Sport-specific training and return to sport after ACL reconstruction in elite athletes: a narrative review.

Background and Objective: Anterior cruciate ligament (ACL) reconstructions remain a prominent surgery performed in the United States. Despite continuous efforts from surgeons and rehabilitation specialists, the return to previous levels of sports participation remains low and the reinjury rates remain high. The purpose of this narrative review is to summarize the progression of post-operative rehabilitation following ACL reconstruction in elite and professional athletes. Methods: A literature review was conducted in 2025, searching for the most up-to-date evidence on criterion-based rehabilitation programs and rehabilitation strategies in the English language. Key Content and Findings: For the purpose of this narrative, the rehabilitation progression begins when the athlete is cleared to begin a jogging progression and highlights the inclusion of all members of the sports medicine and sports performance teams within the rehabilitation process. The narrative review highlights the three elements of the return to sport (RTS) continuum: returning to participation, sport, and performance. In each element, the athlete's goals are defined and how the rehabilitation and performance teams work together to address them. In order for the athlete to progress within their rehabilitation program, they must demonstrate mastery of simple, controlled tasks and movements before performing complex, chaotic ones. This principle also applies to their reintroduction and progression in sports participation. In using these principles, we outline a progression that uses a criterion-based progression, coinciding with time after surgery, to minimize risk of reinjury and restore performance metrics during the rehabilitation and RTS and performance processes. This method also allows the rehabilitation and performance teams to assess, track, and improve upon key performance indicators throughout the rehabilitation process. Examples include, but are not limited to, objective strength testing, jump testing using force plates, volume ran and maximum velocity during rehabilitation and practice sessions, and psychological readiness. Conclusions: This review demonstrates how the principles of the Control-Chaos Continuum, Return to Sport Continuum and Return to Sport Clearance Continuum help to navigate the sport-specific progression of rehabilitation. The review can be generalized to all sports, but there is a specific focus on basketball, football, soccer, and skiing.