I Tore My ACL

Now What? Part 3

In part two I discussed the early post-operative stages of ACL reconstruction. Now we get into the fun stuff! Part three will give you a glimpse of what your ACL rehabilitation will look like!

When Can I Play Again?

So, you’ve been cleared for physical therapy and the one question on your mind is, “When will I be able to play again.” Well, let’s just say this varies from person to person. Research shows that there is 51% decrease in re-injury rate every month until 9 months post operatively. So, the next question- “Well, Adrian Peterson completed his rehabilitation in four months, why can’t I.” Guys and Gals, I hate to break it to you, but we don’t have the same genetic make-up and our full-time job isn’t to attend 2-3 PT sessions per day for months on end. That guy is just some kind of ACL miracle. We’ll just leave it at that.

So more than likely your rehabilitation will span at least 9 months’ time. This is what current literature recommends. I will say, that some people may be 8 months, some may be 24 months! Just because Sally from soccer finished in nine months, doesn’t mean you will be ready then. Everyone is different and we must respect that! So, what will your physical therapy look like?  

Phase One: Acute

So, you’re in phase one of rehabilitation. You come into the clinic on crutches and are dying to ditch them. Your knee still hurts, and you’ve noticed you can’t really lift your leg without pulling on your pants. Oh, and that darn brace is chaffing your skin. Well guess what- this is all normal and all of us who have had or are going through an ACL recovery have felt the same exact way.

Physical therapists’ main goals in phase one of rehabilitation are to decrease your inflammation, improve your knee mobility, get your muscles firing, get you off those pesky crutches and out of that itchy brace! Depending on your surgery type (ACL graft choice, meniscal/multi-ligamentous involvement) some of these progressions may be slower than others.

What will you be doing? Well, this may vary from clinic to clinic and even in-between practitioners. I will say that finding someone acquainted with ACL surgeries will be at your best interest! Let’s just say phase one should include some hands-on soft tissue work in conjunction with range of motion, some generalized exercises in lying down and standing, and re-training your body how to walk properly! If your physician has given your therapist a protocol, this will most likely drive your physical therapy treatment. If you have one and have questions- do not hesitate to ask. One thing I always make sure to do with my patients is sit down with them at the start and discuss a possible timeline and realistic expectations.

Common Questions and Answers:

When do I get to get rid of my crutches?

• So, remember how you’ve been pulling on your pants to lift your leg into your bed, or into the car? Well, before we get rid of your crutches this needs to stop. For some, once you demonstrate the ability to lift that leg in a controlled manner, bon voyage crutches! In a perfect world, we hope to have you off crutches within 2 weeks. Just remember, this can vary if you have had a concurrent meniscal repair or other multi-ligamentous involvement.

When do I get to take this brace off?

• This will depend for everyone. Typically, there are stages of progression when it comes to post-operative ACL bracing. You will more than likely start with your brace locked in a straight position, and as demonstrate improved muscular control, have the brace unlocked to your available range of motion. Once you demonstrate good quadriceps control and knee stability, the brace will come off! For some this may be three to four weeks, for others it may be six or more. Remember, I said, everyone is different!

When can I drive?

• The decision to drive is typically made at a follow up visit with your surgeon. It will vary if you have had your operation on your right and left leg. This is because in a street car we mainly utilize our right leg at the pedals. I have seen most doctors release patients to drive in-between 4-6 weeks if the right leg is involved and slightly shorter if the left leg is involved. Why so long? It may have nothing to do with strength or control, but as medical providers tissue healing is imperative to successful outcomes! One other thing that must be considered is use of prescribed pain medication. We don’t need impaired drivers on the road and we sure don’t want you to be one of them!

After phase one goals have been met, one can enter phase two of rehab! Remember, this may be different for everyone and if it takes you a little bit of extra time to get out of phase one, DO NOT PANIC. I’m sure there are many ACL veterans who can tell you they’re early phase of rehab didn’t go quite as planned. So, even if your delayed, keep a positive mind-set as phase two is right around the corner! Stay tuned for part three of this blog to learn more about the later phases of ACL rehabilitation.

