May 7, 2025 • 34 mins
Tearing your ACL might seem like the end of your athletic journey, but with the right approach, it's just a detour on your path to peak performance. This deep dive into ACL rehabilitation breaks down the entire recovery process from injury mechanics through return-to-sport testing.
Did you know that most ACL tears occur without any contact? The classic "guillotine effect" happens when your knee twists while planting and cutting—a movement pattern that can be trained and improved. Female teenage athletes face the highest ACL injury risk, followed closely by those who've already experienced a previous tear. Understanding these risk factors is the first step toward prevention and successful recovery.
The rehabilitation journey follows distinct phases, each with critical milestones that can't be rushed. From the immediate post-surgical focus on regaining full knee extension (the most crucial early goal), through the progressive strengthening phases, to the final sport-specific training—we map out the entire 10-12 month process. You'll learn why pushing too hard too soon leads to complications like patellar tendonitis, and how specific tests determine when you're truly ready to return to competition.
Most importantly, we emphasize that recovery isn't linear. Even with perfect adherence to rehab protocols, you'll experience both triumphs and setbacks. The key is maintaining perspective and trusting the process. Whether you're currently navigating ACL recovery or supporting someone who is, this episode provides the roadmap for successful rehabilitation and long-term knee health.
Have you experienced ACL injury or surgery? Share your journey with us—the challenges you've faced and the victories you've celebrated along the way. Connect with us at team@athleterc.com or call 899-8725 to discuss your specific situation.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
So I realized we haven't evendone any ACL topics yet, so I
(00:20):
wanted to run through a wholegamut of like.
What is the ACL rehab processlook like for ACL reconstructive
surgery?
And I'm going to say thisdoesn't include a meniscus
repair, because a meniscusrepair is a little bit delayed,
but it's still very similar, andit's not uncommon that a
meniscectomy happens with an ACLreconstruction.
(00:43):
Um and ACL is the anteriorcruciate ligament, and that's um
, a very common injury that youhear in the new like for sports
athletes, figures and stuff.
And, uh, an ACL injury happenswith um, a guillotine effect,
where the tibia is the shin boneand the femur is up top.
And if it, uh, if the tibiadives laterally and the femur
(01:05):
dives medially, and so theyshift different directions and
they rotate a little bit at thesame time, um, where the femur
rotates internally and the tibiaon a usually a fixed leg
rotates um externally.
That's a, it's like aguillotine effect, and it slices
out, it just cuts the ACL.
Something to keep in mind,though is the ACL injuries.
(01:27):
They call it like ligamentfatigue, where the ACL actually
gets frayed over multipleinstances without even knowing
it and then one more final blowkind of finishes the job and it
tears the ACL completely, orenough to where there's enough
symptoms or it's hanging on by acouple of fibers that needs to
be reconstructed.
But it's not uncommon that theACL goes through multiple
(01:51):
injuries, micro injuries, overmultiple episodes where they
didn't know otherwise, and thennow it's just enough to where
there's enough symptoms andswelling and instability that
comes with an ACL injury likethat that leads to a person need
to go to the doc.
You know like I heard my kneepop.
It's partially torn.
Now you know whatever or not,full torn, full tear.
(02:12):
Another really interesting toconsider is the most common ACL
injuries are non-contact, whereit's not like, if you imagine,
in soccer or football.
In soccer somebody slide,tackles a player and they get
hit from the side and their kneebuckles and twists and weird.
You know that in a verytraumatic event.
Or in football somebody getsrolled on and their knee gets
(02:35):
stuck and their foot gets stuckand then their knee twists.
I mean that happens.
But actually in the researchthe most common is non-impact,
where somebody just plants andcuts in a in a uh opposite
direction and for some reasontheir knee buckles and they're
it twists in a weird fashion,like in that guillotine effect I
was talking about, and thatfinishes the job.
Acls cut or uh, ruptures.
(02:56):
So, um, it's interesting tokeep in mind, right.
So it's like all right.
With that being said, then howcan we lower the risk for
athletes of non-contact ACLinjury?
We definitely have to work onsingle leg stability and control
, proprioception, dynamiceccentric control and strength.
And that's like, can a persondescend and load into their leg
(03:19):
with a good control fashion, agood controlled fashion after,
like, imagine landing from asingle leg jump and volleyball
like a slide jump or like asingle leg jump, like that in a
right side slide, or abasketball player going up for a
single leg layup, and if theyland again on one leg, that's uh
, can they land when they hitthe ground and accept their load
(03:41):
of their body weight afterjumping in a good fashion that
looks controlled and not wobblyand unstable?
So those are the things to workon.
Then they also consider thefemales are actually higher
likely of tearing an ACL andusually between the ages young
female athletes like in theirteenage years, teenage athlete
(04:03):
females are the most commonathletes.
Between like in their teenageyears teenage athletes females
are the most common highest riskfor an ACL tear and following
that, actually the highest riskof an ACL tear is a previous ACL
tear.
So unfortunately it's notuncommon where um an athlete,
even in high school, they'vealready had two ACL uh surgeries
.
Now they're on the third right.
It's a bummer.
(04:23):
They usually representsrepresents it's just instability
and poor movement control anddynamic eccentric control with
ballistic movements like agility, cutting, landing, planting,
stuff like that.
And a surgically repaired ACLis already compromised.
So it's super important to justcrush stability and strength
(04:44):
with that knee and not lead tocompensation patterns or
asymmetries between the knee andthe strength.
All right, um, so anyway, I'mgoing to run through.
Like what does that look like?
Let's say somebody tears theiracl, then what do you do?
And then what does the surgeryand rehab look like afterwards?
All right, so the first step isuh, usually somebody has to get
(05:07):
a consult with a doc, all right, and they get an mri.
The only way the whole, thegolden standard is to is to
check out an mri and see if theacl is torn and maybe other
internal derangement which wouldbe like meniscus, mcl, lcl or
pcl.
Pcl is very uncommon.
Pcl is the posterior cruciateligament and the most common way
that they call it a dashboardinjury, where imagine if someone
(05:30):
gets in a car accident andtheir knee gets, or the
dashboard shoves backwards intosomeone's knee as a passenger or
the driver and that shoves the,the tibia, the shin, backwards
against the femur and thatstresses and overly stretches
the PCL and that tears the PCL.
But so the first step got toget a doc consult and get an MRI
(05:53):
and confirm that it's torn.
Let's say you get an MRIconfirm it's torn.
Now what?
All right, you can set up withtheir specialist orthopedic
surgeon and you know if it'sappropriate, schedule surgery.
Um, usually, which they try toget surgery and as quickly as
possible, and uh, getting prehab, getting rehab, uh, exercise
(06:13):
and work done before surgeryreally improves the outcomes
after surgery.
So it's really advocated to getsome kind of physical therapy,
sports, physical physicaltherapy, if that's possible and
accessible for you to get beforesurgery and a lot better
outcomes afterwards.
We can get some of the swellingout, get things strong and
(06:34):
active as best as we can,because after injury like that
very common.
The muscle girth and strengthof the quadricep muscle and all
the other surroundingmusculature already is a little
bit atrophied.
It deadens a little bit andit's a neural defense mechanism,
the body's natural defensemechanism, to shut things off
because things are injured.
So that happens.
(06:56):
So it's important to get thingsreactivated and strong and
reinvigorated and normalize therange of motion, maybe even
decrease swelling before surgeryand the outcomes will be way
better.
So a little bit of prehab formaybe a month, all right, or in
three weeks and then surgery andthen when you wake up from
surgery, this is what we'regoing to talk about.
So initially things are goingto be swollen and it's going to
(07:18):
hurt and it's going to be tenderand muscle atrophy happens
really quick.
It's like as soon as you wakeup from surgery your muscles are
pretty much shut off,especially the quad.
The quadricep muscle on thefront of the thigh is the first
thing that we really focus on toget activated again.
All right.
So you wake up from surgery.
It's not unlikely that ifthere's no meniscus repair, they
(07:41):
want to start rehab that week,like for pro athletes.
