5 Exercises for ACL Rehab (Correct & Prevent Tears)

What Causes and How to Prevent an ACL Tear

By Coach E

5 Exercises for ACL Rehab (Correct & Prevent Tears)

We will cover the whys and hows of exercises for ACL rehab and what to do about it. These exercises can prevent ACL tears from happening. Plus, if you already have a tear, it’ll help prepare you for surgery, and protect your surgical repair.

If you want to follow along with the video, click here.

Contrary to popular belief, most ACL tears aren’t the result of one wrong move or a traumatic event. It’s a very common injury in the sports world. This leads most people to think that they blow their ACL via trauma, like a tackle, car accident, falling off a ladder, you name it.

In reality, only about 30 percent of ACL tears come from trauma. The other 70% happens as a result of wear and tear.

When you move, repetitive stress on the anterior cruciate ligament creates micro-injuries. It could show as knee pain but could also be asymptomatic. Then, you have one event, say you land awkwardly from a layup playing basketball, you’re slowing down to change direction, plant your foot and push off. Your knee hurts, and you’ve blown your ACL.

That could be tennis, soccer, skiing, walking the dog when it sees a squirrel, or just about anything.

Those are actually non-contact wear and tear injuries. So why do these non-contact ACL injuries happen?

Common Causes and Surgery

Well, there are a bunch of risk factors. A quick Google search will bring up thousands of different reasons.

The most common seems to be an imbalance of muscle strength between your quadriceps and your hamstrings. It also seems to be more common in women, thought to be due to the shape of the female pelvis, the Q angle (which is how the kneecap aligns), hormones, and movement patterns.

We can’t control a lot of that. Not much one can do about the shape of their pelvis. But we can control the dynamic movements and the way that you stress your knee.

We will cover exercises down the page, but first, let’s address surgery because you won’t know whether you need surgery or not until you’ve done the exercises we’re reviewing today.

Dr. B says:

“I’ve had patients who fall into one of three categories. One group can do anything with or without their ACL, and this includes high level sport. It has to do with the shape of their bones and their movement mechanics. They feel fine.

I have another group of patients who feel great for everyday life, any type of linear movements like walking around, cleaning the house, or doing their job, but as soon as they try to do any kind of cutting and pivoting sport, they have that feeling of instability.

Then, the third group of people has difficulty doing their regular activities of daily living and any sport.

It’s important that you avoid the episodes of instability.

What we’re trying to prevent by having surgery is your knee wearing out and becoming arthritic. If you lose your ACL and you have symptomatic instability, you’re likely going to tear a meniscus and wear away the articular cartilage, which causes arthritis.”

So let’s avoid those episodes of instability. It’s not fun if your knee hurts and is swollen.

We can do that through exercises to improve the dynamic stability of the leg. But it’s also important to assess what type of activities you are doing in your life. If you’re cutting and pivoting, that puts you at a greater risk.

acl injuries soccer

If you have symptoms of a torn ACL (knee pain, swelling, unable to bear weight,) seeking a professional medical opinion is always a good option, and we encourage you to do so.

Take some time away from activities that will stress your knee. Do the exercises, see if you still have instability with linear movements, and slowly work your way back up.

If you’re only (or mostly) involved with linear activities, you do the exercises, and you still feel unstable, it may be time for surgery. If you do the exercises and feel fine, then carry on with life.

Let’s get into those exercises to prevent, prepare, and protect against an ACL tear.

Exercises for ACL Rehab & Protection

We’ve organized our approach into five areas of focus.

The first is the feet and the ankles. The ankles are your body’s first interaction with the ground when you move. If they’re not working well, that poses a problem because whatever dysfunction is there will travel up the kinetic chain.

The knees will take the brunt of the ankle’s dysfunction.

First, we need an active arch. That’s your ability to create your own arch in your foot, not the arches that fancy footwear forces you into. That means those muscles on the bottom of your foot, called the intrinsics, are working well.

We’ve got a concept called metatarsal pressure that we teach in many of our exercises and course. One of our favorites is the 4-Way MTP Slide.

