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ACL Rehab Case Series - Part 3


Welcome to Part 3 of the ACL Rehabilitation Case Series!





In today’s post we are going to cover pieces of Emmett’s journey from week 2 post-operatively to 3 months. We will specifically be covering his return to normal walking mechanics via PRI techniques, as well as his quadriceps specific strength training using Blood Flow Restriction Training.  In part 2 we recounted the first 2 weeks of Emmett’s ACL rehab journey from our first PT appointment to his 2 week follow up with the surgeon! Read about how that went here


As stated in my previous blog the first couple weeks after surgery are really focused on getting the swelling down and range of motion back to normal. Emmett was able to work really hard, and by week 2 he had mostly full range of motion, normal swelling and was already starting to walk without crutches! 


Surgery is a trauma to tissues and joints, and this disruption and swelling can cause an issue with joint ‘proprioception.’ Proprioception is a term that means “joint position sense or awareness” and is used to describe how well we are able to sense our bodies moving through space. 


After an ACL surgery the brain does not communicate well with the joints and muscles on the operation side, and part of recovery is improving this connection between brain and body. It is important to work on range of motion and strength, but without this neurological aspect to movement, we cannot expect an athlete to perform without compensatory strategies. 


Postural Restoration Institute (PRI) is a style of physical therapy that prioritizes this connection between brain and limb, and works on the neurological side of rehab. As Emmett was returning to normal walking it was important to make sure the brain could process using the correct muscles for standing and walking on his left side, so he did not develop a compensatory strategy that could limit his progress. 


Muscles that are required for left stance include a left proximal hamstring, left adductor (groin), left obliques (abs), left glute medius, and right glute max. Throughout the first 2 months of rehabilitation we made sure to include exercises to target these muscle groups as Emmett began improving his walking mechanics. 


Initial Steps via a PRI Repositioning Program:






Left 90/90 Hip Shift to engage a left proximal hamstring and left obliques (abs)






Left Adductor Pullback to engage a left adductor (groin)






Secondary Steps via a PRI Repositioning Program:






Left 90/90 Hip Shift Hemibridge to advance left hamstring and ab activation in a single leg stance







Left Sidelying Knee Towards Knee to engage and right glute max and left abs and groin






Right Sidelying Supported Hemi 90-90 to engage left glute medius and adductor, left abs and right glute




These drills allowed Emmett to feel more grounded on his left side, and improved his ability to neurologically load into his left side without compensating! He completed these drills daily before and after his strength exercises to rebuild this connection. 


Neurology aside, muscle atrophy is another major factor in ACL rehabilitation. The quadriceps muscle on the surgical side will typically shrink after surgery, causing issues with stability and strength. Regaining this muscle size and strength is a definite focus on ACL rehab, and one modality I use to target these gains is the use of Blood Flow Restriction. 


Blood Flow Restriction, or BFR, works to induce a ‘hypoxic state’ in your muscles, meaning they are operating with less oxygen. While this seems like it would be dangerous, it actually primes the muscle tissue itself to adapt more quickly, having to work harder and therefore grow stronger with less work! BFR uses a strength training repetition structure of 30-15-15-15 (75 total) for 6-8 minutes of work! It is a great bang for your buck, allowing you to get more for less.


Starting in pre-hab, and resuming after Emmett’s 2 week post-op visit with the surgeon, BFR was used 2x/week in progressively harder and harder exercises to focus specifically on growing Emmett’s left quadricep muscle. As Emmett got more used to the BFR we began using 2, and sometimes even 3, 6-minute rounds of BFR in one rehab session! At the early phases of rehab, before we are cleared to really load Emmett with heavy weight, BFR is a great supplement to his strength training programs. 





Short Arc Quad with BFR

(quads)






Double Leg Bridge with BFR

(hamstrings/glutes)







Sit to Stands

(quads and glutes)






Sled Forward Pushes/Backwards Pulls

(quads and glutes)





Using BFR 2-3x/week, in conjunction with his other exercises, for the first 2-3 months made a big different in quad size as well as strength. While they look like easy exercises, the restriction makes them feel like you are lifting closer to your 1 rep max! These exercises are no joke, and I am sure Emmett would be the first to tell you how much muscle burn they elicit!


2 weeks Post-Op 3 months Post-Op




















These two interventions - PRI and BFR - were heavily used in the first 3 months of Emmett’s rehab journey as they serve imperative functions. Neurological (nerves) and mechanical (muscle size and strength) improvements must be addressed in these beginning stages of rehab, and Emmett did a great job of using both in the first 3 months!





Looking back to our ACL checklist, join us next time as we review these different assessments that allow us to prepare for a safe return to jogging!

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