An ACL rehab is a massive undertaking and a lot of hard work that usually takes 9-12 months. It requires proper rehabilitation to return to desired levels of function and sports performance as well as decreasing risk of any re-injury.
Having a plan to progress along the rehab/performance continuum is paramount. Each stage has their different focuses and criteria to aim for to progress to the next stage. Throughout this process we focus on the athlete as a whole and make it a priority to continue training the rest of the body around the injury. Below are the stages, focuses and extra notes within each.
Recovery/Protection
Focuses:
The first stage’s focus is to allow the body to recover after the surgery. Our main focuses here are...
1.Keeping the knee safe by education on what to do and not to do
2.Controlling the pain as much as possible with ice or medication if necessary
3.Reducing the swelling with compressions
4.Increasing knee range of movement with light exercises
5.Starting to develop our quad function/capacity with low level quad exercises
6.Educating you on the full process and answering any questions you may have
Criteria:
Some criteria we want to tick off before moving to the next stage are
1.Minimal to no swelling
2.Knee range of motion 0-90 degrees
3.Walking with a normal gait
Considerations:
Upper body and uninjured limb training can still be performed, but needs to be in a safe environment with a physio or strength & conditioning coach to assist with set up and programming. Off feet conditioning is relatively limited to upper body bike or seated ski erg, but both are great options if possible.
Primary Loading Stage
Focuses:
This next stage looks to start introducing more load into the limb as well as still increasing range;
1. Continued increase in knee range of motion and push for 120 degrees to get on a bike
2. Developing single leg isolated muscle endurance
3. Developing normal movement patterns of the big lifts (squat/hinge/etc.) with bodyweight to no loads
4. Starting very introduction “running/change of direction” drills (not actual running, most will be walking, but focusing on different components and shapes to prepare for when able to run)
5. Intro low level “jump” based exercises (again not full jumps but early exercises to prepare them)
Criteria: Some criteria for progression out of this stage includes; 1. Knee range of motion 0-125 degrees with progressed exercises 2. Single leg capacity tests which are more muscular endurance focus of lower loads or bodyweight for multiple reps. This compares the injured side to the uninjured side and is looking for a 10% difference or less with single leg squats, bridges, calf raises etc. 3. Single leg drop from a box and land feeling confident and no pain
Considerations: The ability to bike is achieved in this stage and other off feet conditioning is much easier to performance and start to rebuild the athlete’s aerobic system. Ability to continue resistance training on the rest of the body is continually pushed here.
Conditioning Phase
Focuses:
Early stage rehab runs will usually start in this stage. The focus here is to continue to develop our single leg strength in isolated and integrated movements while also starting to add in double leg movements again:
1. Single leg strength focus
2. Double leg muscular endurance
3. Progress “jump/plyo” based exercises
4. Progressed field rehab focused on building up speed, change of direction and running aerobic capacity
Criteria: Some criteria here focuses on max strength of isolated muscles and single leg movements as well as some jumps comparing right vs left or ideally pre-injury scores if are available. There are also field rehab criteria to tick off.
1. Hamstring max strength 2. Max quad strength 3. Max calf strength 4. Single leg jump 5. 80% max speed achieved 6. Ability to change direction and decelerate properly
Training Integration/Resilience Phase
Focuses:
This phase is focusing on returning to previous full body gym/field scores while integrating into training.
1.Previous gym/field PB’s or close to them to make sure the whole body is ready
2.Intro skills drills with team
Criteria:
1.Hit previous squat/deadlift personal bests or within 10%
2.Hit upper body lift PB’s
3.Single leg depth jump numbers right vs left within 10%
4.100% max speed hit
5.High level agility games/drill
6.Previous conditioning test scores hit
7.Full contact/collision/combat progressions achieved if playing a contact sport
Considerations:
This stage can often be under done when the focus is only on the knee and not the full body. Hitting previous lifting PB’s and conditioning tests are important to determine readiness.
Return to Performance Focuses: This phase focuses on building confidence through completing training sessions well and minor tune ups/adjustments on any points that might still be lacking; 1. Full training while monitoring/adjusting as needed
Criteria: Some criteria used for this stage 1. Completing multiple weeks of full training for a conditioning and contact/collision/combat perspective
2. Psychologically ready and confident
Considerations: Make sure no stone is unturned and you feel as though you’ve ticked every box possible to make sure the readiness is there.
Ensuring you have a systemised approach to your ACL rehabilitation is crucial in ensuring you return to what you enjoy, without falling into the unlucky 25% that re-rupture the graft. Rehabilitation should progress as you earn the right to do so, leaving nothing to chance and measuring improvements frequently.
If you have any questions about ACL rehabilitation or want to have a chat, email aaron@gametimephysio.com.au
Author: Patrick Wood (Physiotherapist and Level 2 S&C Coach)