ACL Rehab Case Study - Part 2

Mariel Hammond
Feb 22, 2024
5 min read

Updated: May 15

Welcome to Part 2 of the ACL Rehabilitation Case Series!

In today’s post we are going to cover Emmett’s journey from week 1 post-operatively to his 2 week post-op follow up with the surgeon. In part 1 we recounted the month of extensive “pre-hab” Emmett did with Zenith to prepare him for his ACL reconstruction surgery. Read about how that went here.

Starting with a new ACL client there are several important questions that rehab providers should be asking their clients to help direct the plan for rehab back to their desired goals! Here is my list that I always ask even BEFORE the surgery happens:

1.What are your goals for your athletic career? What sport(s) are you trying to return to playing?

*asking these questions allows the provider to include sport specific drills during the rehab. Soccer players should be kicking soccer balls, Ultimate players should be throwing frisbees, etc.

2. How did you tear the ACL? Was it a non-contact tear or was there contact when it happened?

*if there is no contact with a tear I know I will always make sure to include a ton of change of direction (COD) drills and make sure the client feels really safe with these before returning to sport

3. What graft did they use to repair the ACL?

*this question is really important because different grafts can have different complications/limitations and knowing these up front will help the provider recognize potential barriers that can be addressed quicker

In Emmett’s case his goals were to return to high level Ultimate Frisbee so he can play at a college level as well as any other sport he plans to pursue! He tore his ACL attempting to change direction when a frisbee was thrown behind him at a summer practice, so we would classify this as a “non-contact ACL tear.” Emmett and his surgeon decided to go with a patellar tendon graft (the best option in my opinion!). I have used this information to help plan out Emmett’s rehab down the road!

I also have an “ACL Checklist” that I personally use to make sure we are on target with our rehabilitation goals! Obviously everyone is different, and different clients can have different complications during their rehab journey, but this checklist allows me to make sure I am prioritizing the correct things at each “phase” of rehab.

As you can see from the above image, the Return to Sport phase of the rehab process for me will be at a minimum 9 months - there is extensive research to support waiting until at least 9 months after an ACL reconstruction to return to sport with no restrictions. “For every month that return to sport was delayed, until 9 months after ACL reconstruction, the rate of knee re-injury was reduced by 51%.”

I make sure that ALL of my ACL reconstruction clients are fully aware of this information as we begin the rehab process so there are no surprises as we reach the later stages of rehabilitation. At the end of the day it is my responsibility to make sure my clients are safe, and regardless of how well the recovery process is going I will always delay returning to play until 9 months or later.

I saw Emmett for his first appointment 5 days after surgery. I know this seems pretty soon but there is a lot in rehab we can start to work on even as early as 5 days Post Op!

ACL Rehab Case Study - Part 4: First Session

On a first session post operatively I am going to be checking for 4 key things:

Red Flags - how does the wound look? Are there any signs of infection or anything just not quite right with the knee? How is the pain management? Is the client having a normal post operative recovery or is there anything sort of “off” happening?
Knee Swelling - have I educated the client on all of the correct post operative pain and swelling management tools?
Knee Range of Motion - how can we start working on getting the knee fully straightening (most important) and fully bending within the first 2 weeks?
Quad Muscle Activation - How well does the client’s quad muscle want to contract? How full is the contraction? How long can they hold the contraction for?

The surgery itself went very smoothly with no complications, and he had been working diligently on his knee range of motion, swelling management and quad contraction even before our first appointment! We checked the wound for infection, did some soft tissue work to reduce swelling, and began to work on passive stretching of the knee into flexion and extension.

In order to help speed up the quad contraction we also began to use a Neuromuscular Electrical Stimulation (NMES) Device on his quad muscle during exercise. NMES devices work to send electrical impulses to nerves which help the muscle contract.

After surgery it is common for this “WiFi” connection from the brain to the muscles to be disrupted - devices like NMES can help restore the connection and get the muscles back on line. It is imperative to restore this connection as soon as we can after surgery! I like to use at home devices the clients can take home with them - in Emmett’s case we used a PowerDot NMES system.

ACL Rehab Case Study - Part 4: “Homework” Plan Day 1:

Daily:

Towel under heel 3-5 min (2-3x/day)
Quad sets throughout the day (at least 100 per day!)
Quad sets with NMES (5-10 min, can do 2x/day if not sore or swollen)
Straight leg raise without brace 3-5 reps, focus on good quality
Heel slides (stop at stretch, don’t force it)
Hamstrings and ribs breathing
Continue to do swelling and pain management; elevate and compress the knee, take your pain meds on a regular basis

We also checked Emmett’s knee brace setting as well as the size of his crutches during gait to make sure they were fitted appropriately for him. As Emmett’s surgery did not require a meniscus repair, (yay!) he was able to begin

“Weight Bearing As Tolerated” (WBAT) pretty soon after the surgery so the crutches were only really used for a couple of weeks.

