen because of the nature of injury required. Most will occur with a direct blow to the inside of the knee, typically from another player. Medial collateral ligament (MCL) injuries are the most commonly seen clinically because of the wide array of potential injury mechanisms, including a blow to the outside of the knee from another player, changing direction, landing from a jump or twisting of the knee with a planted foot (this is also a common meniscus injury mechanism).

Within the knee are the anterior and posterior cruciate ligaments (ACL and PCL respectively). These ligaments provide support for the femur and tibia to prevent any anterior (forward) or posterior (backwards) shift of the tibia on the femur. The PCL is not a common injury seen clinically as it typically requires a posterior force to the tibia to cause a ligament strain or rupture – the most common mechanism would be a fall onto the knee. ACL injuries are often the most talked about injury in sports and are widely reported in the media. They can either occur in a contact or a non-contact mechanism. Unfortunately, in Australia, non-contact mechanisms are the predominant mechanism – typically we will see the injury with a change in direction or a land from a jump when a player has taken contact in the air. Most ACL injuries will cause a rupture and grade one or two strains aren’t common. Orthopaedic surgeons will typically report that most grade two strains seen on MRI will be a full rupture once assessed in surgery.
Diagram of knee anatomy showing the ACL, PCL, meniscus and collateral ligaments

The menisci lie within the knee with one in the medial compartment and another in the lateral compartment, the menisci act as “shock absorbers” by reducing forces directly to the knee joint itself. A meniscus injury will most commonly occur with a twisting injury – we commonly will hear a story of turning quickly on the spot with foot planted, being twisted in a rugby tackle with a planted or stuck foot, the other potential mechanism we have heard is rising and turning out of a deep squat. The lateral meniscus has a lower level of blood supply than the medial meniscus, which means it might be slower responding to either non-surgical care or in the early periods of recovery after surgery and surgeons may lean towards being more protective of the surgery site.
Diagram of the medial and lateral meniscus of the knee

ACL Rupture Subjective Assessment

A thorough subjective assessment of an ACL injury is necessary. This section of the assessment can largely lead to a diagnosis with a few key factors such as sensations at the time of the injury, as well as what happened over the next 24 hours.

What Happened?

Suffering an anterior cruciate ligament injury is one of the most frustrating injuries. You were playing your sport perfectly fine and then you went to change direction and your knee buckled underneath you. It’s one of the most common stories I hear, but it isn’t the only story. Some people may have contact mechanisms where another player contacted the outside of their knee causing their knee to collapse inwards. Other players may have an “indirect contact injury”. These often occur in situations such as headers in soccer, taking a mark in AFL, or an intercept in basketball or netball where the player is contacted whilst in the air resulting in an injury upon landing. The first discussion point in my assessment will be a description of how the injury occurred. This provides me with a great deal of insight into potential contributing factors to the injury as well as assisting in the diagnostic process. Sensations that you felt, such as pop, snap, crack, or any other sensation you may have felt, are important details to pass on to me too.

What happened next?

ACL injuries can be relatively distinct from other knee injuries in how they respond within the first few hours post-injury. An ACL injury is going to swell up and it will swell up fast, so swelling is always a question I will ask along with any other symptoms or sensations you felt within the following 24 to 48 hours after the injury. One of the common sensations people can describe to me is the sensation of looseness, knee instability, or like the knee wanting to give way on them during day-to-day life. Other potential sensations you may feel could include a locking, catching, or clicking sensation deep within the knee joint. These sensations might indicate a meniscal tear.

Injury History

I will note your previous injury and medical history to help determine potential risk factors and how we can minimise the effects of these to reduce your risk of injury in the future. Of particular note would be any soft tissue, ligament, or joint injuries from the hips down.

Goals for Rehabilitation

The last part of the conversation will revolve around you and your goals for rehabilitation and what you want your knee to do the following rehabilitation. Often, this may not be fully fleshed out in our initial consultation, but it's important to start the conversation early to ensure we are both on the same page.

ACL Rupture Objective Assessment

Hands on testing of an ACL injury should be relatively conclusive and the need for MRI minimal. Specific tests such as Lachmann's Test and the Anterior Drawer test are specific and sensitive for diagnosing ACL injuries. 

Ligament and Meniscus Tests

This portion of the assessment is all about determining structural integrity of the ligaments and menisci within the knee. I will perform a Lachmann's Test and an Anterior Drawer to assess ACL integrity, a valgus and varus stress test to assess the MCL and LCL respectively, as well as a Posterior Drawer and Sag test to assess the PCL integrity.

