It’s important to do ACL rehab right (the first time).

An ACL tear PLUS surgery PLUS 9-12+ months of rehab:

takes a lot of time
is expensive
is a long time away from playing the sport(s) you love
is mentally challenging
is a lot of hard work in the gym
can have long term health consequences (like early onset knee arthritis within the 10 years after injury)

AND 20-40% of the time, athletes return to their sport only to suffer a non-contact re-injury to the same or opposite side ACL within the next year.

A second injury means going through all of the above AGAIN.

We attribute these second injuries to incomplete rehab of the initial injury that leads to the athlete using compensatory patterns that put them at increased risk for that second injury.

The majority of athletes who seek out my services are rehabbing their second ACL injuries. Why is that? It’s because they have finally realized how important it is to work with a provider who:

specializes in ACL injury rehab and preparing athletes for the demands of high level sports
can customize care to them specifically
stays up-to-date with the latest ACL rehab practices

I hear a lot of “I wish I had known better the first time around” from athletes I work with and their parents, so my goal…

with this blog post,
the free workshops I do with club soccer teams,
and a lot of my social media content

…is to spread the education of how to lower risks of sustaining ACL injuries and what quality ACL rehab for an athlete looks like.

On that note:

Here are 5 red flags in ACL rehab:

Red Flag #1 Your Rehab Provider Only Uses Time-Based Criteria To Progress Your Rehab.

The use of time-based criteria occurs when an individual is progressed through stages of rehab ONLY based on the amount of time that has passed since the original injury or surgery. One of my least favorite examples of this is when athletes are cleared to start running just because three months have passed since their surgery. There is a huge spectrum of where an athlete may be in terms of swelling, range of motion, tolerance to loading, strength, and overall recovery at three months post-op, so clearing them to run without any attention to or testing of those variables is irresponsible.

I use a criterion-based metrics to progress athletes along their ACL rehab journeys. Before an athlete is re-introduced to running, they will have met the following criteria:

Full/Symmetrical knee range of motion into extension and flexion compared to opposite side
No swelling or pain after exercise
Quad & hamstring strength 70-80% of uninjured side AND close to 2.0 knee extension torque to bodyweight ratio. These measures are more thoroughly discussed in this blog post.
Low-level plyometric exercises (pogos, step-pause, and base landings) have been introduced and tolerated without increased swelling or pain

Red Flag #2 The only running you do during rehab is on a treadmill.

The biggest difference between running on a treadmill and running in your sport is that running in your sport includes accelerating and decelerating. Running on a treadmill does not, and unfortunately, you are most likely to get injured in your sport when you cannot accelerate or, more importantly decelerate, well. The majority of non-contact ACL tears occur when decelerating during plants, cuts, pivots, and single leg landings, so if the running you are performing during your rehab journey does not progress to include these challenges, it is not preparing you for a safe return to your sport.

The other differences between running on a treadmill vs in sports are that 1) you can’t achieve a true sprint on a treadmill (you can run fast, not sprint) and 2) a lot of running in field sports isn’t linear pathways but more of curvilinear paths. Curvilinear running has different propulsion mechanics and you can’t train it on a treadmill.

To sum it up, it’s ok to do some running on a treadmill during ACL rehab but it shouldn’t be the only running or “sprinting” that you are doing.

Red Flag #3 Most of your strengthening exercises are performed with bodyweight or a light weight (anything less than 50lb)

Weights under 50lbs may work in the beginning stages of ACL rehab, but beyond the first 4-5 months, those won’t cut it.

Let’s talk about sports demands: Imagine you are sprinting in your sport and have to slow down on a dime, change directions multiple times in various angles, and re-accelerate (and that’s not even considering your opponent who is pushing against you as you complete these movements). During that deceleration, your body needs to rapidly slow down 2- to 3-times your body weight in forces, often over one leg, mostly at the knee joint, with proper mechanics of that knee moving forward toward the toes.

The quadriceps muscles (along with some contributions from muscles like the hamstrings and soleus) are primarily responsible for controlling that deceleration, which means they need to have the ability to control a torque (physics speak for rotational force) of at least 2-3 times bodyweight.

One of the biggest reasons I believe athletes get re-injured when returning to sports after a first ACL tear is that their quads are not strong enough to handle these deceleration demands. That’s why I am adamant about regularly measuring/tracking their strength in these areas and training it intensely.

“At the end of your rehab journey, you should be the strongest, fittest version of yourself, you should be in the best shape you’ve ever been in.” This is something I frequently tell athletes rehabbing ACL injuries because we are going to build their leg strength so that, without question, it has the capacity to control their bodyweight during the quick decelerations that occur in sports performance. If your rehab provider does not have the means of loading you to achieve this, you won’t get strong enough.

Red Flag #4 Quadricep and hamstring strength are only measured by hand (not instrument)

If you’ve been paying attention up to this point, hopefully you realize why specific measurements of quadricep and hamstring strength are important.

The “old school” physical therapy practice is to attempt to measure muscle strength by pushing on the leg with one’s hand. Research has shown that this practice can only detect between-limb differences over 15% which won’t cut it in ACL rehab where a 5% difference between sides can be significant and where we really need concrete numbers to gauge how the strength compares to the athlete’s body weight.

The picture above is an example of the inline set up I use to measure knee extension/quadriceps strength. The little wooden box between the carabiners is a force transducer. It connects with an app on my phone to relay measurements of the amount of force being produced.

This is the set up I use for athletes to measure side-to-side symmetry, hamstring-to-quadriceps strength ratios, and torque-to-bodyweight ratios.

I discuss more about the limb symmetry and torque-to-body-weight measurements in my blog post: Why the Quadriceps are Queen in ACL Rehab.

Red Flag #5 There’s no gradual return to sports participation process, it’s abrupt.

One day, you’re in your rehab routine, the next you are being discharged from PT and given the clearance to return to your sports 100%.

That's terrifying.

We do our best during the ACL rehab journey to prepare and expose an athlete to all the demands they may encounter when playing their sport but sometimes, unanticipated challenges arise during the return to sport process—like a tendinitis, a type of movement that doesn’t feel great, or an issue with conditioning. This is why it’s important to ease back gradually, so we can nip issues that come up right away and lower risk of more serious injuries. The return to play progression might look like:

Return to non-contact drills at practice at 50% intensity
Return to non-contact drills at practice at 100% intensity
Return to full practice including contact at 75% intensity
Return to full practice including contact at 100% intensity
Return to game play 10-15 minutes 100% intensity
Return to game play 15-30 minutes 100% intensity
Return to game play 30-45 minutes 100% intensity
Return to game play 45-60 minutes 100% intensity
Return to game play 60-75 minutes 100% intensity
Return to game play 75-90 minutes 100% intensity

Yes, it’s slow, but that allows us to make sure an athlete is thoroughly prepared for game play on all fronts.

Let’s make sure you get the best care during your ACL rehab!

I specialize in ACL rehab and the return to play process for athletes.

Here’s how we can work together

We can work together 100% through your entire rehab journey, including prehab sessions before surgery.
You can work with my concurrently while you see your insurance-covered PT. You’d primarily see your insurance-covered PT and also have occasional check in sessions with me on a weekly, biweekly, or monthly basis to make sure you are on track.
You can work with your insurance-covered PT through the first 4-5 months of ACL rehab and then switch to working with me for the higher level strength and sports training that occurs in months 6+ of the rehab journey.
We can create a care plan that works for you and your resources!

Book a Discovery Call with me to discuss working together or sign up for my Stay In The Game Emails to stay in the loop.

5 Red Flags in ACL Rehab