10 Considerations for Post Rehab ACL Training By Vince Gabriele My first experience with the ACL was standing in a pool of bloody water in an operating room. I was a guest of Dr. John Hurley, one of America’s top Orthopedic surgeons, during one the many ACL surgeries he had performed in his career. I stood in the corner and watched for the most part, but at one point Dr. Hurley called me over and said, “Hey Vince, Check this out.” He showed me the ACL graft he was about to hammer into this poor person’s knee. I stood directly over the patient watching as he was making his repair. You could see everything on the screen. I was amazed at how much it mirrored a construction project, lots of hammering, screwing, and cutting. No wonder people are so sore after surgery. I remember my good friend, Eric Cressey, telling me how he would go watch shoulder surgeries to learn everything possible about the shoulder. I knew if I wanted to be best with postrehab ACL training, I should follow in Eric’s footsteps. Developing a relationship with Dr. Hurley gave me a pipeline of athletes that were 3 4 months postop ACL. This was his specialty and I started to get several athletes each month. I quickly realized I needed a new skill set to work with many of these athletes to get the job done. One of the most important things to have is a beginner’s mind. I certainly had and still have it, so I sought the best to help me become the most effective postrehab ACL trainer I could be. I needed a physical therapist that had experience with strength and conditioning to help me bridge the gap. After all, the goal is to get these athletes back on the field safely, and this is easier said than done. I hired Charlie Weingroff.
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10 Considerations for Post Rehab ACL Training By Vince Gabriele My first experience with the ACL was standing in a pool of bloody water in an operating room. I was a guest of Dr. John Hurley, one of America’s top Orthopedic surgeons, during one the many ACL surgeries he had performed in his career. I stood in the corner and watched for the most part, but at one point Dr. Hurley called me over and said, “Hey Vince, Check this out.” He showed me the ACL graft he was about to hammer into this poor person’s knee. I stood directly over the patient watching as he was making his repair. You could see everything on the screen. I was amazed at how much it mirrored a construction project, lots of hammering, screwing, and cutting. No wonder people are so sore after surgery. I remember my good friend, Eric Cressey, telling me how he would go watch shoulder surgeries to learn everything possible about the shoulder. I knew if I wanted to be best with post-‐rehab ACL training, I should follow in Eric’s footsteps. Developing a relationship with Dr. Hurley gave me a pipeline of athletes that were 3-‐4 months post-‐op ACL. This was his specialty and I started to get several athletes each month. I quickly realized I needed a new skill set to work with many of these athletes to get the job done. One of the most important things to have is a beginner’s mind. I certainly had and still have it, so I sought the best to help me become the most effective post-‐rehab ACL trainer I could be. I needed a physical therapist that had experience with strength and conditioning to help me bridge the gap. After all, the goal is to get these athletes back on the field safely, and this is easier said than done. I hired Charlie Weingroff.
This is me and Charlie after he gave an incredible talk at the Gabriele Fitness Mentorship. Gabrielefitness.com/mentorship Charlie is a physical therapist and a strength coach, so I knew he had the thought process I needed to help these athletes. It also helps that Charlie is one the best in the country at what he does. Charlie helped me map out a system for working with these athletes. We spent an entire day working on this and it continued by email and text long after. I was certainly learning on the fly but got better each time and my results improved with each athlete. We created specific phases based on when the athletes came in and how they performed on their evaluation. The first thing we decided upon was when athletes came to me and still had pain in their knee I would refer out. Charlie always says, everything changes in the presence of pain so I would not get a clear look at how they moved if they had pain. This was rule number 1. Here are 10 considerations when training post rehab ACL athletes. Coach Mindset
One of the things we must remember as coaches is that tearing your ACL is a very traumatic event in the life of a young athlete. Their confidence is strongly challenged. Teaching them the growth mindset, which is taking all failure and considering them learning experiences is crucial. There is an incredible book called “Mindset”, written by Carol Dweck that outlines this concept.
Many athletes will take a long time to feel fully confident in their ability and some may never be the same. They need to be assured that the only thing they can do is their absolute best and worrying about another injury will only continue to prevent a full recovery. I have used this lesson several times and it helps tremendously during the training process when you can talk about having a growth mindset when things get tough. Manual Therapy Most of the time when they did have pain it was from a trigger point somewhere that needed to be released.
For this specific injury, the rectus femoris, popliteus, gastroc, vastus lateralis, and vastus medialis are usually the culprits. Fascial tone in these areas restrict movement and can cause pain in the knee. Manual therapy in these areas are critical to helping the athletes move efficiently with out pain.
