Finally, it's time to get in the gym!
Once an athlete has earned the right to progress to the strength phase of their ACL rehab, it is time to step it up a notch. In the previous phase it was all about improving range of motion, reducing swelling and symptoms, and restoring a baseline capacity for the muscles around the knee, to ensure a successful and seamless progression into the gym.
Now it is all about restoring relative symmetry when it comes to lower limb strength, with the goal of earning the right to return to straight-line running.
ACL REHAB: STRENGTH PHASE
The strength phase of our ACL rehab protocol (download here) is usually between months 3-5, where our aims are:
To restore relative symmetry (<10% difference) in strength of all major muscle groups. The graft site (ie. hamstrings) often lags behind the rest of the key muscles we assess, so we allow a 20% asymmetry to progress.
Introduce low-level plyometrics, hops, bounds and jumps, to prepare the knee for the ground reaction forces experienced during running.
Now when it comes to the strength phase of ACL rehab, the numbers do not lie. Muscles respond to progress overload caused by adhering to your gym and rehab program. If you aren't working hard and stressing those structures consistently and at the right intensity, strength improvements aren't guaranteed.
Now this doesn't mean you live in the gym, spending 6 hours a day repping it out. But the programs that got you to the strength phase won't help you in this phase.
a normal week DURING THE STRENGTH PHASE OF ACL REHAB
Prior to this stage, you may have been doing a daily program which had very little variation day-to-day. Well, progression to the strength phase of ACL rehab not only means things will get harder, but your program will also become far more interesting and varied!
Yaaaaay!
Here at Game Time Performance, our ACL athletes train in the gym 2-3 x per week, following a tailored strength program, ensuring that we are achieving progressive overload, without overdoing it and annoying your knee. These gym sessions start with regressions of all major lower limb movement patterns (ie. squat, hinge, single leg push, single leg pull), accessory movements based off your testing, surgery and ability in the gym, and low-level "plyometrics".
A typical session may look like this:
As you can see, we start with a squatting movement at higher rep schemes (8-12 reps) and pair it up with a low-level landing exercise and a core stability exercises. During the initial periods of the strength phase, we bias more bilateral (2 leg) movements and as the knee improves, shift to more unilateral (one-sided) options where it has no where to hide.
After 3 sets of the A series, an athlete would then move onto their B series. In this instance we have double eccentric hamstring sliders, a great knee-dominant hamstring option to re-integrate hamstring loads similar (however far less) than that when running. This is paired up with leg extensions because chronic quadriceps weakness is quite common in ACLr populations, but not our athletes.
Finally we finish off with our C series, with a controlled single leg leg press (very safe as the movement path is controlled unlike free-weights), helping expose the knee to working on it's own. We pair this with lateral hip and calf strength exercises to ensure we are ticking all the boxes.
Nice and simple and done in 45-60 minutes. Every gym session is different, allowing your physiotherapist to integrate all major movement patterns, accessory movements and low-level plyometrics in different planes over the week.
Here at Game Time, athletes that join our ACL Rehab Program have exclusive access to our Performance Rehab sessions throughout the week. These sessions (>40 session times per week) allow athletes to perform their tailored program in our gym, under the watchful eye of our physiotherapists and strength and conditioning coaches.
Outside of gym days, athletes should also have a home program to chip away with, helping zone in on certain areas that may need more attention. Some athletes may want to go to the gym more than 2-3 days. In those cases, they are allowed to complete upper-body days as well as off-feet conditioning (bike, ski, rower) as their knee and symptoms allow.
Here is what a typical week may look like during the strength phase of ACL rehab:
Now it may seem like a lot, but don't stress. If you need a rest day here and there, that is 100% fine. ACL rehab is a 9-12 month process and as physiotherapists, we understand that adherence isn't going to be 100% every week. Those that get 80-90% of it all done, will often get great results. 50-60% however, won't.
ACL REHAB STRENGTH PHASE: PROGRESSION CRITERIA
To progress to our Power Phase of ACL rehab and start jogging, the following criteria should be met:
Achieved all criteria from the Primary Loading Phase if not already.
<10% difference in quadriceps, hamstring, groin, lateral hip and calf strength*
<10% difference on a forward hop test.
No swelling or symptom progression with the introduction of low-level plyometrics in preparation for jogging.
*Depending on the graft side (patella tendon/hammy) we don't expect relative symmetry just yet in that area, but we would want to see continued progress during testing.
Once an athlete passes all these tests, they have earned the right to start straight-line running! With all ACL rehab milestones, ringing the bell is a non-negotiable!
For more information about our in-person and online ACL rehab options here at Game Time Performance, visit our ACL Rehab page. or submit an enquiry here.
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