Where ACL Rehab Really Breaks Down — And How PTs & Strength Coaches Can Work Together to Fix It

By Mark Jamantoc, PT, OCS, FDM-IC — Praxis Physical Therapy, Bellingham WA

Returning to sport after an ACL injury is one of the most challenging journeys an athlete will face. Even after surgery, months of rehab, and “clearance” to start training, many athletes still struggle during the transition back to team practices, performance training, and full-speed play.

At Praxis Physical Therapy, we work with athletes from high school to college and adult sport, and I see the same issue over and over: Athletes are often “cleared,” but not actually READY.

This blog breaks down the biggest gaps we see in late-stage ACL recovery, what strength coaches should know to support their athletes safely, and how physical therapists and coaches can work together—within their scopes—to set athletes up for long-term success.

1. The Biggest Gaps When ACL Athletes Return to Team Training

1. They’re cleared based on time—not on objective data

A surgeon may say, “You’re good to return”—but the athlete may still have:

• Significant quad strength deficits

• Poor force absorption on the surgical leg

• Asymmetrical landings or cutting patterns

• Subtle compensations that show up only under speed or fatigue

At Praxis, we routinely test athletes using VALD ForceDecks and dynamometry. Many still have measurable deficits at 6–12 months, even when they “feel” fine.

Research shows:

• Returning based only on time increases re-injury risk up to 4x.

• Quadriceps strength symmetry <90% is a major risk factor for a second ACL tear.

• Rate of force development deficits can last up to two years after surgery.

In other words: medical clearance does not equal performance readiness.

2. Landing and cutting mechanics aren’t monitored closely enough

This is one of the biggest performance gaps.

Many athletes returning to practice still show:

• Extensor strategy landings (stiff, quad-dominant, knee extended too early)

• Hip-dominant loading to avoid using the knee

• Medial knee collapse, especially under fatigue

• Offloading the surgical leg during deceleration or change-of-direction

These patterns are not always obvious unless you know what to look for or have access to force plate asymmetry data.

And they matter—because abnormal landing mechanics are strongly linked to re-injury risk.

3. Quad strength progressions plateau once athletes leave PT

Many athletes stop pushing heavy quad bias, single-leg loading, and tempo/eccentric work once they switch from rehabilitation to team training.

But the late stage of ACL rehab depends heavily on:

• High-load quad strength

• Deceleration control

• Single-leg force absorption

• Acceleration mechanics

• Plyometrics, agility, and chaos-based movement

Without structured progression—especially in the weight room—athletes lose momentum or develop compensations.

2. What Strength Coaches Should Know About ACL Rehab (Within Their Scope)

Strength coaches play a MASSIVE role in the final stage of ACL recovery. You don’t need to treat the graft or diagnose impairments—but there are key things that help you support the athlete safely and effectively.

A. Graft Type Influences Movement Strategy

Knowing the graft type helps coaches understand common compensation patterns.

Quad Tendon (QT)

• Slower quad recovery

• Athletes may struggle with deeper knee angles under load

Hamstring Graft (HS)

• Weakness in posterior chain, especially eccentrically

• Difficulty producing stiffness during deceleration

Patellar Tendon (BTB)

• More anterior knee pain

• Athletes may avoid terminal knee extension or deep flexion

Coaches don’t treat these issues—they simply adjust training loads and watch for strategy changes.

B. Compensations Strength Coaches Should Recognize

These are movement-quality cues, not medical diagnoses.

1. Extensor strategy

Stiff landings, early knee extension, trunk forward.→ Higher reinjury risk.

2. Lateral weight shift

Athlete avoids loading the surgical leg during bilateral lifts or landings.→ Very common even 1 year post-op.

3. Hip-only strategy

Knee stays stiff; hips do most of the work.→ Shows up in split squats, lunges, squats, and deceleration.

If coaches recognize these patterns early, collaboration becomes seamless.

C. The Three Most Important ACL RTP Metrics Coaches Should Know

This stays fully within strength & conditioning scope but is extremely powerful:

1. Strength Symmetry (>90% Quad LSI)

A major benchmark for reinjury risk.

2. Force Absorption & Propulsion Symmetry (>90%)

Measured by VALD ForceDecks or similar systems.