For the meniscus I will often perform three tests, the first will be joint line palpation to assess for any tenderness, and then I will perform both McMurray's Test and Apley's Test to further assess the meniscal structure.

Range of Motion

Often in the early stages post ACL rupture range of motion of the knee may be significantly limited. This is most often because of the significant swelling onset that starts quickly. This can restrict knee flexion (bending) in particular. Whilst I'm interested in how much you can bend the knee, I'm wholly aware that it is often swelling restricting it so I may be less concerned. I'm often more interested in your knee extension and whether you have maintained it. Knee extension range of motion is a key factor both pre-surgery and post-surgery and there are significant functional outcomes if we do not achieve full knee extension.

Palpation

Palpation of the structures around the knee is a key part of a clinical assessment. Often this is used to assess for tenderness of certain structures, such as the MCL, the medial or lateral joint line, or for other specific structures such as the fat pad. It can also assess muscle tone. Often a muscle that is high tone will feel tight and stiff. Through palpation, I'm able to determine where the tension within the muscle lies and hopefully will resolve this with treatment to the local area.

Other tests, such as the sweep test, can help assess for knee effusion. It involves me sweeping the knee joint in one direction before then sweeping in the opposite direction and assessing for any bumps of swelling that may appear on the inside of the knee joint.

Functional Assessment

Clients often don't want to be doing a lot after an ACL injury, and that is fine to an extent. But I need to determine a baseline level of function for every client. This will often include activities such as walking, stairs, squats and balance in the first consultation. Over time, this will progress and become more challenging as you progress and improve.

For clients considering non-surgical rehabilitation of their ACL rupture, functional capacity and a thorough assessment is of paramount importance.
It’s vital that an experienced physiotherapist conduct a thorough physical exam on your injured leg before any treatment begins. Assessing knee function early after an ACL injury is the best way to determine whether an anterior cruciate ligament rupture has occurred. If the injury was sustained over five days ago, hands-on tests may not be as reliable because of the presence of hamstring spasm resulting in false negative tests. So the earlier you get in for an assessment, the better.

The knee will often present with significant swelling, causing functional difficulties and range of motion loss. There are two commonly performed ACL tests, Lachmann’s which is the better diagnostic test, along with an anterior drawer test. A physiotherapist should perform these two hands-on tests to assess for laxity of the ACL and to determine whether there is an end feel. I often describe an end feel as a stopping sensation that you will feel when you stretch a ligament to its endpoint. If this sensation is absent, the likelihood of an ACL rupture is quite high.

Other hands-on tests will include assessing other ligamentous structures, such as the MCL, LCL, and PCL. I will also perform meniscus tests to assess for the potential presence of a medial or lateral meniscus tear. A functional assessment will be the other key portion of my assessment.

Following my assessment, I will provide you with a diagnosis and if I believe further investigations such as an MRI I recommend you speak with your GP to get an MRI referral. I can provide a written letter to your GP summarising the details of my assessment and diagnosis.

Surgical vs Non-Surgical ACL Rehabilitation

Surgical Reconstruction

The theory of surgical reconstruction is to reinstate the lost passive stability that the ACL provides. Most often surgeons will utilise a graft from the hamstrings but some surgeons may opt to utilise the patella tendon. Ultimately, this is surgeon preference most times. Most clients respond positively to ACL reconstructive surgery and don’t report any complications, but depending upon your surgeon’s protocol, you may be placed in a knee brace for a period following surgery. It is always important to remember that surgery carries risks and there is not a guarantee of a successful outcome.

Returning to running after ACL reconstruction will typically occur within the 12-16 week period and returning to restricted training often occurs around the 4 to the 5-month mark. I often recommend clients aim for a 12-month return to sport. 9 months is certainly possible but requires a significant investment of time into the rehabilitation that some clients with work and family commitments may not be able to make. Returning to sport prior to 9 months isn’t recommended because of the significant increase in the risk of re-injury due to graft maturity rates.

Non-Surgical Rehabilitation

Non-surgical rehabilitation comprises an individualised and comprehensive exercise program tailored to the individual and their goals. Non-surgical rehabilitation is commonly accepted as an ACL treatment pathway in Europe but is much less adopted in Australia with only around 10% of people undergoing non-surgical rehabilitation compared to approximately 50% in Europe. Current research and guidelines recommend undertaking a period of supervised rehabilitation for 3 to 6 months prior to determining whether surgical intervention is necessary. This is often based on whether instability sensations are present during a functional assessment of the knee or during daily life.

