T Nation

ACL Post-Op - PT That Works with Athletes?


#1

My PT has 5 years of experience in sports medicine but her clientele consist of middle-aged and older adults. I'm the only young patient that is a competitive recreational athlete (played sports in HS and college). I'm only in my 2nd week of rehab but I am beginning to question whether I should go with a PT that has years of experience with athletes since I have to have my knee is top shape in 6 months so I can take a running test and other agility and performance test for the military. By the way, I am in NY if anyone knows of any good PT's please recommend them.

Any advice based on my initial questions?


#2

At this point in time, since you are a fresh surgery, your current PT should suffice. For ACL rehab, there is a specific time frame for progression, at least this early on. Make sure you follow it. It is a slow process with this type of rehab, so even though impulse may lead you to jump the gun, do not give in. Running in a straight line is further down the road, and even then, changing directions while running(cutting) would be out of the question. Protocol is essential this early in the game. You have plenty of time to research for when you can step it up, and who you can proceed with at that point. For the near future, it’s basic, boring rehab, ice, etc.


#3

[quote]BennyHayes wrote:
At this point in time, since you are a fresh surgery, your current PT should suffice. For ACL rehab, there is a specific time frame for progression, at least this early on. Make sure you follow it. It is a slow process with this type of rehab, so even though impulse may lead you to jump the gun, do not give in. Running in a straight line is further down the road, and even then, changing directions while running(cutting) would be out of the question. Protocol is essential this early in the game. You have plenty of time to research for when you can step it up, and who you can proceed with at that point. For the near future, it’s basic, boring rehab, ice, etc.[/quote]

I somewhat agree with what you are saying, but not completely. The first several days are going to be ice and “boring rehab” and you do need to progress slowly in terms of high impact activities. But honestly, IMO, with just an ACL-R with no other complications (meniscus, etc), I would get them walking and work on walking based drills as soon as possible. Personally, I feel that most therapists will shift their clinical skills towards the patients they work with the most. If you work mostly with older, non-active population then your timelines and thought process for rehab can skew towards that population, especially if you rarely ever get a younger, active patient.


#4

[quote]LevelHeaded wrote:

[quote]BennyHayes wrote:
At this point in time, since you are a fresh surgery, your current PT should suffice. For ACL rehab, there is a specific time frame for progression, at least this early on. Make sure you follow it. It is a slow process with this type of rehab, so even though impulse may lead you to jump the gun, do not give in. Running in a straight line is further down the road, and even then, changing directions while running(cutting) would be out of the question. Protocol is essential this early in the game. You have plenty of time to research for when you can step it up, and who you can proceed with at that point. For the near future, it’s basic, boring rehab, ice, etc.[/quote]

I somewhat agree with what you are saying, but not completely. The first several days are going to be ice and “boring rehab” and you do need to progress slowly in terms of high impact activities. But honestly, IMO, with just an ACL-R with no other complications (meniscus, etc), I would get them walking and work on walking based drills as soon as possible. Personally, I feel that most therapists will shift their clinical skills towards the patients they work with the most. If you work mostly with older, non-active population then your timelines and thought process for rehab can skew towards that population, especially if you rarely ever get a younger, active patient. [/quote]

This may be the case. I had an autograph patella tendon and lateral meniscus repair. I’m going to wait and stick it out with this therapist for a while. How long before I start sport specific drills - 2 or 3 months?


#5

Just depends on how your recovery goes. With a meniscal repair, it generally is 3-4 weeks before you can begin full weight bearing to allow for the meniscus and sutures in it to heal properly. After that, you can just progress as tolerated.

For solely an ACL repair, around 2.5-3 months is when athletes are generally cleared to begin straight running. I would lean much more towards the 3.5-4 month timeframe before any lateral based movement or sport specific drills are strongly considered. It is generally closer to 6 months before a physician will release an athlete for full participation in their sport again.

