ACL Rehabilitation

Training Links

-For concurrent training around the recovering knee joint
-For graft care (hamstring, PTTB, quads tendon)

For the clinical decision making of surgical vs conservative management with ACL injury the following markers should guide the call:

(1) Episodes of instability/giving way & recurrence, number of episodes of instability is key
(2) Absence of secondary trauma/damage to surrounding structures (menisci, bony oedema, other ligaments) would warrant an attempt at conservative rehabilitation
(3) History of injury at the affected knee

ACL rehabilitation is CRITERIA-based NOT time-based

Athletes need to be made aware that their efforts will be proportionately rewarded when they train hard & consistently

Swelling/effusion reaction

Any swelling response intra-session or the following morning should be monitored and flagged for over-stepping the tolerance to load/forces introduced at the knee

All strength work done is highly specific; to the many conditions that we train under:

Range of motion, speed, joint angles, stability conditions, load type (stable/unstable), contraction type (we need these to match the demands of the end goal as much as possible, as soon as possible)

Consider other energy systems in the earlier stages of rehabilitation;

Cross-training & aerobic work maintenance is of high value when returning to running & beyond later down the rehab process (integrate with S&C staff)

Gymnastics training

Is an excellent adjunct for upper limb/trunk coordination particularly when the knee may still need to be protected somewhat (rings, parallel bars, hanging work, mobility etc)

Training Autonomy

Autonomy in the gym and exercise selection is very important, allow the athletes to choose a percentage of movements for that day’s session, or the type of load/weights/environment that they complete them in > increases motivation/arousal

Long-term arthogenic muscle inhibition

There will be neuromuscular control deficits & arthrogenic muscle inhibition (AMI) around the surrounding joint for up to 36 months post-operatively/injury, particularly affecting the type 2 (fast twitch muscle fibres), we need to undertake a large bulk of training in these in the form of RFD training, plyometrics, eccentric training, running/COD work – it needs to be proportionately more thorough than the early stages of rehab

Muscle bulk & hypertrophy focus

There will always need to be a concurrent management of muscle bulk (CSA measurements) and hypertrophy-focussed training to address this (chat with S&C staff and discuss best implementation of this long-term)

Categories, progression & testing

In each phase, exercise suggestions are labelled as easy/moderate/hard. One should be able to complete all the 'hard' category movements as well as satisfying the testing outlined at the beginning of each phase

Phase One

Acute Phase

Goals/Checkpoints:

-Aim to be completed by the two week mark post-operatively/post-injury
-Achieve normalized joint homeostasis

-Active ROM should be ceommenced as soon as possible in the pool (pending surgeon’s suggestions/sutures/wound status if post-operative)
-Pool work is reserved almost exclusively for AROM, no further training work is useful
-Take initial quads/calf bulk measurements for cross-sectional area baseline
-Non-WB strength work can commence in conservative amounts with swelling still present in the knee (bridging, pre-bridging work, isolated quads activation/NMES) but this is not high priority in these early stages, the priority is to increase the tolerance to performance training as soon as possible

 

Effusion/swipe test

Negative

PROM

Full extension, full/near full flexion

Quads lag test

Negative

Gait

Normalized, pain-free

Wall march

AROM

Variations

-Spindles

Coaching points

-Become as tall as you can
-Smooth & slow

Volume

2-3 sets, as frequently throughout the day as possible
30s each leg

Pool

AROM & basic movements

Variations

-Marching
-Leg swings
-Kicking
-Squats
-Lunges

Coaching points

-Zero pain during

Volume

60s each movement

AAROM

Banded control

Variations

Coaching points

-Slow and in control of range at top and bottom (flexion/extension)
-Straighten and brace leg at bottom

Volume

As frequent throughout the day as possible
30-60s each side

Phase Two

Strength & Neuromuscular Control

Goals/Checkpoints:

-Achieve baseline level of strength, stability & coordination

COMPONENTS:
-rotational control @ midstance, toe-off
-hip hinge/joint coupling low/medium impact
-graft care
-muscle bulk/hypertrophy
-basic eccentric strength
-hip lock & pelvic control

 

Star excursion balance test

Combined total in three directions, within 90% of unaffected limb

Single-leg box squat

45cm bench, tap bottom to target, within 90% of unaffected limb

Single-leg bridge

Heel elevated on 45cm bench, touch hips to hand target of therapist, within 90% of unaffected limb

