ACL Rehab Part 3: Mid Rehab & Return to Sport
You’ve been working really hard to get your knee moving and the quads firing again. Now is the time to start working on re-building the performance of your leg and knee.
Missed the last blog post?
If you haven’t already, check out our previous blog post on early ACL rehab where we break down the three crucial goals to kickstart recovery:
- Get the knee straight
- Control pain and swelling
- Get the quads firing again
Each of these goals lays down a solid foundation for the work you will do in this stage, so it’s important to nail them!
In this post, we are going to cover the main bulk of the ACL rehab process and give you some useful tips you can use to make the most of your recovery and return to your previous level of function. This one's a juicy one, so let’s dig into it.
Mid-Stage: Time to get strong!
The mid-stage ACL rehab blends through from the early stage. As soon as you can move the knee better, you can begin some simple early/mid-stage exercises.
The goal here? Getting strong… like, really strong.
You will almost certainly have lost strength in your quadriceps and hamstrings but it’s also very common to lose strength in your hip muscles, calf, ankle, and foot muscles.
All of these matter because your entire leg works as a cohesive team. Ignoring one area could mean leaving performance benefits on the table.
What to focus on?
Start by progressively loading each of the key muscle groups, beginning with double-leg exercises to build a solid foundation. As your strength and control improve, the exercises will gradually become more challenging, eventually progressing to single-leg variations for greater strength and stability.
Your physio will carefully guide you through the exercises and progress the movements, sets, and reps as your strength and technical capabilities improve.
Check out this table below for a sneak peek of some examples of exercises you might start with and where they will progress to:
Exercise Type Initial Exercise Target Exercise
Squat Motion Goblet Squat Barbell front squat
Hinge motion B-stance Romanian Deadlift Single leg Romanian Deadlift
Single Leg Squat Single Leg Press machine Single Leg Squat to Box\
Calf Raise Double Leg Calf Raise Single Leg Calf Raise
Foot Movements Banded Exercise Dynamic Control Exrcises
Pro Tip: Timing is everything. These exercises must be introduced at the right stage of your recovery. Too soon, and you risk flaring up the knee or donor sites. That’s why it’s crucial to work with a physio who knows the ins and outs of post-op rehab. They'll make sure each progression is safe, effective, and tailored to your recovery timeline.
So how strong should I be?
Okay, now we are getting to the real crux! They key to moving onto the late stage of rehab.
The short answer is: as close to the non-injured leg as you can get!
Closing the gap until there is at most 10% difference between the two legs is what we are after. For a return to higher level pivoting sports, we might want to see closer to 100% similarity.
At Beyond, we use the VALD strength system to accurately measure how much force each of your muscle groups produce.
That means there's no guess work to be found here. It’s not just about feeling strong, it’s about being measurably and objectively strong!
Here are some of the goals we are aiming to achieve:
✅ Quad, calf, hamstring, glute, foot strength: within 90% similarity on VALD testing
✅ Barbell back squat: 1.5x body weight
✅ Single leg press: 1.5x body weight
✅ Balance, control, and endurance testing: >85% similarity
As you move into the mid-to-late stages of your ACL rehab, the lines between phases may start to blur a little more. You’ll start to see some more dynamic movements in your plan. However, the key here is that it’s crucial to stay focused on hitting your strength and control milestones. These goals lay the foundation for a fully functional, resilient knee. Don’t skip them!
Late Stage: Where the fun really begins!
Here we are! You’ve stuck to your plan and the proof is in the pudding. The numbers on the VALD strength testing systems are all moving on the up and up and the differences in strength are reducing nicely. Time to move into the late stage of rehab!
This stage comprises of 4 key steps
- Return to running
- Introduction of sport-specific training
- Return to team training (participation)
- Return to performance and competition
Let’s break them down.
The Road to Running
This is a big one for a lot of people that we see. When can I get back to running?
It's not just about time when working this out, it’s more about how you are recovering: your pain levels, strength levels and dynamic testing that dictate whether you are ready to run.
Before you get the green light, you’ll already have been doing dynamic and impact-based exercises with your physio to prep your knee for running.
To help us make a decision, we follow the ASPETAR clinical guideline published in 2023. Have a look at some of the pre-requesits for running to get an idea of what you are aiming for:
- At least 12 weeks post-surgery
- Minimal to no swelling
- Full knee extension and 135° knee flexion
- 0/10 pain during running drills and no change in pain or swelling next morning
- Good Single leg hop x 30 repetitions (no pain or swelling)
- Quadriceps at least 70% as strong as the non-injured side.
Once you’ve ticked all of these off, your physio will get you started on a graded return-to-run program, slowly and safely building up your running volume so your knee stays happy and strong.
Getting Sports ready
Once you’re up and running (pardon the pun), it’s time to shift gears and begin some sports specific training.
The goal here is simple: prepare your body for the high demands associated with playing sports. Think sprinting, jumping, twisting, landing, cutting, pivoting, tackling, unplanned movements and reactive strength. These movements require much more force than running in a straight line and so the rehab needs to reflect that now.
The exact exercises in this section will differ from sport to sport but a rough progression might look like
- Linear running drills: Acceleration, deceleration
- Multidirectional running drills: change of direction
- High intensity linear and multidirection drills: sport drills like crossing a football in, hopping and jumping, cutting and pivoting drills
- Sport specific movement and skills: contested efforts, shooting practice, drills under fatigue
- Training simulation: All of the above and adding real game scenarios
Physio Pro Tip: it is generally accepted that waiting at least 9 months before returning to sport significantly reduces your chances of re-injury.
Getting back in the team
You’re almost there! The end is in sight and the sports field is calling your name.
There are two key steps to get you over the finish line: return to participation and return to performance.
Return to participation means you’re back training with your team.Continuing to build fitness, refining skills, and enjoying the fun of being involved again. You might not be playing games just yet, but your knee is handling the intensity of training, and that’s a huge step forward.
Return to Performance means you’re back doing what you love, competing in real games with your team.
By this point:
✅ Your strength numbers will be as close to 100% as possible
✅ Your force plate data (jumping, hopping, landing) will be as close to 100% as possible
✅ You’ll be performing at — or even above — your pre-injury level
Before clearing you for competition, your physio will run through a strict return-to-performance checklist, making sure every box is ticked, to reduce risk of re-injury and making sure you're fighting fit when it counts.
Summary
The mid-to-late stages of ACL rehab are where real progress happens, building strength, control, and performance.
In this phase, you’ll focus on restoring strength across the entire leg, progressing through structured exercises and hitting objective strength targets using tools like the VALD system.
From there, you'll transition into running, sport-specific training, and finally, returning to full team participation and performance. Each step is guided by evidence-based milestones to reduce re-injury risk and ensure you're physically and mentally ready to get back to doing what you love.
This part of the rehab is heavy going and so having someone to guide you through it can make the world of difference.
Get yourself booked in with one of our physios to get the progress started today!
References
- Grindem, Hege, et al. "Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL Cohort Study." The Journal of bone and joint surgery. American volume 96.15 (2014): 1233.
- Hughes, M., 2023. ACL Rehabilitation Guide 2.0. Melbourne: Mick Hughes Physiotherapy. Available at: https://www.thejointstudio.com.au/wp-content/uploads/2024/10/ACL_Guide.pdf
- Kotsifaki, R., Korakakis, V., King, E., et al., 2023. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. British Journal of Sports Medicine, 57, pp.500-514.[Accessed 18 February 2025].
