Essential Guide to ACL Rehab: Your Complete Recovery Process

whether you've had an acl reconstruction you're waiting for the operation or you're managing your injury without

surgery i'm going to tell you everything you need to know about the rehab process before diving into the information i

want to mention two things one the timeline of your recovery may vary based on your injury or surgery for example if

you had an acl reconstruction and repair of your medial meniscus the early stage of rehab will last longer

two precautions for when to initiate certain exercises will vary based on your surgery or surgeon

for example hamstring strengthening may be delayed if you had a hamstring tendon autographed therefore everything in this

video needs to be individualized and this is not medical advice or a substitution for consultations with an

orthopedic surgeon and physical therapist research by ardernidol in 2014

wiggins at all in 2016 and webster and feller in 2019 informs us of three significant issues

one only 55 percent of individuals returned to competitive sport following surgery

two one in four athletes who are younger than 25 and return to high risk sport will go on to have a second acl injury

three expectations for returning to pre-injury sport are often not met for those reasons i can't emphasize

enough the importance of avoiding these seven mistakes one not following fundamental strength

and conditioning principles if your rehab never includes a squat or split squat with relatively heavy weight that

makes you want to quit because it's so challenging you're probably not sufficiently trained

two not incorporating exercises to improve your cardiorespiratory fitness

aerobic exercise can be started fairly early and it should be continued and progressed throughout the process

three not using the appropriate objective criteria to assess your function

your physical therapist cannot measure the strength of your quads with their hands

four only using time to make decisions your surgeon cannot determine that

you're ready to begin running because three months have passed since your surgery the most important aspect about

time which the majority of people get wrong is that you need to wait a minimum of 9

to 12 months before returning to sport if you want to significantly reduce your risk of re-injury

you are not your favorite professional athlete so don't make that comparison 5. ignoring the neurocognitive aspects

of rehab an acl injury is not just about your knee but you as a person six

not training the uninjured leg because it's common for its function to decrease over time secondary to

disuse seven rushing and over complicating rehab instead of sticking to the basics

the basics start with the early stage of rehab where the primary goal is restoring your knee extension range of

motion other goals include restoring knee flexion range of motion normalizing

walking and improving the function of your quads here are two ways to improve knee

extension one prop your heel for 10 minutes three to five times per day the position might

be slightly uncomfortable but it should not be unbearable over time you can add a light weight to

increase the stretch if needed two quad sets all day every day squeeze your quads for 10 seconds relax

and repeat any chance you get over time you can intensify the quad contractions by propping your heel or

using a strap to pull on your foot to add a calf and hamstring stretch other quad set options will include

external resistance such as a ball against a wall or a band anchored to an object

the first major milestone related to quad function is being able to perform a straight leg raise with your knee

completely straight when you can achieve that start performing three sets of 10 to 20 reps

every day on your back side and stomach at some point you'll also perform and

progress wall sits air squats step ups and similar exercises

likely starting with a shortened range of motion part of normalizing walking is simply

restoring your knee extension range of motion and quad function however you can also practice standing

on one leg for up to 60 seconds additionally you can balance with your eyes closed step over cones

and walk backwards similar to knee extension here are two ways to improve knee flexion range of

motion one heel slides with a strap you can do sets of 20 reps at least two

to three times per day two ride a stationary bike

start by performing half revolutions with the seat high progress by lowering the seat and

completing full revolutions you will have moments when your knee is sore or swollen from pushing yourself

too hard but one of your primary roles is to minimize the frequency and severity of those occurrences by

monitoring your response to exercise and adapting appropriately if you have a flare-up you need to back

off a bit if your knee is feeling great continue with your small progressions

do not rush the basics also muscle soreness which is different from soreness of the knee joint

is normal and encouraged as long as it's not debilitating the mid-stage of rehab as defined by

buckthorpe and delavia in 2019 is characterized by muscle strengthening movement training and fitness

reconditioning i'm going to demonstrate exercise options for each body region explain the

rationale for their selection and provide a sample program if you want to improve your function

and reduce your risk of re-injury strengthening your quads needs to be your top priority

here are three progressions that i like option number one is a squat progression level 1 is a bodyweight squat

gently tap your butt to a chair and stand back up if it's too challenging or painful

shorten the range of motion or use your hands for assistance aim for 3 sets of 20 repetitions

level 2 goblet squat aim for 3 sets of 15 reps using a kettlebell or dumbbell level 3 barbell back squat aim for three

to four sets of three to eight reps option number two is a split squat progression

level one is the bodyweight squat again level two is a split squat start in a stride stance and lower yourself down so

that your back knee taps an egg that you don't want to crack if it's too difficult for your front or

back leg shorten the range of motion or use your hands for assistance aim for three sets of 15 reps

level 3 rearfoot elevated split squat the overall technique of the movement and position of your torso should be

