The Primary Loading Phase of ACL Rehabilitation: A Critical Stage in Recovery

The journey through ACL rehabilitation is a carefully structured process, and one of the most crucial stages is the primary loading phase. This comprehensive guide will explore what happens during this vital period of ACL rehab and why it's essential for successful recovery.

Understanding the Primary Loading Phase of ACL Rehab:

The primary loading phase typically occurs between weeks 2-10 post-ACL surgery, although timing can vary between individuals. As the name suggests, this phase focuses on gradually reintroducing load to the muscles surrounding the knee while working to restore full range of motion and "quietening" the knee.

WHAT DOES ACL REHAB LOOK LIKE During This Phase:

Progression can be very different person to person during the Primary Loading Phase of ACL rehab, depending on the exact surgery that has been performed, whether they have been put in a brace or if they have to adhere to weight-bearing restrictions. For those that have an ACL reconstruction without meniscus cutting or repairing, usually bounce back quicker than those who have. This doesn't increase the total rehab time of 9-12 months, it just makes the start slower, with ample time to catch up.

During the first 10 weeks of ACL rehab, the physiotherapist will aim to provide treatment and rehab programs that help restore full range of motion of the knee, prepare the knee for the demands of the next ACL rehab stage (Strength Phase: In the gym) and minimise symptoms as we progress load through the knee.

This may look like seeing your physiotherapist 1-2 times per week for manual therapy and treatment as well as progression of your rehab program as you progress and regain functionality of the knee. Your home program will involve a combination of knee mobility exercises (often biasing regaining full extension), muscle activation and strength exercises of all major leg muscles, especially the hamstring and quadriceps, as well as low-level balance and gait drills.

Advanced Treatment Techniques

During the Primary Loading Phase of ACL rehab here at Game Time, we utilise several evidence-based technologies and methods to speed up knee strength and functional improvements. These include Compex muscle stimulation work and blood flow restriction training.

Compex Muscle Stimulation

After an ACL reconstruction, the muscles around the knee are inhibited by swelling and pain, reducing the activation of your quadriceps, hamstrings and calf muscles.

Using muscle stimulation technology, we get our patients to perform exercises in tandem with involuntary contractions made by the machine, helping improve muscle function and balance post surgery (1). Think of it like a mechanical brain. We can safely "switch" your muscles on more than your system wants to right now, getting the gains we need to progress your ACL rehab.

Blood Flow Restriction training (BFRT)

Another useful technique we use during this stage and the next is BFRT. This involves a wireless cuff applied high up into the groin which cuts off 80% of the blood to the leg whilst you perform low level exercise. This lack of blood flow creates a metabolic environment within the muscle tissue that helps provides similar muscle growth and strength improvements to that of an uninjured person squatting 70% of their one rep maximum (2). The ability to significantly improve lower limb strength during the first few months when we cannot lift too heavy/ load the knee too much is an invaluable method within our ACL rehab programs.

Progression Criteria

To progress to the Strength Phase of our ACL rehab, we make sure our ACL patients are ready and have earned the right to progress. This is never as simple as waiting 3 months, patients must do the work to ensure their knee is ready to meet the demands of the next phase. On testing, we aim for athletes to pass all tests:

• 125 degrees flexion and full extension of the knee

• 20 single leg glute bridges, 20 single leg calf raises and 10 single leg bench squats.

• No swelling at the knee (3)

• Adequate single leg balance (>43 seconds eyes open, >9 seconds eyes closed) (4)

Moving Forward

While 100% achievement of all progress markers isn't mandatory for advancement, these goals provide clear objectives for both patient and practitioner. The primary loading phase sets the foundation for more advanced stages of rehabilitation and ultimately, return to sport.

Tips for Success

1. Consistency is Key

2. Maintain regular attendance at physiotherapy sessions

3. Complete prescribed home exercises

4. Follow progression guidelines carefully

5. Communication

6. Report any unusual symptoms

7. Discuss concerns with your physiotherapist

8. Keep track of progress and setbacks

9. Patience

10. Understand that healing takes time

11. Focus on quality over quantity in exercises

12. Trust the process and avoid rushing

Looking Ahead

The primary loading phase of ACL rehabilitation is a crucial stepping stone toward full recovery. Success during this phase sets the stage for more advanced rehabilitation stages and, ultimately, a safe return to athletic activities. For more information about our ACL rehabilitation program on our website or download a FREE COPY of our ACL rehab protocol!

References

1. Kong, D.H., Jung, W.S., Yang, S.J., Kim, J.G., Park, H.Y. & Kim, J. (2022). Effects of Neuromuscular Electrical Stimulation and Blood Flow Restriction in Rehabilitation after Anterior Cruciate Ligament Reconstruction. Int J Environ Res Public Health, 19(22), 15041.

   
   

2. Hughes, L., Rosenblatt, B., Haddad F, Gissane C, McCarthy D, Clarke T, Ferris G, Dawes J, Paton B, Patterson SD. (2019). Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. Sports Med, 49(11), 1787-1805.

   
   

3. Sturgill, L.P., et al. (2009). "Interrater reliability of a clinical scale to assess knee joint effusion." journal of orthopaedic & sports physical therapy 39(12), 845-849.

   
   

4. Springer, B. A., et al. (2007). Normative values for the unipedal stance test with eyes open and closed." Journal of Geriatric Physical Therapy 30(1), 8-15.