ACL Rehab Case Study - Part 4

Welcome to Part 4 of the ACL Rehabilitation Case Series!

In today’s post we are going to review months 2-3 of my "ACL Rehab Checklist" to see how we used a systematic approach to hit milestones during the first few months of Emmett's rehab. Using these milestones we can then be set up for a successful return to running around the 4-5 month point in rehab! In part 3 we talked about how we used PRI and BFR as modalities and techniques to set Emmett up for a successful start to his rehab journey. Read about how that went here. 

As a reminder, here are some important

milestones I like my athletes to be approaching by the 3 month mark -->

These tests are all vital for normal

biomechanics, range of motion, strength

and appropriate deceleration mechanics

to appropriately and safely return to

running. Let's take a look at a few of them in action!

The first 2 are both metrics of general single leg strength, and more specifically quad strength. We know that quad strength in a post-op ACLR athlete is going to be of utmost importance. I need to see my athletes have the ability to perform 10 single leg squats to a 20" depth (in this case I called them "SL pistols") and 10 controlled forward step downs off a 4" step with good knee and hip control to prove that they are ready to handle the more dynamic movements necessary in running.

Here Emmett is demonstrating single leg squats. He is leaning a bit forward to make up for a lack of quad strength here - something we will clean up as the weeks go by - but a good start with good knee control!

Here are some examples of anterior step downs. He does a great job of keeping his chest upright, and is able to control his knees

over toes position with decent strength. This is pretty good for this early on in rehab!

The next 2 assessments - tibial internal rotation and prone hamstring curl side to side are both metrics that measure ranges of motion at the knee joint. The tibia (lower leg bone) has to be able to rotate slightly internally for the knee to have full bending - something that at times needs manual therapy if knee flexion range of motion is not progressing appropriately. The prone hamstring curl is also a measure of knee flexion range of motion, while also testing the ability of the hamstring to bend the knee against gravity. These are both subtle (but important) tests to make sure we are not missing anything as the rehab process continues!

The third 2 assessments - squat and lateral lunge assessments - are both compound movements that begin to ask the athlete to manage not only their knee, but also hip, core, ankle and back during movements that are more sport specific. It is important that we make sure the athlete has good form on these more complex movements because we will start to load these up pretty heavy as time goes on as a way to globally improve strength and resiliency overall.

The final 3 are all metrics that test an athletes ability to "decelerate" which is required for any running or change of direction sport! The athlete must display an ability to slow their descent with good control and without knee discomfort in order to be cleared for running.

The knee to doorframe test (performed here with the rack instead of an actual doorframe) is one of my earliest exercises for athletes who want to return to running. Here we are seeing a more advanced version, but the goal here is for Emmett to control the knee drive over the toes with good form, and then return to standing. Within the first couple weeks we will start with a small range of motion, and then advance further from the rack as quad strength and tolerance improves. Eventually moving to something more similar to the step down exercise modeled above.

Here we are looking at a single leg depth drop test. Prior to performing this movement the athlete needs to demonstrate the correct control in strength exercises, knee to doorframe testing and double leg movements. We are assessing landing ability, knee and hip control, and how far he can get his knee to translate over his toe with good control. We can see here he still has some work to do to get a softer landing with a slightly more bent knee! We perform these assessments to see where we need to go in the future - test and retest should be a part of EVERY ACL rehab journey!

Finally we have a depth jump variation. This example is a more advanced single leg landing from a jump. We are assessing the athletes ability to appropriately decelerate, pause and then re-accelerate into a jump. That combination of movements will be challenging for a post-op knee, and starting with slow and controlled movements will help the brain relearn how to perform these movements safely. Throughout the rehab process will do a huge variety of these movements in all different directions, speeds and variables to mimic the chaos of sport. Before returning to running I like my athletes to demonstrate a successful depth jump with good control, quick decel and accel, and no pain!

Starting at the very beginning of rehab up until the 3-4 month mark we will be using this checklist as a guideline to help direct our plan of care, see where our weaknesses are, and attack them with data driven metrics! Of course throughout this time we are also building general strength using squats, deadlifts, lunges, etc., as well as continuing to use PRI and BFR throughout to maintain neurological and musculoskeletal improvements.

Join us next time as we review our next phase of rehab - return to running!