similar so use an object to elevate your back foot that isn't too high the majority of your weight should be

through the lead leg level 4 deficit rearfoot elevated split squat

you're going to elevate the front leg using a 2 to 4 inch object to start over time you can progress the height

aim for three sets of three to twelve slow and controlled repetitions option number three step down

progression level one is a step up use a stair or object stacked six to

seven inches high don't push off with the back leg focus on putting all of your weight through

the working leg if it's too difficult decrease the height or use your hands for assistance

aim for three sets of 20 reps per leg level 2 lateral step down same exact cues except this movement

will allow for a little more knee travel aim for 3 sets of 20 reps per leg level three forward step down or

elevated lateral step down you can either step forward off the step or continue to perform the lateral step

down while gradually increasing the height of the step aim for three to four sets of 6 to 12

slow and controlled reps per leg other options include leg presses hack squats single leg squats and anything

else that involves knee extension elevating the heels and driving the knees forward can be strategies used to

emphasize the work done by the quads i also highly recommend leg extensions research by sigward at all in 2018 found

that people unknowingly perform compensations to offload their quads during squats

since no other muscles extend the knee leg extensions ensure that the quads are being trained adequately

it's not about what looks functional it's about doing what's necessary to restore quad function

and no leg extensions are not dangerous to the acl any contemporary clinician or researcher

who has followed the science for the past 30 years understands this but the purpose of this video isn't to convince

you of that or defy any precautions you might have if you're really concerned leg

extensions between 90 and 60 degrees of knee flexion put zero strain on the acl and still provide the majority of the

benefits although i didn't mention it earlier isometrics for three to five sets of 30

to 45 second holds can be useful in the early stages of rehab for improving knee extension tolerance

and function another critical component of mid-stage rehab is improving the function of the

hamstrings as they help to decrease the strain on the acl and reduce the risk of re-injury

here are two progressions that i like option number one is a slider progression

level one is a double leg eccentric slider bridge up keep your glutes squeezed

slowly slide your legs out drop down bring your feet back to the starting

position and repeat if it's too difficult just shorten the range of motion

if you can work up to three sets of 12 reps progress to the next level level 2 double leg slider aim for 3 sets

of 12 reps level 3 single leg eccentric slider aim for 3 sets of 8 reps

level four single leg slider aim for three to four sets of four to eight reps

option number two is a feet elevated long lever bridge progression for level one

place both heels on a bench with a slight bend in your knees bridge up until your hips are straight

and hold this position aim for three sets of 45 seconds level two is a marching variation in

which you slowly alternate lifting and lowering each leg aim for three sets of 60 seconds total

level three is a single leg isometric aim for three sets of 45 seconds per leg and level four single leg foot elevated

long lever bridge aim for three to four sets of eight to fifteen repetitions per leg

other options that you should include to address the hip extension and knee flexion actions of the

hamstrings are nordic hamstring curls rdls seated or prone hamstring curls and

roman chair variations your calves are important for running jumping

landing etc and similar to your hamstrings your soleus one of your primary calf muscles

also helps to unload the acl here are two heel raised progressions option number one is a straight knee

heel raised progression level one double leg heel raises on flat ground

aim for three sets of 25 slow and controlled reps use your hands for balance as needed

level two single leg heel raises on flat ground aim for three sets of fifteen reps

level three single leg heel raises on a step aim for three to four sets of 8 to 15

reps over time you can add weight as needed option number 2 is a bent knee heel

raise progression level 1 seated heel raises on flat ground

aim for 3 sets of eight to fifteen slow and controlled reps level two

deficit seated heel raises aim for three to four sets of eight to fifteen reps you can use a barbell

smith machine dumbbells or seated heel raise machine the strength and control of your trunk

and hips can affect what happens at your knee so here are three exercise progressions that train the hip

abductors extensors and adductors as well as the associated trunk muscles option number one

copenhagen plank progression level one lie on your back and squeeze a ball between your knees or ankles as

hard as you comfortably can level two short copenhagen plank isometric keep your trunk in a straight

line and thighs together level three long copenhagen plank isometric same as the previous exercise

but you're going to keep the top knee straight level four long copenhagen plank aim for

three to four sets of eight to twelve slow and controlled repetitions to progress to level four aim for three

sets of sixty seconds on levels one through three option number two is a hip thrust

progression level one double limb bridge

lie on your back bridge up squeeze your glutes

lower yourself down and repeat aim for three sets of 20 reps level 2 single limb bridge aim for 3

sets of 15 reps level 3 single limb hip thrust aim for 3 to 4 sets of 12 to 15 slow and

controlled reps add weight as needed option number three is a side plank progression

level one short side plank start on your forearm and knees while keeping your trunk in a straight line

hold this position level two side plank straighten your legs stack your feet and keep yourself

