Rehabilitation after ACL reconstruction is a long, sequential process.
We look for specific criteria before progressing our athletes back to running.
Here are the criteria we look for and the progression we follow for plyometrics, running, sprinting, and agility work to help athletes get back to competition after ACL surgery.
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#AskMikeReinold Episode 358: Return to Running After ACL Surgery
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Show Notes
• Evaluation and Treatment of the Knee Course
• Return to Sport Testing after ACL Reconstruction
• Return to Running After an Injury
Transcript
Jacob Kissman:
We got Ellie from Texas asking, “I’m trying to specialize in working with soccer players coming back from ACL surgery. Can you tell me about your return to running progressions after ACL? When do you typically start and how do you progress your athletes?”
Mike Reinold:
Jacob, amazing job. Best question we’ve had today read from a student, so congratulations on that.
Lenny Macrina:
Great reading voice too.
Mike Reinold:
That was really good. I like that. Very fitting. I like that. All right, so this is a good question. What I liked about this question… So I like how she wants to specialize in a sport, so she wants to nail this down. Recently at Champion, we’ve kind of said as a group, “Let’s review some of our systems and processes that we have for some of these things.” So Ellie, I think we’re always revising what we’re doing too. What’s best practices for these sorts of things? Like, how can we integrate that? So I like how you have this here.
I feel like if I were to Google every ACL protocol from different places around the country, when and how to start running programs varies a lot. And we see that with lots of different protocols. But for me, I think this is one of those ones that to me, it usually comes down to… It’s just that running programs are so variable. So if you don’t put a lot of emphasis on a slow ramp up of a running program, you’re probably delaying a little bit and then ramping up really fast.
Our approach, we like to kind of script this out for months to have a slow applicational load. So I’ll let the team dig in a little bit deeper. But why don’t we start with this? I think to fully answer her question, Len, let’s start with you here. She didn’t specifically ask this, but what is your criteria to say, “This person is ready to start a plyo and running progression?” What tests do you do? What do you look for more? When aren’t they maybe ready to do it? Because it’s not about time, especially after ACL, especially when this is a several-month process. You can wiggle back and forth based on that, but Len, what’s your criteria?
Lenny Macrina:
Yeah, it’s complicated but obviously a quiet knee. So first off, do they have good motion? Full basics? Don’t just jump into “what’s their peak quad torque at 60 degrees per second?” You know what I mean? Let’s go simple. Do they have full knee extension range of motion? Do they have quad…
Mike Reinold:
Just to clarify though, you do strength test, right? And that is important.
Lenny Macrina:
We do, yeah.
Mike Reinold:
Okay, good, good. Just checking.
Lenny Macrina:
There’s a whole series that leads to “are they ready for strength testing?” Do they have full knee extension, range of motion, flex range of motion, a quiet knee, good patella mobility, no anterior knee pain? Have they gone through a good strength and conditioning program that’s loading their knee and they’re not compensating using a hip strategy?
So we’re always trying to monitor that and push that. If so, at around three months, you can test early, I know some universities and other practices test early. I wait until about three months. I typically see patella tendon grafts, just so everybody knows, and I’m looking at their peak quad torque using an isometric contraction at 90 degrees of flexion.
It’s just easier for me to set up at 90 degrees of flexion than at 60 degrees. And so I’m looking at bilateral strength testing of quads and hamstrings. I’m looking at ratios. I’m looking at peak torque to body weight and seeing what they’re at at a baseline at three months. And then every four to six weeks after that I’m testing with the goal of getting them about 65 to 70% quad LSI to begin a running program, which in my head is usually between four and five months. Like you said earlier, I tend to wait a little closer to five months, but it depends on the person and their knee and their goals and all that. But if their knee is quiet and they’re doing well, then we start testing, and I’m anticipating the running program so I’m already starting to do plyometrics. I’m starting to do pogos. I’m starting to do things of that nature to test the knee out to make sure it can handle that constant jarring that’s going to occur with the running program.
Mike Reinold:
Yeah, I think biggest take-home from what Lenny just said that most people, especially early career professionals don’t get here… What he kind of said was it’s not just quantitative, it’s also qualitative that he looks at. And that’s actually a big deal. So you can have somebody with a really ugly knee pass a strength test sometimes. And sometimes, especially if it’s just LSI, it’s just because both legs suck.
Lenny Macrina:
Right.
Mike Reinold:
So it’d be interesting to see that quote transcribed on the website there. I shouldn’t have said it that way, but you know what I mean? I don’t think we talk about the qualitative stuff as much, and that was the first thing Lenny said, guys. He was like, “I want to look at it and I want to feel good that the quality of the knee and stuff is there.” That was a good answer to that. So, keep that in mind. And then I think the next thing, and this I think will lead into Dan here, is that at Champion, yes, we run, but there’s a lot of things you can do prior to running. Just like throwing.
We do plyos and stuff before we do throwing. I think it’s the same thing about just increasing load. But Dan, why don’t you walk through. We’ve been talking about this a little bit in the clinic, more about systemizing this better, but what are your thoughts on progressing somebody? So they’ve cleared Lenny to the things he just said and now you’re like, “All right, I want to start a progression to prepare them to run.” Where do you go with that?
