The ACL injury journey – a guide for patients

This blog accompanies two infographics – published in British Journal of Sports Medicine – presenting the best available evidence, and designed with input from people who have experienced ACL injury. Both authors of the infographics are clinicians and researchers who work with many people of all ages and levels of sport after ACL injury. These infographics are designed to be used with your health professional, help guide your decisions and rehabilitation process.

Part 1: Treatment decision

Gathering your rehab team

After an ACL injury, it is common to feel angry, depressed, frustrated and uncertain about your future (1). First, you should gather members of your rehab team to help you make decisions, guide your rehabilitation and keep you motivated. Members of your team can include exercise professionals (e.g. physiotherapist), a surgeon, a sports doctor, your coach, team-mates, your family, and your friends.

Starting rehabilitation straight away

You should begin high-quality rehabilitation immediately after an ACL injury (2). Most experts agree that after your ACL injury, the best course of action is to try to return normal knee function and delay the decision about whether to have surgery or not until after a period of rehabilitation (3).

Deciding whether to have surgery (or not)

Younger, more active patients are more likely to re-injure their knee but this is probably unrelated to whether you have surgery or not (4, 5). Returning to high level pivoting sports is associated with more risk than running in straight lines, for example. Having other knee injuries, like meniscal tears, at the same time as your ACL injury is associated with worse outcomes but again the choice about surgery doesn’t seem to impact this outcome (6, 7). However, some injuries may need to be repaired and this will be an individual decision. It is important to discuss factors like your age, other injuries and your plans to return to high level pivoting sports because you can talk with your rehabilitation team how to reduce your future injury risk (8). Remaining happy, healthy and active is a key consideration for anyone following ACL injury and this may or may not involve surgery.

There is no clear evidence that surgery is superior to undertaking high quality rehabilitation alone. There is only one published randomised trial comparing the two options (9). This reported no difference in pain, function or return to pre-injury activity levels at 1-, 2- and 5-years after an ACL injury (9). Current evidence suggests that, in the long-term, there is no difference in how many people develop osteoarthritis between people who have their ACL surgically reconstructed and people who don’t have surgery (10). It is clear that some people can cope without surgery following an ACL injury (9,10). Some people may even be able to return to high level pivoting sports without an ACL reconstruction (11). We recommend you think about the following things when talking to your rehab team and making your decision:

  • Do I have all the information?
  • What are my goals?
  • What are my values? (Time with kids, playing with friends)
  • What are the risk versus rewards for having surgery now?
  • Am I being listened to?
  • Have I been given enough time to make this decision?

Part 2: Rehab Explained

Working hard on your rehabilitation

Whether you have surgery or not, completing quality rehabilitation is the key to restoring normal knee function, preventing further knee injury and optimising your long-term quality of life (2). You should progress through an individualised, criterion based program, involving 3 distinct ‘phases’ (early, mid and late) (12). Exercises you can think about performing in these stages are as follows (remember to perform these exercises with the guidance of a health professional):

You need to work hard during each phase in order to optimise outcomes. People with better functional performance have lower chance of re-injury and better long term outcomes, including lower rates of osteoarthritis (13, 14, 15, 16).

When to return to play

During the final stage of rehab, people often face a difficult decision – when are you ready to return to sport? Some sobering news is that 56% of people do not return to competitive sport after an ACL injury (17). Additionally, evidence suggests up to 24% of people can re-injure their knee after returning to sport, however this risk is significantly reduced in people who pass important return to sport criteria (18). You can optimise your chances of returning to sport and reduce your risk of re-injury by considering the following:

  1. Work hard on your rehabilitation, and if possible, work with a qualified professional to provide you with the most up-to-date guidance.
  2. You should wait at least 9 months before returning to sport if you have had ACL reconstruction surgery (2). The longer your wait, the lower your chances are of re-injury. If you have not had a surgical reconstruction, the optimal timeframe to return to play is not clear, but you may be able to return to sport sooner.
  3. Before returning to sport, you should include sport-specific training as part of your rehabilitation, and you should pass a battery of performance tests (e.g. hop tests) (1, 12, 18).
  4. Ensure you are confident to return to sport before actually returning (1). Time and quality rehabilitation can help with confidence. In some circumstances, consulting with a sports psychologist might be beneficial.

How to reduce the likelihood of injury

Exercise based injury reduction programs can reduce the incidence of ACL injuries (19). These programs are important to undertake, whether you have had an ACL injury or not. Completing these programs is an important consideration as you near the final stages of your ACL journey and should be front and centre of your mind long after you return to sport. There are many injury reduction programs to choose from, including the FIFA 11+ program, the Netball KNEE Program, the Prevent injury and Enhance Performance (PEP) Program, the ACTIVATE World Rugby program, and it can be a confusing time choosing the best option for you and your sport. There are a few key components of effective programs, including regular strengthening and neuromuscular challenges like landing and agility practice (19). Remember to involve your coach and teammates when you are performing these programs – it’s everybody’s business to reduce the risk of injuries.


Connor P Gleadhill

Christian J Barton


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  16. Patterson B, Culvenor A, Barton C et al. Poor functional performance 1 year after ACL reconstruction increases the risk of early osteoarthritis progression. Br J Sports Med 2020;54:546-553.
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  20.    Gleadhill CPBarton CJ. Infographic. ACL injury journey: an education aid .

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