Exercise 1: 4-Way Metatarsal Pressure (MTP) Slide

The 4-Way MTP Slide also trains all of the ranges of motion in your ankle. That covers:

  • Dorsiflexion – pulling your toes toward your knee
  • Plantarflexion – pushing your toes away from your knee
  • Inversion – the bottom of the foot points inside
  • Eversion – the bottom of your foot points outside

Metatarsal pressure means that you are able to put pressure through the bones just below each of the toes throughout different ranges of motion. Keep your foot flat on the floor throughout this exercise. Go slow.

4 way metatarsal pressure slide - acl tear rehab

  1. Sit on something with your foot flat on the floor
  2. Slide your foot forward
  3. Slide your foot backward
  4. Return to center
  5. Slide your foot out
  6. Slide your foot in
  7. Keep the metatarsal pressure throughout each movement!

That’s one cycle – alternate sides. Do at least 3 cycles on each ankle.

If your ankles feel stiff during this exercise, consider testing your ankle dorsiflexion mobility.

Exercise 2: Quadriceps Strengthening Exercises

The next area of focus is terminal knee extension. It’s controlled by activating the quadriceps.

Now to have a good range of motion and extension here, your quads need good tissue pliability and good VMO activation. Your patella also needs to be able to move.

This is a 4-part quad strengthening exercise, and you can get all of the details here.

Exercise 3: Stability Ball Leg Curl

The hamstrings are very important for healthy knees, especially with respect to an ACL. Here’s why. The hamstrings run from the top of your femur to the top of your tibia on the backside. The ACL runs from the back of the bottom part of the femur to the front of your tibia.

Both structures prevent the tibia from shifting forward, which is one mechanism of ACL injury. If the hamstrings aren’t working well, then all those forces they should absorb get transferred to the next structure, the ACL.

That’s why we need good hamstring activation. The other important factors with respect to the hamstrings are good eccentric control. (That’s lengthening of the hamstrings while they’re active.) For example, when you kick your leg forward while running, you need the hamstrings active at terminal knee extension.

There are two versions of this exercise. We’ll start with the easier one.

sb leg curl easy - exercise for acl rehab and hamstrings

  1. Lay on the ground
  2. Put the back of your heels on top of the stability ball, feet pointing straight up
  3. Lift your hips off the ground
  4. Bring your heels as close to your butt as possible
  5. Slowly return to the starting position

Try to activate those hamstrings by pushing the heels into the ball for better activation. Keep your ankles nice and relaxed.

The harder version involves a little more hip extension force. Again, the feet point straight up on the ball. Don’t let them flop out!

sb leg curl hard

  1. Lay on the ground
  2. Put the back of your heels on top of the stability ball, feet pointing straight up
  3. Lift your hips off the ground
  4. Bring your heels as close to your butt as possible, without bending at the hips
  5. Slowly return to the starting position

Drive your hips up as you bring your heels into your butt this time. So you’re maintaining extended hips throughout. Don’t flex or bend at all. Slowly return to the start position to work the eccentric action of the hamstrings.

Perform 3 reps, then lower down. If you have to lower down to adjust your feet, no problem.

Exercise 4: Supine Hip IR Level 1 ERE

Hip rotation is the fourth area of focus in taking care of your ACL.

Hip rotation is such a neglected range of motion for us humans who sit on our bums too much, especially internal hip rotation.

It’s really important to have good hip internal rotation. If you’re an athlete and you’re running and pivoting and cutting, the reason why you develop ACL problems is because of hip rotation. If you don’t have it, that rotational stress goes through the knee.

The knee is a hinge joint. Flexion. Extension. Flexion. Extension. Not rotation.

When rotational forces go through the knee, those must be absorbed, but by the passive structures like the meniscus and the ACL. So we need to make sure that our hips can move well, especially in rotation.

Supine hip internal rotation level 1 ERE is an end-range expansion technique to improve the internal rotation of the hips.

