Reducing the Strain on ACL Management


Anterior cruciate ligament (ACL) injuries are an extremely common and costly injury in the general and sporting population. The most common mechanism for injuring your ACL occurs with a twist and pivot motion of the body with a planted foot. Other mechanisms include direct trauma or excessive stress from landing from a jump incorrectly, hyperextending the knee or direct contact from an opposition player.

Some of the common symptoms a patient will complain about include:

  • The patient may experience sudden pain or hear a 'pop'

  • Pain and swelling within 24 hours

  • The knee may give way at the time of injury and/or have a recurrent 'giving way' problem after the injury

  • Limited knee range of motion

  • Tenderness around the joint line

  • Discomfort or pain when walking

The clinical diagnosis of an ACL injury is generally formed by a combination of mechanism of injury, patient reporting giving way, positive Lachman’s or Pivot test for laxity and is then confirmed by MRI.

Over many years it has become common practice for these patients to be offered surgical care to return to high-level activity and pivoting sports. The current highest quality evidence has started to challenge these ingrained standards. It is showing that there is no difference between opting for physiotherapy and exercise, over a reconstruction (Frobell et al 2013, Delincé and Ghafil 2013, Smith et al 2014). A five-year follow-up comparison of the reconstruction versus physiotherapy and exercise revealed no significant differences between the groups with respect to pain, function, return to pivoting sport capacity, quality of life and meniscal surgery (Frobell et al. 2013). The evidence is starting to reveal that with a course of conservative management many individuals can return to participating in high-level activities including cutting, pivoting and jumping sports, without symptoms of pain and instability (Hurd et al. 2009, Grindem et al. 2012)

Physiotherapists are the best professionals to undertake the initial assesment and follow-up care of patients with ACL injuries, given our knowledge and training in musculoskeletal and pain management. An integral part of ACL rehabilitation is to regain the functional control of the knee to make up for the reduced mechanical restraint. The key pillars of rehabilitation should contain aspects of strength and power training, along with neuromuscular control and proprioceptive retraining. Strength and power should not be focused solely on the quadriceps. The lower limb kinetic chain approach would place importance on strengthening calves, gluteal and trunk muscles as well. Performing strength exercises on equipment such as Bosu balls, foam mats and mini trampolines can add the extra difficulty to challenge the neuromuscular and proprioceptive systems. As this is what the ACL deficient knee will need to regain the functional control and to build the client’s confidence and trust back with their injured knee. 

Functional performance tests, such as hop tests, are commonly used by physiotherapists to evaluate recovery after ACL injury and reconstruction. Performance on these functional tests can provide valuable information on future risk of knee symptoms, impaired quality of life, ACL rupture and other knee injuries. They make up a vital part of the clinical decision on when to progress patients to the next stages of rehabilitation such as when an athlete can safely return to sport following their ACL injury. 

1. Single Hop Test for distance

1. Single Hop Test for distance

2. Triple Crossover hop for distance

2. Triple Crossover hop for distance

3. Single leg squat strength

3. Single leg squat strength

4. 6 metre timed hop

4. 6 metre timed hop

As a guide to returning to sport if you can achieve >90% in distance, time and strength capacity of deficient compared to non-deficient leg, on the hop and strength tests above it has been shown to reduce the risk of reinjuries (Grindem et al., 2016Kyritsis et a., 2016).


Delincé, P. and D. Ghafil (2013). "Anterior cruciate ligament tears: conservative or surgical treatment?" Knee Surgery, Sports Traumatology, Arthroscopy 21(7): 1706-1707.

Frobell RB,Roos HP,Roos EM,Roemer FW,Ranstam J,Lohmander LS(2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ.Jan 24;346:f232. 

Grindem H, Eitzen I, Moksnes H, Snyder-MacklerL,Risberg MA (2012) A pair-matched comparison of return to pivoting sports at 1 year in ACL-injured patients after a nonoperative versus operative treatment course. Am J Sports Med40(11): 2509–2516.

Grindem H et al (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med.2016 Jul;50(13):804-8. doi: 10.1136/bjsports-2016-096031. Epub 2016 May 9.

 Hurd WJ, Axe MJ,Snyder-Mackler L(2009) Management of the athlete with acute anterior cruciate ligament deficiency. Sports Health1(1):39-46.

Kyritsis Pet al (2016). Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med.2016 Aug;50(15):946-51. doi: 10.1136/bjsports-2015-095908. Epub 2016 May 23.

Smith TO,Postle K,Penny F,McNamara I,Mann CJ(2014) Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. The Knee21(2):462-70.