Considering you had the lateral meniscus repair done as well, it may prolong some of your recovery. But since you had the PTG, you can begin strengthening the hamstrings sooner than if you had the hamstring graft.

Also, not to be a downer, but a recent study released by the American Orthopaedic Society for Sports Medicine showed no differences in laxity between PTG and hamstring grafts, but with PTG they found more increased symptoms of anterior knee pain, kneeling pain, and increased arthritis as well as decreased ROM in full knee extension and decreased performance in single leg hop test and strenuous activity at the 15 year post-op mark. Not saying that this is absolutely going to happen with you, but just something to consider when advancing your rehab and progressing through strengthening protocols.


#6

[quote]LevelHeaded wrote:

[quote]BennyHayes wrote:
At this point in time, since you are a fresh surgery, your current PT should suffice. For ACL rehab, there is a specific time frame for progression, at least this early on. Make sure you follow it. It is a slow process with this type of rehab, so even though impulse may lead you to jump the gun, do not give in. Running in a straight line is further down the road, and even then, changing directions while running(cutting) would be out of the question. Protocol is essential this early in the game. You have plenty of time to research for when you can step it up, and who you can proceed with at that point. For the near future, it’s basic, boring rehab, ice, etc.[/quote]

I somewhat agree with what you are saying, but not completely. The first several days are going to be ice and “boring rehab” and you do need to progress slowly in terms of high impact activities. But honestly, IMO, with just an ACL-R with no other complications (meniscus, etc), I would get them walking and work on walking based drills as soon as possible. Personally, I feel that most therapists will shift their clinical skills towards the patients they work with the most. If you work mostly with older, non-active population then your timelines and thought process for rehab can skew towards that population, especially if you rarely ever get a younger, active patient. [/quote]
Level, there seems to be no disagreement here. When I referred to “boring rehab,” the reference was to the other drills, including walking. It’s just that he may have the idea that he is going to begin sprints much sooner than protocol allows. What I was also saying was that, during the first few weeks that he is following protocol/drills, the additional time can be spent researching more sport-specific therapists.


#7

[quote]LevelHeaded wrote:
Just depends on how your recovery goes. With a meniscal repair, it generally is 3-4 weeks before you can begin full weight bearing to allow for the meniscus and sutures in it to heal properly. After that, you can just progress as tolerated.

For solely an ACL repair, around 2.5-3 months is when athletes are generally cleared to begin straight running. I would lean much more towards the 3.5-4 month timeframe before any lateral based movement or sport specific drills are strongly considered. It is generally closer to 6 months before a physician will release an athlete for full participation in their sport again.

Considering you had the lateral meniscus repair done as well, it may prolong some of your recovery. But since you had the PTG, you can begin strengthening the hamstrings sooner than if you had the hamstring graft.

Also, not to be a downer, but a recent study released by the American Orthopaedic Society for Sports Medicine showed no differences in laxity between PTG and hamstring grafts, but with PTG they found more increased symptoms of anterior knee pain, kneeling pain, and increased arthritis as well as decreased ROM in full knee extension and decreased performance in single leg hop test and strenuous activity at the 15 year post-op mark. Not saying that this is absolutely going to happen with you, but just something to consider when advancing your rehab and progressing through strengthening protocols.[/quote]

How long do you think before I can start jogging, running, and squatting with weights? I know I may be limited in how much I can flex on the squat since I had a lateral meniscus repair. I asked my PT but said PT did not want to give me a timeline and simply stated that she must first wait to see how much strength comes back. The frustrating part is not being able to get a clear answer from my PT.

Also, how much longer do you think I should remain with this PT? I’m in the initially stages but once it is time to start plyometrics, sport specific work, and weighted squatting, if I am not happy with the PT, I’m going elsewhere.


#8

Time before jogging a straight line - about 2.5-3 months
Time before running a straight line - add about 2-3 weeks
Bodyweight squats will begin shortly after you are able to fully weight bear and regain most of your passive ROM, and even then ROM will be limited
Light weight squats will be progressed as part of rehab.
Squats with significant weights is tough to answer, but I’d venture closer to the 3.5-4 month mark, roughly around/right before when lateral based movement is started.

