ACL Rehabilitation Timeline: Month 2

The NFL playoffs have started with some wild endings and excellent entertainment.  I started this yearlong series of blogs after watching Dion Lewis of the Patriots go down with an ACL injury during a game.  I figured it would be informative and fun to write a progressive account of ACL rehabilitation that loosely followed his recovery and return to the NFL.  Patriots fans around the country would give a lot to have him back going against the Chiefs this weekend.  Although I grew up in New England I now live and practice physical therapy in San Jose at Competitive EDGE Physical Therapy where the football buzz is much subdued.  My passion for the Patriots however is unwavering!

http://www.rantsports.com/nfl/2014/09/26/new-england-patriots-vs-kansas-city-chiefs-top-5-matchups-to-watch/

In the last installment, I highlighted what ACL rehabilitation looks like from the day of surgery through the first month of recovery.  This post will discuss the second month of ACL rehabilitation.  I will highlight rehab goals, protocol progressions, and mental points of interest for those in the trenches of recovery.

Physiological Healing

As mentioned in previous posts, the ACL graft is secured into the femur and tibia via a bone tunnel and anchor.  This provides initial stabilization to the knee.  In order to achieve optimal physiological healing, the bone must interface with the tendon itself.  This occurs from bone ingrowth to the fibrovascular tissue that surrounds the bone-tendon junction.  After this bone ingrowth, collagen fibers progressively anchor the tendon to the bone.  Additionally, due to the death of ACL graft cells initially, there is an influx of new cellular growth.  This process takes between 4 weeks and 12 weeks.
During this phase of weeks 4-12, the ACL graft itself is at its weakest point in the recovery process.  It is important to remember this as ACL rehabilitation picks up intensity in the second month of recovery.

Diminishing Pain

During weeks 4-8 after ACL surgery you will notice a steady decrease in pain.  At this point the post-operative pain from the incision and swelling is largely subsided and sleeping has become much more comfortable and uninterrupted.  Most often, patients will complain of pain from prolonged sitting with a bent knee, prolonged standing, and excessive loading.  If you have a long car ride planed during this time you may consider sitting in the back seat with the ability to stretch your leg out on the center console or entire back seat.  This will make the ride more enjoyable.  Also, it remains advised not to fly due to continued mild swelling and the risk for blood clotting. Overall your pain will be minimal during this phase and this may give you an increased sense of confidence.  Be sure to follow your physical therapist’s orders to avoid moving ahead of protocol and causing increased pain or swelling.  Due to the reduction in daily pain most patients are no longer taking pain medication.

I can remember the second month of ACL rehabilitation quite well as it was the first time in the process I felt, “My knee is going to be OK.”  This was an uplifting feeling after going through surgery.

Diminishing Swelling

Swelling will gradually reduce throughout the first 3 months of ACL rehabilitation.  During the second month you will notice that you feel less of a need to use ice or elevate your knee.  It is recommended though to use ice and elevate after physical therapy since you will be using your knee at higher levels than at home.

Swelling can also be used as a barometer for exercise intensity and progression.  If you notice increased warmth and swelling around the knee after a particular workout or activity you know that it likely was too much stain on the knee.  If this does occur be sure to take it easy on the second day with increased icing to return back to baseline.

ACL Rehab Month 2: Physical Therapy

The goals of physical therapy during month 2 of ACL rehabilitation include:
  1. Normalize knee flexion and extension (full range of motion)
  2. Demonstrate excellent quadriceps contraction
  3. Swelling reduced to baseline
  4. Normalize walking gait (walk without a limp)
  5. Able to ascend and descend stairs
  6. Continue to increase gluteal strength, calf strength, and hamstring strength

Normalize Range of Motion

By week 8 in ACL rehab you should be near or at full range of motion at the knee.  Your physical therapist will work on your ability to bend and straighten your knee each visit during this phase.  Often times they will use hands on manual therapy to decrease IT band tightness, patellar tightness, and hamstring and quadriceps tightness.  They will likely work on reducing scar tissue development with scar tissue mobilization.
As you therapist works to improve your overall movement in the knee, you can expect pain to be felt.  This pain is temporary but can in fact be sharp at times.  Your physical therapist is trained to know exactly how much to push your knee to achieve normal range of motion.  They will also advise you on home stretching to piggyback on what is done at physical therapy.
Using a stationary bike is crucial during this phase of rehabilitation.  The cyclic repetitive motion is excellent to improve mobility at the knee and to reduce swelling.  You will be advised to gradually increase the resistance on the bike to help with quadriceps development.  Generally, there is no limit to the amount you can ride on the stationary bike so long as there is no post workout swelling that limits your daily function. 

Normalize Walking Gait

Although you may feel like your walking is completely “normal”, there is likely gait deviations present.  Many studies show decreased knee flexion (bending), hip flexion, and shock absorption even 1 year after surgery.  It is best to address these deviations very early on in the rehabilitation process as habits can form quite quickly.

Here are some common ways your therapist will help you achieve an ideal walking gait pattern.
  • Resisted Walking
    • Using a resistance cord or band around the waist while walking helps you to use your buttocks, quadriceps, and calf to progress forwards.  Your therapist will provide cues during this activity to keep your knee pointing straight ahead and your hips level.  Lower extremity alignment is always paramount in whatever activity is performed to protect the ACL and correct abnormal mechanics.
  • Terminal Knee Extension
    • Using a resistance band around the back of the knee helps to promote quadriceps usage during the stance phase of gait.  By going through motions of bending and extending the knee you will learn “loading response” which allows you to absorb shock during walking.