1RM/3RM squat

Back squat or trap bar deadlift
Easy

Wall touch squats

Shallow range

Variations

-Single-leg
-Double-leg

Coaching points

-Touch bottom on wall
-Start one foot’s distance away from wall

Volume

2-3 sets
8-12 reps each leg

Moderate

Step-off

Counterbalance weight

Variations

-Kettlebell/dumbbell
-Back loaded

Coaching points

-Keep arms straight, lift weight out in front as you bring rear leg toward the ground
-Lift toes on stance leg, shift weight into heel
-Tap rear toe on the ground then return to start position
-Don’t bring weight too high up > will force extra load onto back extensors

Volume

3-4 sets
5-8 reps each leg

Moderate

Single-leg touch squat

W band touch

Variations

-Barbell loaded
-Unstable load

Coaching points

-Control at sticking point/bottom of movement
-Lift toes at bottom/shift weight to heel = glute/hip dominant

Volume

3-4 sets
5-8 reps each leg

Moderate

Single-leg deadlift

Fast throws

Variations

-Fast rowing (opposite hand)

Coaching points

-Keep arms straight
-Throw fast and far apart
-Short, fast throws then return to upright

Volume

2-3 sets
6-10 reps
10 throws each rep

Moderate

Single-leg band rotations

To target

Variations

-Hold at midline and squat
-Squat to knee drive
-Squat & rotate

Coaching points

-Should feel throughout deep glutes, not through TFL/hip flexors/groin
-Focus attention to target
-Pelvis shouldn’t rotate outward in either direction

Volume

2-3 sets
8-12 each leg

Moderate

Step-up hurdle spindle

Front loaded

Variations

-Barbell loaded
-Unstable load

Coaching points

-Maximize time moving through spindle with control
-Smooth movement through step-up to spindle and return

Volume

2-3 sets
4-6 each leg

Easy

Single-leg deadlift

Variations

Variations

-Band control
-Touch rear leg to target

Coaching points

-Touch rear target with foot (if possible)
-Head to heel strong as steel
-Stand very tall at top

Volume

3-4 sets
6-10 reps

Moderate

Single-leg back extension

Short holds

Variations

-Elastic bounces/drops
-Plate punches

Coaching points

-Keep knee slightly bent all the way throughout
-Hollow stomach out so back doesn’t compress too much
-Should feel through hamstring, minimal through lower back

Volume

3-4 sets
4-6 each leg

Moderate

Quarter squats

Heavy & slow

Variations

-Barbell loaded
-Box squat or rack limited squat
-Split squat or square stance

Coaching points

-No pain throughout the lift
-Gradual increase in load to check tolerance
-Fatigue, volume & overload is key here

Volume

3-5 sets
6-10 reps

Hard

Step down double heilos

W plate

Variations

-Aquabag/aquaball version

Coaching points

-Smooth halos around the base of neck
-Continuous squat motion on top leg, don’t pause
-Keep bottom leg straight on landing, squatting leg doesn’t collapse inwards

Volume

3-4 sets
5-6 reps

Hard

Step down aquabag twists

Variations

-Front loaded
-Back loaded
-Fast sharp twists

Coaching points

-Squat movement doesn’t pause throughout
-Keep bottom leg straight on landing, squatting leg doesn’t collapse inwards

Volume

3-4 sets
4-6 each leg

Moderate

Stick drop-catches

Hip hinge

Variations

-Heavy stick/very light bar
-Reactive version
-Split squat version

Coaching points

-Keep elbows locked straight
-Must keep arms straight on catching stick
-Bring stick still as quick as possible by bending through hip

Volume

3-5 sets
6-8 reps

Easy

Sled Push

Scrum style (knees bent)

Variations

-Straightening knees
-Scrum style (bent knees) as above

Coaching points

-Slow, heavy push sustained effort
-Never in socks or low friction surfaces

Volume

4-5 sets
10m distance

Moderate

Single-leg blocked knee squat

Counterbalance weight

Variations

-DB/KB

Coaching points

-Don’t bring load up to high (back extensors will do too much)
-Keep arms straight
-Bring weight out in front as you move down into squat position

Volume

3-4 sets
6-8 each leg

Moderate

Single-leg good morning

W plate punches

Variations

-Light plate
-Slow punches
-Bring plate behind neck after punch

Coaching points

-Keep fixed knee angle
-Should feel through hamstring with punch & hinge
-Keep chest out and long spine