I can completely understand why your PT is hesitant to answer your questions. I’m even hesitant to answer your questions and I’m not directly working with you. You seem so focused ahead that you aren’t putting the needed focus on the current necessities for your early stages of rehab. IMO, it seems like you are just looking for the answer that YOU want, not the answer that is best for you (ie, you want to be told you will be back to running in 2 months and start sport specific drills in 3 month). Instead of focusing on when you will be doing sport specific stuff, why not first focus on the basic stuff, like getting your quad to fire properly and be able to fully extend and flex your knee? Build your foundation before you build the house!

Again, from my experience, most PTs/rehab professionals will end up skewing their clinical skills towards the patients they work with the most, meaning if they work with elderly population they may be more conservative and slower in their progressions. That isn’t always the case, but is what I have noticed a lot in my experience. This isn’t to say you need to run out and find a new PT. And the way that insurances limit the number of visits you get, a lot of things will be on your shoulders.

What specifically has your PT been doing with you? How far out of surgery are you?


#9

[quote]LevelHeaded wrote:
Time before jogging a straight line - about 2.5-3 months
Time before running a straight line - add about 2-3 weeks
Bodyweight squats will begin shortly after you are able to fully weight bear and regain most of your passive ROM, and even then ROM will be limited
Light weight squats will be progressed as part of rehab.
Squats with significant weights is tough to answer, but I’d venture closer to the 3.5-4 month mark, roughly around/right before when lateral based movement is started.

I can completely understand why your PT is hesitant to answer your questions. I’m even hesitant to answer your questions and I’m not directly working with you. You seem so focused ahead that you aren’t putting the needed focus on the current necessities for your early stages of rehab. IMO, it seems like you are just looking for the answer that YOU want, not the answer that is best for you (ie, you want to be told you will be back to running in 2 months and start sport specific drills in 3 month). Instead of focusing on when you will be doing sport specific stuff, why not first focus on the basic stuff, like getting your quad to fire properly and be able to fully extend and flex your knee? Build your foundation before you build the house!

Again, from my experience, most PTs/rehab professionals will end up skewing their clinical skills towards the patients they work with the most, meaning if they work with elderly population they may be more conservative and slower in their progressions. That isn’t always the case, but is what I have noticed a lot in my experience. This isn’t to say you need to run out and find a new PT. And the way that insurances limit the number of visits you get, a lot of things will be on your shoulders.

What specifically has your PT been doing with you? How far out of surgery are you? [/quote]

Thank you so much for this post. I am 3 weeks post-op (patella tendon autograph w/ lateral meniscus repair). At Physical Therapy, I do the following in this order: 15-20 minutes on the stationary bike, quad sets - 3 sets of 10, leg raises without the brace - 3 sets of 10, hip extensions - 3 sets of 10, hamstring stretch - 5 sets of 30 second hold, wall heel slides (assisted with my good leg) - 1 set of 15 with 5 second hold at the maximum flexion I can hold for, then she moves my knee cap around, I guess this is to regain mobility in the area. I finish off the session with 15 minutes of icing.

Physical therapy is 3 times per week and I am closing in on my second week of PT. I am at 125 degrees of flexion and near full extension. All of the exercises that I perform at PT, I do at home at least 4 times per day and sometimes I do it 5 to 6 times per day.

Thanks again and I do agree with everything you said. I am just so focused on getting back on my feet so that I can comeback stronger than ever. I know it is a long road but I am definitely anxious for time to fly.

Any other suggestions and things that I should be aware of throughout this process?

By the way, how long ago did you finish rehab and how are things going for you in terms of being able to do the things you did before your injury?

All the best,
Mario


#10

I have noticed over the years, for example, with professional athletes that rely on explosive bursts(quick and fast running backs) can be functional in a few months and ready for the next season, but tend to regain their explosiveness after another year. Same with rotator cuffs and pitchers that rely on power. You can get funcional for your goals within maybe 6 months(maybe earlier). Kinda vague, but hope it helps. Good luck.


