Episode 274 | Structure Outside of PT Is Not Optional in ACL Rehab

What is up team, and welcome back to another episode on the ACL Athlete Podcast. Today’s episode is one that I’ve been circling for quite a while now. I’ve written it down as a topic four times in the last week alone, which for me means it’s past due. And we are talking about structure outside of your physical therapy sessions—not the structure you get during your PT sessions.

The exercises you might be doing, the stuff you do on the table. It’s the other hours. The hours that, if I’m being honest, determine a huge part of how your ACL rehab actually goes.

And I want to start with some simple math first. There are 168 hours in a week. Specifically, if you’re going to physical therapy three times a week, which is very common as you start off post-op, that’s three hours of your week. Three of the 168 hours in the week. If you’re going twice a week, that drops to two hours. Once a week, one hour. And for a lot of athletes—especially internationally or in the mid to late stages of ACL rehab—it might be once every two to four weeks. You’re essentially on your own the vast majority of the time.

And the other thing that’s really important here is that there’s not a ton of communication in between those sessions. A lot of times, by nature, the way physical therapy is designed, you communicate in those sessions. You get maybe something to take home—a home exercise program, just some things that you’re doing. 

Now, there are situations where people are not given anything or are just told, “Do what we’re doing here.” It’s crazy how much that is used, and I think that is more so because physical therapy is a very high-volume-based structure. There’s not a lot of time to individualize things. It’s just the way that healthcare is.

There’s no perfect system. It’s not designed very well for individualization, and that makes it hard. So like I’m saying, you’re on your own the vast majority of the time, especially if the frequency is less than even two times a week.

Now, I’ve touched on pieces of this in other episodes. I’ve talked about the gap that exists when PT frequency drops, about falling through the cracks, and about why the healthcare system isn’t built to support long-term ACL rehab. This isn’t me trying to just bring that stuff back. Of course, this plays into it, but today what I want to do is zoom in on something more specific and actionable.

Because the real issue isn’t just that PT frequency is low or that the system is broken. The real issue is that nobody is telling you what to do with the time you actually have.

That’s what we’re trying to fix today.

Here’s the assumption I constantly see across all stages of ACL rehab at all levels: athletes treat physical therapy as the full plan. Everything that happens inside those sessions is rehab. Everything outside of it is like extra credit or optional. Do it if you feel like it.

Maybe the PT gave you a home exercise program, maybe they didn’t. Either way, the implicit message becomes: show up to your sessions, do what we tell you, and the rest of the week will take care of itself.

That assumption is wrong, and it is costing so many ACLers—so many of you.

And I want to be clear here, this isn’t a knock on every PT out there. I’m a physical therapist. I trained in the system. I know what we were and weren’t taught, and I know what is happening currently. There’s a structural gap in how rehab is typically framed.

The PT session is the intervention. You do the exercises there. Everything outside of it is maintenance at best.

A lot of athletes assume they move the needle in the PT sessions. And don’t get me wrong—if this is structured two to three times a week with really intentional work, that’s awesome. But what I’m arguing is the opposite: the work you do outside of your physical therapy sessions, when programmed well, is where the majority of your adaptations actually happen.

Your PT sessions should be informing, guiding, and adjusting that work—but the volume, the intention, and the structure of your week live outside the clinic walls.

Let me paint a picture of what most athletes are actually doing between sessions.

The first group does basically nothing between sessions. They show up to PT, do the work, go home, and wait for the next appointment. They’re not skipping on purpose—nobody told them otherwise. Weeks go by. They feel like they’re progressing because they’re going to PT, but outside of those one to three hours a week, their body isn’t being challenged at all.

You’d be shocked at how many ACLers are told not to really do too much, especially in those early post-op phases.

The second group has a home exercise program. It’s a list—maybe 10, 15, even 20 exercises. Sometimes it’s on paper, sometimes in an app. It’s not structured. It’s just a list. And often, that list hasn’t changed in weeks. It started with five exercises, grew to 10, then 15, then 20. Half of them are from the first month post-op. Nobody explained the purpose or progression.

So they’re being compliant. They’re putting in the time. But the quality and intent are all over the place.

I call this junk volume. Most people could reduce that by 50 to 75 percent and get better results by focusing on five to eight key exercises done with the right intensity, intention, and recovery.

