In the Patient’s Shoes: My ACL Reconstruction Journey as a Physical Therapist Part 2: Post-Surgical Recovery
Erik Kust, PT, DPT, OCS
I’m Erik Kust, a board-certified physical therapist at Orthopaedic Hospital of Wisconsin. I’ve treated countless patients for all-too-common ACL injuries, but I never thought I would find myself on the patient-side of the equation. This is what it feels like as a patient going through post-surgical recovery and rehabilitation for an ACL injury.
You may want to start by reading the first part of my ACL reconstruction journey. The previous post focused on how I tore my ACL, my surgery, and the first few weeks after my ACL reconstruction (ACL-R). Continuing, we pick up my ACL journey still in the early phase of post-surgical recovery and rehab.
BASIC REHAB PRINCIPLES TO FOLLOW
Rehabilitation following ACL-R is based more on criteria, rather than time. I advise my patients (and hold myself to the same standard) that just because a certain amount of time has passed since the surgery, it doesn’t mean a physical therapist will give clearance for activity. Everyone’s post-surgical recovery is on a different timeline.
A classic example is declaring at six months you’re ready to return to sport-specific activity. Research has shown the idea of a set timeframe for surgical recovery is outdated and potentially harmful for the patient. Our entire medical team – including the surgeon, therapist and athletic trainer will determine a patient’s progression through different phases of post-surgical rehabilitation by clinical presentation (like swelling, range of motion, pain), objective measures (peak force, limb symmetry index), self-report questionnaires (how the person is feeling about their knee), AND finally, time.
GETTING RID OF THE CRUTCHES AND BRACE AFTER ACL SURGERY
In the early stages following my ACL surgery, I was focused on my first two milestones: getting rid of the crutches and ditching the knee brace. To reach my first ACL-R post-surgical milestone and stop using my crutches, I had to meet specific goals set during my physical therapy treatment and by my surgeon. From my surgeon’s perspective, I was cleared from the beginning for weight-bearing as tolerated.
My physical therapist’s post-surgical goals were a little harder to meet. During physical therapy, I had to complete repetitive straight leg raises without an extensor lag and perform mini-squats with no increase in pain. Couple that criteria with a gait devoid of any significant limp, and about two-weeks post-surgery, I was able to do away with the crutches.
The second milestone in the acute phase is the use of a knee brace. My brace was locked in extension (or completely straight) after surgery. My ACL surgery was different from an isolated ACL-R because it also involved a meniscus repair. Most of the time with an ACL-R, a patient doesn’t need to lock their leg straight.
Post-ACL surgery, the brace is necessary because it protects the knee from buckling when standing and walking. The knee needs protection as it is more vulnerable in the beginning stages of the post-surgical recovery and rehabilitation process due to the high amounts of swelling and discomfort; this may cause the muscles not to work to their maximum potential.
In my case, I didn’t use my brace while in physical therapy. At the clinic, physical therapists control the surrounding environment and are knowledgeable about what movements place excess stress on the ACL. Typically, patients won’t use their brace as much during physical therapy, as they will outside on their own. Always clear the discontinuation of your knee brace with your physical therapist and surgeon.
ACL POST-SURGICAL REHABILITATION PHASE 1: KNEE STRENGTH AND BALANCE
Should you go through ACL surgery yourself, there are a few points you should understand. As you go through the first few weeks of post-surgical recovery and therapy, your physical therapist will continually add exercises to your regimen. Early staples of my program were movements like wall sits, step-ups, mini-lunges, and I incorporated the use of blood flow restriction training.
In the early stages of post-surgical recovery, balance training is also typically part of an ACL-R rehab program. Balance training exercises usually start simple and slowly increase in complexity. Methods to make these exercises more challenging include adding resistance bands, arm movement, or even an external stimulus (i.e., playing catch with a football on one leg).
When I treat an ACL-R patient, I often incorporate balance exercises early in their post-surgical recovery program. These exercises not only help improve knee proprioception (the ability to know where and what your knee is doing without looking at it), but it also makes rehab fun and increases overall confidence. As a patient AND basketball fanatic, it was a great psychological boost to get a ball back in my hands and do balance activities, like standing on one leg with my eyes closed and attempting to dribble.
