When a young athlete tears their ACL, families often assume that physiotherapy alone covers the entire rehabilitation process. In reality, ACL recovery has two distinct phases: medical healing and performance restoration. These require different expertise.
Physiotherapists are essential for medical healing which is also termed early stage rehab but research consistently shows that many athletes return to sport underprepared from a strength, power, and movement standpoint — which is a major (if not THE major) reason why reinjury rates remain high in youth athletes.
The Role of a Physiotherapist
Physiotherapists (Physical Therapists if you are in the USA) are regulated healthcare professionals whose primary responsibility is medical healing/rehabilitation.
Their core role includes:
• Protecting the surgical graft
• Managing swelling and pain
• Restoring range of motion
• Early-stage muscle activation
• Monitoring tissue healing timelines
Physiotherapy is critical during early-stage ACL recovery. However, in many clinical environments — especially busy clinics — sessions may involve multiple patients being treated simultaneously. This model often limits the time available for progressive strength development, objective performance testing, and sport-specific preparation. Plus many clinics does not have the space or equipment to effectively recondition an athlete.
The Role of a Kinesiologist / Strength Specialist
A kinesiologist and strength & conditioning specialist focuses on restoring the athlete’s physical capacity for sport.
This includes:
• Progressive strength development
• Force production and absorption training
• Jumping and landing mechanics
• Change-of-direction training
• Objective return-to-sport testing
Research shows that deficits in strength, power, and neuromuscular control — not pain or range of motion — are the strongest predictors of ACL reinjury risk.
Why Physiotherapy Alone Is Often Not Enough
Studies show that up to 30% of young athletes re-tear their ACL after returning to sport. One of the primary reasons is inadequate physical preparation before return to play.
Also, medical clearance does not mean an athlete is ready for the demands of sport. Without comprehensive performance rehabilitation, athletes may still have significant strength asymmetries and poor movement mechanics.
Differences in Training Expertise and Scope of Practice
It is also important for parents to understand that physiotherapy education is primarily focused on injury management, pathology, and restoring basic physical function — not on long-term athletic performance development. This is completely different expertise. While many physiotherapists have excellent clinical skills, their formal training typically includes limited depth in advanced strength training principles, periodization, high-load resistance training, plyometrics, and sport-specific performance preparation.
In contrast, kinesiologists and strength & conditioning specialists are specifically trained in exercise physiology, biomechanics, load progression, neuromuscular adaptation, and athletic development. Their expertise centers on how to safely build maximal strength, power, speed, and resilience — which are critical components of ACL rehabilitation and injury prevention.
This difference does not mean one profession is more important than the other. Rather, it reflects two complementary scopes of practice: physiotherapists focus on making the knee medically healthy, while strength and conditioning professionals focus on preparing the athlete to tolerate the real forces and demands of sport.
Red Flags Parents Should Watch For in ACL Rehabilitation
As a parent, you don’t need to be an expert to recognize whether rehabilitation is comprehensive. There are several warning signs that an athlete may not be receiving adequate preparation for safe return to sport.
Red flags include:
• Rehab sessions that primarily involve basic exercises (bands, light weights, simple balance drills) 3+ months after surgery
• Little or no measurable strength testing between limbs
• No objective return‑to‑sport criteria being used
• Progression to running, jumping, or cutting without clear strength benchmarks (This is Coach Bott’s biggest one)
• Lack of structured strength training with progressively increasing loads or too much variety of strength work with no intensity
• Minimal coaching on landing mechanics or deceleration technique
• The athlete being treated in a high‑volume setting with limited one‑on‑one supervision - all exercises must be coached and supervised
• Clearance for sport based mainly on time since surgery rather than performance testing
Comprehensive ACL rehabilitation should always include objective testing, progressive overload in strength training, and careful preparation for the forces of sport. If these elements are missing, the risk of reinjury increases significantly.
Research Evidence
Ardern et al. (2011) – Only 65% of athletes return to preinjury sport levels after ACL reconstruction.
Kyritsis et al. (2016) – Athletes who failed strength and functional criteria were 4 times more likely to reinjure their ACL.
Grindem et al. (2016) – Each month delayed return to sport until after 9 months reduced reinjury risk by 51%.
Welling et al. (2018) – Many athletes return to sport with significant strength asymmetries.
Webster & Feller (2019) – Inadequate neuromuscular preparation is a key factor in second ACL injuries.
For more help with ACL return to play click here to learn about Carmen's course on ACL rehab from A-Z