As an example, they're in therethe next day, 24 hours later.
We're ready.
We're starting to do anexercise, exercise being like a
range of motion, movements and aquad activation exercises calf
pumps, ankle range of motion andum, beginning the process of
(08:03):
some.
Um, weight bearing is tolerated,all right.
So usually weight bearing istolerated.
You can put as much weight onas appropriate.
They just want to preventinjury.
So you're going to be in abrace, usually locked out in
extension, for safety whenyou're ambulating around your
house or in the community, or toand from physical therapy, so
that you don't buckle.
All right, because everything'sweak and, like the quad muscles,
(08:25):
your knee is just weak, it'scompromised.
They had a major surgery, theyhad to put tunnels and drill
through bone in order torecreate the ACL.
So things are, you know, weak.
So it's just important to keepthings safe.
And a knee brace that's lockedout in extension doesn't let
your knee bend, so that whenyou're ambulating around, when
your crutches, that's locked outand extension doesn't let your
knee bend, so that when you'reambulating around, when your
(08:46):
crutches, uh, like a, your oneleg is like a peg leg but you
can put a little bit of weightthrough it, but, um, it's not
going to buckle on you so youfall, because that would be, you
know, no bueno, and that wouldlead to more swelling and pain,
discomfort and potentiallyinjure the graft site, which we
don't want to do right.
So that process is, you know,from zero to three weeks.
(09:07):
That first three weeks of time.
The goal of that time frame isjust to get the swelling down,
start some range of motionmovements and get your knee to
bend and extend comfortably,usually up to a little bit of a
restriction.
We don't go past 90 degrees ifthe meniscus isn't repaired.
(09:28):
Just allow the graft site toheal.
Compression sleeves, ankle pumps, range of motion, quad
activations probably the mostimportant thing, followed by
sorry, I take it back the mostimportant thing is to get your
knee fully straight and extended, all right, and then normalize
your gait pattern.
Those are the first mostimportant three things.
(09:48):
Get the knee to fullystraighten out again, get the
quad to start to activate andturn on, and then normalize the
gait pattern, all right, thoseare the top three most important
things.
Getting the knee to bend andflex is important, but with, as
the swelling decreases, thatwill improve, and I'm an
advocate to not crush and overlypush to bend the knee yet.
(10:12):
All right, you will bend theknee.
I feel like I sound like gameof thrones bend the knee.
You will bend the knee, just Idon't.
There's not a rush, all right,because it's sometimes overly
pushing it into flexion likethat can increase irritation and
swelling.
That's going to ultimately leadto more quad inhibition like
deactivation and atrophy or justlack of activation for the quad
(10:34):
, and it's going to limit andhinder the flexion range of
motion anyway and keep theswelling in there.
So I'm like there's a, there'sa threshold.
We want to push a little, youknow, bend it, just get
comfortable with it, but thatwill come.
It's not a threshold.
We want to push a little, youknow, bend it, just get
comfortable with it, but thatwill come.
It's not a rush, but getting itto fully straighten very
important.
It's important to get thatthing pain-free full extension
(10:55):
or a little bit ofhyperextension to match the
other leg if it's like a plusone or a little bit of
hyperextension to match theother one by six weeks.
So at six weeks the knee needsto be fully able to fully
straighten or a little bit, atiny bit of hyperextension just
to match the other side by sixweeks.
Um, after that it gets getsmore and more challenging and we
(11:17):
don't want to have to likereally crush to push into
extension after that.
It just uh, it just sucks andit's a delayed process that can
be avoided.
The thing that I recommend topeople is don't sleep with a
pillow under your knee when youcan just let your knee have your
(11:37):
heel propped up and let yourknee sag and sink to the floor.
Let gravity just pull the kneedown and get comfortable with
being uncomfortable.
You have to be a little bit.
You have to be okay with somediscomfort for the sake of your
knee getting fully straight fora long-term benefit.
So watching TV with your footon an ottoman in front of you,
and let the knee be unsupportedso it can just sink to the floor
(11:59):
with gravity.
Don't sleep with a pillow underyour leg.
Sit with a towel under yourheel when you're just in bed or
when you're laying around sothat the knee can be unsupported
and allow it to just fullystraighten out and sag to the
floor with gravity all the time.
Just get comfortable beinguncomfortable for the sake of
(12:19):
getting the knee to straighten.
That's the most important thing.
That top priority is to get theknee fully extended.
I've seen a lot, even totalknee replacements, patients that
are like in their 50s and 60sand like, 12 weeks out, their
knee is still a little bit notable to get fully extended.
It's a little bit of a flexioncontracture.
(12:39):
That's going to.
They're going to live with thatfor the rest of their life.
It sucks and their, their wholegait pattern is going to be
jacked up because of that.
And you can imagine, like a 64year old, overweight female that
had a total knee replacementthat's never exercised a day in
her life, like getting thatthing to fully straighten is
impossible at that point.
So it's just really importantto get that thing straightened
(13:01):
right away.
While you're still on pain medsand that's okay Take pain meds
at the beginning.
That's what they're there for,so you can sleep.
Sleep is gonna be verychallenging after ACL rehab
surgery, sorry, after the rehabprocess.
So the pain meds are there asneeded.
With the right mental approach,going with end up taking pain
(13:22):
meds of like this isn't a, thisisn't a solution, it's just
temporary pain modulation so Idon't have to live in agony and
I can sleep and I can movearound and go to Publix, I can
go to school, I can do my job, Igo to work whatever, just
sparingly, as needed.
Pain meds can be helpful so Ican do my.
I go to work whatever, justsparingly, as needed.
Pain meds can be helpful so youcan live not in agony,
recovering from just the traumaof the surgery in general.
(13:43):
All right, because it's morelike carpentry than it is like
delicate surgery.
All right, so that's the firstthree weeks.
We could just get the kneefully straight, get the quad to
activate, help to decrease theswelling and be okay with being
uncomfortable at the sake ofjust getting your knee to fully
straighten.
Weeks three to six then wereally hit the gas pedal.
(14:07):
No pun intended, hit likenothing crazy to normalize your
gait pattern by three to sixweeks.
Three weeks for a young,healthy person.
By four weeks the goal is to beoff the crutches and walking
without crutches in a brace witha normalized gait pattern,
which means they need to havealmost full extension at this
(14:28):
point.
Good quad activation and theswelling is decreasing.
We have confidence puttingweight through their leg.
They're doing a little bit at atime to get more confidence
through their leg of weightbearing and the range of motion
is improving and by six weeksthe goal is for the knee to be
fully straight and a little bitof hyperextension, like I said,
(14:49):
to match the other leg where theother knee is.
The goal is to be symmetrical.
So by six weeks we need to bethere and if we're not, we got
to push it at that point Likeit's going to be uncomfortable.
But we have to get that thingstraight, otherwise it's way
worse in the future.
All right, by week six to 12,we're gaining more functionality
(15:09):
.
Our gait is normalized, we'reout of the crutches, we're
getting more confidence, therange of motion, full extension
and almost full knee flexion.
At this point Some of theresidual swelling is not
uncommon.
We're at the very end of fullflexion of the knee.
It still bothers you a littlebit with a little bit of pain,
but that's okay.
Definitely need to be like a120 to 140, right, like 130.
(15:31):
Right now we're getting moreconfident and more functional.
But right now we're gettingmore confident and more
functional and the initial we'restrengthening at this point
Like we need to get somestrength from week six to 12 so
that we can start a runningprogression.
That's next.
At this point we're also doingsome single leg balance and
getting proprioception.
Proprioception is like knowingwhere your joint awareness is in
(15:53):
space, knowing where your jointis in space.
Knowing where your joint is inspace, then all the nerve
endings that innervate yourjoints in the joint capsule and
all the tendons and ligaments inyour joints they have little
nerve endings are in therecalled mechanoreceptors, and
that lets you know where theyare in space when you're not
looking at them.
All right, so proprioception isjust awareness in space where
(16:13):
your joints are in your body andthose nerve endings are
deadened and affected because ofthe surgery.