Emmett was diligent with these homework drills (and a few other progressions including adding more hamstring activation and weight shifting drills) over the next couple of weeks. He had his first post op appointment with his surgeon 2 weeks after the surgery and he was cleared to start walking with the brace unlocked and to begin Blood Flow Restriction Therapy (BFRT)!

By the 2 week mark Emmett had full knee range of motion in knee extension, was very close to full flexion, had no swelling and was practicing walking without crutches, as well as getting better quad activation. You can see from the list below that he was well on his way to having a great first month of rehab!

Join us next time as we begin post-op BFR, strength training and bring Emmett’s awareness back to his left leg using PRI concepts!

See All

ACL Rehab Case Study - Part 4

ACL Rehab Case Study - Part 3

ACL Rehab Case Study - Part 1

Comentarios

A seamless transition from PT to strength training

I worked with Dr. Mariel Hammond who helped relieve my pain from an acute injury and identified the underlying cause. She worked with me to develop a longitudinal plan to prevent this injury from happening again. She was professional, supportive, and positive, and helped provide a seamless transition from physical therapy to a tailored strength training program. The whole Zenith team is great to work with—communication and scheduling is easy, they are friendly, and work with my schedule and individual needs. After graduating from physical therapy, I now participate in strength training sessions with Josh Harper and am happy with my progress. Thanks to Dr. Hammond, Josh Harper, and the whole Zenith team for providing excellent physical therapy care with a smooth transition to a tailored strength training program. If you’re looking for physical therapy, personal or group training in a supportive and respectful environment, Zenith is the place to go.

Christina M

Had me walking pain-free in just a week

An absolutely amazing experience! As I trained for my first marathon, the Eugene Marathon, I unfortunately overdid it and ended up injuring myself just 18 days before the race. Fortunately, Jesse, one of the owners of Zenith, overheard my conversation about the pain I was experiencing and recommended this place to me. I met with Mike Robinson, who quickly identified the issue and had me walking pain-free in just a week. With only a week and a half left before the marathon, I had three more sessions here—each boosting my confidence and ensuring I could run without pain. This place is incredible! I highly recommend it to anyone facing a potential setback due to injury. The team's communication, attention to detail, and dedication to their clients are truly exceptional. Five stars without a doubt!

Julian C

Zenith saw an opportunity no doctor had

After a year and a half of uncertainty regarding a lower leg injury I developed my freshman year, working with Jesse Klein is the only reason I can play pain free. After 4 MRIs, a compartment syndrome test, multiple X-rays, and people telling me it was time to give up my sport, Jesse saw an opportunity and brought to the table new knowledge and possibilities to my injury that none of the 3 doctors had mentioned to me. I am so thankful for this company and all they do for my team—but most importantly, huge thank you to Jesse for beating the odds and taking a new approach to heal me. After playing multiple sports my whole life, I knew something was wrong with my leg freshman year (2022). About two weeks into fall camp, I started experiencing swelling to almost double the size of my calf and leg spasms/cramps that would often keep me up at night. I attempted to push through and unfortunately ended up being diagnosed with bilateral tibial stress fractures and placed in a walking boot on my left side and an air cast on my right side for 2½ months, taking away my full freshman season. I went through about 3–4 months of physical therapy and attempted to return in March (2023) of my freshman season, but the pain wouldn't go away. I played through pain for about a month, but the swelling got to the point where I was having a hard time walking, and ultimately led me back to the boot from April to May. From June–August I was on a strict rehab schedule to get me back, which included no explosive or impact movement for the full time. I thought I was healed. I came back in August (2023) and the pain wouldn’t stop. At this point, I reached out to a new company and they wanted to discuss compartment syndrome testing, which ultimately took place in January—one of the doctors told me I should give it up if I wasn't reliant on scholarship. I went on break worried about what to do—and that’s when I met Jesse Klein. My coach introduced me to Jesse in January and told me he had a couple ideas on my injury. At this point I was looking for a miracle. I worked with Jesse from January to May (2024) and I plan to work with him in the future. We did weekly appointments and I followed his program that allowed me to begin play in moderation and keep up with exercises daily. Jesse brings a new view and unique take to PT and I would honestly recommend him to anyone. Because of him I am now pain free and can finally play the sport that I love. I played the whole 3 months of spring season with no pain and I can’t wait to come back and play in the fall. Without Jesse I don't know if I would be able to play anymore—he's made this experience efficient and comfortable, and my coach and I are eternally grateful.

Jessie M