By: Jasonn Miller, MS, LAT, ATC, CES
I had the privilege of working with collegiate athletes for 10 years as an athletic trainer. I worked with eighteen different sports and have seen more ACL injuries than I’d care to recall. If you are a high school, collegiate, or professional athlete with a recent ACL injury you will spend more time than you can imagine with your athletic trainer/physical therapist for likely the next year or so.
I can honestly say that having to handle the response from the injury, the surgery process, and the daunting task of rehabilitation is one of the hardest things for an athlete to go through. As an athletic trainer, you never want to see an athlete get injured, but unfortunately injuries cannot be completely avoided. Designing and implementing an ACL rehabilitation program is an extremely challenging test. No two programs are ever the same. Even if an athlete has a second ACL injury, it’s never the same. It is a complex, multi-dimensional process that requires you to be able to adapt on the fly because it never follows the exact plan you set out.
There are many little pearls of wisdom I’ve learned and discovered over the years and I always try to pass them on to each athlete before and during the rehabilitation process to help prepare them and keep them motivated. The following are the 10 Things You Need to Know Before ACL Rehabilitation:
1.
Know your support circle, and utilize them
No two people have the exact same support circles in their lives, so it is critical that you identify your specific needs and take advantage of available sources of support. Whether it’s family, friends, teammates, coaches, athletic trainer, etc. It is inevitable that you will need external support and people to talk with during this process. Someone to vent frustration to, someone to celebrate with, someone to comfort you, someone to motivate you, your confidant, etc. Don’t ever be afraid to reach out to someone who can help you no matter what area you need that support with. Some people may not be interested to discuss their struggles with coaches or teammates, so having someone apart from the team can be valuable. But those same coaches or teammates can be especially motivating for some people because ultimately you want to get back to playing and competing with them. Knowing what you need, when you need it, and who to turn to for different situations will make everything about your rehabilitation easier to manage.
2.
The mental and emotional side is every bit as challenging as the physical
It’s easy to see, hear about, and understand the physically difficult side of ACL injury and rehabilitation. It’s outwardly obvious in many ways, but the mental and emotional toll of the process can be just as challenging (if not more so). Being “left out” of practices and games. Stuck on the sidelines and having to spend countless extra hours for rehab and away from your teammates. Being so physically limited and frequently needing the assistance of others can be very stressful and draining. The frustration of not being able to do the activities that you love. The major thing that defines so many athletes’ personalities getting taken away can leave a void that doesn’t seem to be replaceable by anything else. ACL rehab is so much more than physically challenging and having a better idea of what is coming can make preparation much easier.
One way I explain this rehab process to athletes is as a constant cycle of them working hard to get better at an exercise, then once you are good at it… I’ll change it to make it hard again. This may seem like a mean way of explaining it, but it’s the actual truth of what you need. Rehab is a constant process of rebuilding and adaptation. The body will adapt to the stresses that are placed upon it. Struggling with something means you’re working on pushing the limits of your current capabilities. Once you stop struggling, you won’t gain much from that level of the exercise anymore. It’s your therapist’s job to adapt the activity to make you struggle again and push you towards the next level, and then the next. This can be as simple as adding another 5 pounds to your lift, taking a stable surface and making it unstable, reducing rest time, etc. All the “mean” things they come up with are designed specifically to help push your body to get better. Being physically, mentally, and emotionally engaged in this process is critical to balancing all the stressors that can come your way.
3.
Set short-term goals… and celebrate those small victories when they come
Looking at an ACL rehab timeline as one big 6-9+ month process can be incredibly discouraging. Everything seems soooooo far away and like it will never come. Yes, you do need those long-term goals of being able to squat equally, jog, cut, return to play, etc. to keep your mind aware of what you’re ultimately heading towards, but setting short-term goals (and celebrating reaching them) is the key to staying motivated on the day-to-day grind (and it is a grind). If you’re struggling with range of motion, don’t only think about being able to touch your heel to your butt again as the goal, set a goal to gain a specific amount of degrees for the week. A simple goal like this can be measured and provides you with smaller, but frequent victories to reach and celebrate. Those small victories add up quicker than you’ll expect, and you’ll reach those longer-term goals with more motivation.
4.
Just because one body part is injured, don’t forget about all the others
After surgery, you will be limited on what you’re allowed to do with your surgical leg, but don’t let that deter you from continuing to work on your other body parts. If one leg is injured, you can still work on your upper body, core exercises, and on the opposite leg. If you have access to a strength and conditioning coach, make sure your therapist communicates with them so they can design a program built around improving you as an athlete in the areas you are able to. This is also a great way to stay connected to your team. Even though you may be doing a separate program it is always very mentally beneficial to be with your team working out with them. Your teammates will enjoy seeing you in there putting in work alongside them! They don’t get to witness the majority of your rehab sessions so getting integrated back into team lifts can be very therapeutic for everyone involved.
5.
