Injury > Surgery
This stage looks at assessing the athlete and whether they are a coper or non-coper.
A coper is an individual with good knee stability and the ability to compensate well after
injury. A non-coper will have less stability and increased incidences of their knee ‘giving way’
during daily activities. As such, copers can tolerate sport without the ACL and can avoid
having to undergo surgery.
Everything here is very broad as research is still limited in the area and there are no
definitive guidelines to assessing whether someone is a coper or non-coper. With this in
mind, each individual will be different as well as where their graft is taken from (Hamstring,
Patella, ITB or wherever they decide to do next).
A prehabilitation program will consist of 6-9 weeks over 3 main stages and will depend on
whether progress is constantly being made. The athlete must complete each stage to a
satisfactory level before progressing.
The only main thing found to be avoided is full ROM of open kinetic chain exercises as this
position threatens the integrity of the graft.
Stage I :
Stage II :
Stage III :
If they have progressed consistently through all the stages, then it is up to them whether they continue without an ACL or whether they opt for surgery.
Stage 1 is all about giving the graft the best chance to take, reducing infection chance and
gaining normal function back in the leg. It is also a build up into the next stage. If the athlete
is struggling through or has not done this stage, then they have not earnt the right to and
cannot progress to stage 2.
If going for the non-surgical option, the protocol remains the same.
Weeks 1 – 2 After Surgery
Straight after surgery. Not too much should be going on at this point. The biggest key factors for this stage:
Full weight bearing should be built up and commence around the 2-3 weeks post-surgery. Compression bandages can still be worn afterwards for athlete’s comfort.
Weeks 3 – 4 After Surgery
Stationary cycling is a good way to maintain fitness and help strengthen lower limb muscles. It is also good for developing and maintaining ROM. 10-20 Minutes at a low intensity is enough per day. Seated boxing is another fun way to work cardiovascular fitness and add variety to training.
Stage 2 is about getting the athlete prepared to start running again. It is normal for there to still be some pain and discomfort, as well as numbness to still occur. Deep flexion and extension can still cause pain, although it depends on the individual. Being able to fully extend the leg is very important in these early stages.
Intermittent episodes of swelling and discomfort can still occur, especially as gait and weight bearing start to return to normal. If so, just adjust exercises accordingly to not cause further discomfort.
Months 1 – 2 After Surgery
The graft is at its weakest point at roughly the 10-week mark, and then gradually increases in strength over the next year. Although the athlete may be feeling good, make sure to stress the importance of holding off on running or jumping for the next few weeks.
Months 2 – 3 After Surgery
If access to an anti-gravity treadmill is available, running can commence earlier with clearance from your Physio. Otherwise hold off running until approximately the three-four- month mark, also to be cleared by the Physio.
Stage 3 – Implementing and Increasing Running and Preparing for COD
The start of this stage should see the athlete start to jog and then run in a straight line. Some pain and aching around the joint is normal. Very light plyometrics can start to be introduced and slowly progressed with a focus on landing mechanics.
The aim of this stage is to re-introduce running for the athlete and then get them prepared to change direction. The biggest emphasis on this stage is to increase confidence running and make sure gait is normal. It is normal and very common to be nervous.
Months 3 – 6 After Surgery
It is important to not push the graft too hard too early, especially when reintroducing running as this can place strain on the graft. This is a long stage and there is plenty of time to improve slowly and make sure you are doing this properly. Focusing on small attainable goals is a great way to boost motivation and psychological well- being in athletes that may be struggling.
It is common for a big psychological boost following clearance to run, but monotony can set in shortly after. Again, this is completely normal.
Stationary cycling and swimming can be continued and increased in intensity for the athlete to maintain aerobic conditioning. Other activities that are low impact on the knees such as boxing can be enjoyable ways to stay fit and work on a new skill.
Stage 4 – Increased Change Of Direction and Preparing for Return To Training
The individual should be running and have started curvilinear running, if even at a slow pace. As volume and intensity of running increases, it is important to constantly assess competency.
Change of direction will continue to progress to sharper cuts throughout the stage to get the athlete prepared to return to sports specific training. Introduce lateral movements for both strength and light plyometrics.
Months 6 – 9 After Surgery
General consensus of research is that the athlete should ideally be ~20 % difference in quad and hamstring strength between injured and non-injured leg at the 6-month mark. Although missing this is not a big deal as there is still plenty of time.
Stage 5 – Work Weaknesses and Prepare for return to play
Running, changing direction and returning to sport specific skills, even if only light, should have been achieved. This stage is about getting the athlete prepared to return to playing and training.
The 12-month mark should be the earliest they return, even better if they can hold off for another month or two, with 13-14 being the ideal. Each month will further reduce chances of re-injury.
Focus on any weaknesses the athlete may show or imbalances between limbs.
Months 9 – RTP
One of the biggest contraindications for returning to sport is psychological readiness. If they have reached this stage in their rehab then physically they are able to return, they just need to be mentally prepared. Slowly returning to warmups and advancing through drills is a great way to start re- introducing yourself to your sport. This also helps with the gradual return to playing and helps with psychological readiness.
Quad and Hamstring strength should be less than ~10% between injured and non-injured leg by 12-month mark, and definitely before returning to play.
Post Stage – Return to Play – Maintain and Build
The athlete should have eased into their return to sport, slowly building up their match endurance and confidence. At this stage the athlete can stop being treated as a rehab client for the sake of S&C and programming and undergo the usual training for where they are in season and what they need as an individual.
The biggest contraindication to an athlete returning to play is their psychological readiness. Physiologically they will be as prepared as they can, but mentally they may be struggling with the realisation that they will be put back in the position in which they got injured.
After the 12–14-month mark and as the athlete is returning to play they will go onto a more standardised strength and conditioning program, while maintain they are still an ‘ACL rehab client’. Timeframes here will be very individual based.
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