So we have to get those thingsactivated again and working on
balance and proprioceptionlittle exercises is part of the
rehab process and that's reallyimportant.
So we're initially doing some ofthat stuff that we, you know,
from week six on or earlier ifit's, if they're able to balance
(16:35):
and work on some confidencewith balance and then the you
know, the initial strengthening,because oftentimes for most
people a lot of surgeons it's wewant to start initially doing
some running progressions andinitiating and starting some
running at week earliest week 12, but definitely by week 16.
(17:00):
So for pediatrics under likeage, you know, usually I say
like from 18 under, imagine likea 13 to 14, a 14 year old kid
athlete we don't want to startrunning progressions until maybe
week 16.
There was a pediatric surgeonorthopedic pediatric surgeon I
was working with in Houston awhile a lot and he was like the
risk benefit ratio wasn't there.
(17:21):
There's nothing wrong withstarting running progressions at
16 weeks instead of 12, just tomake sure things are strong
enough and they have a goodunderstanding of what's going on
and they feel confident theswelling has improved week 16.
Confident the swelling isimproved week 16.
So for pro athletes, probably 12.
Week 12 for a grown man, grownwoman.
(17:42):
But for pediatrics we'rethinking 16 weeks.
But that's gonna be dependenton an individual.
If they're not ready yet,they're not ready, we're not
gonna go that.
We're not gonna start early atthe expense of creating more
inflammation, pain andinstability.
That's not, that's no bueno.
It's gonna delay the process.
And one more thing I want topaint with this.
So that's week six to 12.
In 12 to 16 weeks we're doingthe initial running progressions
(18:02):
.
We're getting more consistentand aggressive with
strengthening.
We need to be doing someeccentric strength, progressing
into some eccentric strengthcontrol, which is like how well
can you descend on one leg to abox right, like a box squat or
like stepping down stairs?
How well can the surgery leg beokay with descending down to
(18:23):
the next stair on one legwithout wobbling or collapsing
or being shaky with it orgetting stuck.
So it's really important towork on the eccentric strength
control of the quadricep muscleand the load acceptance through
the joint and the patellartendon and the kneecap with good
quad control and strength,because that's super important
(18:47):
for running.
If you think about jogging andrunning, the initial stages of
these running and joggingprogressions is like the day one
at week 15, let's say, or 16,that they look.
You know they look good week 15.
It's like we're just going tostart trundling along and I'd
start some jogging right Just tosee what it looks like.
But jogging and running it's aseries of single leg falls every
(19:11):
single time, like you catchyourself as you're advancing
forward on the ground.
They're like individual singleleg falls.
So your quadricep muscle has tobe really good at accepting
that load and eccentricallycontrolling for the next step.
And if it's not ready yet,compensation patterns happen.
Or if you progress too fast andthe load is too much, it's
(19:32):
going to cause tendonitis.
All right, patellar tendonitisSuper common.
It just means you're going toofast and the eccentric control
isn't there yet and we're justprogressing a little bit too
much for the strength that'sthere right now.
So you have to wean back alittle bit and solidify some
things and then progress again.
It's not worth it to try to pushthrough, because tendonitis
(19:54):
doesn't just work itself out,especially post-surgical like
this.
Yeah, pardon me.
So I went to the zoo yesterdaywith my kiddos, the big zoo in
miami and we're just likethey're like having blast and
run around and yelling at mykids like, hey, don't go too far
, hey, come over here.
(20:14):
Hey, look at this coolalligator, you know just yeah.
So I'm a little, uh, mythroat's a little, bothered this
morning, all right.
So one thing I wanted to paintthe picture.
So right now we're at week 16,where we're beginning load
acceptance, as in like can youload through your knee and it
feels okay, beginning theprocess of jogging and running.
But week, I mean date, 24 hoursout, and week 16 I mean we're
(20:43):
you're not just sitting arounddoing nothing, like we were up
and moving this, this rehabprocess, like you're moving,
you're walking, you're up andabout, you're moving your leg
around, range of motion, you'realways working on range of
motion, extension, quadactivation.
Literally, it's like your job,like your number one priority
and consumed in your life isjust getting your freaking knee
(21:06):
to be confident and active andstrong and range of motion for
the first five, four months,because that's a very important
initial phase of progressing andfor very active individuals it
consumes your life for the firsteight to 10 months and then
after that it's more sports,specific and you feel pretty
confident in your knee If you'vedone everything right at the
(21:27):
beginning.
This is full invest, like itconsumes your life.
Cause if you really need tofocus and prioritize getting
that thing strong cause I'veseen it when it wasn't
prioritized and it's not a goodtrajectory but it's just at the
beginning.
It's just six months.
It's really not that long, ifyou think about it, to set
yourself up for success for likeyears to come.
(21:47):
Right, all right.
So at week 16 to 24 weeks, whichis six months, we're doing
single leg strength and power,initial agility, work load
acceptance, again with agilityand single leg loading.
So this is where the fun stuffbegins Week 16 to 24 weeks.
The single stuff begins.
(22:08):
Week 16 to 24 weeks.
The single leg strength isreally important, the number one
test that we ask our athletesor that in the literature it's
like hey, can you play sports?
Hey, coach, I'm ready.
All right, show me 10 singleleg squats, pistol squats with
good form, good mechanics, theknee isn't wobbling and isn't
hurt compared to the other leg.
Right, that's the number one,that's one of the main tests.
And if they don't do good withthat, then like you're not ready
(22:29):
, like we have to keep, we haveto keep working right.
But this is where we startprogressing into stuff like that
, right, single leg squat stuff,Bulgarian split squats, reverse
lunges, a lot of closedkinematic chains, strength
exercise, glute, hip stability,strength, balance,
proprioception, all that stuff.
This is where we get all thosethings and initial agility like
(22:53):
agility, ladder and loadacceptance through that, some
lateral movement, lateralagility and maybe some
rotational agility movements andtransverse plane stuff, as long
as their knee looks good andconfident, because we don't want
to rush that process.
It's going to create tendonitisand just more swelling and pain
(23:13):
.
You can't cook horns with this.
And then, maybe at six to eightmonths, is when we start
testing, just to get a look atwhat the single leg strength
compared to the other leg lookslike, and we call that a limb
symmetry index testing, where wedo a battery of tests on that
surgery leg and the non-surgeryleg to see what does the
(23:34):
strength and power look likecompared?
What percentage strength isthis one compared to the other
one?
What symmetry level are we atright now?
So we do like the best ones wefound in the research is a
single leg vertical jump test.
So you stand on thenon-surgical leg and you jump as
high as you can, right, and youdo that twice.
What's the displacement?
That's your vertical jump.
And then you test the surgeryleg Single leg vertical jump.
(23:56):
How high are you getting, right?
We document those numbers.
Then a single leg forward hoptest same thing Two trials on
the non-surgical leg and thentwo trials on the surgical leg.
And what was the distancejumped compared to both?
And then a triple hop.
A triple forward hop is anothergood option of a test of like
(24:17):
what's the total distance atthree hops in a row on the same
single leg, over and over andover again for three hops
compared to the surgical leg?
You have two trials each oneand you compare the numbers.
A crossover hop test is anothergood one that's been found in
the research, where you jumplaterally and forward at the
same time and see the distancejumped and we're also looking at
, just subjectively, what doesthe quality of movement look
(24:38):
like?
Like, are they really unstableand wobbly, or are they loading
and landing well and landing anddecelerating in a good fashion,
that's under control, withoutpain, right?
That's another big one too.
And another big one is a sixmeter timed hop.
So like a single leg sprintfrom for six meters and how fast
?
Like a 40 yard dash, right, buton one leg for six meters.
(25:00):
How fast can you get there whenthe non-surgical leg, two
trials.
And then how fast can you runthat distance on non-surgical
leg, two trials, and then howfast can you run that distance
on the surgical leg, for twotrials.
And you compare those numbersand then those four or five or
at least four tests, you compileall the numbers and you have
your overall comparison, calledyour limb symmetry index, and
you get a good percentage oflike.
