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There have been no long-term follow-up studies comparing a predominantly home-based rehabilitation program with a standard physical therapy program after anterior cruciate ligament (ACL) reconstruction. Demonstrating the long-term success of such a cost-effective program would be beneficial to guide future rehabilitation practice.To determine whether there were any differences in long-term outcome between recreational athletes who performed a physical therapy-supervised rehabilitation program and those who performed a primarily home-based rehabilitation program in the first 3 months after ACL reconstruction.Randomized clinical trial; Level of evidence, 1.Patients were randomized before ACL reconstruction surgery to either the physical therapy-supervised (17 physical therapy sessions) or home-based (4 physical therapy sessions) program. Eighty-eight of the original 129 patients returned 2 to 4 years after surgery to assess their long-term clinical outcomes. Primary outcome was the ACL quality of life questionnaire (ACL QOL). Secondary outcomes were bilateral difference in knee extension and flexion range of motion, sagittal plane knee laxity, relative quadriceps and hamstring strength, and objective International Knee Documentation Committee score. Unpaired t tests and a chi-square test were used for the comparisons.The home-based group had a significantly higher mean ACL QOL score (80.0 ± 16.2) than the physical therapy-supervised group (69.9 ± 22.0) a mean of 38 months after surgery (P = .02, 95% confidence interval [CI]: 1.7, 18.4). The mean change in ACL QOL score from before surgery to follow-up was not significantly different between the groups (physical therapy = 40.0, home = 45.8, P = .26, 95% CI: - 15.8, 4.4). There were no significant differences in the secondary outcome measures.This long-term study upholds the short-term findings of the original randomized clinical trial by demonstrating that patients who participate in a predominantly home-based rehabilitation program in the first 3 months after ACL reconstruction have similar 2- to 4-year outcomes compared with those patients who participate in a more clinically supervised program.