3. Movement Quality

• No valgus collapse

• Symmetrical landing strategy

• Good trunk control

• Efficient deceleration mechanics

These three categories—strength, force, and movement—define an athlete’s readiness far more than time since surgery.

3. How PTs and Strength Coaches Can Work Together (Without Blurring Scope)

PTs Handle:

• Diagnosis

• Medical restrictions

• Tissue healing timelines

• Objective testing

• Identifying impairments or red flags

• Clearance for progression

Strength Coaches Handle:

• Strength, speed & power development

• Agility & plyometrics

• Conditioning and workload

• Quality of movement during load

• Progression to sport speed and chaos

Best Practices for Collaboration

1. Use shared language

Examples:

• “Hip-dominant landing strategy”

• “Reduced surgical side impulse”

• “Limited single-leg deceleration tolerance”

2. Use objective data

Return to play scores help coaches know when to push and when to hold.

3. Respect scope boundaries

If coaches see:

• Swelling

• Instability

• Giving-way

• Sharp or increasing pain

→ The athlete needs to return to PT.

4. Joint progression planning

PT builds capacity → Coach builds athletic expression of that capacity.

This team-based model significantly improves outcomes and lowers reinjury rates.

Bottom Line

ACL rehab isn’t just about healing—it’s about restoring the speed, power, confidence, and movement quality needed for the chaos of sport.

By combining objective testing, movement coaching, and structured progression, PTs and strength coaches can work together to build stronger, safer, more resilient athletes.

At Praxis Physical Therapy, this integrated approach is at the core of how we help athletes return—not just to play, but to compete at their highest level.

References

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;44(7):1861–1876. doi:10.1177/0363546515621554

2. Pietrosimone B, Lepley AS, Harkey MS, et al. Quadriceps Strength Predicts Self-reported Function After ACL Reconstruction. J Orthop Sports Phys Ther. 2020;50(3):120–127. doi:10.2519/jospt.2020.8969

3. Buckthorpe M, Della Villa F. Optimising the “Mid-Stage” Training and Testing Process After ACL Reconstruction. Br J Sports Med. 2019;53(7):345–352. doi:10.1136/bjsports-2018-099397

4. Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical Measures During Landing and Postural Stability Predict Second ACL Injury After Reconstruction and Return to Sport. Am J Sports Med. 2010;38(10):1968–1978. doi:10.1177/0363546510376053

5. Di Stasi S, Hartigan E, Snyder-Mackler L. Sex Differences in Knee Flexion Angle During Gait After ACL Reconstruction. Med Sci Sports Exerc. 2013;45(3):523–529. doi:10.1249/MSS.0b013e3182752d47

6. Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing Quadriceps Strength After ACL Reconstruction. J Athl Train. 2008;43(2):118–124. doi:10.4085/1062-6050-43.2.118

7. Schmitt LC, Paterno MV, Hewett TE. The Impact of Quadriceps Femoris Strength Asymmetry on Functional Performance at Return to Sport Following ACL Reconstruction. Med Sci Sports Exerc. 2015;47(5):1007–1016. doi:10.1249/MSS.0000000000000503

8. Hughes JD, Watkins CJ, Owen PJ, Dewar DC. Quadriceps Tendon Autograft for Primary ACL Reconstruction: A Systematic Review. Arthroscopy. 2020;36(2):594–612. doi:10.1016/j.arthro.2019.07.022

9. Bourke HE, Salmon LJ, Waller A, Patterson V, Pinczewski LA. Survival of the Hamstring Tendon Autograft ACL Reconstruction: A Comparison of Hamstring vs Patellar Tendon Autografts. Knee Surg Sports Traumatol Arthrosc. 2012;20(5):896–902. doi:10.1007/s00167-011-1669-4

10. Benner RW, Shelbourne KD, Freeman H, Gray T. Knee Pain and Kneeling Ability After ACL Reconstruction Using a Bone–Patellar Tendon–Bone Autograft. Knee. 2017;24(4):776–781. doi:10.1016/j.knee.2017.03.006

11. King E, Richter C, Daniels KAJ, et al. Biomechanical Measures During Single-Leg Drop Jump Predict Lower Limb Injury Risk After ACL Reconstruction. Orthop J Sports Med. 2020;8(2):2325967120904143. doi:10.1177/2325967120904143

12. 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;50(13):804–808. doi:10.1136/bjsports-2016-096031