Injuring your knee can be a frustrating and crippling problem - especially when the instability continues for longer than you would have planned. Unfortunately, this is quite a common occurrence without a structured plan to get back into activity. Depending on where you are in your rehab you’ll likely have quite a few different questions. How long does it take? Do I need to have surgery? Will my knee ever feel ‘normal’ again?
The answers to these questions aren’t necessarily straight forward and rehab is different for everyone depending on past injuries, body type and dedication. Generally, surgery is recommend for young, fit athletes who place heavier demands on their body. If however, you're a weekend warrior without too many complications you’re probably a good candidate for conservative rehab. The most important thing to do right now is set yourself some goals
and make a plan.
1. Start strengthening the inner quad early.
Think of the quad as pulleys on the kneecap. After an ACL injury, there is inhibition of the inner quad muscles and if left unchecked, this can lead to big problems down the road. So get started with some gentle contract/relax exercises in sitting to get these going again. It’s a bit like tensing your bicep but applying the same principle to your inner quad.
2. Address what has happened with your torso.
Your trunk is your ribcage and spine so most of the time when there’s been an injury to a limb, there are compensations happening in the trunk from changes to the abdominal wall. It’s a no brainer but for some reason is often forgotten. This comes down to simple things like monitoring your posture and catching yourself if you’re tensing your back or shoulders. Because ACL injuries tend to be longer term, these changes can creep in over time so it’s important to address early and not pick up bad habits. This is part of the reason you might need crutches to stop limping after your injury. Try to walk as soon as you can and as normal as you can.
3. Don’t forget about the hamstring and hip
The hip and hamstring both get affected in 100% of ACL injuries that I've seen (and that's a lot). The instability in the knee changes how the muscles fire around your leg and you can end up with more problems. Your hamstring will get tight to stabilize the knee - this is really common but what tends to also happen is a hamstring timing issue. This is where one hamstring muscle works harder than the others. It’s very common to get a lazy inner hamstring muscle and this can wreak havoc on the knee and even lead to a re-injury. It's an easy fix if you can catch it early. I can’t tell you how many times I’ve seen this missed when I see people 5 or even 10 years down the road. It doesn’t matter where you are in your journey – get this happening early and it will save you a lot of hassle down the track.
4. It can also affect the foot and ankle
Biomechanics are changed after ACL injury. If you’re really lucky, this might be minimal but 99% of the time it is worthwhile addressing. It’s very common to get rigidity in the foot and calf - while this might not be noticeable in the short term, over the long term it compromises how you move your hip and knee. This can have quite devastating consequences like affecting a ski turn or golf swing. Foot and calf mobility isn’t difficult to do. It just takes a spikey ball and a bit of grit. You'll probably want to check this out with a physio because that's what they're experts at.
5. Balance is everything
Our ligaments tell our brains where our joints are in space. After an injury, this messaging can get weaker and we need to retrain this. So balance exercises should always be included in a rehab program. You can start with simply balancing on one leg and then progress this to a pillow. Once you've regained appropriate balance, quad strength, hip strength and power, you need to move into sport specific rehab.
6. Power is performance I wish I had a penny for every time a person told me their ACL rehab didn't have a power component. When it gets down to it, power is everything. If you've trained adequate strength in the hip, torso, knee and foot (should be about 90% of the other leg) and you don't integrate a power component into your sports or goals then you're asking for trouble. At the end of the day, power is performance. I find there are two major reasons for this. Firstly, you need to be able to habitually use the right muscles and biomechanics without conscious effort. This comes from repetition and practice which means training, training and more training. Secondly, if you haven't trained the hard stuff then there will generally be a lack of trust when you do get back to your goals. Trust is everything - without it, you won't be performing well and you probably won't be having fun either. This often means being disciplined and progressing things even when your knee feels great. It's on these days that you'll really need to push yourself that all this hard work will pay off.
So what's the plan from here?
You are free to co-create your own rehab plan. The real success will come from what you put in. Generally though, progressive rehab runs in three phases. If you've had an ACL surgery you're looking at 8-12 months but if you go conservative, you can get it done in 3-4.
Phase 1 is all about stability waking up the right muscles and developing the right movement patterns. This goes for about a month and should ideally be a whole body program including everything mentioned above.
Phase 2 is all about strength and starts as soon as possible – a rough benchmark for this is 4-6 weeks post surgery/injury and goes for 6-8 weeks. This is all about loading as much as possible to the point of fatigue.
Phase 3 is where you need to start power and explosive training. Like I mentioned, this is what will make all the difference.
Through a program, you generally need do to some form of training everyday, with 2-3 quite heavy training days and 2-3 light recoveries. With the right instructions the human body is capable of amazing things. Learn more about integrative physio.