Phase Two: Strength Building

So, you’ve ditched your crutches, you can lift your leg unassisted and you’re range of motion is coming along nicely. You feel like you’ve been doing straight leg raises for days and are ready for the next step. Phase two is an imperative part of ACL rehabilitation as this is where you will start developing the necessary strength & motor control for the “return to activity or sport” phase of your treatment plan. The biggest complaint I get from individuals in this phase is, “is there anything else I can do?”. Typically, the answer is- not really. This phase is a slow, progressive phase making sure that you develop adequate strength and strategies to be successful in the next phase of rehabilitation. What will you notice during this phase? Things will become easier! You’ll no longer question standing up from a chair or walking up a set of stairs. You will begin to feel somewhat normal again. Don’t let this normalcy fool you, this is also a point in your rehabilitation where if the ACL graft is put under too much stress, it is at a higher risk of re-tearing.

What will phase two include? During this phase your physical therapist will monitor your strength gains and build you an appropriate training platform. You will most likely be in PT treatment 1-2 times per week and during those times be performing a variety of squats, lunges, step downs, balance tasks & possibly even some small agility tasks. This may even be the phase where the word “running” is re-introduced into your vocabulary. I cannot stress enough that training with a physical therapist two times a week is not enough to build the strength that you need to have a successful progression. What does this mean? You need to be performing your home exercise program regularly!

Common Questions:

When can I run again?

• There are several things we will look at when assessing return to running. We want to make sure that you have adequate knee range of motion and most importantly adequate strength. Your physical therapist should watch you move and observe things such as a single limb step down forwards and sideways before giving you the go ahead. What I will say, is that just because we release you to run, does not mean go run 5 miles right away! Remember, ACL rehabilitation is a progression not a race!

When can I go to practice?

• Well, you can go whenever you want but you may not be able to play! I always recommend that my athletes go to practice from week one post operatively. Practice truly is a great time to do your home exercise program. Also, this will show your coach that you’re doing your best to get back. As you near the end of this phase, you may begin small activities utilizing a ball or bat, but just because this happens doesn’t mean you are ready. I want to re-iterate, there is a 51% decrease in re-injury rate every month up until 9 months post-operative. Research typically doesn’t lie ?.

How long until I can cut and jump?

• Phase three is coming, I promise. In this phase you will begin more return to sport activity. Of course, this is after you pass your phase two testing. So… two weeks, three weeks? Remember phase two of ACL rehabilitation is slow and progressive and everyone is different. Some may begin some light return to sport at approximately 14 weeks meanwhile for others it may be more like 22 weeks. Let me reiterate, everyone is different!

You’ve been building strength and have passed all phase two criteria! Phase three is now approaching. Whatever you do, keep a positive mind-set and keep looking toward the end goal. Things may be bumpy, but you will get through this! So what should one expect in phase three?

Phase Three: Return to Sport

You’ve progressed from double limb strength tasks to single limb strength tasks and are now running pain-free with a normalized gait. Welcome to phase three, my friends.

Remember, although this is titled “Return to Sport”, it does not necessarily mean, “Return to Play”.  It is a common misconception that many athletes and parents have when talking about ACL rehabilitation. When a physical therapist states, “We’re going to begin some sport activities today”, I want you to be excited, but also remember you still have a bit of time before you’re back on the playing field, riding your dirt-bike or running your toughest trail.

So, what does phase three include? During this time, you’ll continue strengthening and begin basic return to sport movements. Small jumps and hops may be some of the first activities re-incorporated into your athletic profile! Once proficiency is noted with these, you’ll progress to more single limb activities and possibly even cutting, running & pivoting. How exciting, right? Just remember, your physical therapist is there to guide you. He or she will give you the go ahead to jump higher, run faster, or even stop and make that first cutting motion. There may be times your PT may have you back-track to improve upon movements that may not be ideal. Just know, we’re not here to bog you down, just make you successful in your rehabilitation.

