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      The ACL Comeback Client

       

      With most clients undergoing a 12-month + exercise journey, ACL management has become a hot topic of conversation with a debate around research and practical management strategies.

      In this presentation, we will cover:

      • Considerations for the ACL Client.
      • What are the go-to assessments for each stage of the comeback journey including which AxIT Force Plate and Dynamometer Tests you need to be using and what results to expect.
      • How to keep your client motivated over 12 months of management.

      A Criteria Based Approach

      1. Preoperative Phase (If Applicable)

      Goals:

      • Minimize swelling and inflammation.
      • Achieve or maintain full knee extension ROM.
      • Ensure normal gait mechanics if possible.
      • Establish early quadriceps activation and basic neuromuscular control (a “quiet knee”).

      Key Actions:

      1. Restore Extension ROM: Aim for symmetrical knee extension compared to the uninvolved side; research suggests better outcomes post-operatively if the knee is near full extension pre-surgery.
      2. Address Swelling and Pain: Use ice, compression, and elevation to keep inflammation under control.
      3. Quadriceps Activation Exercises: For example, straight leg raises, terminal knee extensions, and neuromuscular electrical stimulation if needed.
      4. Patient Education: Discuss graft options, realistic timelines (9–12 months for return to sport), and the criteria-based approach.

      2. Early Postoperative Phase (Weeks 0–3)

      Goals:

      • Protect healing tissue while maximizing safe mobility.
      • Achieve a “quiet knee”: minimal swelling, restored extension ROM, and good quadriceps control.
      • Transition off crutches/brace (if used) once safe and cleared by surgeon.

      Key Actions:

      1. Manage Swelling, Pain, and Inflammation: Continue with cryotherapy, compression, gentle movement.
      2. Restore ROM:
        • Extension: Emphasize full passive and active extension (0°).
        • Flexion: Gradual progress toward 120° knee flexion to enable cycling.
        • Monitor using goniometry or ROM tools.
      3. Activation & Weight-Shifting Drills:
        • Gentle static quadriceps exercises (e.g., co-contractions).
        • Standing weight distribution checks on force plates (Quiet Stand Test) to track symmetry improvements each week.
      4. Begin Light Strengthening: Isometrics (quadriceps, hamstrings) in safe ranges.

      Criteria to Progress:

      • Minimal to no effusion and pain.
      • Full active extension ROM.
      • Restored flexion to at least ~120°.
      • Safe single-leg stance (~5% or less shift off the operated leg) with good control.

      3. Intermediate Phase (Weeks 3–8)

      Goals:

      • Continue restoring ROM (flexion beyond 120°, near full extension).
      • Improve muscle strength (especially quadriceps) and neuromuscular control.
      • Gradually normalize gait pattern (without brace, if used).

      Key Actions:

      1. Progressive Strength Work:
        • Knee Extension & Flexion Strength Tests:
          • Aim for benchmarks (~50-60% BW knee extension, ~35% BW hamstrings, though exact numbers vary by source).
        • Begin adding low-to-moderate load, closed-chain exercises (e.g., bilateral squats, split squats, step-ups).
      2. Neuromuscular Control & Balance:
        • Single-leg balance progressions on force plates (Quiet Stand, Single Leg Stand).
        • Gentle squats (assess depth, force production, and alignment)
        • Step-down tests to monitor control of eccentric load.

      Criteria to Progress:

      • Near-full flexion (~90–95% of the other limb).
      • Quadriceps strength ~60–70% of the uninvolved side.
      • Pain-free single-leg squat to ~60°–70° knee flexion with minimal compensations.
      • Good control on step-down tasks (<20% asymmetry in peak force relative to body weight).

      4. Strength & Neuromuscular Advancement (Weeks 8–16)

      Goals:

      • Regain foundational lower-limb strength approaching baseline (or pre-injury).
      • Develop baseline explosive strength and begin more dynamic tasks.

      Key Actions:

      1. Isometric & Concentric Strength Testing:
        • Periodic re-assessment (e.g., monthly) of knee extension/flexion with handheld or fixed dynamometry.
        • Isometric multi-joint tests (e.g., Iso Squat, isometric mid-thigh pull using force plates) to gauge global lower-limb strength.
      2. Progress Resistance Exercises:
        • Gradual increases in loading: back/front squats, lunges, deadlifts (if tolerated), and machine work to strengthen quadriceps, hamstrings, glutes, and calf muscles.
        • Monitor force production on force plates or similar.
      3. Single-Leg Strength & Power:
        • Single-leg press, single-leg RDLs, and partial single-leg plyometrics (low-impact hopping in place when cleared).
        • Monitor jump performance safely if introduced (e.g., low-level jump tests on force plates).

      Criteria to Progress:

      • Quadriceps strength ~80% of uninvolved side.
      • Hamstring strength ~80% of uninvolved side.
      • Sufficient neuromuscular control in single-leg tasks (e.g., no gross knee valgus).

