Case Study: ACL Rehab

There are too many abstract discussions in the performance space these days about how to train and rehabilitate athletes. These circular arguments usually yield nothing substantive or actionable because providers spend too much time defending their ideology and trying to articulate why they are in the right instead of just being transparent and “showing their portfolio”.  As an example, investors should demand that financial advisers share their own portfolios instead of pontificating about macroeconomic theory. Words matter but what people do when they have skin in the game reveals more about them than their explanatory justifications for said actions.  The point of these case studies is not to suggest that what we did in any of these situations is particularly good. If we’re being honest, we don’t always have robust outcome measures to suggest that what we do really “works”. More often than not, we default to the eye test. We coach and own our decisions. The intent here, therefore, is to be completely transparent about what we did when an athlete’s time, money, and readiness was at stake in hopes that other providers share their experiences and contribute to a more genuine collective conversation. 

Background

31 year old male status post L ACL reconstruction in October 2019. He had been doing virtual physical therapy with another provider the past few months and felt like he'd plateaued. His goal was to strength train and play pickup basketball and ultimate frisbee confidently.

Constraints

• Time: Patient was willing to devote 6 days/week (6 hours total) to rehab from home. His commute was too far for regular visits but he made an exception for an evaluation and to review a home program.
• Logistics: Patient had a home gym set-up with a barbell, adjustable dumbells, and bench that includes a leg extension/curl attachment
• Financial: Patient's insurance policy did not cover out of network care. Financially, patient's desire was to come in for one paid visit every 3-4 weeks to receive a new program.
• Interpersonal Factors: Patient was highly motivated and eager to begin a more aggressive routine. His previous rehab included little strength training and no running or change of direction progressions.

Evaluation Findings

• No deficiencies on the treatment table in terms of range of motion, swelling, or atrophy
• Performance "testing" consisted of putting him through a consolidated version of the program below, with some trial and error required to select exercises that could be performed safely at home. Patient hadn't done any unilateral strength work so any unilateral jump or strength exercise was grossly deficient on the left side.
• The "A Run" served as the patient's return to run entry point. Together, we were able to identify an amplitude and cadence that looked and felt right. Return to run rehab coincides nicely with technical running progressions so rather than have this patient do a bunch of low quality running on a treadmill then progress to sprinting, we employed sprint drills, modified to tolerance, to develop timing and rhythm, elasticity, vertical force production, and front side mechanics. The plan was to introduce actual running (via tempo repeats) and resisted acceleration in the next block.

Plan of Care

A1-E1 daily, F1-K2 3x/week, Conditioning 3x/week. Complete the program for 3-4 weeks, assuming no setbacks, and return for a follow-on evaluation and new program.

A1) Couch Stretch from Wall - accumulate 2 mins/leg, hold something for support as needed, don't arch through lower back to be upright

B1) Hip Shift Hamstring Bridge Reps - 2x8-10, only side shown in video

C1) Inch Worm Peddling - 2x40/side, weight on fists

D1) Hurdle Mobility: Overs - 10/direction/leg

E1) Hurdle Mobility: Unders - 10/direction/leg

F1) Extensive: Single Leg Rebound Jump - 3 sets of good form/leg, focus on control, let left leg dictate number of reps

G1) Lateral: Low Box Shuffle - 3 sets of 10-12s/direction, as fast as you feel comfortable, band resisted and concentric only

H1) Single Leg Squat - 3 sets of good form/leg, back rounded throughout

J1) Leg Extension - 3 sets of 8-10/leg, pause 1s at top, 3s lower

J2) Hip: Swiss Ball Hamstring Curl - 3 sets of good form/leg

K1) Hip: Sumo Kettlebell Deadlift Iso Hold - 2 sets of 30-45s, start from top position and lower yourself down, dont stick chest out

K2) Bench Side Plank Extended - 2 sets of 30-45s/leg, choke up as needed

Conditioning

Speed: A Run - 3 sets of 5x8-10s on the minute, rest 3 mins bt sets, amplitude and intensity dictacted by comfort, over time work up to 3 sets of 12x8-10s

Post running, easy bike breathing through nose for 20-30 mins