Rehabilitation After an ACL Surgery

John,

Thanks for the site and CrossFit Football. I have been following the training on and off for the 2 years with great results. I recently tore my ACL while competing in MMA and know you have experience with rehabbing back to full strength. I know my doctor has a conservative timeline for recovery, can you a more aggressive one?

Thanks,

G.P.

G.P. ~

Thanks for the support and glad you think enough of me to ask for direction in rehab. 20 years ago a torn ACL about ended your career, the doctor would open up your knee like he was deboning a fish, cut apart your patellar tendon to harvest a graph for the ACL, drill and use screws and staples to hold it in place. The rehab was extensive as the most of the severe damage came from cutting the knee apart for the ACL graph. Patellar tendonitis, severe knee pain, non-existent vastus lateralis and vastus medialis obliquus and about 12 months of recovery were all you had to look forward to.

Fast-forward to today and a completely different process. Doctors can perform an ACL reconstruction arthroscopically with a cadaver graft and have you back to full strength in a third of the time.

While the surgical techniques have changed, the rehab milestones have not. When you look at coming back from a major injury it is best to have milestones and small victories to keep you going.

Day 1- 6 goals: full range of motion, reduce swelling and normal gait. Full extension allows the newly reconstructed ligament to fit perfectly into the intercondylar notch. Restricting full extension will allow the notch to fill with scar tissue, block extension and never allow the muscles in the quadriceps to fully fire. Full flexion of 130+ degrees will come with time, but you should shoot for 110 degrees coming out of surgery.

Ice and compression are the key players to controlling swelling. Fred Tedeschi, trainer for the Chicago Bulls, told me the only time to not have ice on your knee was when I was training. Compression boots and socks were worn as much as possible to push swelling from the injury.

A normal gait is a smooth walking motion unimpeded by a limp. The sooner you can get off your crutches and start walking normal the faster the process of healing can begin.

You asked about a more aggressive training program and I agree many of the doctors, unless they are used to working with competitive athletes, will be very cautious. The training cannot begin until you reach full ROM, control the inflamed tissue and return to walking normal. Once you reach full terminal extension the strength and proprioceptive training can begin.

Week 2-4 goals: Full ROM, start strength training and building GPP. The majority of strength work should be done closed chained. Squatting, pulling, riding the bike, rowing and calf raises make up the majority of work. Sled pulls to build calves, hamstrings and restore some GPP.

The strength training focus becomes two fold. One, approach the same level of strength you had pre injury and create symmetry in the legs. You had better know a little bit about hypertrophy and the ability to build some leg mass as symmetry between the legs is a key factor in being cleared for full duty.

Week 4-8 goals: Full ROM, continue strength training, begin proprioceptive work and return to controlled sport specific training. Once the strength has been established in the squat and deadlift, more planes of motion are added with the lunges and step ups. Balance training also begins with the use of single leg balancing on foam blocks, two legged wobble boards and slide board.

The slide board isn’t big in CrossFit circles, but its benefits in ACL rehab is well documented. I have used the slide board in all of my knee rehabs; it has worked well for working change of direction in a controlled environment.

The doctors set rules for activity in weeks 4-6, as, no pain during or after activity, no increase in swelling and no change of gait. However, if you are training hard you will get some swelling but you have to manage the swelling with ice and compression. Changes in gait are unwanted so if you find yourself limping you have done too much.

Week 8-12 goals: full ROM including terminal extension, improved muscle tone in the quad, at least 80% of strength has returned and you should be involved in an agility/proprioceptive program geared towards returning to sport.

At this point you should be able to squat below parallel with a heavy weight. I am not expecting you to be back to squatting 600+ lbs, but you should be able to perform an Olympic style squat with a fairly heavy weight. That means knees over your toes involving the quad in the squat. A box squat with a vertical shin or negative knee angle places the stress on the hamstrings and butt. We need to start stressing the quad and the knee and preparing for more ballistic training.

Week 12+ goals: you should be approaching your pre-injury strength levels and symmetry between the two legs. The hamstrings should be strong (think steel cables), as the hamstring is the major stabilizer for the knee. You should be able to run, plant and change direction without pain or buckling.

Here is my major caveat, when doing strength training range of motion has be monitored daily to make sure you are not losing motion. If you are getting stronger and increasing tone but losing extension, then you need to look at your rehab protocol and make changes. Symmetry with ROM and strength are the keys to being back to normal.

The more diligent and hard working you are in the rehab process, the quicker you will recover. The most important part of the rehab process is to train to not have issues down the line. I have had many successful rehabs that have allowed me to come back and perform at a high level. Put in the hours and dedication in the rehab process and you should not have to deal with these injuries for years to come.