When Southern Cal star basketball player JuJu Watkins tore her right ACL in the Trojans’ third game of the 2025 NCAA Women’s Basketball Tournament, the questions surely started.

How soon will she have her surgery? What type of graft will be used? How long after the surgery will she return to play?

Perhaps, the question should have been, “Is she starting her rehabilitation before or after her surgery?”

Perhaps, the question should have been, “Is she starting her rehabilitation before or after her surgery?”

The greatest fear – in the wake of an anterior cruciate ligament reconstruction (ACLR)– is the graft failing or tearing. A 2020 literature review found that, among athletes age 19 and younger, the failure rate varied by type of graft. Bone-patellar tendon-bone (BTB) was the best at 8.5%, followed by 16.6% for hamstring tendon, and 25.5% for allografts. (Quadriceps tendon grafts were not studied.) The allograft difference was significant.

On the other hand, a study out of the University of Wisconsin School of Medicine, published in September 2024 in the Orthopaedic Journal of Sports Medicine, found that those who received hamstring tendon grafts took significantly less time to achieve recovery criteria than those who had a BTB procedure.

However, another study, published online in Sports Health in December 2024, identified the one variable that may be the most important of all.

Done at Virginia Tech University, the investigation looked at 1245 patients who had an ACLR between January 2015 and December 2021.  Of those, 70 had their grafts fail within two years of the surgery.

The study authors looked at graft type (including quadriceps tendon), fixation device, whether or not there was also a meniscal or MCL injury, how the injury occurred, days from injury to surgery, race and ethnicity, gender, age, BMI, and whether or not the patient went through pre-habilitation. Only the latter factor significantly affected the failure rate.

The overall failure rate was 5.6%. Yet, the 337 ACLR patients who went through pre-operative therapy experienced a failure incidence of only 2.7%. The failure rate for the other 908 subjects was nearly three times higher, at 6.7%.

The overall failure rate was 5.6%. Yet, the 337 ACLR patients who went through pre-operative therapy experienced a failure incidence of only 2.7%. The failure rate for the other 908 subjects was nearly three times higher, at 6.7%.

While previous studies have not specifically examined whether or not pre-habilitation affected the chance of graft failure, they have looked at how it influenced recovery course. It has been the catalyst to a far smoother one. Better range of motion and quadriceps strength and fewer post-operative complications have been the result for those who did therapy first. 

It stands to reason because other major joint surgery outcomes also benefit from prior therapy. A literature review to be published in the May 2025 issue of the Journal of Orthopaedic and Sports Physical Therapy determined, “Pre-habilitation reduced complication rates and improved objective and subjective post-operative outcomes following THA and TKA.”

Consequently, athletic trainers should be working daily with their athletes in the immediate aftermath of an ACL tear, while they are waiting for surgery. The focus should be on swelling reduction, improved range of motion, and quadriceps control.

A 2013 study in the Journal of Athletic Training found that, “Both pain and effusion led to quadriceps dysfunction, but the interaction of the two stimuli did not increase the magnitude of the strength or activation deficits. Therefore, pain and effusion can be considered equally potent in eliciting quadriceps inhibition. Given that pain and effusion accompany numerous knee conditions, the prevalence of quadriceps dysfunction is likely high.”

Ice, compression, and elevation will work to counteract those initial effects of a torn ACL. If available, the Game Ready device is particularly effective.

So is electrical muscle stimulation when attempting to re-activate the quadriceps muscles.

Mindful of the instability now present in an ACL deficient knee, the AT should limit strengthening exercises to those that will not expose that instability. While some exercises will increase the chance of the knee pivot shifting, so does an accumulation of daily activities.

A study out of Baylor, published in August 2024 in the journal Knee Surgery, Sports Traumatology, Arthroscopy, looked at the length of time from injury to surgery. Those who waited more than 40 days faced an increasing risk of suffering further injury inside the joint that made arthritis later in life much more likely. Delaying surgery more than 12 weeks put patients at the highest chance for pre-operative complications that are brought on by the joint’s instability.

In short, each time the knee gives way or shifts, there is a real danger of damaging the articular cartilage and/or the medial meniscus.

The pre-operative goal is to “quiet” the knee and to re-establish full range of motion, if possible, while restoring strength as tolerated. Quadriceps sets, straight leg raises, short and long arc quadriceps exercises, heel slides, stationary bike, calf stretches with a strap, and heel props on a bolster are generally safe.

Depending on stability, calf raises, standing hip exercises, and quarter squats may be added.

A successful partnership between athlete and AT, in the pre-operative phase to maximize range of motion and strength, could very well be the difference between success and failure post-operatively. 

A successful partnership between athlete and AT, in the pre-operative phase to maximize range of motion and strength, could very well be the difference between success and failure post-operatively. 

The other issues – timing of surgery, type of graft, post-op recovery duration – are important, too.

Surgery just days after the injury may mean a quicker return to play. However, ACLR so soon, in the face of post-traumatic swelling, often complicates the recovery.

Waiting too long for the surgery is not without its risks, too, as illustrated by the Baylor study. 

Many surgeons still seem to favor the BTB graft. Yet, there are those who prefer grafts from the quadriceps tendon or a hamstring tendon. Allografts have generally fallen out of favor.

Few seem to argue for a return any faster than nine months after the procedure. Still, the more conservative crowd argues any return before a full year risks re-tear, no matter how well the muscles around the knee have regained strength and function has seemingly returned. Their reasoning? The graft itself takes at least that long to mature.

Many of those other issues, though, are to be determined between patient and surgeon and all of them are secondary to the need for AT and injured athlete to focus on pre-habilitation first.

John Doherty is a licensed athletic trainer and physical therapist. This column reflects solely his opinion. Reach him at jdoherty@powershealth.org. Follow on X (formerly Twitter) @ JDohertyATCPT.