End-Phase ACL Rehabilitation & Return to Sport

By Daniel Wadsworth Physiotherapist On Your Game Physiotherapy

What to Expect and Why Ongoing Physiotherapy Matters
 

Recovering from an ACL injury or reconstruction is a big journey, and while the
early stages of rehabilitation often feel very structured, the final phase can feel
less clear. This stage often called end-phase rehab or return-to-sport rehab is
one of the most important parts of your recovery.

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This phase is not just about getting fitter or stronger. It is about making sure your
knee is truly ready for the demands of sport, work, or higher-level activity. At On
Your Game Physiotherapy, we follow evidence-based guidelines such as the
Melbourne ACL Rehabilitation Guide and Aspetar recommendations to help
guide you safely through this stage, with ongoing physiotherapy support every
step of the way.

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Many people feel “good” before their knee is fully ready. Pain may be minimal, daily activities may feel easy, and confidence can start to return. However, research shows that strength differences, movement habits and confidence under pressure often lag behind how the knee feels. Without proper guidance, this is the stage where the risk of re-injury is highest.

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Ongoing physiotherapy during end-phase ACL rehabilitation helps to identify and address these hidden gaps. Your physiotherapist monitors how evenly both legs are working, how well you control your knee during more demanding movements, and how your knee responds to increasing loads. This guidance helps reduce injury risk and supports a safer, more confident return to activity.

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As you move into this phase, rehabilitation begins to look and feel more like real-life activity or sport. Strength training continues, particularly for the thighs, hips and calves, but the focus shifts towards power, the ability to produce force quickly and control it during fast movements. Jumping, hopping and landing exercises are introduced to help your knee learn how to absorb and manage load safely.

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Running is progressed gradually, starting with straight-line running and building towards faster speeds and changes of direction where appropriate. These progressions are carefully guided by your physiotherapist and only advanced when your knee is coping well. This approach ensures progression is based on readiness, not just time since injury or surgery.

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As rehabilitation continues, exercises become more specific to your sport or activity. This may include drills that resemble training or competition situations, helping you feel physically and mentally prepared before returning. Throughout this process, your physiotherapist closely monitors pain, swelling, fatigue and movement quality, making adjustments when needed to avoid setbacks.

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Confidence is a major part of returning to sport after an ACL injury. Many people feel strong in the gym but still worry about their knee when movements become faster or less predictable. This is completely normal. Physiotherapy helps rebuild confidence by gradually increasing challenge, practising realistic movements, and ensuring confidence grows alongside physical ability rather than being rushed.

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Being “cleared” to return to sport does not mean rehabilitation suddenly stops. Returning to training and competition is a gradual transition, and your knee continues to adapt during this time. Ongoing physiotherapy support helps manage increases in training load, maintain strength and movement quality, and reduce the risk of future injury. This stage is important for long-term knee health and performance.


 

A Personal Note from Our Team:
I know firsthand how challenging the final stages of ACL rehabilitation can be. I had my own ACL reconstruction in October 2022, with the goal of returning to regional field hockey. By the time I reached the later stages of rehab, my knee felt strong, but I still questioned whether it was truly ready for the demands of training and competition. On top of that, I experienced ongoing knee pain related to patella tendinopathy, which made it difficult to trust what I was feeling and created doubt about whether continuing with sport was the right decision.
 

What made the biggest difference during this phase was having clear reassurance and guidance from my physiotherapist. Being told that what I was experiencing was common and that pain or flare-ups didn’t automatically mean something was wrong helped take away a lot of the fear. Objective testing was also a key part of the process. Strength testing, movement assessments and regular check-ins helped confirm that my knee was being loaded appropriately and that I wasn’t pushing beyond what it could tolerate at that stage.

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That combination of reassurance, structure and evidence-based testing allowed me to keep progressing without feeling like I had to guess or constantly second-guess myself. It reinforced how important physiotherapy guidance is during the end phase of ACL rehab not just for physical preparation, but for confidence, clarity and peace of mind when returning to sport. This experience shapes how we support our patients because we understand that returning to sport after an ACL injury is not just about the knee, but about trust, confidence and feeling supported throughout the process.
 

Frequently Asked Questions
 

How long does end-phase ACL rehab last?
This varies for each person. Progression is based on how your knee performs rather than a set timeline.
 

Why can’t I return to sport just because my knee feels good?
Your knee may feel good before strength, control and confidence are fully restored. Returning too early increases the risk of re-injury.
 

What testing is involved before returning to sport?
Testing may include strength assessments, jumping or hopping tasks, running and change-of-direction drills, and questionnaires about confidence and readiness.
 

Is it normal to feel nervous about returning to sport?
Yes. This is very common, and physiotherapy helps rebuild confidence through gradual and supported exposure to sport-specific movements.
 

Do I still need physiotherapy once I return to training or sport?
In most cases, yes. Ongoing support helps manage training loads, prevent setbacks and support long-term knee health.

At On Your Game Physiotherapy we believe returning from an ACL injury should feel supported, structured and individualised. By combining evidence-based guidelines with hands-on physiotherapy guidance, we aim to help you return to activity feeling strong, confident and ready — not rushed or unsure.
 

If you are approaching the final stages of ACL rehabilitation or have questions about your readiness to return to sport, our team is here to help.



References

1. Adams D, Logerstedt D, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. Journal of Orthopaedic & Sports Physical Therapy. 2012;42(7):601–614. DOI:10.2519/jospt.2012.3871. JOSPT
2. Aspetar Clinical Practice Guideline on Rehabilitation after ACL Reconstruction (ACLR). Available from Aspetar: https://www.aspetar.com/en/professionals/aspetar-clinical-guidelines/recommendations-on-rehabilitation-after-aclr aspetar.com
Aspetar Clinical Practice Guideline on Rehabilitation after ACL Reconstruction (Download PDF for criteria and return-to-sport recommendations). https://www.aspetar.com/en/professionals/aspetar-clinical-guidelines/download-aspetar-clinical-guideline-aclr aspetar.com
3. Melbourne ACL Rehabilitation Guide (criteria-driven rehabilitation protocol). Available online via Melbourne ACL Rehab Guide resources.
4. 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. doi: 10.1136/bjsports-2016-096031. Epub 2016 May 9. PMID: 27162233; PMCID: PMC4912389.