ACL Series: Return to Confidence (Post Surgery)

Even with the best programming for risk reduction, ACL injuries still happen. And when they do, it is the responsibility of the therapist or performance coach to rebuild the athlete’s confidence as well as their strength.

Quite often, there is a lack of confidence or the physiological factor that contributes to the athlete’s ability to return to sport (Ardern, 2011). According to the research, many ACL injuries stem from factors that involve strength imbalances, inefficient propreoceptive feedback and unsafe use of momentum in deceleration (positioning and movement pattern synchronization). Many times athletes come out of their rehabilitation program still lacking the confidence and fitness to perform up to their pre-injury level. But this is avoidable… Below is a chart of one athlete’s testing as she returned to train with her team after an ACL surgery (taken from the SoccerFIT Game Speed Level 1 Test). Her tests are compared to the best scores in her age group as well as the average scores in her age group within each category.

A recent study on the return to activity rate shows that although sixty-seven percent of patients attempted some form of sports activity, by 12 months postoperatively only 33% returned to competitive sport (Ardern 2011). These numbers might lead one to believe that there is something missing in the rehabilitative process. The authors of this study suggest, “The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes.”

The Return to Confidence Protocol is a relatively new program we have designed to parallel to the patient/client’s physical therapy program in order to address the fitness and athletic confidence factors that are currently lacking in most physical therapy programs. To achieve this goal, this protocol will focus on several critical areas:

  • Movement Efficiency (Confidence and Coordination)
  • Strength and Power (Acceleration & Deceleration – Jumping & Landing)
  • Reactivity (Elastic Plyometric Programming & Agility Foundations)
  • Fitness (Repeatable Bouts of Intense Work)

The program is designed to address these factors from both a rehabilitative, and a risk reduction stand point, making it an ideal program for Physical Therapists, Coaches and Practitioners in the sport and fitness realm. From a reduction of risk standpoint, a recent study points out another key aspect in regards to retention that mirror what we have seen over the last 12 years. Results suggest that training duration may be an important factor to consider when designing injury prevention programs that facilitate long-term changes in movement control (Padua, 2011). Training duration is referring to the athletes dedication to an ongoing program… There are no “quick fixes,” instead we are looking for a lasting result.

In this study, one group participated in a “prevention” program for 3 months, while another group carried out the program as a warm up for 9 months. While the 3 month group improved throughout the study, only the 9 month group was able to retain these effects 3 months after they stopped using the warm ups. My point is simple… Programs designed to reduce the risk of injury should not be viewed as short-term preventive programs. Instead they should be carried out for much longer periods, integrated into on going training sessions, and progressed over time. This is the only way these programs work. And even though in this text we progress through a phase based time line, these exercises, drills and movement patterns take time to develop and should be thought of as an essential part of year round athletic development programs.

The program is broken up into several phases that parallel the suggested introduction of new exercises and intensities based on 20 different ACL rehabilitation protocols we have received from physicians. These phases will generally run in 4 week blocks, but will require the patient / client to reach some level of aptitude before moving on to the next phase. It will also be assumed that the patient / client has no pain or medical limitation that would effect their ability to perform each exercise or activity within a particular phase of the program. These limitations could include, but not be limited to meniscus repairs, swelling, range of motion, infections, other injuries (ankle, hip, back), etc.

Phases of the Return to Confidence Protocol:

Phase 1: Weeks 1 thru 4 – Done at PT location only

  • Return to weight bearing activity
  • Reduction of swelling
  • Improve quad control, ankle strengthening
  • Balance

Phase 2: Weeks 4 thru 8

  • Introduce conditioning protocol on the Cybex Arc Trainer
  • Closed chain strengthening activities
  • Athletic balance and positioning drills (lunge progression video shown below)
  • Strength training for non-involved side, core and upper body

Phase 3: Weeks 9-12

  • Begin lateral movement work (controlled pace) – walking agility program
  • Progress intensity on Cybex Arc Trainer interval program – A1 Mode (Controlled Watts)
  • Progress intensity on strength training – Increase Load / Dynamic Movement / Circuits / Complexes
  • Begin Plyo “Preparatory” Program (Jump/Landing and Box Step Up)
  • 5 minute Block Circuits (alternate Cybex Arc with DB total body strength activity)

