Suggestions for ACL rehab

Training Q&A [Moderated]
1

Hey,

I will be starting rehab with a patient who is thought to have suffered an ACL injury ~7 months ago. Landed awkwardly playing soccer, felt a pop, swelling for one week, and intermittent giving way of the knee since. Patient would like to eventually return ti playing soccer and even if an ACL tear/rupture is confirmed, would prefer to trial a course of rehab and avoid surgery.

ACL rehab is not something I’m particularly familiar with. I’ve read Derek’s article on returning to power training following injury, which was helpful, and also been reading around conservative vs surgical management for ACL injuries (it seems that outcomes are sort of similar in the long term).

The patient has a job where he is on his feet all day. Experiences occasional episodes of pain, swelling, and his knee giving away, so will need to adapt his duties. Single leg squat was very weak compared to the uninjured side when assessed.

Where would your priorities lie with this patient? I’m thinking about sticking to the basics I.e, improving strength on mostly bilateral movements, but including some single leg movements, upper body work, conditioning work, and maybe start to work on single-leg balance. So something like below as a typical session:

Goblet squat to box (gradually lower box) 3 sets of 8 @7
RDL - 3 sets of 8 @7
Push variation - 3 sets of 10 @ 7
Pull variation - 3 sets of 12 @7
Step ups (increase height of step as able) - 2 sets of 10
Single leg stance - held as long as possible x 3 sets

  • steady-state conditioning on off-days

And then over time increase the amount of dynamic work, proprioception work, explosiveness etc, before a gradual return to practice and then play.

Any major tweaks you would make to the above, or any sources you would recommend for information on this? Seems like a lot of sources are geared towards post-OP rehab, although I guess principles are similar.

Thanks!

2

The principles of rehab are similar regardless of whether someone’s been surgerized. Similarly, the priorities of rehab are no different. While I do not think it is likely they will get adequate results without surgery if involved in a dynamic sport like soccer, particularly this remote from the injury, keeping with the individual’s preferences for conservative management is fine too.

I cannot really weigh-in on what their rehab programming should look like, as I do not know what the individual can and can’t do right now based on symptoms and sensitivity, their training history, or what they want to do.

Off the cuff, I would jettison the single leg stance and “proprioception” work. The rest of it doesn’t really look like a strength program at this point, but again, I’m not sure what this person can do. We’d be happy to consult on the management of this individual, if needed.

3

Is this specific to ACL injury (or a subset, i.e. a “complete” tear or otherwise as indicated by the knee giving way), or generally true of knee ligament injuries? Does the opportunity for conservative knee rehab (rehab sans surgery) significantly worsen with time from the initial injury, or is this again true mostly in cases where there are “red flag” symptoms like the knee buckling or giving way and less so with generalized pain from tweaks or similar?

4

The reply is specific to ACL tear w/ instability and I would not apply this to all knee ligaments, no. Do you have an ACL rupture?

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5

Good to know! Thanks for the reply. I don’t believe so no (if your post was referring to me). I have a history of patellar tendonopathy in both knees and the pain I’ve had over the last few months has been more consistent with MCL “injury” and broadly patellar tendonopathy. No instability and no sudden acute injury along with transitory/travelling symptoms, so I thought it safe to assume it “nonspecific knee pain” (thanks to Dr. Baraki).

Mostly just trying to absorb as much info as possible and pass it along with references, I know far too many physios and “rehab” people personally that are still stuck in the traditional Sahrmann/Janda/“functional movement” approach and too many friends with injuries over the years who assume surgery is the go-to option.

6

Yea, each case is different depending on the injury, symptoms, activities, individual, etc. I would agree with Dr. B about calling it knee pain and seeing how it responds to dedicated conservative management.

I also agree that lots of folks are still living 20 years ago with knee pain management. Very frustrating!

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