The third group is doing the DIY process—YouTube, Instagram, Threads. They’ve got a saved folder of ACL rehab exercises. They’re trying to piece something together.

Honestly, I give them credit. They’re trying to fill in the gaps. But what they’ve built is a Frankenstein program from a dozen different sources, with no coherent thread or underlying principles.

All three groups have the same core problem: no structure.

Structure is what converts time spent into progress made.

Now, I want to make an argument, especially for those of you in the mid and late stages of ACL rehab. Every phase matters, but this is where the details really matter. This is where strength needs to reach real thresholds. You can’t keep protecting things—you have to start pushing.

Power development kicks in. Plyometric capacity builds. Sport-specific movements layer in. The demands are more complex and higher than in the early post-op phases.

And here’s the irony: the phase where programming requirements are highest is also where PT frequency tends to drop.

You’re seeing your PT less, just as your rehab needs to become more sophisticated.

That mismatch is where a lot of ACLers get stuck.

So when PT frequency is low, and programming demands are high, what fills that gap matters enormously. Right now, for most people, that gap is filled with nothing, a static exercise list, or random internet content.

Let me give you a different frame.

Think of your week as a training week, not a PT attendance schedule.

Those are two very different things.

A training week has a structure. It has loading days and recovery days. It has purpose. Each session builds on the last. Nothing is random. Nothing is just killing time.

Early post-op, even if you’re going to PT two to three times a week, the other days should have intention—mobility work, activation, upper body training, maintaining fitness.

Mid-stage, strength should be climbing. You’re working on hypertrophy, max strength, maybe power. That requires structured sessions outside of PT.

Late stage, when you might be seeing a PT once every few weeks—or not at all—this is where many ACLers drift. They feel “done” but aren’t back to full performance.

Without structure, they either rush back too fast or stay stuck in neutral.

Across all stages, the principle is the same: your week should be mapped out.

Structure means knowing what you’re doing each day and why. Each session has a purpose. It connects to where you are in the process. There’s a progression. There’s a way to measure if you’re doing enough or too much.

Structure means your program evolves. It’s not the same for eight weeks straight. ACL rehab is dynamic. If nothing changes, something is off.

Structure also means someone is reviewing your work—adjusting based on how your knee responds, answering questions, and keeping you accountable.

And here’s the key point: structure does not require someone standing next to you every day.

You can have high-level programming, oversight, and support without being in the same room as your provider. Especially in mid and late-stage ACL rehab, a well-run remote program can deliver more structure than a couple of in-person sessions with no plan around them.

The room doesn’t build you. The plan does.

So I want to close with this.

At some point in your ACL rehab, the formal PT sessions are going to become less frequent. Maybe you’re already there. And when that happens, there are two ways it can go.

Option one: the structure disappears with the frequency. You lose the appointments, and you lose the plan. You start improvising. Progress stalls. You’re unsure if you’re ready to return because nobody is really tracking it.

Option two: the structure stays. The plan adapts, but it doesn’t disappear. Your week is mapped out. Your program evolves. Someone is still reviewing your work. You know where you are, where you’re going, and what’s next.

That second version is what you deserve.

So wherever you are right now, take an honest look at your week—all seven days, not just PT days. Is there a real plan for the hours outside your sessions? Is it written down? Does it connect to your stage of ACL rehab? Is it progressing week to week?

If yes, you’re in a good spot. Keep going.

If not, that’s the opportunity.

There are 168 hours in your week. Even if you dedicate just five to eight intentional hours, structured properly, you can move the needle in a big way.

But if you don’t have structure—if you don’t know where you are or what’s next—you’re going to feel like you’re flying blind. And that doesn’t fix itself.

Make sure you find a better solution. Trust your gut. Make this your last ACL rehab. Do it right.

And as always, if you have questions or you’re looking for more support through this process, we are here. Find us at the ACL Athlete. We are here to support you in any way that we can. And if you feel like someone in your life needs to hear this, share this episode with them.

Hopefully, this can be helpful for many of you because I feel like many folks run into issues where they’re just not getting the structure and the guidance that they need. Let’s make sure we do that. Let’s do the thing. This is your host, Ravi Patel, signing off.