Phase 4: Weeks 13 thru 18

  • Strength/power endurance – Progress 5 minute Block Circuits (PowerFIT Program)
  • Low level plyos with a focus on elasticity (reducing GCT)
  • Leg Press Drop Sets / Jump Squats or Cybex Arc Sprints Combination
  • Intensify resisted cardio on Cybex Arc Progression of speed/agility, speed drills (form and confidence)

Although this program is set up in 4 week blocks, we sometimes have to hold an athlete back for a few weeks until they master the form, show adequate strength or demonstrate confidence in each exercise in that block. This is a general progression that focuses on the entire body. Instead of spending 12-16 weeks in a rehabilitative program which only focuses on the involved limb, we take the approach of conditioning and strengthening the entire body so that when the athlete returns to activity, they are stronger (and possibly fitter) than they were prior to the injury.

In our final post tomorrow, we will highlight several case studies of players who participated in our Return to Confidence Program. Here is a sneak peak at one of the soccer players Game Speed Profile.


  1. Hi Scott
    Timely article. Yesterday I had Arthroscopic surgery on my knee to repair some meniscus tears. 6 years ago I had ACL replacement surgery on the same knee. It that time I was back training with a brace after 4 months. My physio really pushed me through rehab.
    The meniscus damage was from wear and tear over the last couple of years. During that time I had really cut back on the strength conditioning I was doing on that knee. Could I use your above protocol to get back to where I should be?

    1. You could certainly use aspects of this protocol to get back, but with a meniscus tear, you will want to consult your PT as there are some modifications that you will want to be aware of regarding impact. I still would check out the Cybex Arc Trainer and use it as soon as possible to begin building a base of strength and conditioning in a low impact environment. After that, let me know how things are going and I can send you some specifics.

  2. Should I do different agility training drills rather than L Drill (Cones) which involve hard cutting? Should I avoid hard cutting even 9 months post op? What drills should I do?

    1. First off, you should always do “different” agility drills. If possible, try to vary your patterns and distances along with your pace and transition speed. Use reactive drills where you are reacting to slow moving players, and then progress to quicker, more dynamic movements. Also, our ACL Rehab athletes are cutting hard in games at 9 months, but it depends on your rehab specifics and your training that has led up to this point. Heck, Adrian Peterson is leading the league in rushing and he’s about 10 months out.

      Start HERE (short post on form of deceleration) and then if you feel weak on the inside leg, use our Training Ideas and Discussions Tab (on the top of this page) to search for plyo and strengthening activities. This should give you some background on our strength programs. After that, look into our agility progressions, starting with quick feet cone drills, crossover patterns, shuffle to shuffle and shuffle to run progressions, triangle cutting, diamond patterns drills, simple reaction drills, complex reaction drills with defensive footwork (diagonal backward crossovers), and transition to integrated ball skills. We cover a lot of this in blog posts or you can find it in our books. If you have a specific question, please reply and I will do my best to point you in the right direction.

  3. My 14-year-old daughter had acl repair surgery on April 5. She had a meniscus tear as well, so it put us a little behind rehab-wise. We were able to track down a Cybex Arc Trainer but we aren’t sure of the amount of time, incline, etc, she should working at. She has been using the machine for about 15 minutes for the past five weeks.

    1. We usually start at about 4-6 weeks post-op with some light cruising (100-120 Strides per Minute) with a resistance between 25 and 35 depending on her comfort level. We will keep the work intervals short (1-3 minutes) with 1 minute rest between sets. During rest, stay on the machine, but move extremely slow (walking pace). We will use the rest time to let her evaluate the knee, fatigue, pain or discomfort, etc. The patient usually will report that there is no pain or discomfort, but they are feeling fatigue in the quads, glutes and hamstrings. We want to watch the fatigue level as well as any discomfort. Too much fatigue can lead to poor mechanics and eventually be counterproductive on a number of levels.

      Over the first few sessions we are simply trying to build a comfort and confidence with the movement, assess our tolerance and fitness, adjust the settings to comfortable, sustainable levels, and slowly start to increase resistance, time and speed. Typical sessions last between 20-30 minutes and progress from 1 minute on 1 minute off x 12, to 3 minutes on 1 minute off x 7, to 9 minutes on 1 minute off x 3.

      Please check with your physical therapist before starting this program, as there are so many factors that come into play when recovering from this type of injury. There is no exact protocol for when a patient should elevate their program, instead it is all based on their progress, strength increases, range of motion, type of surgery, etc. If you email me, I can send you a document we are working on that outlines this in more detail.

Leave a Reply