Getting Back to Running After ACL Surgery
Am I ready to return to running after ACL surgery? And what criteria do we use with our patients in ACL rehab?
A guide to return to running post ACL surgery, by expert physical therapists.
Return to running (RTR) in ACL rehab
After ACL reconstruction surgery, the return to running (RTR) is a key milestone as we transition from doing impairment-based exercises on the table (knee range of motion, isolated quad strengthening) to more functional, sport-specific tasks such as running, cutting, and jumping.
The timing of RTR is very important because returning to sport too early increases the risk for reinjury while delayed progress may reduce motivation and psychological readiness to return to sport
What is the criteria for returning to running after ACL surgery?
Time-based criteria:
12 weeks post-op
12 weeks post-op is the median time for clearance for RTR cited in most ACL rehab studies. This time-based criteria respects the biological healing time frame of the ACL graft.
There is also an assessment-based criteria that includes clinical, strength, and performance-based criteria to measure whether patients are functional ready for RTR.
Assessment-based Criteria:
Clinical
Pain < 2/10
95% knee flexion compared to unaffected side
Full knee extension ROM
No joint swelling (or trace effusion)
Adequate postural control and normal gait pattern
Strength
Isometric quadriceps and hamstring Limb Symmetry Index (LSI) >70%
We use force transducer technology to measure this
Set up & execution for Quad Isometric Strength Exercise
Set up and execution for Hamstring Isometric Strength Exercise
Isokinetic quadriceps and hamstring LSI >70%
LSI is calculated by dividing the affected limb score by the unaffected limb score
Performance-based
Single Leg Hop Test LSI >70%
Controlled and balanced landing
Single leg squat
45 degree knee flexion
Without loss of balance or dynamic knee valgus
Step-up-and-holds
Without loss of balance or dynamic knee valgus
The clinical criteria above must be met to ensure adequate loading for RTR. If the knee is still symptomatic (e.g. increased pain, effusion and ROM restrictions) after daily activities such as walking or rehab activities such as strengthening and/or ROM exercises, then it is not yet appropriate to increase loading demands with RTR. If you are still walking with a limp or noticeably favoring one leg, RTR should be delayed due to indicators of poor load management. If the clinical criteria above is not met, RTR should be delayed regardless of the time since surgery.
The strength and performance-based criteria above are used to judge a patient’s physical capacity to RTR. Because the hamstring and quadriceps work to actively stabilize the knee and for motor control strategy, these are the two most important muscle groups to measure strength. The functional tests such as hop test, single leg squat, or step up are important for replicating some of the physical requirements for running.
What are some exercises that we perform when returning to running after ACL surgery?
Single leg squat
45 degree knee flexion
Maintain trunk control and knee alignment without valgus
Step-up-and-holds
8 inch step
Maintain trunk control and knee alignment without valgus
Single leg landing off step
8 inch step
Controlled and balanced landing
Maintain trunk control and knee alignment without valgus
This mimics the repeated single leg landings that occur while running.
Sample Return to Run Program
PHASE I: Walk/Jog
Warm up walk 15 minutes, cool down walk 10 minutes
Week 1:
Walk 5 min/Jog 1 min for 5 cycles
Rest day
Walk 5 min/Jog 1 min for 5 cycles
Rest day
Walk 4 min/Jog 2 min for 5 cycles
Rest day
Walk 4 min/Jog 2 min for 5 cycles
Week 2
Rest day
Walk 3 min/Jog 3 min for 5 cycles
Rest day
Walk 3 min/Jog 3 min for 5 cycles
Rest day
Walk 2 min/Jog 4 min for 5 cycles
Rest day
Week 3
Walk 2 min/Jog 4 min for 5 cycles
Rest day
Walk 1 min/Jog 5 min for 5 cycles
Rest day
Walk 1 min/Jog 5 min for 5 cycles
Rest day
Rest day
*Only progress if there is no pain or swelling during or after the “run”/jog*
PHASE II: Return to Run
Warm up walk 15 minutes, cool down walk 10 minutes
Week 4
Run 20 min
Rest day
Run 20 min
Rest day
Run 20 min
Rest day
Run 25 min
Week 5
Rest day
Run 25 min
Rest day
Run 25 min
Rest day
Run 30 min
Rest day
Week 6
Run 30 min
Rest day
Run 30 min
Rest day
Run 35 min
Rest day
Run 35 min
Week 7
Rest day
Run 35 min
Rest day
Run 40 min
Rest day
Run 40 min
Rest day
Week 8
Run 40 min
Rest day
Run 45 min
Rest day
Run 45 min
Rest day
Run 45 min
Week 9
Rest day
Run 50 min
Rest day
Run 50 min
Rest day
Run 50 min
Rest day
Week 10
Run 55 min
Rest day
Run 55 min
Rest day
Run 55 min
Rest day
Run 60 min
Week 11
Rest day
Run 60 min
Rest day
Run 60 min
Rest day
Rest day
Rest day
Recommendations
Run on softer surfaces during Phase I
Treadmill
Perform non-impact activity on off days
Strengthening, stretching, etc.
No plyometrics
First increase volume (duration/mileage) then increase intensity (pace/speed)
DO NOT increase 2 variables at once
10% rule: No more than 10% increase in mileage per week
Smart and steady progressions to avoid injury
If you’re an athlete dealing with an ACL injury, and would like to work with us, contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Vincent Liu PT, DPT
Dr. Paul Nasri PT, DPT, OCS, COMT
Doctor of Physical Therapy
The Game Plan Physical Therapy