Volume

2-3 sets
6-8 reps each leg

Easy

Sled Push

Heavy (knees straighten)

Variations

-Straightening knees
-Scrum style (bent knees)

Coaching points

-Slow, heavy push sustained effort
-Never in socks or low friction surfaces

Volume

4-5 sets
10m distance

Easy

Counterbalance squat

To box

Variations

-DB/KB

Coaching points

-Don’t bring load up to high (back extensors will do too much)
-Keep arms straight
-Bring weight out in front as you move down into squat position
-Gentle tap onto box, don’t sit

Volume

3-4 sets
8-12 reps

Moderate

TBA

TBA

Variations

-Light plate
-Slow punches
-Bring plate behind neck after punch

Coaching points

-Keep fixed knee angle
-Should feel through hamstring with punch & hinge
-Keep chest out and long spine

Volume

2-3 sets
6-8 reps each leg

Moderate

Wall squat & lift

Loaded

Variations

-With barbell on wall

Coaching points

-Touch inside of knee and foot to wall at end position
-Heel comes off the ground ASAP

Volume

3-5 sets
4-5 reps each leg

Moderate

Floor tap single-leg squats

All angles

Variations

-DB/KB

Coaching points

-Use a square or lines as markers to touch over
-Further the distance, the more difficult the squat

Volume

3-4 sets
8-12 reps

Moderate

TBA

TBA

Variations

-Light plate
-Slow punches
-Bring plate behind neck after punch

Coaching points

-Keep fixed knee angle
-Should feel through hamstring with punch & hinge
-Keep chest out and long spine

Volume

2-3 sets
6-8 reps each leg

Phase Three

RFD & Power

Goals/Checkpoints:

-Improve type 2 (fast twitch) muscle fibre development and control at speed
-Prepare for the commencement of running reconditioning

COMPONENTS:
-RFD with stiff extended & flexed knee
-swing leg retraction
-rotational control w extended knee & in hip hinge
-hip hinge/joint coupling medium impact
-graft care > progression
-muscle bulk/hypertrophy

Drop jump

From 45cm height, subjective analysis

Drop hop

From 45cm height, subjective analysis

Step, hinge & pushback

From 10cm plate, as fast as possible, subjective analysis of hip hinge

Catapult throw (med ball)

10m mark in collegiate footballers = high correlation with VJ
Easy

Roll-up landings

From box/bench

Variations

-Single-leg
-Double-leg
-Low box
-High box
-Races

Coaching points

-Hold landing for 3s
-Change angles for variations
-Strong, stable hold positions

Volume

4-5 sets
4-5 reps each leg

Easy

Box assisted hops

One knee propped on box

Variations

-Reduce support on box knee
-Hop over hurdle

Coaching points

-Try to minimize countermovements
-Focus on control on landings

Volume

4-5 sets
4-5 reps each leg

Moderate

Front leg box taps

W rotations

Variations

-Plate punches
-Aquabag punches
-Halos

Coaching points

-Feet split running stride distance apart
-Taps on plate/box as fast as possible
-Keep rear foot & pelvis in straight line
-Punch fast out to side, keeping chest out

Volume

10-12 taps
2×12 each leg = 1 set
3 sets

Easy-Moderate

Lateral bounds

Aquabag variation

Variations

-Holds
-Faster landings and push-offs

Coaching points

-Use soft mat only initially to minimize impact
-Strong landing/push-off position
-Use aquabag to stiffen trunk & minimize compensation

Volume

4-5 sets
4-5 reps each leg

Moderate

Box jump

Plate behind neck

Variations

Coaching points

-Keep plate still behind neck
-Not touching neck
-Minimize countermovements as much as possible

Volume

4-5 sets
4-6 reps

Moderate

Step & chop

W plate

Variations

-Step, chop & pullback
-Chop with aquabag

Coaching points

-Chop across the body in both directions (alternate reps)
-Straight arms on chop
-One side chop will be harder to control than the other
-Hold strong in end position

Volume

3-4 sets
4-6 reps

Easy-Moderate

Step & chop

Hip hinge

Variations

-Aquabag/aquaball punch
-Dangling weights
-Punch & pullback to chest

Coaching points

-Encourage hip hinge over spinal flexion
-Hold strong end position 2s
-Punch to target, hit target hard