Dan Pope:
Yeah, for sure. It’s pretty timely. I feel like we’re always trying to change our programs at Champion to optimize and make them better, and we’re doing that currently. So, that’s kind of fun. Unfortunately, Kevin’s not here today. We’ve been brainstorming a little bit together. I think running is interesting because you can jog, you can sprint, and then there’s acceleration, there’s curvilinear running, and there’s agility. There’s a million different pieces. We’ll just keep it simple. I’m going to start talking about just regular straight plane running and some sprinting stuff, and then maybe Dave or Videtto can kind of pick up with the change of direction stuff so I don’t talk too much.
But what’s interesting is that we can start with very low-level plyometrics that are less stress than a slower jog. And usually that means a double-legged exercise, like a pogo jump. When you’re running, it’s one leg at a time. Pogo jumps with two legs. And I think a couple keys early on is that we’re not really working on power. We use the words “plyos,” and plyos typically mean you’re moving really quickly. I think a lot of this is first establishing a little confidence with the athlete. It may have been like six months since they left the earth. If you think about that, they’re a little bit freaked out when they start jumping.
So sometimes we’ll even do an assisted pogo. We’ll have a band and go overtop of a rack, hold down, get some tension to assist them with their jumping… And over the course of time, we wean them out of the band and just do more and more repetitions with the goal of building a little bit of capacity. Let’s say you do around two weeks’ worth of different pogo jump variations, and then we’ll start a return to run program. And when we say return to run, it’s a jog. It’s pretty slow. And I tell people to kind of select the pace you would use for a long, slow run, and it’s a walk and jog protocol. And let’s say it’s 30 seconds of a jog, 30 seconds of a walk, 15 minutes. And over the course of, let’s say, two to four weeks, you start to do less and less walk, more and more run. Let’s say that lasts for around four weeks.
During this time period, we’re also advancing plyos a little bit too. So it’s not like we stop plyos after that initial phase. And then we start doing some faster running and we tend to break it down into two different types of runs. So you have acceleration and you have top-end sprinting. And we usually introduce these via fall runs. So basically stand up nice and tall, leaning forward until you’re about to fall, and then you accelerate. And let’s say you do 10, 15 meters, not very far. And we usually start with a percentage-based strategy. Whatever the athlete perceives is the 50% of the max we’ll say.
We had talked about this before. Should we use miles per hour? Should we use a treadmill? One of the problems, I see this a lot with lifters too, is that after you have a major injury, you have no idea what your one rep max is. It doesn’t really make any sense to use percentages of what your max is. It’s currently going to be very different, and it’s not really safe to test that out. I’m not going to have that athlete sprint as fast as they can and then use a percentage of that. It makes no sense. So we just use a percentage of their perceived effort. Let’s say we start with around 50% and we work our way up over the course of time. We do the same thing with a build-up run. So you can do this outside or on some sort of treadmill that’s self-propelled. So I usually give people five seconds or so to build up to a percentage of their max.
Let’s say we’re starting with 50 or 60%, hold that for around 10 seconds, and then break down a little bit. And then what you’ll see over the course of, let’s say, around two months or so, you start with a lower percentage of the max, lower volume, you start to slowly increase the intensity, slowly increase the volume a little bit over the course of time. The plyometric should be going up over the course of time with the run progression with the thought being as the volume of sprints increases, the volume of plyometrics actually goes down a little bit. And eventually, as we incorporate more agility, more sport-specific activity, we actually do less and less sprinting acceleration work. And hopefully by the end of all this, we’re just doing gameplay situation drills and so on, so forth. So I think I said enough, I’ll let someone else talk.
Mike Reinold:
I don’t know if you’re on the subway, if you’re driving in traffic right now, I feel like we need to all stand up and applaud. I feel like we’ve been in the middle of many episodes where I’m like, “This is a bad episode,” but right now I’m like, “This is a good episode. This is pretty sweet.” Dan, that was amazing and I think there’s a few nuggets in that. So I want you to go back and re-listen to that there. And once you hear it once, I want you to then go back and listen again and take notes a little bit because that was very regimented what Dan just did there, and he had very sequential with what he wanted to do with people.
That was perfect. So, I love that. And to Dan’s point too, the only thing I would emphasize, when we started looking at this… It’s kind of funny, if you look at plyometrics, to Dan’s point, plyometrics is a way too broad of a term. You could argue we’re not really doing plyometrics with some of the drills we’re doing, but there’s some plyometrics where ground reaction forces are less than running, and some that there’s more than running. So you have to know that, you have to understand that, you have to put that together. That’s important. All right, let’s end at this. Anthony, you want to jump in on a little like… That was straight line running, stuff like that. How about some agility or just multi-directional cutting type stuff? When do you tend to introduce that? How do you like to do that? Any tips for the audience?
