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

 
ACL rehab return to run checklist
 

Strength

A set up for a quad isometric strength test in a gym with a force transducer

Set up & execution for Quad Isometric Strength Exercise

 
A set up for a hamstring isometric strength test in a gym with a force transducer

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:

  1. Walk 5 min/Jog 1 min for 5 cycles

  2. Rest day

  3. Walk 5 min/Jog 1 min for 5 cycles

  4. Rest day

  5. Walk 4 min/Jog 2 min for 5 cycles

  6. Rest day

  7. Walk 4 min/Jog 2 min for 5 cycles

Week 2

  1. Rest day

  2. Walk 3 min/Jog 3 min for 5 cycles

  3. Rest day

  4. Walk 3 min/Jog 3 min for 5 cycles

  5. Rest day

  6. Walk 2 min/Jog 4 min for 5 cycles

  7. Rest day

Week 3

  1. Walk 2 min/Jog 4 min for 5 cycles

  2. Rest day

  3. Walk 1 min/Jog 5 min for 5 cycles

  4. Rest day

  5. Walk 1 min/Jog 5 min for 5 cycles

  6. Rest day

  7. 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

  1. Run 20 min

  2. Rest day

  3. Run 20 min

  4. Rest day

  5. Run 20 min

  6. Rest day

  7. Run 25 min

Week 5

  1. Rest day

  2. Run 25 min

  3. Rest day

  4. Run 25 min

  5. Rest day

  6. Run 30 min

  7. Rest day

Week 6

  1. Run 30 min

  2. Rest day

  3. Run 30 min

  4. Rest day

  5. Run 35 min

  6. Rest day

  7. Run 35 min

Week 7

  1. Rest day

  2. Run 35 min

  3. Rest day

  4. Run 40 min

  5. Rest day

  6. Run 40 min

  7. Rest day

Week 8

  1. Run 40 min

  2. Rest day

  3. Run 45 min

  4. Rest day

  5. Run 45 min

  6. Rest day

  7. Run 45 min

Week 9

  1. Rest day

  2. Run 50 min

  3. Rest day

  4. Run 50 min

  5. Rest day

  6. Run 50 min

  7. Rest day

 

Week 10

  1. Run 55 min

  2. Rest day

  3. Run 55 min

  4. Rest day

  5. Run 55 min

  6. Rest day

  7. Run 60 min

Week 11

  1. Rest day

  2. Run 60 min

  3. Rest day

  4. Run 60 min

  5. Rest day

  6. Rest day

  7. 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

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Return to Sport Testing After ACL Reconstruction

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