(25:21):
Let's say somebody jumps 10,just for the sake of numbers 10
inches on their non-surgical leg, on the single leg vertical
jump, and they jump eight incheson the surgical leg on the
vertical jump, right.
That'd be like an 80% symmetryindex, right, it's 80% strong
compared to the other one.
And then a forward hop test.
Let's say they jump, just forthe sake of numbers, 50 inches
(25:42):
on the non-surgical leg and thesurgical leg.
They jump 40 inches right again.
That's 80 percent of thedistance.
So right now we're at like an80 percent limb symmetry index
and that's the case across theboard for all those four or five
battery tests.
That's a good indicator of like.
What's the strength look like onthe non-surgical leg compared
to the surgical leg?
Are they ready for sports yet?
Well, according to the, theysay at least 90% limb symmetry
(26:06):
index is what's indicated to belike you're good, you know, go
go play.
Let's get cleared by the doc.
Doc looks at the limb symmetryindex numbers, talks to the
physical therapist and it's likenow we think you're good, right
, what does that look like?
It's usually at least a 90%limb symmetry index.
On our end we would love 95% andwe would love 100%, of course,
(26:28):
but sometimes there's timeconstraints and time windows
that run out that we need topush the envelope a little bit.
Where it's like are you good,we're right at the cusp, do we
play or not?
Playoffs are coming up right.
That's where pro athletes arereally pushing the envelope with
that.
So that's what limb symmetryindex looks like and we're
starting that at like six toeight months to look at and see
what kind of paint the picture.
Where's our knee at and what dowe need to focus on and
(26:51):
prioritize for the remainingfour months of this year-long
journey is what they suggest.
So now we're six to eightmonths.
We're still trying to get fullconfidence with load acceptance
I would say the priority withthis, starting at 16 weeks.
Even with 12 weeks of likedescending and decelerating in a
confident, non-painful, strongway right, but definitely by six
(27:15):
months we're like you need todo some single legs, progressing
, a single leg hopping andlanding in a good, decelerating
and a load-acceptant way thatlooks confident and not hitching
but landing in a smooth fashionand then able to jump back up
again and land in a smoothfashion.
So it looks very fluid versus aland and a hitch and the knee's
(27:38):
wobbly and they're notconfident loading through their
knee.
It just takes time.
That's just the process.
But we're looking forconfidence and all that fluidity
through deceleration and thedescent and then back up again
and then once they look good andthey feel confident, it's not
hurting.
The pain is number one.
You know thing that we look at,uh, and just the overall
(27:58):
fluidity and confidence andmovement.
But then we progress that,right, they're doing single leg
box jumps, single leg dip, depthlanding and all the fun, cool,
creative exercises that you seeon Instagram of like of a knee,
stability and agility exercisesand strength and power exercise.
And then by eight to 12 monthswe're getting into sports
specific stuff with speed,agility explosion, single leg
(28:21):
speed, single leg agility,single leg explosion Definitely
some transverse plane likerotational agility, single leg
explosion, definitely sometransverse plane like rotational
agility movements and lateralmovements, sports specific.
And another big one is justendurance and then load capacity
, as in like we're doing a bunchof training stuff but they're
just out of shape, right.
They just haven't been able todo this kind of stuff at this
(28:43):
high level for a long time,right?
So just endurance and loadcapacity and then, once they
look good on one leg as anexample, descending and
exploding back up again in likea single leg hop and Bulgarian
split squats, revert lunges,step ups, lateral lunges, like
(29:05):
single leg strength exercises.
Once they look good and wenotice they're not they're not
too far off from the other leg,like 90, 95% that's when we can
start feeling confident tointroduce like double leg
strength exercises like barbell,squats, deadlifts, power cleans
, snatches, olympic liftingstuff.
Because if they're notdemonstrating single leg
strength that's symmetrical theother leg they're just going to
(29:27):
compensate with the other legwith doing those, those double
leg exercises.
So I'm a huge advocate forsingle leg strength exercises up
to like eight month, eightright, or maybe at least six
months until they show, at leastright, that they're not going
to compensate with the other legwhen doing a double leg
exercise like a squat orsomething.
So we're definitelyprioritizing single leg strength
(29:50):
exercises first.
But in general that's like theum, the overall picture from
month week zero to month 12 um,where the research indicates
usually it's like a year-longprocess.
They say like it's like ayear-long process.
They say like it's like ayear-long process.
They say 12 months is what wewant to shoot for.
(30:10):
At least have some kind of anexpectation.
We don't want to rush thisprocess versus like oh, adrian
Peterson a while back did it inseven months, I'm going to do it
in six.
It's like ah, it just takestime for nerves to reinvigorate
and activate again and forstrength and stability.
We can't rush this process.
(30:31):
It's just going to create a lotof problems in the future if we
cut corners or go too fast,tendonitis being one of them.
And then ACL re-injury on thesame leg or the other leg is the
other biggest common thingwhich we want to avoid for sure,
which we want to avoid for sure.
So I would say, at earliest, 10months would be like for a very
strong, grown individual that'smature, versus like a pediatric
(30:53):
patient that's still growingand still learning their body or
growing into their body.
That's going to be at least 12months.
It is what it is, but we'll behere every step of the way,
doing the best we can to get youto 100% and lower the risk of
injury from the future for otherthings.
And then back to playing sports.
That's the ultimate goal is toget back to playing your sports
or having fun or doing thethings you want to do in life.
(31:15):
If you're past the age ofcollege sports and you're an
adult weekend warrior, there'sno rush.
An adult, a weekend warrior,there's no rush.
But getting you back to ahundred percent is the goal, and
that we want to go as fast aspossible, of course, but we
don't want to rush and skipsteps and just progress for the
(31:37):
sake of looking like we'reprogressing when we're actually.
It's detrimental of the process, of the, of the speed we're
going, of progressions, andsometimes you have to back it up
.
You know the whole journey isn'tjust a straight linear journey.
It's going to be good days andbad days and good days and bad
days, but over several weeks andseveral months the overall
trajectory should be a positivetrend when you zoom out far
(31:58):
enough.
So I'm not going to jump off acliff when it's like a bad day
and it's like sore, and notgoing to be like elated and say
like I'm done and I'm good to gowhen I go after a good day,
right, but um, we want tominimize the rollercoaster and
minimize the bad days and then,um, ride the momentum of good
days so that we can keep a goodtrajectory.
(32:20):
But, um, that's what thepicture looks like.
So, um, hopefully this helpsshed some light for some people
where, like you're not aftersurgery, you're not going to be
like laying in bed for weeks onweeks and not doing anything,
waiting quote for things to heal.
It's like, bro, everything'sgood, like you're structurally
sound.
(32:40):
Now, if the surgeon did a goodjob, where at this point, like
we're pretty confident that youknow surgery is the surgeons are
going to be doing a good job,especially this point.
Like, we're pretty confidentthat you know surgery is the
surgeons are going to be doing agood job, especially if they
have range of motion, quicklycome back.
That means things are alignedpretty well.
But, um, uh, you're not whatyou're moving.
Like we got to get up and movethat thing pretty quickly, right
, even though you don't want to.
But, um, so hopefully thispaints a picture and if you have
(33:00):
any questions don't hesitate toreach out.
But that's like an overallgeneral summary for, uh, acl
rehab and surgery and processand there's different graphs,
though before we, before we endthis land the plane, there's
different types of acl graftingso that you can do a, an
autographed, where they use yourtendon and it's usually either
(33:23):
the hamstring tendon, a groinmuscle tendon, the gracilis, or
a bone, patellar bone, which isfrom the patellar tendon and the
kneecap and the tibial bone,and that's just the reason why
they do bone.
Patellar bone is bone to bone is.
It's a faster healingprogression.
So the bone solidifies in thebone tunnels that they create to
(33:47):
implant the new ACL.
It just heals faster.
But anyway, it just depends onwhat the surgeon does.
The Achilles tendon could beanother one that they use, and
the other common one is justusing a cadaver.
