When is it safe to return to sports after ACL reconstruction?

It is that time of the year with Fall sports back in full swing and basketball around the corner that I see an increase in ACL injuries. Unfortunately, far too many youth athletes are suffering these injuries, and in some cases multiple times.

Increasingly, the rate of re-injury has become a significant concern for athletes seeking to resume their prior activity level after an ACL surgery. One paper published in the American Journal of Sports Medicine in 2016 concluded athletes younger than 25 years who return to sport have a secondary ACL injury rate of 23% (1).

Additionally, Webster et al. looked at a group of 354 patients who were all under age 20 when they had their first ACL reconstruction using a hamstring tendon autograft procedure. Their study found that graft ruptures occurred in 57 patients (18%) at an average time of 1.8 years after surgery, and almost half (47%) occurred within the first postoperative year, while 74% occurred within the first 2 years following surgery (2).

Simply put, re-injury rates are too high. This begs the question of what do we do about it. Following surgery, it is absolutely critical that patients go through a comprehensive rehab program that is evidence-based and clinically informed, meaning that the clinician not only uses sound research principles to guide decision making, but more importantly implements treatment progressions on each patient individually based on his/her status and healing response. Pushing athletes too fast or too slow during therapy can delay optimal healing and recovery.

With that said, this desire to return to play as fast as possible can lead to problems. Often, patients hear that their child may be able to resume activity at 6 months post-op, but they fail to realize the body is still healing and their child needs time to ease back into higher level movement patterns safely. No two rehabs are alike, and some progress faster or slower based on the procedure, as well as other damage that may occur. In some cases, fear of re-injury (kinesiophobia) may even hamper physical progress. Other limitations may include prolonged swelling, pain, tendinitis, weakness or poor movement/landing form.

The type of sport may also dictate the rehab progression and estimated return to play timeline. For example, level I sports such as soccer, basketball and volleyball involve a lot more jumping, cutting and pivoting than baseball, softball or track. The higher the demand in such activities, the higher risk of neural fatigue and possible re-injury.

One recent paper by Grindem et al. published in the British Journal of Sports Medicine concluded that returning to level I sports after ACL reconstruction leads to a more than 4-fold increase in re-injury rates over 2 years. The paper revealed return to sport (RTS) 9 months or later after surgery and more symmetrical quadriceps strength prior to return substantially reduced the re-injury rate by 51% for each month RTS was delayed until 9 months after surgery (3).

So, how do you really know when the time is right to go back? Essentially, it is a multi-factorial decision making process that involves ongoing assessment of physical and emotional readiness, functional testing to determine strength, power, and movement capacity, and consultation with the MD, athlete and parents. Understanding potential re-injury risk as well as looking at any prior injury history is also important in order to make the best decision possible for the athlete. In the end, following a sound individualized rehab plan and performing appropriate post-rehab training to prepare for the demands of one’s sport is paramount to optimize recovery and prevent re-injury.


  1. Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul;44(7):1861-76.
  2. Webster KE, Feller JA.Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016 Nov;44(11):2827-2832.
  3. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8.

About Brian Schiff, PT, OCS, CSCS: 

Brian Schiff graduated from Ohio State University in 1996 with a Bachelor’s of Science degree in Allied Health Professions, Physical Therapy. He became a Certified Strength & Conditioning Specialist (CSCS) through the National Strength & Conditioning Association in 1998. From 2002-2006, Brian served as the Strength & Conditioning coach for the Columbus Crew Major League Soccer Team. Brian is an APTA board certified Orthopaedic Clinical Specialist (OCS) and also certified in Functional Movement Taping (FMT) and the Functional Movement Screen (FMS). In 2014, he became credentialed to perform Dry Needling.

Brian has worked as the supervisor and Sports Physical Therapist for EXOS @ Raleigh Orthopaedic since 2010. He specializes in treating orthopaedic and sports medicine cases and has a special interest in rehabbing baseball injuries and ACL prevention/rehab. Brian has worked with athletes in NFL, NBA, MLB, NHL, MLS, USTA, US Rugby as well as numerous Division 1 Collegiate athletes. He currently serves as a PT consultant for the Carolina Hurricanes. Brian is also a faculty member for Allied Health Education and presents continuing education webinars and live seminars for PT’s, ATC’s and fitness professionals.