Anthony Videtto:
Yeah, I’d say you definitely want to see a solid completion of this return to running program that Dan was just talking about first. So I want to see them be able to handle the capacity of running itself. So do four to six weeks of a run, walk progression. Once we feel like they have completed that and they can run for 30, 40 minutes at a time, then I feel like they have a good capacity to then start kind of straight line running from that point.
Once we work on full straight line sprinting, then it’s like, okay, can we work on change of direction stuff so that we can start utilizing some cutting and single leg type plyometric movements? So that when we know we can get back to kind of like field work, that we can really work on sport specific stuff from there. I feel like for us as PTs, once we get them past the straight line sprinting stuff, that’s where Diwe and some of the strength and conditioning coaches come in and they can really work on that agility type stuff. So maybe Diwe has some good points that he can touch on on that, for sure.
Mike Reinold:
Yeah. Diwe, you want to jump in and talk about like… Because that’s actually a good point that Anthony makes. It’s very hard to do this all in a PT session. We’re fortunate that we get to collaborate with some strength coaches. If you don’t have that at your facility, I do urge you to find somebody nearby who can do this. But Diwe, any thoughts from you on this? And then also to Anthony’s point, I think sometimes we rush into starting to get into agility. If you can’t accelerate and decelerate and brake, why are you doing a cutting drill? You know what I mean? You’re not ready for that. But Diwe, what are your thoughts on those late-stage progressions from the strength and conditioning side from that, and what would you do different?
Diwesh Poudyal:
Yeah, definitely want to reemphasize, to Anthony’s point. Let’s definitely take care of the straight line stuff first from a confidence perspective and a comfort perspective. Maybe even start to see some pretty good outputs as in speed and stuff like that. And then as far as the agility stuff goes, no, I start with a lot of the basics. And when I say agility work versus agility drills, I bucket those as two different things in my head. An agility drill is not an actual agility exercise that’s trying to expose yourself to high speeds or high amounts of forces. It’s teaching body control and body awareness and to start getting used to joint angles that you might see in cutting.
And even then, I kind of bucket it into like my different movement skills that are involved in change of direction. So we have our different angle cuts. We have our 45-degree cuts, 90-degree cuts, full 180 turns. We have our shuffling type skills, we have our crossover type skills, and we got to build all these starting at the baseline. So I might, early on, just work on some shuffling and body control type stuff. We call it a little low box change direction drill where we’re literally switching feet from one side to the other, getting used to that change in center of mass from one stance leg to a different stance leg.
We might do a crossover to base where you’re crossing over at the hip, dissociating torso and hip, and sticking your landing. And we might do some singles and doubles and maybe work into some triples, meaning you’re going to go crossover, crossover, crossover in the same direction. You might do some band assists or band-resistant stuff. So now you’re starting to accelerate the decel forces that are required. So if you have a band that’s pulling you into a crossover to base type position, now it’s making that speed faster because the band is accelerating that. And you got to work on just decelerating that, hitting the brakes.
So, I haven’t even done any actual running type agility stuff yet. I’m just working on the baseline ability to control the forces and get my joint angles ready to handle a lot of the stressors. And then from there, I might start actually getting into, “All right, I’m going to start in a straight line and I’m going to get into a 45-degree cut and make it a box drill where it’s not a reactionary drill yet. I want you to just get comfortable.” I think a lot of people tend to jump in and say, “Oh, box drills are useless because that’s not what you do in sport. But let’s start with the easy stuff, give them a ton of opportunity to have success, and then let’s introduce a little bit of reaction. And then let’s introduce a little bit more of a gameplay type situation where we have reaction. Maybe a little bit of contact, maybe reaction to multiple layers of defense, if you want to call it that.
I’m doing that with some of our ACL people right now. But yeah, I like to have a very layered approach. Honestly, it’s pretty similar to what Pope just laid out for the straight line running program. Have a very layered… Start with drills that don’t involve speed, don’t involve a ton of forces, get comfort, and then slowly start adding in the speed, start adding in the high forces, start adding in complexity, start adding in reaction. So that’s where I would start.
Mike Reinold:
Yeah, and to me, Ellie, this is a beginning. So obviously that was a lot. I think things that you can take from this is that the sequential layer that Diwe just kind of alluded to from Dan there is… How you are going to build that? And then just realize that like, man, there’s a few buckets here. This isn’t just like return to running program. There’s agility change, direction change, speed, all these types of things.
I would say for you, Ellie, just personal advice for you as you’re going through this and you’re starting to specialize, like you said, is tackle each one of those buckets individually and dig in deep on the research. Look at it, kind of outline how you would put that bucket, and make those buckets how you put it together. And then see where they fit and where they cross over. Where can they start interacting?
Because this is like a masterclass. All of that that we try to cover in one episode, that’s challenging, but I think that’d be a super important way for you to kind of hit that, Ellie. Okay? All right. So great question, great answers. I think this is an amazing episode. So, good job, everybody. That was awesome. If you have more questions like Ellie, just ask away. We’ll do our best to answer as best as we can. Head to mikereinold.com, click on that podcast link, and be sure to subscribe so that way you get notifications when we have a new episode. Thank you.