in a straight line both from a front view and top view level three side plank hip abduction

position yourself in the same way as the previous exercise but slowly move that top leg up and down with good control

aim for 3-4 sets of 60 seconds as you work through each exercise the last category here is dynamic

balance to help address some of the proprioceptive deficits associated with acl injuries here are two options

option number one why balance set up tape cones or imagine standing on an upside down y

stand on one leg and reach in each direction of the y try not to put any weight through the

foot that is tapping the ground start with small reaches and gradually increase the distance as your balance

improves begin with three sets of 30 seconds each and work up to 60 seconds

option number two is a single leg rdl progression level one single leg rdl stand on one

leg while keeping a slight bend in both knees hinge at your hips until your trunk is almost parallel with the ground

and then return to the starting position repeat this movement without touching your foot to the ground if this is too

challenging use your hands to help with balance shorten the range of motion or tap your foot to the ground

aim for 3 sets of 12 to 15 reps level 2 3-way rdl reach your arms in three directions to

the left middle and then to the right that counts as one rep aim for four to five reps total

level three three-way rdl with the knee drive you can progress the previous movement by adding a knee drive

how do you put all of this information together to create a structured program let's start with the early stage of

rehab every day multiple times per day you'll be working

on your knee extension and flexion range of motion by incorporating quad sets heel props heel slides and cycling on a

stationary bike you'll also be performing isometric leg extensions at least one time per day

you'll eventually start performing straight leg raises which is an important milestone

sideline hip abductions prone hip extensions single leg balance air squats step ups etc

remember the primary goals here are to restore range of motion normalize walking and improve the

function of your quads while sticking to your precautions minimizing flare-ups and reducing swelling

for the mid-stage of rehab resistance exercises should be performed at least two to three times per week

here is an example of a three day program on monday you can perform split squats nordic hamstring curls hip

thrusts standing heel raises and the three-way rdls with a knee drive on wednesday you can do rdls

leg extensions side planks seated heel raises and the y balance on friday you can perform squats

sliders copenhagen planks and heel raise and dynamic balance options i'm trying to make this information

simple and straightforward but in reality it's pretty complex and context dependent so here are six other things

to consider one the stages of rehab aren't distinct meaning that you're not in the early stage of rehab one day and

suddenly in the mid-stage of rehab the next day there's going to be some overlap because it's more of a continuum

two you should be including upper body exercises as well not just for the physical benefit but also the mental

aspect of feeling like an athlete three as i mentioned earlier don't forget to train the uninjured leg hard

early and often so it doesn't become deconditioned four incorporate aerobic conditioning as

soon as it's appropriate for example you might ride a stationary bike for 45 to 60 minutes two to four times per week

five the mid-stage of rehab is an ideal time to build your work capacity you wanna be able to handle more volume over

time for instance you might start with lower body resistance training two times per week and build up to the three-day

program i provided you might also begin with three sets per exercise and

progress to four to five sets on certain exercises lastly the intention of the exercises

may fluctuate over time early on you're probably going to stick to higher repetition ranges to improve

work capacity and endurance over time you'll likely transition to increasing hypertrophy strength and

power by manipulating the repetition ranges rest times effort or intensity and speed

of the movements once again you can have overlap here but you can't expect to return to sport if

you're only accustomed to performing 20 repetitions of every exercise at a low effort

your parameters should range from 3 to 20 repetitions with minimal rest between sets or exercises up to

5 minutes of rest between sets or exercises depending on the goal one aspect of the mid-stage of rehab

that i haven't discussed yet is running returning to straight line running is an important landmark and something that

most people look forward to historically people were given permission to run after 12 to 16 weeks

based on the healing of the graft after surgery however it is now highly recommended that the initiation of

running is based on your objective function in addition to having minimal pain

near or full knee range of motion and minimal to no swelling here's the objective criteria that you should meet

prior to returning to running recommended by buckthorpe and delavia one display good quality single leg

squats and bilateral landings two demonstrate isometric knee extensor strength greater than seventy percent of

the uninjured side three be able to perform a single leg exercise

such as a leg press of at least 1.25 times your body weight other criteria discussed by amy

arendelle on our podcast include being able to perform a single leg landing from a 30 centimeter box and at least 22

single leg sit-to-stands in one minute for the physical therapists watching who are using a dynamometer eric metta

suggests two newton meters per kilogram of quadriceps torque to body weight as a reasonable bare minimum

you can't just go back to running because the timing feels right you have to earn it

with regards to returning to plyometrics buckthorpe at all recommend progressing from bilateral landings to bilateral

plyometrics to unilateral jumping and landing to unilateral plyometrics to initiate bilateral landings you

should be able to perform a single limb leg press of at least 100 of your body weight to initiate the single leg

plyometrics you should be able to do at least 150 percent of your body weight we made a previous video about this