#11

From the looks of things, your PT is doing all that can be done at the moment since you are not allowed to be full weight bearing. I know it is a long road and it is expected that you will be anxious to want to do fully functional things again, but you just HAVE to be patient. I tell all of my ACL-R athletes not to even ask about running or jogging until we are at least 2 months into rehab.

Suggestions would be to not forget about your healthy leg! Continue to train that normally as you can without putting yourself in a risky position to do damage to your ACL-R leg of course. Things like single leg squats with something nearby to help grab your balance with in case you lose it, SL glute bridges, SL Swiss ball ham curls, etc. will all be beneficial. Keep your overall cardio/conditioning up as well. This will not only help you down the road, but also, IMO, help with immediate recovery. Upper body bike, circuit based upper body weight training, and similar things will all be of great benefit.

Thankfully I have never had an ACL-R (knock on wood). I just have tons of experience working with athletes who have. Majority of those athletes have returned to full function without issues. The ones who did have issues generally were the ones who did not follow the rehab protocols properly and did not do what was needed/expected of them.


#12

[quote]BennyHayes wrote:
I have noticed over the years, for example, with professional athletes that rely on explosive bursts(quick and fast running backs) can be functional in a few months and ready for the next season, but tend to regain their explosiveness after another year. Same with rotator cuffs and pitchers that rely on power. You can get funcional for your goals within maybe 6 months(maybe earlier). Kinda vague, but hope it helps. Good luck.[/quote]

Thanks Benny. You guys have been helpful with your responses to this thread.


#13

[quote]LevelHeaded wrote:
From the looks of things, your PT is doing all that can be done at the moment since you are not allowed to be full weight bearing. I know it is a long road and it is expected that you will be anxious to want to do fully functional things again, but you just HAVE to be patient. I tell all of my ACL-R athletes not to even ask about running or jogging until we are at least 2 months into rehab.

Suggestions would be to not forget about your healthy leg! Continue to train that normally as you can without putting yourself in a risky position to do damage to your ACL-R leg of course. Things like single leg squats with something nearby to help grab your balance with in case you lose it, SL glute bridges, SL Swiss ball ham curls, etc. will all be beneficial. Keep your overall cardio/conditioning up as well. This will not only help you down the road, but also, IMO, help with immediate recovery. Upper body bike, circuit based upper body weight training, and similar things will all be of great benefit.

Thankfully I have never had an ACL-R (knock on wood). I just have tons of experience working with athletes who have. Majority of those athletes have returned to full function without issues. The ones who did have issues generally were the ones who did not follow the rehab protocols properly and did not do what was needed/expected of them.[/quote]

Thanks for the tip re: exercises I could be doing now. I actually started a modified version of “Westside for Skinny Bastards.” I used the following movements: DB Floor Press, Chin-ups, seated DB power cleans, seated lateral raises, seated shrugs, and seated DB hammer curls. I’m going to add the single leg glute bride you suggested using my good leg. After PT tomorrow, I plan on continuing PT at home at least 4 more times during the day followed by some ab exercises such as toe touches and crunches. I’m not sure what else I can do for my abs, any ideas?

And thanks again for all of your great advice. My conditioning as definitely dropped since pre-surgery. I completed two 20 minute sessions of the stationary bike today and was drained after the second go at it.

Best,
Mario


#14

For core, off the top of my head, you can try some single leg plank variations, single leg body saw, seated pallof press, seated rotational med ball throws. Just try out some seated or single leg variations of other core exercises. See what works and what doesn’t. Just make sure that you won’t be placing your surgical leg at any large risk of injury during them.


