ACL Rehab Phases: How To Stay On Track

ACL
Written By Zach Wagner

It’s no secret that ACL rehab is a long process. For athletes after ACL reconstruction, it can be easy to feel lost in the day to day of Physical Therapy. A good Physical Therapist will help you set goals for each phase of your rehab so you can stay focused and not get overwhelmed.

This blog will outline one of the ways we approach the phases of ACL rehab. To be clear, this is not the way we approach every ACL rehab program, but it is a good framework to help athletes understand what we are doing in each phase and WHY we are doing it. It is based on THIS ARTICLE from 2020. 

It also helps reinforce the idea that ACL rehab is a 9-12 month process. Each phase builds on the previous one and you can’t skip steps if you want to be successful.

Let’s dive into the phases of ACL rehab. 

Task Based Progressions for ACL Rehab

This framework uses “task based” progressions. This means that we are looking for athletes to successfully complete a certain task or movement without pain or swelling while also showing

  • adequate ROM and strength

  • good movement quality

These are not the only things we work on in each stage, things are happening at the same time. This is just a framework to understand how things progress.

Prehab for ACL Surgery 

This is technically “stage 0.” It’s a bonus stage that we feel very strongly about including. 

Optimizing knee range of motion, quad strength, gait and swelling BEFORE surgery leads to much better (and faster) outcomes after the surgery. This is an easy thing to do in the rehab process and includes pretty basic stuff.

It is most common now for athletes to wait a few weeks after their injury before getting surgery. This leads to the best outcomes. 

Early Physical Therapy After ACL Reconstruction

These first 3 stages can be thought of as the “early phase of ACL rehab.” 

We are focusing on:

  • Improving range of motion

  • Improving quad control and strength

  • Regaining normal walking mechanics

  • Getting rid of crutches and other assistive devices

  • Starting/maintaining basic strength and conditioning 

Side note: throughout the entire rehab process, you should be training the rest of your body and the uninjured side as normally as possible. This includes strength training and conditioning. It’s important to keep the rest of your body strong and feeling good. A good PT will help you do this. 

Below are the first 3 phases of the rehab process, according to the specific article we are referencing here. You will see each task listed, along with the range of motion we want to see and some other metrics that can help athletes understand how they are progressing.  

Even though we are using task based progressions, there are multiple ways to assess progress (ex: leg press). 

The “early phase” of ACL rehab typically takes 12 weeks or so, but like all rehab this timeline is very individualized. 

Phase 1: Walking

  • normal walking with no limp or use of assistive devices

  • full knee extension and quad control

Phase 2: Bilateral squat

    • perform squat to 90 degrees of knee flexion with less than 20% asymmetry between legs

    • full knee extension and greater than 90 degrees of knee flexion

    • 8-10 reps of single leg press with at least 50% of body mass

Phase 3: Single leg squat

    • perform single leg squat to 90 degrees of knee flexion

    • at least 120 degrees of knee flexion

    • 8-10 reps of single leg leg press with at least 80% of body mass

As you can see, this early phase starts with basic stuff like range of motion, quad strength and walking and progresses to some more challenging strength work that incorporates the entire lower body.

Returning To Running After ACL Surgery

The focus of the next phase of rehab is returning to running and basic work on absorbing impact. We take the basic strength and range of motion built in the first phase and work on adding speed and force. 

The early phase can feel like a big of a slog, so getting back to running is a great way to give athletes a “win” and something to build on. 

This phase typically takes another 3 months or so. 

Phase 4: Bilateral landing

    • at least 130 degrees of knee flexion

    • landing from sub maximal height 

    • 8-10 reps of single leg press with at least 100% of body mass

    • or 8-10 double leg press reps with at least 150% of body mass

Phase 5: Running

    • optimal running gait on treadmill (about 5 mph)

    • 130 degrees of knee flexion

    • 8-10 single leg press reps with at least 125% of body mass OR

    • 70% quad Limb symmetry index (LSI) 

What is Limb Symmetry Index and Why Does It Matter for ACL Rehab? 

Simply put, limb symmetry index is the ratio of strength between opposing limbs. It compares the strength/force output of an injured or “affected” side to the opposite or “unaffected” side. 

This number is one of the many metrics we use to understand when athletes are ready to progress in their rehab and where they may be falling behind. We can also compare these numbers to norms for an athlete's age, weight and height to make sure they don’t have any major weaknesses. 

Phase 6: Bilateral plyometrics

    • building up to bilateral 30 cm (12 inches) drop jump

    • full knee flexion and extension

    • isometric knee extensor strength 80%+ LSI

    • 8-10 repetitions on single leg press with at least 125% body mass

Return to Sport and Late Stage ACL Physical Therapy 

The last few phases of ACL rehab can be lumped together into a “return to sport” category. This is another long phase and returning to sport after an ACL surgery is more of a “dimmer” than a “light switch.” 

Even though athletes tend to “get cleared” by their surgeon for return to sport, this really just means they can progress their rehab to include sport specific tasks. It’s important that return to sport after ACL surgery isn’t rushed. 

This phase starts with more single leg force absorption and plyometrics, then eventually leads to agility and sport specific training. In addition to this we are continuing focus on training the whole body and ramping up conditioning so athletes aren’t limited by this. 

Usually this phase starts somewhere around 6-8 months post op and continues at least until an athlete has successfully returned to sport. Ideally we continue to train in a really smart way indefinitely. 

Phase 7: Single leg landing/deceleration

    • single leg deceleration/stop from a straight line run

    • isometric or isokinetic knee extensor strength 80%+ LSI

    • 8-10 single leg press reps with at least 150% of body mass

Phase 8: Single leg plyometrics

    • single leg drop jump with good control

    • 80%+ quad LSI

    • 8-10 reps of single leg press with at least 150% body mass

Phase 9: Pre-planned multi directional movements

    • good control during a 90 degree cutting maneuver

    • 80%+ quad LSI

    • 8-10 single leg press reps with at least 150% body mass

Phase 10: Sport specific movements

    • demonstrate good control of trunk, pelvis and lower limb during a 45 degree reactive change of direction

    • 90%+ LSI

    • 8-10 single leg press with at least 200% of body mass

ACL Rehab Isn’t The Same for Everyone

It’s important to have a good plan for your ACL rehab. A lot of planning, testing and tweaking goes into a successful rehab program and return to sport process. 

We are so adamant about this because ACL re-injury rates are way too high. 

This is for a couple basic reasons:

  • Poor rehab

  • Rushed rehab

Poor rehab doesn’t follow any real plan, doesn’t progress appropriately and doesn’t take the individual athlete into account. ACL rehab shouldn’t be easy and it should be tailored to an individual athlete’s specific surgical technique, age, training experience, sport and more. 

Rushed rehab means unrealistic timelines are used, regardless of how an athlete is progressing. If someone tells you they can get you back to sports in 6 months, be very wary. Things like full graft healing, strength, neuromuscular control and athlete confidence/mental readiness require a methodical rehab program.

We hope this timeline is a helpful way to organize your thinking about ACL rehab but keep in mind that everyone is different. You need a good PT who specializes in this area to guide you along the way and provide the best program for you. 

ACL Rehab Specialty Programs in Lakeville, MA

At Wagner PT & Performance, we specialize in working with athletes and provide custom ACL rehab programs for whatever phase of recovery you’re in. 

See what’s included in our ACL rehab programs HERE and contact us to get started!

References:
Buckthorp M et al. A tend task-based progression in rehabilitation after ACL reconstruction: from post-surgery to return to play-a clinical commentary. IJSPT. 2020 Aug; 15(4) 611-623
Zach Wagner
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