The complete ACL rehab process
Ahh yes.. The ACL rupture, the most feared injury in sport. It’s an injury that can ruin your confidence and stop an athlete from playing sport ever again. This is due to the lengthy rehab process and the fear of having to do the rehab all over again from scratch. It’s a mind game but those that turn up with the right attitude have already ticked 1 extremely important box for any ACLR return. The mindset to get back to sport and to do whatever it takes is the key to a successful return (as well as a successful surgery, great physio and exercise physiologist planning and programming for your return to sport or life). In this article we plan to give you all the needed information on the process of an ACL rehab, how to handle it before surgery and how to make a successful return to sport.
From the Beginning
BANG, you have just changed direction rapidly, your knee has just collapsed upon itself and you heard a loud pop. Oh and to make it worse, it's the last game of the season (it always seems to be the way). You stumble off the ground with the help of a doc, sports trainer or volunteer, you mind is heading into some dark places. That's it.. Im done.. My career is over.. Why now, why me? Fast forward 20 minutes, your knee has changed colour and its doubled in size, But! The pain has gone away. So maybe you will be right? Let me tell you, from someone who has seen probably 50 ACL ruptures happen right in front of me they all look the same. The knee is swollen due to the rush of blood entering the affected area in an attempt to protect and treat the injured site. The pain has alleviated because its a clean snap.. There's no pain receptors connected to a clean tear of a ligament.
The physio has just performed tests and its a positive lachman's ACL confirmation. From here you rush to the doctors for scans, you are sent for an MRI and referred to a specialist to discuss your options. This is where rehab begins. There is no benefit in just waiting for surgery and staying still. Your ACL plays a large role in rotational stability, so as long as stay away from twisting and jumping/landing you are encouraged to walk and keep that muscle mass alive. Our focus for anyone post ACL rupture is to preserve muscle mass through the athletes quads, hamstrings, calves, glutes and adductors. This will give us the best chance of a successful return to sport as it accelerates the rehab process post surgery.
Early days, it's best to see your physio. They will control the swelling and improve your range of motion. Make sure they give you some homework exercises, because nothing gets better if we do it once a week. We then recommend 6 weeks of hypertrophy training before surgery. We need to build that muscle up to decrease the huge decline your about to witness. Our go to for muscle building is high volume of 10-15 reps at a lower intensity for 3-4 sets. If you are lucky enough to have occlusion cuffs at your disposal (we are) we can accelerate the hypertrophy process by restricting venous return and allowing arterial blood flow into the muscle. This creates a greater metabolic response or hypoxic environment within the muscle, stimulating a hypertrophic adaptation.
Surgery and Beyond Week 1-6
It’s D Day. You are locked in for surgery and you are going under the knife. A few hours later you wake up and you are encouraged to start walking on it (depending on the surgery and graft type). After Surgery and a few weeks of hobbling you will notice your quads have almost halved in size and you can’t bend or straighten your knee. From here the physio will give you some very simple stretching and mobility exercises to help with its range of motion. There pivotal role in the ACLR process is to also aid in the rapid decrease in inflammation. The quicker we can get rid of the swelling and pain, the quicker we can get to moving and weight bearing. Its extremely important to note, that the more you rest after surgery, the greater the drop in muscle mass. We need you to keep moving, if you keep moving, you preserve what's there and that's gives your rehab coach a foundation to work with.
The most frustrating part of the whole ordeal is trying to tense your quads, hamstrings and then both together. Re-learning the neurological pathway to muscle contraction and then co-contraction is a significant step in the right direction as you can now consciously activate muscle and keep it stimulated. At Resistance Sports Science, we use compex to electrically stimulate progressive muscle contractions whilst limiting any load on the joints and hence minimising stress on the knee. This is a fantastic tool we are very lucky to have for the first 6-8 weeks post surgery. You can basically keep the muscle working whilst sitting down and watching TV). Please note, this will not get you abs of steel like you have seen in the infomercials at 8am weekdays.
