Navigating ACL Rehab

I have been performing ACL rehab for over the last decade across the highest levels of professional and collegiate sports. Coming up on a year now I have been performing ACL rehab in Pittsburgh at Rebuild Performance & Rehab. The one constant issue I see across all environments is a lack of clarity and understanding on what the rehab process should look like and how to navigate it. Lack of clarity and understanding creates anxiety, unrealistic expectations, and sets the athlete up for failure. In this blog I am going to explain how we at Rebuild approach the ACL rehab process and how to navigate it phase by phase so the athlete can return BETTER than before the injury occurred.

Phase 0

Phase 0 begins as soon as the injury occurs and ends as soon as the surgery takes place. This time usually gets taken for granted. But if done correctly can set you up to hit the ground running after surgery. First we need to plan. What Doctor are we seeing? What operation are we having exactly? What kind of graft are they using and why? Do we need to get a second opinion? Who are we going to be rehabbing with? These are all questions you need to get answered as soon as the injury occurs. Next is the psychological prep. ACL rehab can be just as much a psychological venture as it is physical. Tearing your ACL is a traumatic experience in and of itself. The athlete goes from playing their sport at a high level every day to almost zero activity. They are separated from their team (community) and begin to feel lost. Providing them with the necessary psychological support throughout the entire rehab is vital to a successful return. Last piece of phase 0 is the Pre-hab. Pre-hab is any sort of rehab or exercises done prior to the surgery. For a long time people would blow this time off and just assume they'll start from zero anyways after the surgery. But in my experience athletes that are proactive with their pre-hab come out of surgery in a much better position and progress much faster than those who don't.

Phase 1

Phase 1 starts as soon as the surgery is over. Surgery is more traumatic often than the injury itself leaving athletes in an even less functional state than after the injury. This time is about healing and recovery. Making sure to manage pain, swelling, and scar healing. Providing an appropriate amount of rest and an environment optimal for healing. Nutrition is key during this phase as it is throughout the entire process. Making sure the athlete is getting the necessary hydration, protein, carbohydrates, and supplements to support the healing process. After a few days have passed we can now begin to restore joint function and range of motion. We need to begin restoring flexion, extension, and rotation as soon as possible. If you fail to fully restore these now you are setting yourself up for failure later on. Depending on whether or not their was meniscus damage is going to dictate what kind of flexion we can reach initially in rehab. It is important you consult your doctor on range of motion restrictions. Last is the motor control piece. After surgery the athlete is going to present with inhibitions that prevent them from "activating" their quadricep and surrounding muscles. This is the brain trying to protect the body from further damage. We need to address these inhibitions immediately or we run the risk of them lingering. This can lead to greater atrophy, loss of strength, and function. We can combat these inhibitions with electrical stimulation, isometrics, targeted exercises, and proper therapy. Phase 1 will end when the athlete has met range of motion demands, restored walking gate, scar has healed, and presents with minimal swelling. If you take anything from this blog, its that the first 6 weeks of ACL rehab are the most important. If you fail to execute this phase correctly, you will be playing catch up the rest of the way.

Phase 2

Phase 2 is the longest phase. Now that we have restored joint function and range of motion. We can now begin to turn our focus to mastering movement and reinforcing efficient movement patterns. Movement is the quality at which other qualities are expressed. It doesn't matter how strong or fast you are if you cannot move efficiently. Our primary focus of this phase is mastering the basic movements of squatting, hingeing, lungeing, pressing, pulling, rotating, and bracing. Once we have mastered these movements, we can now begin to load them and restore general strength. Global strength in the patterns listed above but also isolated strength at the knee and quad. Making sure to restore hypertrophy. Once the athlete has met an appropriate level of general strength we can begin our return to run process. Starting with stationary drills and plyometrics. Then gradually progressing to linear drills and short accelerations. Phase 2 ends when they have shown a proficiency in basic movements, restored quad strength within 25% of the unaffected limb, and show the ability to hop and land proficiently.

Phase 3

Phase 3 is considered mid-stage rehab. The athlete has made a lot of improvements but still has a ways to go before actually returning to play. Our focus starts with developing max strength and closing the gap on any asymmetries still present. It is not uncommon that by the end of this phase, for athletes to hit lifetime PR's in compound exercises like deadlifts, squats, or lunges. This is also when we will begin to introduce power training. Learning to express these newfound force capabilities at high speeds. Next we want to master our linear movement with sprinting and introducing conditioning. Once the athlete has become proficient in linear movement, we can now introduce closed change of direction drills. This is also when the athlete can begin to return to technical training of their sport depending on the demands. This technical practice needs to begin stationary and with no external response. For example, a basketball player performing free throws or a soccer player doing some stationary passing. Phase 3 ends when asymmetries are below 15% on quad strength and jumping, and have shown competency in sprinting/change of direction.

Phase 4

Phase 4's focus will be on restoring elastic and high speed force outputs. In my experience strength and hypertrophy can come back quite quickly in rehab when done correctly. Its the rate of force production and elastic qualities that can take longer to return. Which is why it is the primary focus on this phase. We will begin to introduce agility and game scenario's to the athlete. Making them respond to external stimuli like they will have to do in their sport. Our conditioning will also start to mirror the time motion demands of their sport. Once they have done this, they can now begin to integrate back into open technical practice. Still not re-joining their team in formal practice. But performing drills where they are moving and reacting. For example, a basketball player doing a run and weave drill or a soccer player working on passing transitions and shooting. Phase 4 ends when quad strength and jumps are within 10% asymmetry and have shown a tolerance to daily and weekly training demands.

Phase 5

Our last phase of rehab is phase 5. This is when the athlete will begin their gradual re-acclimation back into the formal training environment with their team. This in my experience is one of the worst handled areas of ACL rehab. Athletes do an amazing job of rehabbing over 6-12 months and then when it comes to return to their sport they either are all out or all in. It needs to be a gradual and progressive acclimation back into formal training. For example, 1 week at 55%, 70%, 85%, and then 100% participation. Failure to do so drastically increases the chances of re-injury. Putting the athlete at major risk of never being able to compete again. Rehab is continued throughout this process to reduce any signs that injury had taken place. Phase 5 ends when athlete has shown they can tolerate all daily and weekly training demands with the team, have maintained all previous benchmarks, and have been cleared by medical staff for return.

This is a 30,000ft view of what the ACL rehab process looks like when working with Rebuild. Hopefully now you have a better understanding of what ACL rehab should look like. When this framework is followed and done correctly, in my experience athletes come back from ACL injury a better and more robust athlete than ever before.

If you're interested in learning more about Rebuild and how we can help you. Contact us at https://www.rebuildperformancerehab.com/contact