Rethinking ACL Rehab and Return to Play from a Clinical Perspective


Do We Need to Change How We Treat ACL Tears in Athletes?

ACL rupture is an all-too-common athletic injury that physical therapists have been treating for decades. Yet the statistics surrounding return to play (RTP) after an ACL tear and surgical reconstruction are dismal, with only 55 percent of athletes returning to competitive sport after ACL surgery. Statistics for ACL tear treatment without surgery are similar. Of those who do return to play, one out of four will experience an ACL re-injury. Therapists often pride themselves on how quickly they put an athlete back into play, yet here again the statistics are grim, as the likelihood of re-injury enjoys an inverse relationship with treatment time.

Traditional protocols for evaluating an athlete’s RTP readiness typically revolve around time spent in recovery. Therapy is centered on rehabbing the knee as an isolated unit, and the decision to approve RTP is made by a single individual. In a recent podcast interview on Healthy, Wealthy and Smart, Belgian Sports Physical Therapist and University Researcher Bart Dingenen challenges traditional treatment and evaluation protocols for RTP, citing a number of deficiencies in traditional protocols.

Treat the Patient, Not the Knee

Because Dingenen is both a researcher and a clinical practitioner, he seeks to bridge the gap between the questions clinicians want answered and the type of research that is conducted. He insists that doctors, physical therapists and trainers need to take a more wholistic approach to ACL rehab by treating the athlete, not just the knee. He views the rehab process as a biopsychosocial continuum that demands a multifactorial approach to treatment and assessment.

Dingenen argues that, by failing to treat the whole person, we are setting them up for failure. Injured athletes often have psychological barriers to overcome, and are under social pressure to return to play, or to not return, depending on the source. Dingenen advocates criteria-based treatment that is evaluative over the course of recovery. He believes in a team approach to treatment, with the athlete at the center of decision making about treatment and RTP.

Train Smarter and Harder

Treatment that focuses primarily on knee function is deficient, according to Dingenen. He cites many shortcomings of traditional physical therapy for ACL tear, including:

● Rehab typically centers on isolated knee mechanics, yet the knee does not function as an isolated unit, particularly during sports. Sports movement is multidirectional and involves multiple simultaneous tasks, requiring the coordinated movement of multiple body segments.
● Rehab training is internally focused, conscious and relies on visual perception, leading to maladaptive changes in neurosensory processes in the brain. Sports play is externally focused and requires instinctual sensory responses that bypass conscious processing.
● Instructions in motor learning do not transfer to sport, and the rehab environment does not allow for sport-specific training that demands unconscious neuromotor responses in an open environment.
● Patients are underloaded during rehab, and training is geared to satisfying average performance demands that do not prepare athletes for real game situations.
● Decisions about RTP should not be made by one individual, but by a group of stakeholders, including doctors, therapists, trainers and others, with the athlete at the center of decision making.

Defining Success

Dingenen believes that goal-setting is key to optimal recovery from ACL reconstruction. He advocates a sport-specific training protocol that demands gradual increases in workload as recovery progresses. Involving the athlete in the training process and in setting short term goals places responsibility on the athlete to keep moving ahead, providing motivation to satisfy goal criteria and ascend to the next level of recovery.

Communication is Key

Finally, Dingenen emphasizes the importance of open communication among all stakeholders, again with the athlete at the center. The athlete should not be getting mixed messages about what is expected of them, or about their perceived level of readiness to return to play. Taking an athlete-centered team approach to treatment and arriving at consensus about protocol and RTP places the athlete in the optimal position for full recovery and RTP.


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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