Mid-late stage ACL rehab: Expert insights
So your client is going well; their pain and swelling are under control, they have good quad control, good strength, and they’re able to run ~2kms in a straight line – now what? As physios we play a pivotal role in the middle and later stages of ACL rehab. Bridging that gap between pain-free running and return to sport requires a clear idea of the rehab aims to develop a targeted program. Without this clarity, exercise prescription can become convoluted. In his Practical, Tim McGrath outlines mid-late stage ACL rehab; this blog outlines a few key points from Tim on how to prescribe exercises for return to sport and reduce the risk of re-injury.
If you want to learn exactly how top expert Tim McGrath manages mid-late stage ACL rehab, watch his full Practical HERE.
1- Train the ability to produce force
Working on the ability to produce force is an important part of getting people back to sport – this includes strength progressions, as well as the addition of acceleration/deceleration and change of direction drills. Tim McGrath uses weighted exercises such as deadlifts, squats, and ball slams – he elects to use fast movements over heavy load, with the aim of improving the rate of force development. Research suggests that the rate of force development of the affected knee is reduced at six months post-ACLR (1,2), and thus should be addressed in the later phases of rehab.
2 – Train the ability to absorb force
Where there is force production, the person also needs the capacity to absorb that force. This is particularly true of the ACL population, as stiff, straight-legged landings put the ACL at risk of rupture (3) – absorbing force through a bent knee is an important part minimising re-injury risk when returning to sport. Force absorption can be trained on its own, or as part of a force production/absorption drills. Tim Mcgrath emphasises the importance of working on both vertical and horizontal force production and absorption. See Tim use a Borzov jump for vertical force production/absorption training in the snippet from his Practical below:
3 – Return to sport practice
Late stage rehab requires the retraining of sport specific movement patterns (2). Exercises can be made sport specific by adding external perturbations and ball-specific drills. In the below snippet taken from his Practical, see how Tim Mcgrath uses a water bag to add perturbation for training optimal foot position in change of direction:
This could then be adapted to more sport specific drills later on. For example, maintaining optimal foot position while bouncing a basketball with an opponent pressuring the ball. Tim also notes the importance of educating clients to avoid looking at the ground during return to sport training, to simulate game play, and improve their ability to maintain optimal movement patterns without visual input.
4 – Consider the barriers to adherence
Rehabilitation of an ACL injury takes commitment over a relatively long period of time, and there are a range of factors which may affect the person’s adherence to exercise prescription. One review identified a long list of factors which may act as motivators or barriers to adherence (4):
- athletic identity
- positive self-talk
- social support
- goal setting
- fear of re-injury
- locus of control
- age and sex differences in psychology
- pain tolerance
- mood disturbance
- situational stability
- cognitive appraisal
- coping strategies
- previous experiences
While some of these may not be amenable to physio input – it is useful to have the list in the back of your head the next time you find somebody is not engaging at any given stage of the rehab journey. You can develop the best return to sport program known to man, but it’s useless if your client is not motivated to get it done!
Rehabilitation of ACL injury can be a long road for both you and your client; establishing clear aims (and communicating these to your client!) can not only help to clinically reason your exercise prescription, but help to keep your client motivated. Exercise prescription is individualised and will vary based on each client’s goals – prescribing exercises based on key rehab principles such as the above will not only enhance your client’s ability to return to previous activities, but also minimise the risk of re-injury.
If you’d like to see how an expert rehabilitates those mid-to-late stage ACLs to get them sport-ready, watch Tim McGrath’s full Practical here.
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- Angelozzi M, Madama M, Corsica C, Calvisi V, Properzi G, McGaw ST, Cacchio A (2012). Rate of force development as an adjunctive outcome measure for return-to-sport decisions after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 42(9): 772-780.
- Buckthorpe M (2019). Optimising the late-stage rehabilitation and return-to-sport training and testing process after ACL reconstruction. Sports Med. 49(7): 1043–1058.
- Larwa J, Stoy C, Chafetz RS, Boniello M, Franklin C (2021). Stiff landings, core stability, and dynamic knee valgus: A systematic review on documented anterior cruciate ligament ruptures in male and female athletes. Int J Environ Res Public Health. 18(7):3826.
- Walker A., Hing W, Lorimer, A (2020). The influence, barriers to and facilitators of anterior cruciate ligament rehabilitation adherence and participation: A scoping review. Sports Med – Open. 6(10: 32.
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