Volume

3-4 sets
6 reps each side

Moderate

Step, chop & pullback

W plate

Variations

-Aquabag version

Coaching points

-Chop both directions across the body
-Spend very little time on the ground with front foot
-Keep looking forward/up

Volume

3-4 sets
6 reps each side

Moderate

Trap bar jump

Light load

Variations

-Shallow start
-Countermovement or non-countermovement

Coaching points

-Try to come to a strong landing position as fast as possible
-Explode up from low loaded position

Volume

4-6 sets
3-5 reps

Moderate-Hard

Hop & throwdown

Hip hinge

Variations

-Without hopdown from box
-To target

Coaching points

-Keep elbows straight
-Bring ball down fast towards floor/object as quick as possible
-Stop before touching object
-Throw ball down at same time as foot hits the ground

Volume

3-4 sets
6 reps each side

Easy

Bench bunnies

Double leg

Variations

-Change bench height

Coaching points

-Use hands to offload legs as much as needed
-Gradually build confidence and take arm support away
-Strong, stable landing position, ready for next play (looking up, chest out)
-Make every repetition different (landing angle, hand support, start position etc)

Volume

3-4 sets
6 reps each side

Easy-Moderate

Bench bunnies

Single-leg

Variations

-Over box
-Over bench

Coaching points

-Use hands to offload legs as much as needed
-Gradually build confidence and take arm support away
-Strong, stable landing position, ready for next play (looking up, chest out)
-Make every repetition different (landing angle, hand support, start position etc)

Volume

3-5 sets
6 reps each side

Moderate-Hard

Lateral hop & hold

With weighted hold

Variations

-Hop over hurdle
-Hop over target lines
-Increase height/distance of hops

Coaching points

-Straighter elbows & heavier weight = increased rotational torque
-Must hold for ~2s
-Keep plate very still

Volume

3-4 sets
6 reps each side

Easy

Lateral bound & punch

W aquabag

Variations

-With plate or aquabag
-Increase height/distance of bound

Coaching points

-Make big splash with bag
-Pullback to chest after punch
-Minimize compensation of the trunk upon landing with punches/holds

Volume

3-4 sets
6 reps each side

Moderate

Lunge paddle

W aquabag

Variations

Coaching points

Volume

Phase Four

Plyometrics & Elastic Impacts

Goals/Checkpoints:

-High impact loading under time pressure
-To be ran concurrently with running reconditioning

COMPONENTS:
-foot plant from above
-swing leg retraction
-trail leg catching up (extended force closure)
-hip hinge medium impact
-graft care & muscle bulk/hypertrophy

Side hop test

Continuous hops, between 40cm tape distance, for 15-30s, within 90% of unaffected limb

Single-leg hop for distance

Must hold landing, within 90% of unaffected limb

Triple hop for distance

Must hold landing, within 90% of unaffected limb

Triple crossover hop for distance

15cm laneway, must hold landing, within 90% of unaffected limb
Easy

Hurdle jumps

Fast

Variations

-Mixed hurdles & boxes

Coaching points

-Be as fast off the ground as possible

Volume

4-5 sets
6-10 reps total

Easy

Step & hinge

W pertubations

Variations

-Step & punch

Coaching points

-Bend at the hip
-Step and push back as fast as you can
-Should feel tension through hamstrings/glutes as opposed to all at the knee

Volume

3-4 sets
6 reps each side

Hard

Double step down

W aquabag rotations

Variations

-With plate rotations/punches
-Multiple steps

Coaching points

-Very fast steps
-Fast momentum followed by strong stop & hinge at hip
-Hold end position
-Keep chest out when rotating
-Splash water in bag loud

Volume

3-4 sets
4-6 reps each side

Moderate

Ramp runs

Barbell

Variations

-Short steps
-Longer 4-5 steps on stairs

Coaching points

-No collapse into ankle dorsiflexion
-Very fast off steps
-Stand very tall

Volume

6-8 sets

Easy

Lateral shuffle

Over plates

Variations

Coaching points

Volume

3-4 sets
6 reps each side

Moderate

Step-throughs

W hurdle

Variations

Coaching points

Volume

3-4 sets
4-6 reps each side

Phase Five

Running Reconditioning

Running Reconditioning

Agility T-test

Symmetry within 90% of turning direction

Agility star

Symmetry within 90% of turning direction

5-10-5m

Symmetry within 90% between sides

Stop & go, lateral shuffle, decel & backpedal

Subjective analysis of high impact, time pressured COD