They harvest a ligament ortendon from a cadaver and they
create a new ACL on what youneed from that.
(34:10):
So those are the most commongraft options.
It just depends on what thesurgeon wants, what they think
might be the best option for youand your body and what their
comfortability level is andconfidence.
So it just depends it's case tocase and you get multiple
opinions.
It's okay to get multipleopinions, but if you have any
questions, don't hesitate toreach out.
We've done this a bunch andit's always a journey.
(34:30):
There's no rush, but it willheal and it will get better if
you work on the right things.
So don't hesitate to reach out.
We are always open to questions, comments, concerns, complete
opinions, and call us if youhave any questions at
895-61-899-8725, or you canemail us at our administrative
(34:51):
email team at athlete rccom.
We'd love to hear from you.
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
So I realized we haven't evendone any ACL topics yet, so I
(00:20):
wanted to run through a wholegamut of like.
What is the ACL rehab processlook like for ACL reconstructive
surgery?
And I'm going to say thisdoesn't include a meniscus
repair, because a meniscusrepair is a little bit delayed,
but it's still very similar, andit's not uncommon that a
meniscectomy happens with an ACLreconstruction.
(00:43):
Um and ACL is the anteriorcruciate ligament, and that's um
, a very common injury that youhear in the new like for sports
athletes, figures and stuff.
And, uh, an ACL injury happenswith um, a guillotine effect,
where the tibia is the shin boneand the femur is up top.
And if it, uh, if the tibiadives laterally and the femur
(01:05):
dives medially, and so theyshift different directions and
they rotate a little bit at thesame time, um, where the femur
rotates internally and the tibiaon a usually a fixed leg
rotates um externally.
That's a, it's like aguillotine effect, and it slices
out, it just cuts the ACL.
Something to keep in mind,though is the ACL injuries.
(01:27):
They call it like ligamentfatigue, where the ACL actually
gets frayed over multipleinstances without even knowing
it and then one more final blowkind of finishes the job and it
tears the ACL completely, orenough to where there's enough
symptoms or it's hanging on by acouple of fibers that needs to
be reconstructed.
But it's not uncommon that theACL goes through multiple
(01:51):
injuries, micro injuries, overmultiple episodes where they
didn't know otherwise, and thennow it's just enough to where
there's enough symptoms andswelling and instability that
comes with an ACL injury likethat that leads to a person need
to go to the doc.
You know like I heard my kneepop.
It's partially torn.
Now you know whatever or not,full torn, full tear.
(02:12):
Another really interesting toconsider is the most common ACL
injuries are non-contact, whereit's not like, if you imagine,
in soccer or football.
In soccer somebody slide,tackles a player and they get
hit from the side and their kneebuckles and twists and weird.
You know that in a verytraumatic event.
Or in football somebody getsrolled on and their knee gets
(02:35):
stuck and their foot gets stuckand then their knee twists.
I mean that happens.
But actually in the researchthe most common is non-impact,
where somebody just plants andcuts in a in a uh opposite
direction and for some reasontheir knee buckles and they're
it twists in a weird fashion,like in that guillotine effect I
was talking about, and thatfinishes the job.
Acls cut or uh, ruptures.
(02:56):
So, um, it's interesting tokeep in mind, right.
So it's like all right.
With that being said, then howcan we lower the risk for
athletes of non-contact ACLinjury?
We definitely have to work onsingle leg stability and control
, proprioception, dynamiceccentric control and strength.
And that's like, can a persondescend and load into their leg
(03:19):
with a good control fashion, agood controlled fashion after,
like, imagine landing from asingle leg jump and volleyball
like a slide jump or like asingle leg jump, like that in a
right side slide, or abasketball player going up for a
single leg layup, and if theyland again on one leg, that's uh
, can they land when they hitthe ground and accept their load
(03:41):
of their body weight afterjumping in a good fashion that
looks controlled and not wobblyand unstable?
So those are the things to workon.
Then they also consider thefemales are actually higher
likely of tearing an ACL andusually between the ages young
female athletes like in theirteenage years, teenage athlete
(04:03):
females are the most commonathletes.
Between like in their teenageyears teenage athletes females
are the most common highest riskfor an ACL tear and following
that, actually the highest riskof an ACL tear is a previous ACL
tear.
So unfortunately it's notuncommon where um an athlete,
even in high school, they'vealready had two ACL uh surgeries
.
Now they're on the third right.
It's a bummer.
(04:23):
They usually representsrepresents it's just instability
and poor movement control anddynamic eccentric control with
ballistic movements like agility, cutting, landing, planting,
stuff like that.
And a surgically repaired ACLis already compromised.
So it's super important to justcrush stability and strength
(04:44):
with that knee and not lead tocompensation patterns or
asymmetries between the knee andthe strength.
All right, um, so anyway, I'mgoing to run through.
Like what does that look like?
Let's say somebody tears theiracl, then what do you do?
And then what does the surgeryand rehab look like afterwards?
All right, so the first step isuh, usually somebody has to get
(05:07):
a consult with a doc, all right, and they get an mri.
The only way the whole, thegolden standard is to is to
check out an mri and see if theacl is torn and maybe other
internal derangement which wouldbe like meniscus, mcl, lcl or
pcl.
Pcl is very uncommon.
Pcl is the posterior cruciateligament and the most common way
that they call it a dashboardinjury, where imagine if someone
(05:30):
gets in a car accident andtheir knee gets, or the
dashboard shoves backwards intosomeone's knee as a passenger or
the driver and that shoves the,the tibia, the shin, backwards
against the femur and thatstresses and overly stretches
the PCL and that tears the PCL.
But so the first step got toget a doc consult and get an MRI
(05:53):
and confirm that it's torn.
Let's say you get an MRIconfirm it's torn.
Now what?
All right, you can set up withtheir specialist orthopedic
surgeon and you know if it'sappropriate, schedule surgery.
Um, usually, which they try toget surgery and as quickly as
possible, and uh, getting prehab, getting rehab, uh, exercise
(06:13):
and work done before surgeryreally improves the outcomes
after surgery.
So it's really advocated to getsome kind of physical therapy,
sports, physical physicaltherapy, if that's possible and
accessible for you to get beforesurgery and a lot better
outcomes afterwards.
We can get some of the swellingout, get things strong and
(06:34):
active as best as we can,because after injury like that
very common.
The muscle girth and strengthof the quadricep muscle and all
the other surroundingmusculature already is a little
bit atrophied.
It deadens a little bit andit's a neural defense mechanism,
the body's natural defensemechanism, to shut things off
because things are injured.
So that happens.
(06:56):
So it's important to get thingsreactivated and strong and
reinvigorated and normalize therange of motion, maybe even
decrease swelling before surgeryand the outcomes will be way
better.
So a little bit of prehab formaybe a month, all right, or in
three weeks and then surgery andthen when you wake up from
surgery, this is what we'regoing to talk about.
So initially things are goingto be swollen and it's going to
(07:18):
hurt and it's going to be tenderand muscle atrophy happens
really quick.
It's like as soon as you wakeup from surgery your muscles are
pretty much shut off,especially the quad.
The quadricep muscle on thefront of the thigh is the first
thing that we really focus on toget activated again.
All right.
So you wake up from surgery.
It's not unlikely that ifthere's no meniscus repair, they
(07:41):
want to start rehab that week,like for pro athletes.
As an example, they're in therethe next day, 24 hours later.
We're ready.
We're starting to do anexercise, exercise being like a
range of motion, movements and aquad activation exercises calf
pumps, ankle range of motion andum, beginning the process of
(08:03):
some.
Um, weight bearing is tolerated,all right.
So usually weight bearing istolerated.
You can put as much weight onas appropriate.
They just want to preventinjury.
So you're going to be in abrace, usually locked out in
extension, for safety whenyou're ambulating around your
house or in the community, or toand from physical therapy, so
that you don't buckle.
All right, because everything'sweak and, like the quad muscles,
(08:25):
your knee is just weak, it'scompromised.
They had a major surgery, theyhad to put tunnels and drill
through bone in order torecreate the ACL.