A few weeks will pass and you will be able to start with easy bridging, banded glute exercises and low level calf and quad “strength” movements. One thing we can’t neglect is what happens to someone's lower back after an ACL operation. It's usually really tight and sore. Why's that? You are dominating your movement through one leg. All the weight shifts to your dominant hip, there's usually some fairly significant hip shifting occurring when we stand on one side. Meaning your glutes, hamstrings, calves, quads and adductors all tighten up as they aren’t getting any help from the other side. A completely weak side and completely tight side are not great for a healthy back. It causes an imbalance through the hips, stiffens your QL on either one or both sides and causes constant irritation. So how do we avoid this? Keep moving! Trigger your hips, stretch your dominant side, plus you need to keep activating muscle on your ACL injured side. Learn how to activate your lower abs and your glute med and this will go along way in progressing your rehab with your coach. If we can keep the rest of your body healthy whilst working on your ACL return, we can minimise all the other issues that can come with it, allowing us to primarily focus on getting your ACL right and ready to return to sport.
Week 7-12 Build a Foundation and Grow Some Muscle
From around the week 6 mark (depending on the person), you can start seeing your rehab coach. From weeks 6-12 this looks fairly similar to the pre surgery routine. We need volume and we need it now. 2x lower body strength sessions a week & 3+ bike sessions weekly is the goal. This should be incrementally added over a number of weeks. Here we re-learn what it's like to feel sore the next day. I call this phase the foundation phase. The bigger we can make your muscles, the greater potential we have to create maximal force when deeper into the rehab program.
Week 13-18 Strength Transition
Here we have our strength transition. We all know 6 weeks isn’t enough to become the ultimate hypertrophic being, so simply cutting out volume training won’t do us any favours. In this next block, we start introducing strength work with volume accessories. We want to continually add extra load to create muscle and joint resilience. Learning to land and absorb force is a big focus of this block. Most of the time it's clear why people have torn their ACL through a non contact injury after witnessing how they naturally land. By around week 15 we usually get the all clear to start running. This is very basic straight lines. 50 metres at a time with walk recoveries. Not very interesting but for anyone who has been through an ACL surgery, it's a feeling of freedom and relief.
Week 19-25 Pure Strength and Power Transition
The ligament is starting to heal nicely, the knee is no longer causing any aches or pains. It's time to start putting some weight on the bar. Every week in this block, the weight goes up by 5% until we are eventually maxing out. On top of this we are improving our jumps. Vertically, horizontally and through single leg. Your running starts to increase in intensity and distance, plus we are ticking off agility and coordination drills.
Week 26-32 Power and Plyometrics
We are now strong, arguably the most important part of any rehab program is the strength foundation. Power = Force x acceleration. Strength being Force. Now to make someone powerful we need to be able to make them move fast. Jumping, bounding, hurdling, skipping, sprinting and maximal efforts all play a role in the return to sport. The aim is to improve an athletes stretch shortening cycle capacity, their absorption through different planes of movement and overall robustness to whatever their chosen sport can throw at them. This sort of block is where people can hurt themselves if they aren’t careful. At Resistance we ensure to continually keep on top of the small accessory exercises which are designed to prevent injury.
Injury free, explosive athletes, what more could you ask for?
Week 33 - 40 Return to Training
The most exciting part for any rehab coach and the athletes themselves and getting them back on track. Providing they have passed all the strength and fitness tests. Week 33-40 is all about returning to training, taking contact, lifting heavy, jumping and sprinting to max velocities. Everything is tailored to the person and the sport they are returning to. By this time, their headspace is in a great spot also. Confidence is high and there's not a doubt of hesitation that when you get back to playing that your knee is the least of your issues. Your mindset has switched to performance! Winning games and giving it your absolute best! When we tick those boxes, the physio and surgeon give you the good to go and we sit and wait for your first game.
Don’t let your ACL injury ruin your love for sport. With the right program and a great support group chances are you will return to your sport stronger than you were previously!
Director Resistance Sports Science