ACL POST-SURGICAL REHABILITATION PHASE 2: STRENGTHENING THE MUSCLES AROUND THE KNEE
After I completed the initial protective phase of my ACL repair journey, the fun began. With minimal restrictions to adhere to, it became more and more focused on strengthening all the muscles around the knee. When working with ACL-R patients, I often use the phrase, “Quad is king,” and I followed the same rule.
The quadriceps play a vital role in producing movement and controlling forces going through the knee. Weakness in this muscle—more specifically, weakness on the surgical side compared to non-surgical—is a major risk for re-injury of the ACL. With these facts in mind, I tried to make every movement in my program as quad-dominant as I could, whether it was step down, lunge, or squat. I manipulated the positions of my hip, knee, and ankle to increase the demand of the quadriceps.
MY RESISTANCE TRAINING PROGRAM FOR POST-SURGICAL REHABILITATION
It’s important to create a well-rounded resistance training program to address all muscles around the knee. An example of an ACL post-surgical rehabilitation session is as follows:
- 0 – 10 minutes: exercise bike warm-up, progressive increase in resistance
- 10 – 15 mins: dynamic warm-up
- 15 – 20 mins: unique balance exercise
- 20 – 30 mins: strengthening block 1
- 30 – 40 mins: strengthening block 2
- 40 – 45 mins: core and stretching
The strengthening blocks were the most important areas of my routine. In each block, I would incorporate 2-3 exercises targeting the same muscle group (i.e., quadriceps or hamstrings).
The resistance training and strengthening program was the most extended portion of my ACL journey. I worked on strengthening my left leg 3-4 times per week for the better part of 6 months. I predominantly used single leg strengthening exercises to minimize movement compensations. (The mind and body are terrific cheaters!) You can see the exercises I used on my Instagram page @mke_physio.
I felt my body compensate for my weak ACL, firsthand. Throughout my post-surgical rehabilitation, it was difficult for me to work hard enough to make my quadricep muscles sore. No matter how many squats or lunges I did, I never felt the typical post-exercise soreness, indicating muscles have worked hard enough to change. I decided to transition to mostly single leg work and focus on bending my knee as much as possible throughout the exercises. After the transition, I finally felt I was making the necessary changes to increase my leg strength.
TESTING MY LEG STRENGTH POST ACL-R SURGERY
After about eight months of strengthening post-surgery, I had my strength formally tested via isokinetic testing. This type of testing is the gold standard for quantifying a person’s ability to produce force with specific muscles. The testing must be part of the process of deciding when to return to sport.
The number to aim for is 90% equal side-to-side, otherwise called 90% limb symmetry index (LSI). The test revealed I had over 90% LSI at multiple speeds, which boosted my confidence! I had been feeling good about my strength, but the test gave concrete evidence I had progressed. However, the isokinetic analysis revealed a discrepancy—my leg power wasn’t up to standard yet.
The power, or “rate-of-force development,” is how quickly you can produce force in a short amount of time. Once I knew I had a power deficiency, I focused my rehabilitation regimen on fast movements with quick reactions, including step-ups, jumps, and changes of direction. It took time and hard work for my body and mind to learn to produce force rapidly.
This phase of rehabilitation was the most difficult for me because I know injuries typically happen at high speeds. I was hesitant to follow through because of the fear of re-injuring my knee. Knowing I had built up strength was the most crucial factor for me to get over this “speed bump.” I spent much of the next month focusing my post-surgical rehabilitation on incorporating fast, powerful movements until I felt confident changing direction and controlling my actions.
At nine-months post-surgery, I had built up enough strength and felt confident in my ability to produce force quickly. The only hurdle left was getting back out there to play! However, the process isn’t ever as straightforward as merely walking back on the court. Stay tuned to learn the steps I’ve taken so far and the challenges I’ve overcome to return to normal life and to play sports again.
Disclaimer: This blog details the physical therapy and exercise regimen I used in my rehabilitation after ACL-R and meniscus repair. Everyone’s therapy and exercises should be unique, as no person’s rehabilitation process is the same. Open communication between the patient, physical therapist, and surgeon is essential to achieve your goals. This post isn’t medical advice; it is merely a depiction of my journey through this process.
If you or someone you know has injured their ACL, we are here to help. Contact Erik Kust at the Orthopaedic Hospital of Wisconsin or any of our therapists at 414-961-6880 to discuss a rehabilitation plan tailored for you.