#15

All that can be said has been said, for the rest it’s just patience. I just recently went through this and it is not easy, so I can sympathize. The meniscus work is especially tricky. I found just setting small milestones and working to achieve them is the quickest way to get through it


#16

[quote]LevelHeaded wrote:
For core, off the top of my head, you can try some single leg plank variations, single leg body saw, seated pallof press, seated rotational med ball throws. Just try out some seated or single leg variations of other core exercises. See what works and what doesn’t. Just make sure that you won’t be placing your surgical leg at any large risk of injury during them.[/quote]

Thanks. I’ve never heard of the single leg body saw before. I don’t think I’m ready for the single leg plank variation yet. I just did some v-ups, crunches, and a pilates based core exercises called dishwasher hold ( I believe thats the name of it) where I hold my legs a few inches off the ground with my upper back off the floor and my arms pointed upwards.

I did some chin-ups yesterday and was very careful with my surgical leg, however, I noticed some pain so I’m going to skip on any form of chins and pull-ups until I am capable of doing so.


#17

[quote]rehanb_bl wrote:
All that can be said has been said, for the rest it’s just patience. I just recently went through this and it is not easy, so I can sympathize. The meniscus work is especially tricky. I found just setting small milestones and working to achieve them is the quickest way to get through it[/quote]

Thanks, it is definitely challenging but I am up for it and will do whatever possible to get back to full function. Like you guys said before, I have to be patient throughout this process. I also had lateral meniscus work (a repair), did you also get a meniscus repair? If so, what are the most important things I should keep in mind? I am 3 weeks post-op and am partial weight bearing although I feel I can put full weight on the leg I have not and I am at 123 degrees of flexion. I think my flexion should be better next week when my PT measures it again. Next week is officially 1 month post-op, can’t wait to hear what the doctor says.

Also, how long did it take to get an MRI post-op just to make sure that everything in the knee (ACL and meniscus) was ok?


#18

[quote]MarioX wrote:

Also, how long did it take to get an MRI post-op just to make sure that everything in the knee (ACL and meniscus) was ok?[/quote]

I honestly don’t feel a post-op MRI is needed, unless you have ongoing issues (lacking full extension, catching in the knee during activity, ongoing significant pain) or a re-injury. The doctors use the arthroscopic cameras to make sure all is clean when they finish the surgery and the MRI would be useless IMO.


#19

[quote]LevelHeaded wrote:

[quote]MarioX wrote:

Also, how long did it take to get an MRI post-op just to make sure that everything in the knee (ACL and meniscus) was ok?[/quote]

I honestly don’t feel a post-op MRI is needed, unless you have ongoing issues (lacking full extension, catching in the knee during activity, ongoing significant pain) or a re-injury. The doctors use the arthroscopic cameras to make sure all is clean when they finish the surgery and the MRI would be useless IMO.[/quote]

I see what you are saying. Makes sense. Thanks again for all your help.


#20

[quote]MarioX wrote:

[quote]rehanb_bl wrote:
All that can be said has been said, for the rest it’s just patience. I just recently went through this and it is not easy, so I can sympathize. The meniscus work is especially tricky. I found just setting small milestones and working to achieve them is the quickest way to get through it[/quote]

Thanks, it is definitely challenging but I am up for it and will do whatever possible to get back to full function. Like you guys said before, I have to be patient throughout this process. I also had lateral meniscus work (a repair), did you also get a meniscus repair? If so, what are the most important things I should keep in mind? I am 3 weeks post-op and am partial weight bearing although I feel I can put full weight on the leg I have not and I am at 123 degrees of flexion. I think my flexion should be better next week when my PT measures it again. Next week is officially 1 month post-op, can’t wait to hear what the doctor says.

Also, how long did it take to get an MRI post-op just to make sure that everything in the knee (ACL and meniscus) was ok?[/quote]

The only thing to really keep in mind is that compared to only an ACL reconstruction your rehab process will be slightly delayed. Just requires more patience and a lot of dedication. I felt that ultra sound/ soft tissue work in the latter stages help a lot with reducing inflammation.
I had a medial meniscus repair from a brutal bucket handle tear. Just do what your physio says and you should be fine