My strong advice is to develop a great relationship with a local ART practitioner, massage therapist, graston specialist, etc. I almost always have ACL post rehab clients get manual therapy even if they are not in pain. Full Knee Extension
Make sure they have full knee extension. This is essential. Most of the athletes we have gotten have had full knee extension because this is one of the priorities in physical therapy. I always check to be sure because there have been athletes that have come to me 3 and 4 months post-‐op that have not had full knee extension. By this time if they do not have it, there is usually a problem or there will be a problem soon. Athletes that do not have full knee extension will be constantly putting stress on the patellar tendon and
will eventually develop tendonitis, a big problem with post rehab ACL athletes. To test for full knee extension have the athlete sit with their legs extended and flex their quad. If the back of the knee is against the floor and their heel comes off the floor they have full knee extension. If not, and there is space between the back of the knee and the floor, they do not have full knee extension and my advice is to refer out. The Hip Shift
The initial evaluation for the pain free athlete is the Functional Movement Screen. The first test in the FMS is a deep squat and in almost every case there is a hip shift. The hip shift is almost always away from the surgical side. This must be fixed. Training on top of this shift will cause a host of other issues. Our method for fixing the hip shift is RNT squats to box. If the shift is to the right, wrap a band around their left hip and pull them to the right.
This feeds the mistake and will train the brain to relearn how to squat without a shift. Ankle Mobility It is common that people who lack ankle mobility will eventually have a knee issue based on the Joint by Joint approach from Mike Boyle.
We always check the range of motion of the ankle joint and incorporate corrective work if needed. To assess ankle mobility, have the athlete set up in half kneeling with their foot 4 inches from the wall.
Be sure to do this with shoes off. If they can touch the wall they are good. If they cannot than we will incorporate ankle mobility drills in their corrective program. Nutrition Most high school athletes eat very poorly. I always shock the parents when I tell them the food they eat has an impact on how their knee feels. Bad food like sugar, processed carbs, and dairy can cause inflammation. In a tissue that is working hard to heal, inflammation will slow the healing process. I have all athletes keep a food journal and make sure their nutrition is on point and they are eating plenty of quality protein, fruit, vegetables, and good fat. I always emphasize the importance of this at the START of their training. Cardiac Output Training Most athletes who have torn their ACL are in poor condition and rightfully so, they have pretty much done nothing in terms of cardiovascular training for 4-‐6 months. I have them take their resting heart rate, if above 60 beats per minute I have them perform low level cardiac output training. This is usually a bike, elliptical, sport specific skill work, or sled walking for 60 minutes 2-‐4 times per week. I am not crazy about them jogging due to the excess stress on the knee. Once their resting heart rate gets to a comfortable spot, we will incorporate higher intensity interval work to prepare them for competition. Vertical Tibia
Anyone that had some type of knee issue will always train with a vertical tibia. This puts the least stress on the knee and will be more effective in training the glutes and hamstrings. In the initial phase we will usually choose the sumo deadlift over the trap bar for this reason. Any split squat variations are always performed with a vertical tibia.
The best coaching cue you can give with the split squat (pictured here) is to drop the back knee straight down to the floor. Many times the mobility of the back leg will be an issue and cause pain in the knee moving toward the floor. This usually means they need some pretty good manual
therapy to help. In the short term, you can use a stick or foam roll the back leg right before performing the exercise. Get them doing KB Swings ASAP The swing is my go to power exercise for post rehab ACL athletes. It develops core stability, eccentric hamstring strength and develops power in the hips with no impact to the knee, all necessities with this population. Many are not ready to go right into swings so start them on KB Deadlifts for a bit and then get them swinging. I am certified by the RKC and this is not a necessity but a very well ran program that I would definitely recommend.
Creating a Return to Play Test One of most common questions I get from parents and athletes is when can I play? Computerized athletes will want to return to their sport well before they are ready. The doctor is the one who makes the call but you can always offer your opinion based on your own assessment. The doctors word is the final say but it always good to have your own evaluation on whether you think they should play or not. This always makes parents feel good that they will have to demonstrate proficiency before they return to play. Charlie and I put together a testing procedure to evaluate when they are ready to get back on the field.
One of tests we used was the called the hop and stop test. This was created by Paul Juris and there are a few studies that have been done using this test. I did a ton of research and learned all I could about this test and usually use it when athletes are about 6 months to get a baseline. The hop and stop test measures force absorption and production of each leg. Minimal equipment is necessary and is very easy to administer. The other tests we used were the FMS, single leg squat, 5 hurdle hop and a conditioning test. Training post rehab athletes has been a challenging but very rewarding learning experience. Athletes cannot go from the PT clinic to the field, they need strength and conditioning to bridge the gap. I hope this article has sparked some interest in this subject because it is a huge need, as many athletes are taking the field after this injury unprepared. If you would like me to share my full outline of Post Rehab ACL training please email me at [email protected] Even though this article was about a very specific topic there are many things to take from it that in general will help improve results and bring success.
• Learn about Mindset • Ask for help from people smarter than you • Sometimes you just need to ask • Demonstrate passion and interest • A niche is waiting for you • Do your homework, research • Relationships are the key to business
Bio
Vince Gabriele is the owner of Gabriele Fitness & Performance in Berkeley Heights NJ. Vince and his team work with hundreds of middle and high school athletes and have quickly become one best training facilities on the east coast. www.vincegabriele.com For more information about Gabriele Fitness and their upcoming business development mentorship on November 1 and 2nd please visit: gabrielefitness.com/mentorship
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