So things are, you know, weak.
So it's just important to keepthings safe.
And a knee brace that's lockedout in extension doesn't let
your knee bend, so that whenyou're ambulating around, when
your crutches, that's locked outand extension doesn't let your
knee bend, so that when you'reambulating around, when your
(08:46):
crutches, uh, like a, your oneleg is like a peg leg but you
can put a little bit of weightthrough it, but, um, it's not
going to buckle on you so youfall, because that would be, you
know, no bueno, and that wouldlead to more swelling and pain,
discomfort and potentiallyinjure the graft site, which we
don't want to do right.
So that process is, you know,from zero to three weeks.
(09:07):
That first three weeks of time.
The goal of that time frame isjust to get the swelling down,
start some range of motionmovements and get your knee to
bend and extend comfortably,usually up to a little bit of a
restriction.
We don't go past 90 degrees ifthe meniscus isn't repaired.
(09:28):
Just allow the graft site toheal.
Compression sleeves, ankle pumps, range of motion, quad
activations probably the mostimportant thing, followed by
sorry, I take it back the mostimportant thing is to get your
knee fully straight and extended, all right, and then normalize
your gait pattern.
Those are the first mostimportant three things.
(09:48):
Get the knee to fullystraighten out again, get the
quad to start to activate andturn on, and then normalize the
gait pattern, all right, thoseare the top three most important
things.
Getting the knee to bend andflex is important, but with, as
the swelling decreases, thatwill improve, and I'm an
advocate to not crush and overlypush to bend the knee yet.
(10:12):
All right, you will bend theknee.
I feel like I sound like gameof thrones bend the knee.
You will bend the knee, just Idon't.
There's not a rush, all right,because it's sometimes overly
pushing it into flexion likethat can increase irritation and
swelling.
That's going to ultimately leadto more quad inhibition like
deactivation and atrophy or justlack of activation for the quad
(10:34):
, and it's going to limit andhinder the flexion range of
motion anyway and keep theswelling in there.
So I'm like there's a, there'sa threshold.
We want to push a little, youknow, bend it, just get
comfortable with it, but thatwill come.
It's not a threshold.
We want to push a little, youknow, bend it, just get
comfortable with it, but thatwill come.
It's not a rush, but getting itto fully straighten very
important.
It's important to get thatthing pain-free full extension
(10:55):
or a little bit ofhyperextension to match the
other leg if it's like a plusone or a little bit of
hyperextension to match theother one by six weeks.
So at six weeks the knee needsto be fully able to fully
straighten or a little bit, atiny bit of hyperextension just
to match the other side by sixweeks.
Um, after that it gets getsmore and more challenging and we
(11:17):
don't want to have to likereally crush to push into
extension after that.
It just uh, it just sucks andit's a delayed process that can
be avoided.
The thing that I recommend topeople is don't sleep with a
pillow under your knee when youcan just let your knee have your
(11:37):
heel propped up and let yourknee sag and sink to the floor.
Let gravity just pull the kneedown and get comfortable with
being uncomfortable.
You have to be a little bit.
You have to be okay with somediscomfort for the sake of your
knee getting fully straight fora long-term benefit.
So watching TV with your footon an ottoman in front of you,
and let the knee be unsupportedso it can just sink to the floor
(11:59):
with gravity.
Don't sleep with a pillow underyour leg.
Sit with a towel under yourheel when you're just in bed or
when you're laying around sothat the knee can be unsupported
and allow it to just fullystraighten out and sag to the
floor with gravity all the time.
Just get comfortable beinguncomfortable for the sake of
(12:19):
getting the knee to straighten.
That's the most important thing.
That top priority is to get theknee fully extended.
I've seen a lot, even totalknee replacements, patients that
are like in their 50s and 60sand like, 12 weeks out, their
knee is still a little bit notable to get fully extended.
It's a little bit of a flexioncontracture.
(12:39):
That's going to.
They're going to live with thatfor the rest of their life.
It sucks and their, their wholegait pattern is going to be
jacked up because of that.
And you can imagine, like a 64year old, overweight female that
had a total knee replacementthat's never exercised a day in
her life, like getting thatthing to fully straighten is
impossible at that point.
So it's just really importantto get that thing straightened
(13:01):
right away.
While you're still on pain medsand that's okay Take pain meds
at the beginning.
That's what they're there for,so you can sleep.
Sleep is gonna be verychallenging after ACL rehab
surgery, sorry, after the rehabprocess.
So the pain meds are there asneeded.
With the right mental approach,going with end up taking pain
(13:22):
meds of like this isn't a, thisisn't a solution, it's just
temporary pain modulation so Idon't have to live in agony and
I can sleep and I can movearound and go to Publix, I can
go to school, I can do my job, Igo to work whatever, just
sparingly, as needed.
Pain meds can be helpful so Ican do my.
I go to work whatever, justsparingly, as needed.
Pain meds can be helpful so youcan live not in agony,
recovering from just the traumaof the surgery in general.
(13:43):
All right, because it's morelike carpentry than it is like
delicate surgery.
All right, so that's the firstthree weeks.
We could just get the kneefully straight, get the quad to
activate, help to decrease theswelling and be okay with being
uncomfortable at the sake ofjust getting your knee to fully
straighten.
Weeks three to six then wereally hit the gas pedal.
(14:07):
No pun intended, hit likenothing crazy to normalize your
gait pattern by three to sixweeks.
Three weeks for a young,healthy person.
By four weeks the goal is to beoff the crutches and walking
without crutches in a brace witha normalized gait pattern,
which means they need to havealmost full extension at this
(14:28):
point.
Good quad activation and theswelling is decreasing.
We have confidence puttingweight through their leg.
They're doing a little bit at atime to get more confidence
through their leg of weightbearing and the range of motion
is improving and by six weeksthe goal is for the knee to be
fully straight and a little bitof hyperextension, like I said,
(14:49):
to match the other leg where theother knee is.
The goal is to be symmetrical.
So by six weeks we need to bethere and if we're not, we got
to push it at that point Likeit's going to be uncomfortable.
But we have to get that thingstraight, otherwise it's way
worse in the future.
All right, by week six to 12,we're gaining more functionality
(15:09):
.
Our gait is normalized, we'reout of the crutches, we're
getting more confidence, therange of motion, full extension
and almost full knee flexion.
At this point Some of theresidual swelling is not
uncommon.
We're at the very end of fullflexion of the knee.
It still bothers you a littlebit with a little bit of pain,
but that's okay.
Definitely need to be like a120 to 140, right, like 130.
(15:31):
Right now we're getting moreconfident and more functional.
But right now we're gettingmore confident and more
functional and the initial we'restrengthening at this point
Like we need to get somestrength from week six to 12 so
that we can start a runningprogression.
That's next.
At this point we're also doingsome single leg balance and
getting proprioception.
Proprioception is like knowingwhere your joint awareness is in
(15:53):
space, knowing where your jointis in space.
Knowing where your joint is inspace, then all the nerve
endings that innervate yourjoints in the joint capsule and
all the tendons and ligaments inyour joints they have little
nerve endings are in therecalled mechanoreceptors, and
that lets you know where theyare in space when you're not
looking at them.
All right, so proprioception isjust awareness in space where
(16:13):
your joints are in your body andthose nerve endings are
deadened and affected because ofthe surgery.
So we have to get those thingsactivated again and working on
balance and proprioceptionlittle exercises is part of the
rehab process and that's reallyimportant.
So we're initially doing some ofthat stuff that we, you know,
from week six on or earlier ifit's, if they're able to balance
(16:35):
and work on some confidencewith balance and then the you
know, the initial strengthening,because oftentimes for most
people a lot of surgeons it's wewant to start initially doing
some running progressions andinitiating and starting some
running at week earliest week 12, but definitely by week 16.
(17:00):
So for pediatrics under likeage, you know, usually I say
like from 18 under, imagine likea 13 to 14, a 14 year old kid
athlete we don't want to startrunning progressions until maybe
week 16.