      5. Intro to Impact & Jump Training (Weeks 16–24)

      Goals:

      • Safely reintroduce impact (landing mechanics) and slow stretch-shortening cycle (SSC) exercises.
      • Improve single-leg deceleration and propulsion capacity.

      Key Actions:

      1. Landing Mechanics & Plyometric Progressions:
        • Bilateral to single-leg jumps; begin low box landings.
        • Countermovement jump (CMJ) to measure braking/propulsion impulses.
        • Single-leg jump (SLJ) for higher limb demands once bilateral is stable (~80–90% limb symmetry in bilateral tasks).
      2. Force-Plate Monitoring:
        • Track braking/propulsion impulses, and landing asymmetries.
        • Identify “offloading” strategies on the operated limb (e.g., less force or reduced knee flexion).
      3. Progressive Plyometrics & Impact Conditioning:
        • Gradually increase height and speed demands (e.g., repeated hops, bounding drills, mini hurdle hops).
        • Use real-time biofeedback (where available) to encourage symmetrical force application.

      Criteria to Progress:

      • Limb symmetry index (LSI) for strength ~90%.
      • SLJ or CMJ showing near-symmetrical force and impulse metrics (~≤10% asymmetry).
      • Pain-free, confident landings with proper knee flexion angles.

      6. Reintroduce Running & Change of Direction (Weeks 20–30+)

      Goals:

      • Build the ability to tolerate linear running volume and progress to more complex multi-directional movements (e.g., cutting, pivoting).

      Key Actions:

      1. Running Readiness:
        • Ensure good knee flexion ROM, no effusion, and adequate quadriceps strength (e.g., ~80% of contralateral side) before starting a jog program.
        • Introduce progressive run/walk intervals, then continuous running.
      2. Change of Direction (COD) Drills:
        • Begin planned low-velocity cuts (e.g., 45°) and agility ladder.
        • Gradually increase angles (e.g., 90°, 135°) and speed, introducing unplanned reactive drills later.
      3. Assess COD Performance:
        • Force plates or inertial sensors can measure ground reaction forces, identify any lingering asymmetries in braking or push-off.
        • Focus on hip-knee-ankle alignment, trunk control, and confidence.

      Criteria to Progress:

      • Near-symmetry in strength/power measures.
      • Ability to perform submaximal to near-maximal cuts without pain or instability.
      • Satisfactory movement quality on deceleration drills and no knee effusion post-session.

      7. Late Stage / Return-to-Sport Preparation (Months 7–9+)

      Goals:

      • Achieve sport-specific power, agility, and neuromuscular demands.
      • Demonstrate test benchmarks consistent with safe performance.

      Key Actions:

      1. Sports-Specific Conditioning:
        • Incorporate skill drills under fatigue.
        • Increase intensity and complexity of COD and jumping tasks (e.g., reactive agility, maximal sprints).
      2. Advanced Plyometrics & Power Tests:
        • Depth jumps, bounding sequences, single-leg drop jump progressions.
        • Monitor RSI, single-leg hop distances, and any GRF asymmetries.
      3. Return-to-Play (RTP) Criteria:
        • Strength near 90–100% LSI in key areas (quadriceps, hamstrings, hip, calf).
        • Satisfactory performance on jump and landing tests (CMJ/CMH/RSI-Mod).
        • Confident, pain-free participation in full training sessions.

      Decision-Making:

      • Use data-informed benchmarks (isometric strength, jump metrics, COD performance) plus quality of movement and psychological readiness scales.

      8. Ongoing Maintenance & Long-Term Monitoring

      Goals:

      • Prevent re-injury and maintain performance capacity.
      • Continue to address any chronic deficits or compensatory strategies.

      Key Actions:

      1. Performance Testing at Regular Intervals:
        • Even post-RTP, scheduled testing (e.g., monthly or quarterly) of strength, power, and balance can detect early warning signs of overload or asymmetry.
      2. Progressive Overload in Training:
        • Continue periodized strength and conditioning (heavy lifts, plyometric progressions) to optimize knee health.
      3. Movement Strategy Refinement:
        • Reassess ROM, single-leg function, dynamic stability in sport-specific scenarios (e.g., cutting under match load).
      4. Psychological & Technical Support:
        • Maintain communication with coaches, sports psychologists, and other support staff to address confidence and technique flaws.

      Key Takeaways

      1. Objective Measurement Guides the Process:
        • Use ROM measurements, force data, and jump/COD assessments to track progress (or plateaus).
      2. Move Only When Criteria Are Met:
        • Each phase has clear benchmarks (e.g., ROM, strength symmetry, safe jump landings).
      3. Individualize & Listen to the Athlete:
        • Monitor pain, swelling, and psychological readiness.
      4. Don’t Rush:
        • Most return-to-sport guidelines suggest at least nine months and even beyond 12 months for many athletes.

      By following these structured, criteria-based steps—drawing on objective testing at each stage—a practitioner can systematically progress a client from the earliest phases of ACL reconstruction rehabilitation all the way to safe, confident return to sport.