  • Walking Progression on Treadmill
    • Using a treadmill helps to attain the necessary repetitions to re-learn walking.  Your therapist may have you use a band around your knees to press against to provide resistance.  You will gradually add an incline to your walking to increase strength.
By the end of the second month of recovery you will be able to walk comfortably without pain 1 mile or greater. 

Squatting and Stairs

The newest addition of movement in month two is stairs and squatting.  These are two essential movements to daily life.  Unfortunately, these motions are often done incorrectly and place a large strain on the knee. Squatting

As you begin to load your knee in weight bearing squatting you will realize that it is not as easy as it used to be!  It is best to use a mirror to help with controlling the alignment of your knee and pelvis.  If your ACL injury occurred from a non-contact situation, you may have more difficulty than others keeping your knee from collapsing inward.  This position needs to be avoided as it places increased strain and torque on the ACL graft itself.  Also you should be aware of the alignment of your pelvis as often times patients will shift away from their surgical leg.  Here are some tips to be sure you are squatting correctly.
  1. Use a resistance band around your knees.  By pushing your knees out into the band and imagining you are “separating the floor” with your feet you will shift the work during the squat more towards your hips and off of your knee.  This activates the gluteus maximus which is the main muscle the controls the alignment of your knee.
  2. Use two separate weight scales, one for each foot, to equalize loading pressure.  As you squat look straight ahead and have your physical therapist provide cues on moving pressure from one foot to the other to make loading even.  This is a great tool for those of you who are hesitant to load your knee due to fear.  By the end of this exercise you will be squatting without issue.
  3. Vary the squatting angle to provide variability of training to help improve neurological input.  Squat with one foot facing outward like a surfer or squat to varying depths.  It is important to make your rehabilitation different so you and your therapist don’t get bored!

Stairs

We encounter stairs every day.  Being able to negotiate stairs correctly can save your knees a great deal of wear and tear.  Most people after surgery will get up and down stairs by avoiding the usage of their quadriceps.  This may sound silly since you can remember your quads burning the last time you did stair workouts for soccer practice.  When healthy, yes, you will predominantly use your quadriceps with stairs.  After surgery; however, you quadriceps are still gaining strength and your body is going to shift the work to your actual knee joint and calf.

In order to be sure you are using the stairs correctly here are some tips for proper form.
  1. Start your stair training one step at a time.  If you try to just walk right up the steps you will “vault” over your stance leg.  By this I mean you will press yourself up with the opposite calf muscle and avoid using your operated leg all together.  By going slowly you put more of the work on your operated side.
  2. Use a mirror to help visualize knee and torso position.  For proper stair climbing it is important to keep your knee behind your toes, hip hinged, and torso forward so your chest is over your knees.  As you ascend upwards drive through your buttocks and hip to propel yourself forward.  This same position is used coming down the stairs although some find it scary to bend forward coming down stairs.
  3. Be sure to keep your pelvis level.  Often times on stairs patients will “reach” for the next step and this will change pelvic alignment and put more pressure on the knee and hip.  Imagine you are holding a stick across your waist and try to keep it level.
In this picture of a step up a quadriceps dominant posture is observed.  Cuing for this patient would entail advice to lean forward putting your chest over your knees and drive through the hips

Mental Focus

The second month of ACL rehabilitation has both highs and lows mentally and emotionally.  With the integration of stairs, resisted walking, squatting, and more aggressive biking I remember a sense of progress and hope that things are returning to normal.  Being able to get off the coach and physical therapy table and out in the gym is uplifting.  Focus on these positive feelings if you can.

If I am being honest, this stage was also a time when I came to grips with the fact that I was in it for the long haul.  As I practiced squatting and stairs I realized how weak my leg had become and how far I still had to go to get back to football.  You have to be in the valley to understand the height of the mountain.  I had a great physical therapist who helped coach me mentally through this process by giving my small goals along the way.  We focused on changing diet, getting to the gym for upper body training, and listening to motivational speeches from athletes.  Find something that motivates you and follow it every day.  Surround yourself with positive friends and family.  I found it helpful to attend the team’s practices and games and help out where I could.  The comradery of the guys was a great boost.

"We Are on to Month 3"

Just like the Patriots coach Bill Belichick who repeated “We are on to Cincinnati” about 15 times during a press conference, you have to focused on what is to come and not dwell in the past.  Hopefully next month the Patriots will be in the Super Bowl.  Even if they don’t make it to the big show another addition of this post will be published describing month 3 of ACL rehabilitation.  As always, for more information visit Competitive EDGE Physical Therapy in San Jose at www.compedgept.com or follow on twitter with the handle @CEmotionPT.  I have helped athletes of all ages and fitness levels return to the sport they love following ACL reconstruction.  Having gone through the surgery and rehabilitation myself I understand first hand how a great physical therapist can make all the difference.

If you have questions about your knee, surgery, recovery, or physical therapy and would like to speak with a physical therapist please give me a call at 408-784-7167.

You can also send me an email: kevin@compedgept.com

Written by:
Kevin Vandi DPT, OCS, CSCS
Physical Therapist in San Jose-Los Gatos-Campbell-Almaden