ACL REHAB: THE PROCESS
ACL rehabilitation is a slow and arduous process which takes motivation, dedication, and persistence to see good results.
This is designed to be a general guide to help understand the rehabilitation process, specific guidance from your Physiotherapist is recommended with regards to exercise progression, return to activity, and return to sport.
Commonly people find themselves at points in the process where they feel stagnant and lost with how to progress, or they’re told there’s nothing more they can do even though they’re still in pain and lack function.
The most common mistake I see people make when rehabilitating an ACL injury is not working hard enough. They’ve been doing the same exercises for weeks or months with no progression and they are far too easy to stimulate change.
The second most common mistake I see people make is progressing through each phase of training too fast, and returning to high level functioning activities, such as pivoting sports, without setting the foundations to build a robust system.
And the third most common mistake I see people make is skipping key exercise types such as power or plyometrics.
The rehabilitation process is generally broken down into 5 phases (1: Pain Management, 2: Reloading, 3: Strengthening, 4: Athletic Development, 5: Return to sport) however, within each phase are multiple phases of development which are often overlooked that are the building blocks for a complete system.
All phases should follow the principles of progressive overload and gradually increase intensity, volume, and frequency to continue to provide adequate stress to the system.
Pain and injury management: The early stages post-injury are aimed at reducing pain, reducing swelling, maintaining movement, and managing fear.
This will consist of exercises such as walking, stretching, mobility exercises and
relative rest from aggravating activities are important
Progression to Phase 2 occurs when swelling is gone, full range of motion has been
achieved, and pain is minimal.
This generally occurs within 2-6 weeks, however can take longer sometimes.
Reloading: Once the knee has settled, the process of re-introducing load begins. The goal of this phase is to slowly increase tolerance to resistance, bodyweight and volume of exercise.
This will consist of bodyweight exercise such as squats, lunges, step-ups, and leg extensions etc. with a progressive increase in volume and intensity.
Progression to Phase 3 occurs when you can safely perform these movements
without increase in pain, or swelling.
This generally takes 4-12 weeks
Strengthening: The goal of this phase is to build strength as a foundation for higher level function. This is often the area where people fail to work hard enough for long enough before progressing on.
The strengthening phase should be broken down into 2 phases of training.
Hypertrophy: The increase in size and number of muscle cells resulting in increased muscle mass is the first step in building strength.
The same movements can be used from phase 2, but the emphasis is on volume, intensity, and time under tension.
Exercises should be between 3-4 sets, 8-12 repetitions of slow controlled tempo (e.g 2s up, 1s pause, 2s down, 1s pause) movements with a 7-9/10 intensity meaning by the last rep you should feel like you almost couldn’t do another one, with 30-90s rest between sets and 0-2 days rest between days exercising.
In general weekly volume should be at least 10 sets per muscle group.
The hypertrophy phase may be anywhere between 6 weeks to 6+ months depending on how much muscle you already have.
Strength: Using the muscle mass you now have, you can teach your body to be more efficient in using each cell together to develop strength.
Strength exercises are similar movements, but with an emphasis on intensity, because of this, time under tension and volume is reduced, and rest and recovery is increased.
Exercises are between 3-6 sets, 1-6 repetitions with an intensity of 7-9/10, so when you’re doing a 2 rep squat at 9/10 intensity you feel like your eyes are going to burst out of your skull. Rest between sets can be between 60 seconds to 3 minutes, and recovery between 1-3 days.
The strength phase generally lasts between 4 weeks to 3-6 months.
Progression to phase 4 may occur when 90% strength is achieved in the injured limb
compared to the uninjured limb and you can perform a forward hop to 70% of the
distance of your uninjured limb.
4. Athletic Development: The goal of this phase is to increase aspects of
athletic ability; the ability to jump high, run fast, and turn quick. When broken
down, there are 4 main training types that develop these abilities.
Power: Recruiting your muscle units to generate strength as quickly as possible.
Using the same movements used to build strength, now the emphasis is on moving the weight as fast as possible.
Exercises are between 1-4 reps, with 4-8 sets using 30-60% of the weight you would use when aiming to build strength. The focus is on explosive movement. Rest between sets is 2-3 minutes with recovery of 2-3 days between workouts.
The power phase may last between 4-12 weeks.
Plyometrics: Recruiting maximum reactive muscle force as quickly as possible and utilising the energy stored in your muscles and tendons when they are stretched.
These exercises involve movements such as jumping and hopping and emphasise maximum effort and quick reaction. For example jumping over hurdles and trying to reduce the time you are in contact with the floor as much as possible.
Exercises range between 5-20 or more repetitions of 3-5 sets with an overall session volume (e.g number of foot contacts of 50-200).
Exercises are generally bodyweight or assisted with 1-3 minutes rest between sets with 1-3 days recovery between sessions.
The plyometrics phase may last between 4-8 weeks.
Speed: The ability to move all parts of the body as quickly as possible.
The emphasis of this phase is to develop joint and whole body speed.
Running and sprint training are the basis for speed development in ACL
rehab.
Training may consist of 3-8 sets of 10-100m sprints at 70-100% effort with 1-5 minutes rest between efforts. Recovery may be between 2-4 days between sessions.
Speed training may last between 4-6 weeks.
Agility: The ability to change direction rapidly.
Emphasis on turning, pivoting, and changing direction as fast as possible.
Agility training is generally similar to sprint training but incorporates fast, explosive changes in direction.
Training may consist of 4-8 sets of 2-20m sprints with rapid changes in direction at 70-100% effort with 1-5 minutes rest between efforts. Recovery may be between 2-4 days between sessions.
Agility training may last between 4-6 weeks.
Progression to phase 5 may occur when you have >90% strength, >90% hop
performance
5. Graduated Return to Sport: The aim of this phase is to progressively introduce the athlete back into pre-injury sport through graded exposure to sport specific
movements, training, games, and competition.
Exposure: Gradually becoming exposed to sport specific movements, skills, and challenges is important to build confidence, skill,and fitness in a safe environment before returning to training and competition.
This may consist of 1 v 1 drills which replicate small parts of the game in predictable and unpredictable circumstances and progress toward small sided 3 v 3 drills.
Progress toward return to training may occur once confidence has been regained, all movements can be safely performed, and return to sport psychological questionnaires have been passed.
Return to Training: Once all return to sport criteria are met, you may return to unrestricted training.
It’s recommended that participation of at minimum 4 weeks of unrestricted training occur before returning to sport.
Return to Sport: Once all criteria have been met, return to sport may be safe.
6. Return to Performance and Injury Prevention: Once return to sport has been
achieved the focus turns to regaining performance and preventing reinjury.
Continuing to follow the principles of progressive overload in the strength and athletic
development phases can continue to improve performance and reduce injury risk.
Incorporating an injury prevention program such as the FIFA 11+ or Netball KNEE
program during training and match warm-ups and cool-downs is essential to lowering
risk of reinjury, and should be performed for the life of your sporting career.
Spending enough time in each phase of training, particularly the strength phase is essential to build a robust base for high level functional performance!
