Anterior Cruciate Ligament (ACL) tears and reconstruction are very common in the world of athletics. Either you know of someone who has had their ACL reconstructed or you have yourself. (Prior to being a physical therapist, I had mine reconstructed TWICE!)

The risk for ACL tears and reconstructions is on the rise and some say it can be considered an epidemic. Women are 4-5x more likely to tear as men. ACL tears are not something that can be totally prevented, but with sound training, the incidence of them can be reduced.

As Mike Boyle has said, “ACL injury prevention is just good training.”

We can do all that we can to try and decrease the incidence of an ACL tear from happening to one of our athletes or clients. But, what if our athlete has already suffered an ACL injury? Where do we go from there?

First off, a licensed physical therapist will handle the immediate post-operative phases of the rehab process. This will include:

• Improving Range of Motion (ROM) – ideally hyperextension and full knee flexion
• Ensuring Proper Quadriceps Firing
• Decreasing Swelling
• Improving Core, Hip, Knee, and Ankle Stability
• Optimizing Single Leg Stance

Just because someone may be done with physical therapy and may have optimized the aforementioned areas does not mean they are ready to return to sport.

Many physical therapists are great at Stage I of the rehab process after an ACL reconstruction. But unless the PT has a background in strength and conditioning, this is typically where a gap is present.

More often than not in the physical therapy realm, patients or clients will be discharged from physical therapy at approximately 3 months after surgery. Whether it be due to insurance limitations or because the physical therapist believes this is as far as they can take the patient, and there is where you find that wide gap between the end of physical therapy and full return to sport.

I will typically take someone from the pre-operative phase of rehab to the post-operative phase… and then to the eventual return to sport.

// A Big Disclaimer

First off, if you are a strength and conditioning coach or personal trainer, contact the physical therapist!

Find out where the athlete left off in their rehab and what basic movement patterns they were performing (e.g. squat, hip hinge, etc.). This will give you a better idea of where to start the athlete and how to progress them.

An ACL reconstruction is a specific type of surgery, but there are different variations and specific post-operative restrictions when returning to strength and conditioning. Make sure you are part of the team and speak to the treating physical therapist to help guide your training program.

// The 3-Month Mark

At the 3-month mark, most athletes should be able to perform the basic fundamental movement patterns such as:

Find out where the athlete left off in their rehab and what basic movement patterns they were performing (e.g. squat, hip hinge, etc.). This will give you a better idea of where to start the athlete and how to progress them.

An ACL reconstruction is a specific type of surgery, but there are different variations and specific post-operative restrictions when returning to strength and conditioning. Make sure you are part of the team and speak to the treating physical therapist to help guide your training program.

This is where the strength and conditioning professional comes in.  

If a client comes to you 3 months after surgery and they are done with physical therapy, where do you go from there?

Get them STRONG and ATHLETIC!

I would avoid testing athletes in their 1 to 3-RM until they are cleared to return to sport.  

For frequency of training, 2-4x/week would be ideal to help improve the athlete’s strength and work capacity. Mind you, most athletes haven’t been on the field or court since their injury. They need to increase their work capacity in order to handle more stress on their body.

Regarding repetition schemes, bilateral compound movements such as squats, deadlifts, etc. should be trained between 3-6 reps. For rep schemes for single leg movements, repetitions can range from 6-12 reps.

Regarding progression and loading parameters, use typical progressive overload principles and progress the athlete as needed if movements are becoming too easy. As said before, avoid 1 to 3-rep max testing or movements where technical failure is likely.

// Core

Besides lower body strengthening, we want to make sure we are working on core strengthening as well. Stabilizing the core 360 degrees is ideal to make sure the athlete can stabilize their trunk and lower body.

Movements consisting of anti-extension, anti-lateral flexion, anti-flexion, and anti-rotation are key.  Examples of these are:

Form and technique are of the utmost importance as with any training. If an athlete or client cannot maintain good technique, correct them. OR you can adjust the movement so they can be challenged, but their technique is on point.

Prior to commencing training, we want to make sure mobility is where it needs to be.

Strength is important, but so is mobility! We want to make sure the athlete is displaying sufficient mobility at the hip, knee, and ankle to decrease the chance for future injuries.

From the 3-month mark post-operation and ahead, continue to improve the athlete’s strength, mobility, etc. Typically, around the 4-month mark, the athlete or client will return to the physician for a 4-month post-op appointment.

Depending on the athlete and the surgeon, this is when the athlete will often start a Return to Running Protocol.  

Prior to commencing a Return to Running Protocol, I like to check a few things.

If any of these tests have variance side to side, it would be beneficial to place running on hold for the time being to iron out any of the inefficiencies. If someone attempts to run with these differences, they will become magnified and can potentially lead to pain, etc. that will only slow down the process of an eventual return to sport.

// Return to Running Progression

There are many “Return To Running Protocols, but the key among all of them is Gradual Progression.

Start with a small dose of running paired with walking. Gradually increasing the running dose and decreasing the walking dose is key.  

People who return and attempt to run too far, too fast, or too soon will end up spending more time trying to “bat down the flames” and decrease pain/discomfort due to improper loading patterns.

A typical Return To Running progression looks like this:

• Walk x 4 min, Run x 1 min, Repeat x 3 rounds
• Rest x 1 day
• Walk x 3 min, Run x 2 min, Repeat x 3 rounds
• Rest x 1 day
• Walk x 2 min, Run x 3 min, Repeat x 3 rounds
• Rest x 1 day
• Walk x 1 min, Run x 4 min, Repeat x 4 rounds
• Rest x 1 day
• Walk x 1 min, Run x 5 min, Repeat x 3 rounds
• Rest x 1 day
• Walk x 1 min, Run x 6 minutes, Repeat x 3 rounds
• Rest x 1 day
• Walk x 1 min, Run x 7 minutes, Repeat x 3 rounds
• Rest x 1 day
• Walk x 1 min, Run x 8 minutes, Repeat x 2 rounds
• Rest x 1 day
• Walk x 1 minn, Run x 10 minutes, Repeat x 2 rounds

Once that is complete, progress to 3 minute walk x 12 minute run then 15 minute, 18 minute, 20 minute run with 1 day of rest between each those days. Once you have completed walk x 3 minutes, and run x 20 minutes, repeat 2 more times on separate days and the progression is complete.

Athletes will say that they feel “weird” or “off” when running for the first few times. This is normal.  For someone who hasn’t run for at least 5 months prior to this due to surgery/rehab, this is a common message you will hear.

Some athletes and clients will have complaints of mild discomfort when returning to running. As long as it goes away after running and improves with increased exposure, that is ok. If someone is continuing to experience pain/discomfort with the Return to Running Protocol, consult with the treating physical therapist to develop the best game plan heading forward.

At approximately the 6-month point – as long as the Return to Running Protocol progressed as planned – a program for returning to jumping/plyometric work commences.

// Wrap It Up

There you have it! A complete progression from physical therapy discharge to a return to jumping. Make sure to stay tuned for a future post detailing the return to jumping and plyometric program!