Call for a Paradigm Shift in ACL Rehab


ACL Injury and Return to Play

For athletes whose lives revolve around their sport, having an injury that takes them off the playing field can be torture. In eagerness to get back in the game, athletes often play down their symptoms and exaggerate their degree of recovery. Without objective guideline to assess an athlete’s readiness to return to play (RTP), we may be setting them up for failure by putting them back on the field prematurely.

ACL rupture is a common sports injury that can range in degree of damage from mild to severe. Many factors come into play, such as whether multiple ligaments were damaged, whether menisci were torn, whether there are patellar-femoral tendon issues, and whether there are associated micro fractures. There is also the question of whether surgery is necessary, or whether the athlete can achieve ACL tear recovery without surgery. Given the various scenarios, it is clear that ACL rehab protocols should be considered on a case-by-case basis.

The Trouble with Time-Based Protocols

To date, established protocols for RTP after injury have completely or in part been based on a timetable, with nine months being the generally accepted time for full ACL recovery. In a recent podcast aired on The Sports Medicine Broadcast, renowned athletic trainer Bubba Wilson asserts that a protocol is a guide, not a cookbook. There is no one-size-fits-all recipe for recovery from an ACL injury. Wilson sees recovery as more of a road map, with many different routes that will all get you to your destination, depending on where you are coming from.

Given the many factors that determine the severity of injury, along with the psychological profile of individual athletes, time alone is inadequate to determine RTP. Even if the athlete has physical therapy for an ACL tear without surgery, time alone is an insufficient marker for RTP. In fact, time-based protocols can create frustration in athletes who expect to be cleared to play within a given period of time, when they may not yet be ready. Premature RTP sets the athlete up for impaired performance and further injury.

Proposal for Criteria-Based Protocols

With years of experience working with injured athletes, Wilson knows that recovery time varies from one athlete to the next, and from one injury to the next. He is calling for a criteria-based protocol for RTP that evaluates the athlete’s progress objectively through the use of assessment tools and performance-based evidence. Wilson’s protocol identifies phases of recovery, and specifically outlines performance and readiness standards for each phase.

Phases of Recovery for RTP

Wilson identifies four phases of recovery for RTP, each with its own punchlist of performance and readiness standards:

● Phase I: Acute phase from injury to full ambulation without supportive devises.
● Phase II: Jogging.
● Phase III: Return to sport with agility training.
● Phase IV: Return to play with a pain scale score of ≲ 2.

Each phase uses multiple assessments to establish the degree of recovery, including balance tests, joint range of motion, landing pattern assessment, pain scale, functional performance tests and more.

“You’re Ready When You’re Ready”

The time it takes an individual athlete to return to play is dependent on many factors, including how hard and how consistently the athlete is wiling to work to rehabilitate their injury. Wilson’s criteria-based protocol enables athletes to get a clear picture of which milestones they must achieve to advance to the next phase, and what type of training they need to do to get there. According to Wilson, there is no shame in taking longer than expected to recover. He argues that physical therapy for ACL tears should focus on what is best for the athlete, not on how quickly they return to play. “You’re ready when you’re ready,” says Wilson, and he is working hard to put together a criteria-based protocol in which time is not a factor.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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