ACL rehab - are we doing enough?
No, the answer is no. When reviewing the “top” ACL protocols I had something hit me hard - none of them called for doing deadlifts, none of them called for incorporating push and pulls (push ups, sled drags), few of them give conditioning guidelines - AKA - get back in shape. While reviewing protocols is something I do often - this revelation hit me like a ton of bricks.
When returning to a high level sport 30% of people re-injure their knee - unreal. When I look at research studies and am reading protocols the why is becoming more clear to me - we are SIGNIFICANTLY under training those who are returning to sports. Significantly.
Most clinicians and physicians agree that a protocol is “a guide”, it does not need to be followed verbatim. There is room to problem solve as the physical therapist but certain criteria are crucial to include. For years I have followed the research and the same remains true today: the goals for the beginning of rehab are clear, the goals at the end of rehab - including returning to sport are varied and not clear.
We now know that confidence is a key factor in an individuals ability, desire and success with return to sport. There are many measures and questionnaires that one can perform to help to determine readiness. These are all great, research and proven to give good information.
My issue comes in how we are training people - literally from day 1. What are we all doing from DAY 1 to help build strength, cardio conditioning, confidence and make people feel strong, resilient and immediately start to reduce (not encourage) fear of movement. I think all too often - we are instilling fear in people unintentionally - rather than intentionally helping people feel resilient and strong again.
Here are some thoughts
When can I start cardio conditioning?
If you can use your arms, probably within the few first week. There are “arm bikes” on which you can get moving, you can also perform arm exercises with minimal rest time to get your heart rate up. Once you have sufficient range of motion, and minimal pain with biking - then it is time to start to use the bike for cardio. Also- do not underestimate the power of walking which again can began 4-6 weeks out. You do not have to wait to do cardio conditioning until you can run again (generally around 4 months, give or take).
Can I weight lift?
Yes - let your PT help guide you - but you may need to ask them. You need to be smart about the stress you put through the knee as it is healing, but there is plenty you can do to get started.
By week 4 - I believe you should be able to do the dead lift motion (weight pending your personal abilities), from then on deadlifts become about progression, increasing weight etc.
By week 8 - other than heavy rotational activities you absolutely can be back to lunging, squatting, sled work - and now from week 8 to the end of rehab (and beyond) these exercises become again about load management - progressively, intelligently increase the weight to build your strength. Yes there is research that the graft is at it’s weakest 6-12 weeks post surgery, this is not to be ignored. But if we are following the bodies capabilities and really in tune with our programming to meet the patient in front of us, we can work just fine and progress through this phase.
Can I kneel?
My question - how does it feel? Don’t crank it, don’t push into pain, but if you are kneeling and it doesn’t hurt - why not? I like to get people kneeling early if they tolerate it - the earlier you can do it without significant symptoms - the better.
You are going to have to kneel in life. If you return to sport, you are going to fall on your knee. As appropriate - better start getting the body ready for these events.
What should end-stage programming look like?
As you are moving into the running phase (3-4 months after surgery) and the return to play phase (9+ months after surgery) - a program should continue to consistent of all over strengthening - extra emphasis on quads, hamstrings, gluts, soleus, gastroc…………………….the list goes on an on - but with a well desired program - you can hit all of the areas in your rehab and/or workouts.
Your weight lifting should match what you are trying to get back to - if it is an elite sport - you should be increasing that weight progressively.
Balance work a muscle in various scenarios (throwing a ball, with a single leg dead lift - much more than just on a foam cushion)
You should feel like you worked out - the later phase is not easy - it is work, hard work, get your *** going work, huff and puff work,.
Plyometrics, hopping, jumping, shuffling, sliding, sprinting, etc - should all be included
Sports specific activities, light drills first, then medium, then it is time to get it! Exercises can be done with said sport equipment to make it feel more realistic.
In this phase there needs to be a well defined guide of not only strength but cardio conditioning - how will be ensure you are ready to go game speed when it is time to go.
I will have other writes up to break out the phases of rehab, but people and healthcare providers alike - we need to get going here - train these people to be the athletes that they are and want to be. “Rehabilitation is simply training with the presence of an injury”. Don't forget the basics, don’t forget to build strength, don't forget about the rest of the body. Building confident, resilient people back is crucial for success following an ACL injury.