Common Questions:

When can I play in a game?

• I’m sorry if I am starting to bore you; however, I will continue to reiterate this fact. Research shows that there is 51% decrease in re-injury rate every month until 9 months post operatively. I recommend no less than a 9 month recovery phase for all of my athletes. I will say, that although 9 months is recommended, some individuals may have up to a 24 month rehabilitation. The answer to this question is truly- it depends.

Do I really have to keep doing this?

• You may not have to see your physical therapist as often, but my recommendation would be YES. Continue physical therapy and have someone monitoring your progress. Remember, having an ACL tear is the #1 predictive factor for having another one. Let your PT work with you as long as possible to decrease the risk for another injury!

How do I know I am Ready To Play Again?

• You’ll have to read the last section for the answer to this one!

Phase Four: Successful Return to Play & Performance

So, you’re nine months into your ACL rehabilitation. You feel normal walking around and can run three miles without pain. You and your physical therapist have worked on pivoting, cutting, jumping and sports activities in the clinic and you feel pretty good. So how do we determine the answer to the ultimate question?

As physical therapists we have an obligation to return you to sport well-prepared. How do we determine preparedness? We not only observe your physical strength and movement patterns but also your psychological readiness to return to sport. There is not one specific test that is suitable to determine if you’re ready. Hence, a battery of tests & observations should be made. If we feel as if you are physically ready but not psychologically ready or vice versa, we may delay your return to sport to ensure success in the long run!

Not all physicians require a return to sport test; however, they also do not see you as often as your physical therapist. I (and  many of my colleagues) recommend that every individual looking to return to sporting activities whether it be soccer, lacrosse, motocross, mountain climbing, etc., undergo a thorough return to sport protocol. If you are released to return to sport, just remember it does not necessarily mean return to full performance. What this also means is that your rehabilitation is not over! Once cleared to return to sport, strength and conditioning is of extreme importance. This is not only to ensure success, but to continue to improve your sport performance over time.

Common Questions:

What is a Return to Sport Test?

• This will vary from clinic to clinic; however, research shows there is not one specific test that is the prime determinant for return to sport. At Feldman Physical Therapy & Performance, we utilize a generalized movement assessment, strength testing, balance tasks, hop tests, deceleration drills, and change of direction drills. We also use a wearable technology (Dorsa Vi) to examine running & movement patterns to ensure limb equality.

Why Won’t You Release Me if I Seem Strong Enough?

• Strength does not always equal proper function. Just because you can perform equal weight on single limb squats, leg press or dead lifts does not mean that you can control functional movements (running, cutting, jumping) with proper form or mechanics. Also, even if you pass a hop test, it is not always a proper time to allow an athlete to return to sport. I know this may be frustrating but trust your healthcare provider. It’s all in YOUR best interest!

Why am I not as fast?

• Remember when I said that rehabilitation is not over. All movement patterns and sequences that were once present like a radio pre-set in your brain have been altered. Completion of physical therapy does not mean return to full performance. This is something you will have to continue to work on over time. If you’re unsure how, discuss this with your physical therapist. They’ll help point you in the right direction.

Do I need a brace?

• This will depend on what your healthcare provider sees. For some people, we use it as a tool to improve comfort of return to play. Personally, I like to get my athletes to such a capacity where a brace is not needed for return to sport!

Yes, the journey through ACL rehabilitation is scary and daunting. It is also not the same for everyone. There is one thing that I can assure you- you will get there! Nine plus months seems like a lifetime, but don’t let it get you down. Set goals with the help of those around you. Discuss your concerns with your medical team. Keep your head up and you’ll be back in the game before you know!

Well, here is to the completion of a three part blog! Please reach out to us at Feldman Physical Therapy and Performance if you have any questions or concerns!

Ashley Witson, PT, DPT