“Hurting” to help
One year I met with a freshman soccer player, and her parents, after she moved onto campus. She recently had an ACL reconstruction surgery and had been working with a physical therapist at home and I’d be taking over her rehabilitation now that she was at school. She was behind in where she should’ve been in her flexion because her past therapist hadn’t pushed her passed her comfort zone. They would stop as soon as it was uncomfortable. I remember telling her (and her parents) very directly in that first meeting that I was going to have to push her harder than she’s been used to, and that it was going to hurt. We needed to gain back what she was lacking to avoid getting behind in other areas. It’s vital that your therapist not only knows what it is needed but to be able to explain why. This was a long and painful process to catch back up, and her teammates would regularly ask why what I was doing was causing that type of pain while I was bending her knee. I would tell them it’s “Hurting to Help.” She understood that although it did hurt during the bending that it actually helped her get better. It becomes a lot easier to push yourself through the painful times if you know why it needs to happen. These things are done in a controlled and calculated manner that is designed to help you improve. This is just one example of this concept, but being prepared to accept the stress of pushing your body back to sport will make the process easier to prepare for.
6.
Control what you can control
ACL injuries can happen to anyone. Sometimes the person down on the field in pain is the last person you’d ever expect. Sometimes it’s just plain bad luck. You can’t control it, and no work out program can completely eliminate the possibility of it happening, or happening… again. Once it’s happened, take a short period to let the emotion out. Whether it’s anger, sadness, despair, confusion, etc. Let it out… then start to prepare for surgery. There are many things that can be done prior to surgery (pre-hab) to help prepare your body and mind for surgery and to put you in a more advantageous position coming out of surgery.
There will be many times during rehab where it won’t go as planned. Sometimes you won’t know exactly why it’s off plan, or it will be because of something out of your control. Don’t focus on not being able to understand why or feeling helpless because something unplanned happened. Instead, figure out what things about the situation you can control. Focusing on that will lead you to be able to get back on schedule. Rehab planning is fluid, a constantly changing beast. Keep the communication open and work in collaboration with your therapist to figure out why you can’t do what you need to and what parts of that can be controlled to correct the path.
7.
You will have setbacks/plateaus
No matter how great your surgeon’s reputation is, no matter how experienced your therapist may be it is almost a guarantee that you will suffer at least one significant setback or plateau. That doesn’t mean that you or anyone else involved will do something wrong. It’s just the unfortunate likelihood that there will be some part of the process that you will struggle with. It can be range of motion, or regaining muscle mass, or tweaking your running gait to get it back to normal, or having the confidence to cut hard or hit someone for the first time back in action. It can also be a setback like developing tendinitis in the patellar tendon or hamstring tendons from pushing to gain strength faster than the tendons are prepared. There’s no predicting what it may be or when it may come but in my experience, no one has ever just cruised through without any type of setback or plateau that we had to reevaluate and push through. I’m not trying to say your mindset should be just waiting for something to go wrong, but that you should always be prepared to alter your course to meet the demands of the current situation.
8.
Don’t get caught up in timelines, focus on being prepared for the next phase
Yes, there are timelines in most phases of your physician’s protocol that guides your rehab, but they are not the ultimate power in determining your activity. The timelines establish the minimum amount of time that must pass before you can begin a new activity, but you MUST be physically ready to perform that activity. If it says jogging can begin between 12-16 weeks post-surgery, that doesn’t mean you can’t possibly have to wait until after 16 weeks if your range of motion, strength, and confidence are not at an acceptable level. The timeline doesn’t supersede your readiness. Keep your focus on what attributes you need to be able to move on to the next activities. Talk with your therapist so you can be informed and keep focused on the next level and what you need to be able to do to get there.
9.
Work hard in rehab, Work smart outside of rehab
It is always important to work hard and be dedicated to your rehab sessions and eventually weight room workouts. But your muscles don’t grow while you’re physically in the weight room. Your muscles adapt to the stresses placed upon them. Muscle fibers are being broken down during workouts. They are rebuilding, remodeling, and eventually growing while you’re OUTSIDE the weight room. Just as much focus needs to be placed on recovering from workouts as is placed on performing the workouts. Focus on your sleep quantity and quality, nutrition, stress relief, and hydration to give your body the optimal environment to recover and adapt. If you have access to treatment modalities (ice baths, compression devices, deep muscle stimulation, cupping, etc.)… use them! Find out what works for your body and utilize these items. This is how you regain your lost muscle mass and strength, but also how you recover adequately to be able to come back day after day and physically perform the workouts.
10.
COMMUNICATE, COMMUNICATE, COMMUNICATE!
This one is pretty self-explanatory but cannot be understated, and since it’s actually involved with all the other items on this list I wanted to end by emphasizing the most consistent concept. Communication is crucial to the rehabilitation process. Communication builds trust. Without trust you will have a difficult time getting the most out of your rehabilitation program.
Communicate with your therapist on how you’re feeling, what you’re struggling with, what you feel confident with… basically everything. No one knows your body, and what it’s going through, better than you, so share that knowledge! The more information they have, the better they can adapt the rehab protocol to your exact needs and progression.
Communicate with your coaches. Unfortunately, many coaches don’t realize just how much of a struggle your rehab process is, and their focus tends to be on those healthy enough to play, but if you take the time to talk with them they can better understand your situation. If you are feeling isolated, or disconnected, they may be able to find new ways for you to interact and be involved