There was a pediatric surgeonorthopedic pediatric surgeon I
was working with in Houston awhile a lot and he was like the
risk benefit ratio wasn't there.
(17:21):
There's nothing wrong withstarting running progressions at
16 weeks instead of 12, just tomake sure things are strong
enough and they have a goodunderstanding of what's going on
and they feel confident theswelling has improved week 16.
Confident the swelling isimproved week 16.
So for pro athletes, probably 12.
Week 12 for a grown man, grownwoman.
(17:42):
But for pediatrics we'rethinking 16 weeks.
But that's gonna be dependenton an individual.
If they're not ready yet,they're not ready, we're not
gonna go that.
We're not gonna start early atthe expense of creating more
inflammation, pain andinstability.
That's not, that's no bueno.
It's gonna delay the process.
And one more thing I want topaint with this.
So that's week six to 12.
In 12 to 16 weeks we're doingthe initial running progressions
(18:02):
.
We're getting more consistentand aggressive with
strengthening.
We need to be doing someeccentric strength, progressing
into some eccentric strengthcontrol, which is like how well
can you descend on one leg to abox right, like a box squat or
like stepping down stairs?
How well can the surgery leg beokay with descending down to
(18:23):
the next stair on one legwithout wobbling or collapsing
or being shaky with it orgetting stuck.
So it's really important towork on the eccentric strength
control of the quadricep muscleand the load acceptance through
the joint and the patellartendon and the kneecap with good
quad control and strength,because that's super important
(18:47):
for running.
If you think about jogging andrunning, the initial stages of
these running and joggingprogressions is like the day one
at week 15, let's say, or 16,that they look.
You know they look good week 15.
It's like we're just going tostart trundling along and I'd
start some jogging right Just tosee what it looks like.
But jogging and running it's aseries of single leg falls every
(19:11):
single time, like you catchyourself as you're advancing
forward on the ground.
They're like individual singleleg falls.
So your quadricep muscle has tobe really good at accepting
that load and eccentricallycontrolling for the next step.
And if it's not ready yet,compensation patterns happen.
Or if you progress too fast andthe load is too much, it's
(19:32):
going to cause tendonitis.
All right, patellar tendonitisSuper common.
It just means you're going toofast and the eccentric control
isn't there yet and we're justprogressing a little bit too
much for the strength that'sthere right now.
So you have to wean back alittle bit and solidify some
things and then progress again.
It's not worth it to try to pushthrough, because tendonitis
(19:54):
doesn't just work itself out,especially post-surgical like
this.
Yeah, pardon me.
So I went to the zoo yesterdaywith my kiddos, the big zoo in
miami and we're just likethey're like having blast and
run around and yelling at mykids like, hey, don't go too far
, hey, come over here.
(20:14):
Hey, look at this coolalligator, you know just yeah.
So I'm a little, uh, mythroat's a little, bothered this
morning, all right.
So one thing I wanted to paintthe picture.
So right now we're at week 16,where we're beginning load
acceptance, as in like can youload through your knee and it
feels okay, beginning theprocess of jogging and running.
But week, I mean date, 24 hoursout, and week 16 I mean we're
(20:43):
you're not just sitting arounddoing nothing, like we were up
and moving this, this rehabprocess, like you're moving,
you're walking, you're up andabout, you're moving your leg
around, range of motion, you'realways working on range of
motion, extension, quadactivation.
Literally, it's like your job,like your number one priority
and consumed in your life isjust getting your freaking knee
(21:06):
to be confident and active andstrong and range of motion for
the first five, four months,because that's a very important
initial phase of progressing andfor very active individuals it
consumes your life for the firsteight to 10 months and then
after that it's more sports,specific and you feel pretty
confident in your knee If you'vedone everything right at the
(21:27):
beginning.
This is full invest, like itconsumes your life.
Cause if you really need tofocus and prioritize getting
that thing strong cause I'veseen it when it wasn't
prioritized and it's not a goodtrajectory but it's just at the
beginning.
It's just six months.
It's really not that long, ifyou think about it, to set
yourself up for success for likeyears to come.
(21:47):
Right, all right.
So at week 16 to 24 weeks, whichis six months, we're doing
single leg strength and power,initial agility, work load
acceptance, again with agilityand single leg loading.
So this is where the fun stuffbegins Week 16 to 24 weeks.
The single stuff begins.
(22:08):
Week 16 to 24 weeks.
The single leg strength isreally important, the number one
test that we ask our athletesor that in the literature it's
like hey, can you play sports?
Hey, coach, I'm ready.
All right, show me 10 singleleg squats, pistol squats with
good form, good mechanics, theknee isn't wobbling and isn't
hurt compared to the other leg.
Right, that's the number one,that's one of the main tests.
And if they don't do good withthat, then like you're not ready
(22:29):
, like we have to keep, we haveto keep working right.
But this is where we startprogressing into stuff like that
, right, single leg squat stuff,Bulgarian split squats, reverse
lunges, a lot of closedkinematic chains, strength
exercise, glute, hip stability,strength, balance,
proprioception, all that stuff.
This is where we get all thosethings and initial agility like
(22:53):
agility, ladder and loadacceptance through that, some
lateral movement, lateralagility and maybe some
rotational agility movements andtransverse plane stuff, as long
as their knee looks good andconfident, because we don't want
to rush that process.
It's going to create tendonitisand just more swelling and pain
(23:13):
.
You can't cook horns with this.
And then, maybe at six to eightmonths, is when we start
testing, just to get a look atwhat the single leg strength
compared to the other leg lookslike, and we call that a limb
symmetry index testing, where wedo a battery of tests on that
surgery leg and the non-surgeryleg to see what does the
(23:34):
strength and power look likecompared?
What percentage strength isthis one compared to the other
one?
What symmetry level are we atright now?
So we do like the best ones wefound in the research is a
single leg vertical jump test.
So you stand on thenon-surgical leg and you jump as
high as you can, right, and youdo that twice.
What's the displacement?
That's your vertical jump.
And then you test the surgeryleg Single leg vertical jump.
(23:56):
How high are you getting, right?
We document those numbers.
Then a single leg forward hoptest same thing Two trials on
the non-surgical leg and thentwo trials on the surgical leg.
And what was the distancejumped compared to both?
And then a triple hop.
A triple forward hop is anothergood option of a test of like
(24:17):
what's the total distance atthree hops in a row on the same
single leg, over and over andover again for three hops
compared to the surgical leg?
You have two trials each oneand you compare the numbers.
A crossover hop test is anothergood one that's been found in
the research, where you jumplaterally and forward at the
same time and see the distancejumped and we're also looking at
, just subjectively, what doesthe quality of movement look
(24:38):
like?
Like, are they really unstableand wobbly, or are they loading
and landing well and landing anddecelerating in a good fashion,
that's under control, withoutpain, right?
That's another big one too.
And another big one is a sixmeter timed hop.
So like a single leg sprintfrom for six meters and how fast
?
Like a 40 yard dash, right, buton one leg for six meters.
(25:00):
How fast can you get there whenthe non-surgical leg, two
trials.
And then how fast can you runthat distance on non-surgical
leg, two trials, and then howfast can you run that distance
on the surgical leg, for twotrials.
And you compare those numbersand then those four or five or
at least four tests, you compileall the numbers and you have
your overall comparison, calledyour limb symmetry index, and
you get a good percentage oflike.
(25:21):
Let's say somebody jumps 10,just for the sake of numbers 10
inches on their non-surgical leg, on the single leg vertical
jump, and they jump eight incheson the surgical leg on the
vertical jump, right.
That'd be like an 80% symmetryindex, right, it's 80% strong
compared to the other one.
And then a forward hop test.
Let's say they jump, just forthe sake of numbers, 50 inches
(25:42):
on the non-surgical leg and thesurgical leg.
They jump 40 inches right again.
That's 80 percent of thedistance.
So right now we're at like an80 percent limb symmetry index
and that's the case across theboard for all those four or five
battery tests.
That's a good indicator of like.
What's the strength look like onthe non-surgical leg compared
to the surgical leg?