Supine Hip IR Level I ERE - exercise for ACL rehab

  1. Lie on your back
  2. Place your foot flat and a little out to the side
  3. Push the ankle/foot  off the ground by rotating your femur in the hip joint
  4. Focus on hip internal rotation, pushing the ankle out and turning the upper thigh in
  5. Hold for 10 seconds
  6. Bring the foot down under control
  7. Lift your other foot and put the outer ankle across your knee
  8. Push the knee into the opposite ankle (for external rotation)
  9. Hold for 10 seconds

That is one cycle. Switch sides and repeat for 2-4 cycles.

Maintain activation the whole time, and remember to take big, deep breaths.

One little note about that technique and doing hip rotation exercises in general, when you rotate, think of your femur (your thigh bone) rotation – not your foot, not your lower leg.

It’s easy to deceive yourself by thinking you’ve got a lot of rotation when you’re doing those exercises, but it’s actually coming from the tibia or the ankles. So keep picturing that femur rotating when you’re doing the exercise. That will help engage the muscles you need to achieve good active hip rotation.

Exercise 5: Monster Band Walk

Sir Mix-A-Lot would really appreciate this final area of focus. That’s the glutes.

The glutes are so important for healthy knees. The gluteus maximus is the hip extender. That’s the big one. It extends the hip and absorbs forces when you squat, run, and land. If you don’t have a good glute max, a lot of those forces will be absorbed by the quads. That, in turn, stresses out the patella. It will pull the tibia forward.

Remember when we talked about the hamstrings? The tibia sliding forward on the femur is when the ACL gets stressed.

So we need the glutes to work well, and we need them to be strong.

The glute medius makes sure that the knees don’t go cave inward. That’s called valgus stress. It puts a lot of stress on the ACL, the meniscus, and other passive tissues.

For more gluteus medius exercises (and particularly addressing valgus knees), read this article here.

So we need the glute medius to help us maintain alignment. We need the glute max to help absorb forces.

We train both of those functions through the Monster Band Walk.

The Monster Walk gets the glutes and external rotators of the hip working and strengthened in a functional closed chain pattern.

Focus on the outer hip muscles and control your steps. To control your steps, don’t use momentum. Easy to do with the front leg, but also focus on not letting the band snap your trailing back leg into place.

acl injury exercise - monster walk

  1. Step into an exercise band with the band around your mid-foot
  2. Get into a partial squat
  3. Step out (with control!) to the side
  4. Step with the trailing leg
  5. Repeat in the opposite direction

Go back and forth a couple of times. If you don’t have a lot of space, you can do a back-and-forth. If you have some room, you can take several steps in one direction before monster walking back the other way.

Repeat for 10-15 steps per side.

How to Prevent an ACL Tear

Those are the five areas of focus to prepare, prevent, and protect an ACL tear: ankles/feet, quads, hamstrings, hip rotation, and glutes. There are a number of different exercises for ACL rehab that we could slot into all of those areas of focus. These are 5 examples that work well together and will give you a great start.

To build proper progression, you need to build the foundation, with tissue pliability and endurance first. Then build upon this by increasing to strength, then power/speed.

Then go to more dynamic, faster, and more powerful exercises. It’s a long progress, and you need to ensure everything is working well.

That’s why we’ve put together a program called the Knee Pain Solution. This is a great program to prevent or prepare you for surgery. You can check that out to take care of your knees no matter when you ask of them.

Click here to learn more about the Knee Pain Solution Program.

Everything outlined here helps make sure that your knees stay healthy for the long term.

Thanks for sticking with us.

This article was reviewed and updated on November 18, 2022 by our Chief Medical Officer, Dr. Erin Boynton, MD, FRCS to include new research and information on latest surgical developments. Read more about Dr. B here.

About the Author

Eric Wong (aka Coach E) is the founder of Precision Movement and has a degree in Kinesiology from the University of Waterloo. He's been a coach since 2005 and spent his early career training combat athletes including multiple UFC fighters and professional boxers. He now dedicates himself to helping active people eliminate pain and improve mobility. He lives in Toronto (Go Leafs Go!) with his wife and two kids and drinks black coffee at work and IPAs at play. Click here to learn more about Eric.