Non-surgical ACL rehabilitation consists of the same processes for recovery as surgical rehabilitation. You will perform the same exercise program with the same goals and the same criteria to return to sport.

The major benefit of non-surgical rehabilitation is that you can return to sport much quicker if your body can adapt to not having an ACL. Or, as is being found to be quite common, your body heals your ACL rupture. Some clients, however, may simply be unable to return to sport with non-surgical rehabilitation and my aim is to find these people as soon as possible and refer them on for a surgical opinion.

What does our ACL surgery rehabilitation program involve?

I’ve never said that rehabilitating an ACL injury is easy. From discussions I have with clients I believe it is a more rigorous mental recovery than it is physical. Developing confidence in the athlete and their knee is one of my key aims as a physical therapist.

Should I Access ACL Physiotherapy Post Injury or Post Knee Surgery?

In the early rehabilitation phases, it is all about settling down the inflammatory process, maximising the range of motion, and keeping the knee and leg muscles active to minimise strength losses. Hands-on techniques such as massage, dry needling, and joint mobilisations are integral to maximising mobility and maintaining the functional capacity of the knee. At home, the utilisation of ice and compression bandages to minimise the swelling build-up throughout the day is important. Regarding an exercise program, the early emphasis is on light but consistent loading for range of motion and consistent isotonic and isometric quadriceps exercises, focusing also on the quadriceps, hamstrings, gluteals, and calves. We may also include seated knee extension exercises in your program.
Knee after ACL reconstruction surgery, with dry needles in the thigh

Strengthening Phase

As fun as all the plyometric and change of direction work is, we can’t do that work if we don’t have a solid base of strength. Developing a well-rounded strength and conditioning program, not just for the knee but for you as an athlete, is the next stage of your progress. I will work with you to develop a complete strength and conditioning program, including a gym program and home program, so that you can maximise your results. This process takes time. We can’t rush strength training as magic can’t happen in 2 weeks. This stage takes commitment and consistency in training to see results. You will get out of it what you put in. Ideally, I like most of my clients to be getting to the gym for a leg session at least twice per week.
Client balancing on one leg with tape supporting their foot and ankle

Plyometric Loading

This is where it gets a bit more fun. Prior to fully developing into plyometric work, we will have done some introduction work prior to this to develop your movement patterns and ensure that you are nailing them before making things more complex. The key point I will hammer home during the stage is technique and consistency. An athlete may produce a lot of power, but if they can’t control it, or have poor technique, they will significantly increase their risk of injury. We will also work on change of direction and multidirectional drills in this stage as well as we prepare you for the workload up to returning to training.
Physiotherapist assessing a client's hip and knee on a treatment table

Field/Court Based Rehabilitation

This is often the biggest portion of the rehabilitation process that I feel gets missed by clinicians and it’s integral to a good outcome. Without being able to assess and see how an athlete moves and operates on the field or court, it is difficult for practitioners to truly give advice. As a mobile physio, I am at an advantage in that I can meet you at your nearest sporting field or court and watch and take part in field-based drills with you, and we can discuss your performance. There’s no need for you to come back and see me in 3 weeks and tell me how you went because you can tell me in real-time and we can optimise and hone in on what you most need to work on maximising your performance. All of this work is feeding in with returning you to training in a progressive and staged manner. Increasing the complexity of the surrounding environment by manipulating the number of players involved in a drill or increasing contact are just some ways I work with you and your coach to seamlessly work your way in.
Physiotherapist stretching a client's hamstring on a treatment table

Optimising for Return to Sport

The end goal for any athlete is to get out there in a competitive game. Here, we need to put all the pieces of the puzzle together of your strengthening program, agility and plyometric work, and your gradually increasing training load. Culminating in a return to sport assessment that includes clinical, psychological, and physical testing measures to ensure you are truly ready to return to sport. My return to sport assessment is based upon the latest evidence and research to ensure I am providing you with the best information possible.

Your Questions About ACL Injuries

How long does ACL rehab take?

After an ACL reconstruction, returning to pivoting sports like football, netball and basketball usually takes 9 to 12 months, and sometimes longer. Research shows the risk of re-injury drops for every month you delay returning, up to around 9 months. Getting back to everyday activities, work and straight-line running happens much earlier. If you manage your ACL injury without surgery, the timeline depends on your goals and how your knee responds, but a structured program still usually takes several months. My ACL Rehabilitation Package maps out each stage.

