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ACL Series Part 3: Rehab

Manny Tharrington

ACL Series Part 3

ACL Rehabilitation

The third and final part of this ACL series is where the fun really begins!  If you have been following along you have read about my personal experiences with ACL reconstruction including pre-surgery, surgery, and acute post-op phases.  Parts 1 and 2 are linked here:

Part 3 will cover all things strengthening!

I don’t tend to name specific dates when it comes to post-ACL rehab timelines.  I have seen enough ACL tears and have now had my own personal experience to know that every athlete’s timeline is going to be different.  Everyone recovers at different rates and are presented with combinations of obstacles along the way.  It is important to recognize that just because a protocol outlines a timeline, it is imperative that the athlete has met all the requirements of the previous phase before moving on to the next.  For the purposes of this blog, I will be discussing these timelines based on typical patterns, my own experience, and evidence-based practices, not any one protocol.

In part 2 of this series, we left off on the goals of the first week after surgery with emphasis on managing pain levels/swelling, restoring range of motion, and initiating quad activation.  As the athlete begins incorporating more strengthening, it will be important to keep these goals in mind as it will help provide a guideline for appropriate progressions.

ACL POst Operative Quad Weakness

In the first few weeks of rehab the athlete will likely have noticeable weakness in quads, hamstrings, and proximal hip musculature.  They will also likely still have some residual swelling and range of motion deficits- particularly in knee flexion.  This phase can be difficult to navigate as we want to make sure the athlete is not experiencing increases in pain/swelling or decreases in range of motion while also progressively loading the weak areas.

In my own personal rehab, I can remember attempting a heel lower/tap down exercise and quite literally not being able to activate my quad enough to bend my knee to touch the ground from a 1-inch box.  At this point I was still extremely weak in my quad, but I was also limited by pain from the incision down the front of my knee where they harvested my patellar tendon.  It felt ridiculous having such difficulty with that small of movement, but hey, that’s rehab.

ACL Rehab Consistency is Key

With all of that in mind, this is the part where consistency of hard work really pays off.  There are so many creative things you can do in this stage to stay moving and maintain your previous level of activity.  As someone who participated in higher levels of fitness before my surgery, I was determined to avoid losing this level of activity.  I made sure I kept my routine of 4-5 CrossFit classes a week.  Obviously, the movements I was able to participate in were very different from those pre-surgery but nonetheless, I was there, and I was working hard. 

how a typical REHAB session would go for me:

1.       10-15 minutes of dynamic mobility

Check out my blog post on the importance of warming up for a list of my favorite dynamic mobility movements.  Of course, some things needed to be modified and then progressed based on my strength and range of motion at any given time, but you get the point.

2.       25-30 minutes of Physical Therapy

When it comes to exercise prescription, we need to take into consideration the load, volume, and ranges of motion with each movement.  Every athlete will likely have a different tolerance with each exercise.  This could be due to a variety of reasons such as graft choice, baseline strength prior to surgery or even experience level with new movements.  At this stage we are mostly focusing on restoring strength.  It is important to provide progressive, yet varied, activities and ensure proper mechanics with each movement.  We want to make sure we are not increasing stimuli, whether that be volume, load, or intensity, of a particular drill until the athlete has mastered the basic movement pattern. 

 These were some of my favorite movements to incorporate:

3.       15-20 minutes of Crossfit/Metabolic Conditioning/HIIT

To be honest, my workouts looked a little odd considering I had very limited use of my right leg for the first few weeks.  I find that it is easy to “throw in the towel” and accept the multitude of excuses that can be made to avoid maintaining a high level of activity when undergoing post-surgery rehab.  It takes a lot more grit and creativity to stay motivated and engaged.  I focused on trying to do as much of a crossfit workout as I could while staying safe and protecting my surgical knee.  You could find me using an Airdyne or Assault bike with just my arms and not my legs.  You’d see me using the rower with my right foot extended on a slider to avoid knee flexion ranges that my knee would not allow at the time.  Even modifications as simple as seated movements instead of standing.  These adjustments allowed me to not only continue to elevate my heart rate and burn some calories, but it also allowed me to continue feeling like an athlete.  It’s easy to feel fragile but there are still so many things to work on and get better at, even when recovering from a torn ACL!

4.       10 minutes of miscellaneous recovery drills as needed

This is where I would address any ongoing limitations that needed a little TLC.  I had quite a bit of hip flexor tightness initially from walking around in my locked brace for the first few weeks, so I would spend time doing some soft tissue work here. 

Not everyone’s journey will look the same, especially at this phase.  Some days will feel like you are making no progress at all, and others will make you feel like nothing ever happened in the first place.  Just remember that our bodies are incredible and much more resilient than we sometimes feel.  Be smart about your rehab, follow your PT’s instructions and show your knee who’s boss!

Stay tuned for ACL Journey Part 4
Manny writes about the specifics of her Return to Sport (RTS) protocol and personal experience.

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AUTHOR:

Manny Tharrington, PTA, CSCS, CFSC

CONTRIBUTORS:

Dr. Christopher Wahl, MD
Frm UW & Chargers Team Physician, Sports Medicine Physician & Orthopedic Surgeon
Dr. Dayne Mickelson, MD
Former College Basketball Starter, Proliance Orthopedics and Sports Medicine
Dr. Ron Gregush, MD
ProOrtho Kirkland
Dr. John Manning, MD
Evergreen Health Orthopedics & Sports Medicine
Ben Wobker, PT, MSPT, CSCS, CFSC, SFMA
Founder & Director LWPT

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