topic and people were quite surprised by these numbers but the purpose of this video and our content is to make sure

that you return to sport safely these might be difficult goals to achieve but adequate preparation is

going to enhance your performance and reduce your risk of re-injury don't take shortcuts

since there's an infinite number of plyometric options and progressions to choose from i want to emphasize the

importance of at least including a vertical jump as it's more indicative of knee function than the traditional

horizontal hop tests an example progression would be counter movement jump to a box

counter movement jump bilateral depth drop bilateral depth jump

single leg depth drop and single leg depth jump it's also important to focus on

deceleration since it's highly dependent on the capacity of the quads an example progression would be forward

lunge forward lunge with step back step and land

step and land to step back and running with a step back you definitely should still incorporate

other hopping and jumping exercises especially side to side and rotational movements

but vertical jumps and deceleration cannot be overlooked with regards to programming you can

practice these movements on your sport specific training days which i'll talk about shortly or put them on the front

end of your gym sessions when you're the most fresh at the very least aim to do three to

four sets of four to eight reps two to three times per week focus on the quality and execution as

opposed to trying to turn this into cardio the late stage of rehab is dependent on

developing and continuing to develop the solid foundation that i've been discussing

do you have full range of motion no swelling and minimal to no pain how is your strength muscle mass and

power have you been working through plyometric progressions how's your conditioning

this is when you'll be performing more sport specific movements and increasing the intensity and complexity of training

the straight line running on a treadmill will eventually turn into full sprints and cutting maneuvers

pre-planned movements should progress to reactive movements you're going to slowly try to simulate

your sporting environment and demands return to sport criteria from the university of delaware include being at

least 9 to 12 months out from surgery and possessing quad strength that's 90 to 100 percent of the uninvolved side

but you should be getting tested by a physical therapist with access to a dynamometer once again for the physical

therapist watching eric metta suggests a minimum of three newton meters per kilogram of quadriceps torque to body

weight an important caveat here though is that returning to sport doesn't necessarily

mean returning to full competition in order to return to full competition brinley and colleagues suggest working

through this progression without apprehension pain instability swelling or

compensations non-contact practice small sided contact practices

full practice return to competition with restricted workload and return to competition unrestricted

returning to sport and competition require you to gradually increase your training loads and exposures just like

everything else it's a continuum it's a process if you haven't played your sport in a year that's a lot of work that you

need to make up also the psychological aspect of rehab is extremely important you need to be

confident in your ability to return to sport and competition since there are many neurophysiologic

adaptations that occur after an acl injury and reconstruction motor learning strategies should be

applied throughout rehabilitation you want to drive implicit learning implicit learning is when you are able

to complete a task without necessarily having direct knowledge of how you are performing it

you don't think about how each joint is moving while you walk or ride a bike you perform those movements without much

thought required this is also known as automaticity simply put when you go back to your

sporting activities you shouldn't have to think about how to perform those tasks or how your knee should be

positioned you should just be able to do them there are a few ways that you can help

encourage implicit learning one shift your focus externally while performing exercises and movements you

should aim to have an external focus of attention initially it might be helpful to watch yourself in a mirror but

eventually you need to take that mirror away you should also try to focus on something outside of your body for

example during a split squat instead of telling yourself to drive your knee forward over your toes

place a foam roller or another object in front of you and tap your knee to it two train dual tasking dual tasking is

when you must complete some task while also performing a motor task for example a soccer player has to scan

the field to locate opponents and teammates while also dribbling a soccer ball

there are many ways to train dual tasking try catching a ball while performing single leg balance or solving

math problems while doing vertical jumps three add reactive training most sports require you to engage with and react to

the environment try performing movements and exercises in response to a stimulus

this can start early in the rehabilitation process by performing straight leg raises to the beat of a

metronome or in response to a flashing light in the mid-stage of rehab you can do a

lunge when someone yells go or perform a drop landing when someone throws a ball for you to catch

driving motor learning shouldn't be seen as an isolated exercise or session instead you should approach all

exercises and movements with the goal of improving implicit learning or automaticity this is your chance to have

fun and get creative just so i don't make this video any longer than it already is i want to leave you with five

brief final points one as i mentioned at the beginning this information needs to be individualized

based on your surgery prior level of function goals etc

two this video is not all inclusive i unfortunately can't pack 12 months of rehab into one youtube video

three other than the timelines because you should return to sport and competition much sooner

most of this information applies to non-surgical management as well four we have 10 other videos relevant to

acl rehab including a dynamic warm-up that everyone should be performing to help reduce the risk of re-injury i'll

link those videos below lastly my advice doesn't supersede that of your surgeon or physical therapist

but it may be helpful to discuss certain aspects of this video with them if you have questions or concerns

thank you so much for watching please if you enjoyed the video smash that like button subscribe turn on

notifications and leave any questions or comments down below peace