ACL Prehab: The Secret Weapon for Faster, Stronger Recovery

Undergoing ACL surgery can feel overwhelming, but did you know that preparing your body beforehand can help to improve your recovery?

Research-backed prehabilitation, or "pre-hab," can lead to better post-surgery outcomes, including a higher return-to-sport rate and improved knee function.

In this blog, we'll explore

• What is prehab
• How can you optimize your body for surgery
• How to Monitor Progress

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What is Prehabilitation?

Prehabilitation, or "pre-hab," is a structured program designed to prepare your knee for surgery. 

Guided by a physiotherapist, it typically includes targeted range-of-motion and strengthening exercises for the muscles supporting the knee joint.

Why is Pre-Hab Important?

Studies show that if you achieve full range of motion, strong quadriceps and hamstrings, and minimal swelling before surgery experience better recovery outcomes in post-operative return of strength and potentially a faster return to sport! (Cunha and Solomon, 2022, 

In contrast, research shows rushing into surgery with restricted movement and swelling might increase the risk of post-surgery stiffness and muscle inhibition (Giesche et al., 2020)

Pre-hab ensures you go into surgery in the best possible condition, leading to a smoother recovery 

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Goals of Prehabilitation

Pre-hab is divided into two key stages:

1. Recovery from injury – Reducing swelling and regaining full knee range of motion.
2. Readiness for surgery – Strengthening key muscle groups to enhance post-surgery recovery.

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Stage 1: Recovery from Injury

Managing Swelling

Swelling is common after an ACL injury, but controlling it early is crucial. Here’s how:

• Regular icing to reduce inflammation
• Compression with wraps or tubigrip 
• Elevation when resting
• Gentle range-of-motion exercises to reduce swelling and build movement

Physiotherapy input early is key to getting your swelling under control as the first step, make sure to discuss this with your therapist.

Restoring Full Range of Motion

After an ACL injury, knee movement is often restricted due to pain and swelling. The goal here is to regain the following:

• Full knee extension (fully straight or equal to the other knee)
• Knee flexion of at least 125+ degrees

Techniques to improve motion include:

• Gentle range-of-motion exercises
• Passive and assisted stretching
• Cycling (as tolerated) to promote flexibility

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Stage 2: Readiness for Surgery

Once swelling and mobility improve, it's time to build some strength back into the muscles surrounding the knee. This phase often overlaps with the recovery phase as pain decreases.

Strengthening Key Muscles

The focus is on progressive strengthening of:

• Quadriceps & Hamstrings (directly support the knee)
• Calves, Glutes, Adductors (indirectly contribute to knee stability)

Your physiotherapist will tailor your program based on factors like pain levels, previous strength training experience, and functional limitations.

Sample Pre-Hab Exercises

Compound Movements (Multi-joint exercises)

• Squats & Front Squats
• Deadlifts & Romanian Deadlifts
• Step-Ups & Single-Leg Squats
• Hip Thrusts

Isolated Muscle Exercises

• Knee Extension Machine
• Hamstring Curl Machine
• Nordic Hamstring Curls
• Calf Raises

Monitoring Your Progress

Tracking strength gains is crucial to ensure continuing improvement. 

At Beyond, we use VALD Dynamometer and ForceDecks to precisely measure muscle strength and compare both legs. 

Our goal is to achieve at least 90% strength symmetry, particularly in the quadriceps and hamstrings, before your surgery.

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Food for thought: Surgery might not be your only option

The decision to undergo surgery should not be taken lightly! In fact, there might be other options that you should consider and research. Lets take a look… 

ACLs Can Heal! 

It was long thought that ACLs couldn’t heal. However, that view might be changing. There is some emerging evidence that shows some ACLs might heal themselves (Filbay et al., 2023a). 

Cross-Bracing Protocol 

As a result of this new research, the cross-bracing protocol was developed. This is a novel way of treating ACLs without surgery and just using braces to limit the movement of the knee. The initial research was promising with 90% of the ACLs in the study showing some healing at 3 months on an MRI. (Filbay et al., 2023b). For this to work it must be done in the first 4-10 days after injury. 

Exercise vs Surgery 

There has also been some research into comparing those who have ACL reconstruction surgery and those who don’t. The general consensus is that in the long term (years after injury) there is little difference between those who had the ACL reconstruction and those who managed without surgery for strength function and complications (Papaleontiou et al., 2024).

BIG Caveat! 

All these options should be on a case-by-case basis. Some people will do better with surgery and some people will do better without. 

Chat about your options with your surgeon AND your physiotherapist before making a decision!

Key Takeaways

Prehabilitation plays a crucial role in optimizing your ACL surgery and recovery. By reducing swelling, restoring full range of motion, and progressively strengthening key muscle groups, you can dramatically improve post-surgery outcomes.

Take Action

• Book an appointment with us at Beyond to create your personalized pre-hab plan
• Chat to your Physio and Surgeon about your options for managemebnt
• Prioritize swelling reduction, mobility restoration, and strength training
• Track your progress with Strength Testing
• Follow Beyond Physio on Social media for more information on ACL rehabilitation

By dedicating time to prehabilitation, you set yourself up for a smoother recovery and a faster return to the activities you love!

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References 

Cunha, J. and Solomon, D.J., 2022. ACL prehabilitation improves postoperative strength and motion and return to sport in athletes. Arthroscopy, Sports Medicine, and Rehabilitation, 4(1), pp.e65-e69. Available at: https://doi.org/10.1016/j.asmr.2021.11.001 [Accessed 24 February 2025].

Filbay, S.R., Roemer, F.W., Lohmander, L.S., Turkiewicz, A., Roos, E.M., Frobell, R. and Englund, M. (2023a) 'Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial', British Journal of Sports Medicine, [Online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9872245/

Filbay, S.R., Dowsett, M., Jomaa, M.C., Rooney, J., Sabharwal, R., Lucas, P., Van Den Heever, A., Kazaglis, J., Merlino, J., Moran, M., Allwright, M., Kuah, D.E.K., Durie, R., Roger, G., Cross, M. and Cross, T. (2023b) 'Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol', British Journal of Sports Medicine, [Online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10715498/

Giesche, F., Niederer, D., Banzer, W. and Vogt, L., 2020. Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport-related and self-reported knee function: A systematic review. PLOS ONE, 15(10), p.e0240192. Available at: https://doi.org/10.1371/journal.pone.0240192

Papaleontiou, A., Poupard, A.M., Mahajan, U.D. and Tsantanis, P. (2024) 'Conservative vs surgical treatment of anterior cruciate ligament rupture: a systematic review', Cureus, 16(3), e56532. doi: 10.7759/cureus.56532.