Are they ready for sports yet?
Well, according to the, theysay at least 90% limb symmetry
(26:06):
index is what's indicated to belike you're good, you know, go
go play.
Let's get cleared by the doc.
Doc looks at the limb symmetryindex numbers, talks to the
physical therapist and it's likenow we think you're good, right
, what does that look like?
It's usually at least a 90%limb symmetry index.
On our end we would love 95% andwe would love 100%, of course,
(26:28):
but sometimes there's timeconstraints and time windows
that run out that we need topush the envelope a little bit.
Where it's like are you good,we're right at the cusp, do we
play or not?
Playoffs are coming up right.
That's where pro athletes arereally pushing the envelope with
that.
So that's what limb symmetryindex looks like and we're
starting that at like six toeight months to look at and see
what kind of paint the picture.
Where's our knee at and what dowe need to focus on and
(26:51):
prioritize for the remainingfour months of this year-long
journey is what they suggest.
So now we're six to eightmonths.
We're still trying to get fullconfidence with load acceptance
I would say the priority withthis, starting at 16 weeks.
Even with 12 weeks of likedescending and decelerating in a
confident, non-painful, strongway right, but definitely by six
(27:15):
months we're like you need todo some single legs, progressing
, a single leg hopping andlanding in a good, decelerating
and a load-acceptant way thatlooks confident and not hitching
but landing in a smooth fashionand then able to jump back up
again and land in a smoothfashion.
So it looks very fluid versus aland and a hitch and the knee's
(27:38):
wobbly and they're notconfident loading through their
knee.
It just takes time.
That's just the process.
But we're looking forconfidence and all that fluidity
through deceleration and thedescent and then back up again
and then once they look good andthey feel confident, it's not
hurting.
The pain is number one.
You know thing that we look at,uh, and just the overall
(27:58):
fluidity and confidence andmovement.
But then we progress that,right, they're doing single leg
box jumps, single leg dip, depthlanding and all the fun, cool,
creative exercises that you seeon Instagram of like of a knee,
stability and agility exercisesand strength and power exercise.
And then by eight to 12 monthswe're getting into sports
specific stuff with speed,agility explosion, single leg
(28:21):
speed, single leg agility,single leg explosion Definitely
some transverse plane likerotational agility, single leg
explosion, definitely sometransverse plane like rotational
agility movements and lateralmovements, sports specific.
And another big one is justendurance and then load capacity
, as in like we're doing a bunchof training stuff but they're
just out of shape, right.
They just haven't been able todo this kind of stuff at this
(28:43):
high level for a long time,right?
So just endurance and loadcapacity and then, once they
look good on one leg as anexample, descending and
exploding back up again in likea single leg hop and Bulgarian
split squats, revert lunges,step ups, lateral lunges, like
(29:05):
single leg strength exercises.
Once they look good and wenotice they're not they're not
too far off from the other leg,like 90, 95% that's when we can
start feeling confident tointroduce like double leg
strength exercises like barbell,squats, deadlifts, power cleans
, snatches, olympic liftingstuff.
Because if they're notdemonstrating single leg
strength that's symmetrical theother leg they're just going to
(29:27):
compensate with the other legwith doing those, those double
leg exercises.
So I'm a huge advocate forsingle leg strength exercises up
to like eight month, eightright, or maybe at least six
months until they show, at leastright, that they're not going
to compensate with the other legwhen doing a double leg
exercise like a squat orsomething.
So we're definitelyprioritizing single leg strength
(29:50):
exercises first.
But in general that's like theum, the overall picture from
month week zero to month 12 um,where the research indicates
usually it's like a year-longprocess.
They say like it's like ayear-long process.
They say like it's like ayear-long process.
They say 12 months is what wewant to shoot for.
(30:10):
At least have some kind of anexpectation.
We don't want to rush thisprocess versus like oh, adrian
Peterson a while back did it inseven months, I'm going to do it
in six.
It's like ah, it just takestime for nerves to reinvigorate
and activate again and forstrength and stability.
We can't rush this process.
(30:31):
It's just going to create a lotof problems in the future if we
cut corners or go too fast,tendonitis being one of them.
And then ACL re-injury on thesame leg or the other leg is the
other biggest common thingwhich we want to avoid for sure,
which we want to avoid for sure.
So I would say, at earliest, 10months would be like for a very
strong, grown individual that'smature, versus like a pediatric
(30:53):
patient that's still growingand still learning their body or
growing into their body.
That's going to be at least 12months.
It is what it is, but we'll behere every step of the way,
doing the best we can to get youto 100% and lower the risk of
injury from the future for otherthings.
And then back to playing sports.
That's the ultimate goal is toget back to playing your sports
or having fun or doing thethings you want to do in life.
(31:15):
If you're past the age ofcollege sports and you're an
adult weekend warrior, there'sno rush.
An adult, a weekend warrior,there's no rush.
But getting you back to ahundred percent is the goal, and
that we want to go as fast aspossible, of course, but we
don't want to rush and skipsteps and just progress for the
(31:37):
sake of looking like we'reprogressing when we're actually.
It's detrimental of the process, of the, of the speed we're
going, of progressions, andsometimes you have to back it up
.
You know the whole journey isn'tjust a straight linear journey.
It's going to be good days andbad days and good days and bad
days, but over several weeks andseveral months the overall
trajectory should be a positivetrend when you zoom out far
(31:58):
enough.
So I'm not going to jump off acliff when it's like a bad day
and it's like sore, and notgoing to be like elated and say
like I'm done and I'm good to gowhen I go after a good day,
right, but um, we want tominimize the rollercoaster and
minimize the bad days and then,um, ride the momentum of good
days so that we can keep a goodtrajectory.
(32:20):
But, um, that's what thepicture looks like.
So, um, hopefully this helpsshed some light for some people
where, like you're not aftersurgery, you're not going to be
like laying in bed for weeks onweeks and not doing anything,
waiting quote for things to heal.
It's like, bro, everything'sgood, like you're structurally
sound.
(32:40):
Now, if the surgeon did a goodjob, where at this point, like
we're pretty confident that youknow surgery is the surgeons are
going to be doing a good job,especially this point.
Like, we're pretty confidentthat you know surgery is the
surgeons are going to be doing agood job, especially if they
have range of motion, quicklycome back.
That means things are alignedpretty well.
But, um, uh, you're not whatyou're moving.
Like we got to get up and movethat thing pretty quickly, right
, even though you don't want to.
But, um, so hopefully thispaints a picture and if you have
(33:00):
any questions don't hesitate toreach out.
But that's like an overallgeneral summary for, uh, acl
rehab and surgery and processand there's different graphs,
though before we, before we endthis land the plane, there's
different types of acl graftingso that you can do a, an
autographed, where they use yourtendon and it's usually either
(33:23):
the hamstring tendon, a groinmuscle tendon, the gracilis, or
a bone, patellar bone, which isfrom the patellar tendon and the
kneecap and the tibial bone,and that's just the reason why
they do bone.
Patellar bone is bone to bone is.
It's a faster healingprogression.
So the bone solidifies in thebone tunnels that they create to
(33:47):
implant the new ACL.
It just heals faster.
But anyway, it just depends onwhat the surgeon does.
The Achilles tendon could beanother one that they use, and
the other common one is justusing a cadaver.
They harvest a ligament ortendon from a cadaver and they
create a new ACL on what youneed from that.
(34:10):
So those are the most commongraft options.
It just depends on what thesurgeon wants, what they think
might be the best option for youand your body and what their
comfortability level is andconfidence.
So it just depends it's case tocase and you get multiple
opinions.
It's okay to get multipleopinions, but if you have any
questions, don't hesitate toreach out.
We've done this a bunch andit's always a journey.
(34:30):
There's no rush, but it willheal and it will get better if
you work on the right things.
So don't hesitate to reach out.
We are always open to questions, comments, concerns, complete
opinions, and call us if youhave any questions at
895-61-899-8725, or you canemail us at our administrative
(34:51):
email team at athlete rccom.
We'd love to hear from you.
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