What tests show I'm ready to return to sport?

I use a set of criteria rather than time alone. That includes full knee range of motion with no swelling, quad and hamstring strength within about 10 percent of your other leg, a series of hop tests comparing both legs, and running, agility and change of direction drills at full speed. I also look at confidence, because feeling ready matters as much as testing ready. Finally, you need to have completed full training without problems before playing a game. Meeting all of these lowers your risk of another injury.

Should I do physio before ACL surgery?

Yes. Physio before surgery, often called prehab, is one of the best things you can do for your recovery. The aim is to settle swelling, get your knee fully straight and bending well, restore a normal walking pattern and build quad strength before the operation. Research shows people who go into surgery with a calm knee and good strength tend to recover faster afterwards. Prehab is also a chance to learn your early exercises, so you are ready to start straight away after surgery.

What are the chances of re-injuring my ACL, and how do I lower them?

Re-injury is a real risk, particularly for young athletes returning to pivoting sports, and it includes tearing the new graft or the ACL in the other knee. The good news is that much of that risk can be reduced. Waiting until at least 9 months after surgery, passing return-to-sport testing, and completing a full block of training before playing all make a difference. Continuing an injury prevention program, like a structured warm-up with strength, landing and change of direction work, is one of the most effective ways to protect both knees long term.

Can I play sport without an ACL?

Some people can. Sports that are mainly straight-line, such as running, cycling and swimming, are usually fine without an ACL once your strength and control are good. Pivoting and cutting sports put more demand on the ACL, and some people find their knee gives way without it, which can damage the meniscus and cartilage. Others cope well with excellent strength and control. A structured rehab program is the best way to find out which group you fall into, and if your knee keeps giving way, surgery can be reconsidered.

PRP Physio’s ACL Rehabilitation Package

As a physiotherapist, I have managed many ACL clients, whether they undergo surgical reconstruction on their injured knee or opt for non-surgical management. From football players of all codes (union, league, AFL, and soccer), to basketball and netball players, I have helped just about any athlete return to sport after their ACL injury.

I pride myself on my ACL rehabilitation program which was developed in-house that helps take anyone from day one post-injury all the way through to return to sport should that be their goal. The program includes everything from home exercises, a gym program, a return to running program, and return to training progressions.

Each stage of the program requires you to pass certain criteria. Recent evidence has identified that criteria-based progression has shown both better results in rehabilitation and lower re-injury rates compared to time-based progressions.

Anterior cruciate ligament injuries get expensive, once you factor in potential surgical costs, time off of work, doctors’ appointments, and specialist consults, it all adds up. I genuinely believe my ACL rehabilitation package provides the best value for money in physiotherapy rehabilitation for the best results.
PRP Physio ACL Rehabilitation Program booklet

Everything included

All of your physiotherapy sessions as well as an individualised injury prevention program is included. There's no surprises along the way, and I believe this will give you everything you will need to succeed.

No hidden fees

What you pay for is what you get. There are no hidden extras involved, just high quality physiotherapy with the aim of returning you back to the life you love.

Who is it for?

This program is applicable for clients undergoing either surgical ACL reconstruction or for those opting for a non-surgical approach to their recovery.

Physiotherapy is a key factor in maximising your recovery, ensuring you return to your maximum performance on your return to sport, and ensuring you maximise your quality of life in the future. As a mobile physiotherapist, I can cover everything for you as I am not bound by the structures of a clinic. If you need field-based rehabilitation, I'll meet you at a field, and if I need to reassess your gym program, I will meet you at your gym. Wherever we need to be I will be there.

Stages of PRP Physio's ACL Rehabilitation Program

The rehabilitation program includes a total of 52 physiotherapy appointments throughout the 12-month program. Why so many some may ask? This program was designed for those who want the best outcome possible and is designed to not cut any corners, following all ACL rehabilitation protocols. When you work with me, I will leave no stone unturned through your recovery and be with you every step of the way. The amount of contact we will have throughout the 12 months will change depending upon the stage of recovery that you are at to best suit your needs and goals. I have detailed below the aims of each stage and what changes throughout the program.

Weeks 0-6

2 x week physio
Begins at the point of surgeon recommendation or if opting for non-surgical care from the date of first consultation

After your ACL rupture or ACL reconstruction, it’s extremely important to get you off to the best start possible. Optimising your range of motion, minimising swelling, and engaging muscles are all key components of this portion of the rehabilitation and physiotherapy. Tolerating weight bearing is a key component of this phase, utilising crutches to offload weight to maintain a normal gait pattern is the recommended choice at this stage. This is the best way to ensure a straightforward return to full-weight bearing on your knee.

Other key components of this stage include gait retraining, education about use of crutches and weaning off of them, and utilising blood flow restriction training.

Early neuromuscular control exercises can be adopted in this phase to ensure motor patterns and balance and stability is maintained from early on.

Weeks 7-16

1 x week physio
Beginning a gym program is one of the key components of this stage of rehabilitation. Developing higher levels of strength above your own bodyweight is an integral portion of returning to tasks such as running, jumping, and deceleration and acceleration.

Likely at this stage, anterior knee pain and swelling isn’t a significant concern so we can begin to progress towards single leg exercises to improve knee bend and extension.

Often components of rehabilitation such as the introduction of early stage agility and change of direction skills can be included in this phase. You can read more in my article on the ACL rehab exercises for each stage.

Weeks 17-28

1 x week physio
This phase is a consolidation section for the strengthening portion of the program. This is a phase that takes time as we want you to develop the adequate strength before progressing to the next phase of rehabilitation where we look to progress towards returning to training and sport.

During our physiotherapy appointments we will often be looking to work on sport specific movement patterns and increasing the complexity of the movements and the environment around you.

We require you to be consistent with both your gym program, home exercise program, and at home agility program to obtain the best results from this phase.

Weeks 29-32

2 x week physio
As we ramp up towards getting back to training and the eventual return to sport we increase the intensity of physiotherapy. The important factors in this stage is ensuring change of direction mechanics are optimised to reduce risk of re-injury and to ensure confidence in the knee in sport specific movements and positions.

A large portion of rehabilitation at this stage will be field or court based and will also factor in components of performance enhancement with training including sprint training, agility training, strength and conditioning, and aerobic fitness training.

Weeks 33-52

1 x fortnight physio
Most aspects of rehabilitation should be covered at this stage and it is simply a process of returning through training and returning to sport. We continue to support you throughout this phase to continue to supplement your training schedule, maximise your performance and fitness, ensure you have maximal confidence in your knee, and build towards developing an individualised injury prevention and performance program.

How much does the package cost?

ACL rehabilitation can be expensive, particularly if you are opting for surgical management. Once you account for specialist consults, surgical fees, the cost of an anaesthetist, and imaging costs it adds up, and we haven’t yet included any potential time off from work yet. We don’t believe that finances should play a role in an athlete being able to have access to the best rehabilitation possible.

Now I understand that given the early costs of managing an ACL injury are quite high which is why payment plans are available. Weekly, fortnightly, or monthly payment options are available depending on what best suits your needs and capacity. I will work with you to find an option for you to access the care you desire and deserve.
Total Value: $5720
Package Price: $4570

ACL FAQs

Yes. Most people can walk within a few days to weeks of an ACL tear, once the first swelling settles. Being able to walk does not mean the ligament is intact, and the knee can still give way when you twist, land or change direction. That is why an assessment matters even if your knee feels like it is improving.

Not always. Current guidelines recommend a period of supervised rehab, often 3 to 6 months, before deciding on surgery. Many people who do not return to pivoting sports manage well without it. People returning to sports such as football, netball or basketball, and people whose knee keeps giving way, are more likely to need a reconstruction.

As soon as possible, ideally within the first week. Early physio helps control swelling, restore full knee straightening and keep your quadriceps working. Whether or not you have surgery, a settled and strong knee leads to a better outcome.

My ACL Rehabilitation Package includes 52 appointments over 12 months for one price, which works out cheaper than paying per session. The price and everything included are listed further up this page. If you would rather pay per session, each 45 minute consultation costs $110.

Yes. You can claim a rebate from your health fund for every session. PRP Physio is not a preferred provider for any fund, so your rebate may be slightly smaller than at a preferred provider. Your fund can confirm the exact amount using item code 500 for your first consultation and 505 for follow-ups.

Yes, if you injured your knee at work. Your GP starts the claim and gives you a WorkCover certificate, which acts as your referral. Once your claim is accepted, I bill WorkCover directly, so there are no out-of-pocket costs for you. WorkCover covers your first five sessions, and I speak with your case manager if you need more.

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