Episode 139 | Practical Application of Designing a Gym-Based ACL Rehab Session (Including a Case Study of 3-Month Post-Op ACL – Quad Autograft + Meniscus Repair)

What is up team, and welcome back to the ACL Athlete podcast. Before we dive in, I have an exciting update for you guys for any of my clinicians, or coaches, whether you’re an athletic trainer, a physical therapist, a rehab provider of any sort, or you’re maybe a strength and conditioning coach who kind of works alongside with ACLers in this process, we’re pumped to announce our ACL Athlete Mentorship, that is kick-starting very soon.

This ties back to our mission, which is to redefine ACL rehab, elevate the standard of care, and essentially just serve our ACLers. And we know we do that through this podcast, through our remote coaching, in-person, through our resources. Our goal is to serve ACLers. But we also know that there could be a force multiplier by sharing that information with other rehab and coaching professionals who are also working with ACLers. So that’s our goal is to share basically this vision that I’ve had since the start of the company. 

And that’s where this mentorship comes in, where we will teach you our processes and systems based on principles, using testing, program design, practical application, frameworks, all the things that we’re looking for in physical therapy school or through all the different maybe online resources. And we’ve taken all the continuing education, all the things we’ve learned, all the things we’ve failed at, and we’re packaging this up and we’re all going to grow together. 

If this is something that is of interest to you, please jump on our insider list, which you can find that information in the link in the description below in order to get early access for this mentorship, which we are keeping at limited spots. And we’ve already gotten so much overwhelming support for this and people on the list, more surprising than expected. We’re super pumped to roll this out and really grow with all of you that do join and put our egos aside and be able to really focus on how we can improve this ACL rehab process for our ACLers or just the landscape as a whole.

I promise you, I’m going to give you my best. If you are a professional working with ACLers, I suggest getting on the list. You’ll get early access to all the information and be able to sign up. And if all the spots are taken, then we will not roll this out to the public. Do yourself a favor, if you’re interested at all, to do that and sign up in the show notes below.

And if you’re an ACL or listening to this, I promise you we’ve got so much planned for you. We’re so excited as a company, and as a team for all the resources we are going to be rolling out for you here very, very soon. Stay tuned. 

Now, to dive into this episode for today, the practical application of designing a gym-based ACL rehab session. Basically, how are we going to take a framework of a gym session? And then how can you really apply this to your own situation? Whether you’re a clinician coach, ACL, or just kind of trying to structure all this stuff and just being able to have some of those tools. I want to give you some of that today and practically how you can apply that.

And one of the things that I think is really hard in this space is that there’s a lot of variables to juggle. You’re almost overwhelmed with the barriers or the things that you’re working up against in the ACL rehab process. You’ve got a range of motion issues, you’ve got pain, swelling, you’ve got worrying about your knee and the ligament healing. All these different pieces and then now you’re trying to work along to get back to running and cutting and all the things that you want to get back to doing. 

Today, I want to focus mainly on a gym-based session, so there’s an organization around it, you have a framework to operate from. And it’s something that can be really helpful to organize based on the qualities we’re trying to develop. And it’s more agile and you can adapt it to the session and to the week and to the phases that you’re in. But this can help to just apply that in any phase of this process, especially for the gym. And I’m going to use today one of our ACLers as a very specific example so we can really ingrain this and see how this can be put into play. 

Now, the one thing I do want to mention is that if you’re an ACLer listening and you’re like, hey, I’m going to go do this exact session or this is me or I’m going to put this in play. Don’t undermine anything that you’re given from your own professional, talk with them, and just make sure that it’s cohesive. But if you’re just lost and you’re like, well, where can I start with trying to structure something? Well, this can potentially help. But at the end of the day, there’s a lot of moving pieces with what I’m going to share today in order to really utilize this framework.

Let’s dive into this ACLR’s case. This guy’s name is Jake. He’s an ACLer of mine. He’s 28 years old, a skier. That’s how he tore his ACL. He tore his ACL plus his medial meniscus. He got a quad autograft with a meniscus repair. He was non-weight bearing for four weeks. The surgeon also locked him up in a brace into extension which just sucks, but it is what it is. We didn’t start working together actually, until two months postop. He had a pretty rough start. You take the four weeks non-weight bearing, which I get there’s limitations. But you combine that with just like the rehab that wasn’t really going well. It wasn’t very prescriptive. There wasn’t a lot of structure guidance and he was just kind of chilling a lot of the time. And there was an opportunity cost with that. We had to work with what we had and be able to move forward. With him, we did a performance needs analysis. We do this with every single one of our ACLers at the start and throughout the process. This is ongoing and adapting.

But this is where we just dive into the ACLer story to be able to understand the backstory, to understand where they are. Some of more the technical nuance pieces that we’re not going to dive into today. But this is basically where we’re getting where they are, where they’re going, and what are the next steps and the needs of those next steps and their long-term goals.

So again, not getting too technical here because we could get into the nuances of breaking down the needs analysis. But we’re just going to keep it pretty broad and zoomed out. He is now three months postop. We’ve been working together for about a month. He’s still slightly shy of that heel pop and that end-range extension, dealing with some residual swelling that’ll come here or there. End-range flexion still does not feel super great, especially with that non-weight bearing and being locked in a brace. It did take him a while to be able to get that flexion back. When we tested his quads, they’re pretty weak, as you can imagine, with his limitations. Plus, he had a quad autograft, so he is sitting at 47 percent symmetry.

Given the donor site, that also created some issues where he got that quad tendon taken. There’s some sensitivity there. ACL rehab in a nutshell just makes your quads shrink down to a hot dog. So that didn’t work necessarily in his favor, but here we are. We’re just working with current capacities and we’re going to build those up.

The other last piece I wanted to add is that he doesn’t really want to drive his knee forward. This all makes sense. He’s got some pain, and some swelling that he’s dealing with. He is not feeling good with end-range knee flexion. He’s got some quad weakness. His body is going to organize and figure out ways to avoid that movement and to be able to load the knee in general in order to just do the thing.

When we’re looking at where we’re heading, long term, of course, is to get him back to skiing, which he loves. But short term, the next thing is to get him back to running. Because running is this big barn door that opens up and allows you to start doing a lot more stuff from a dynamic standpoint, such as being able to do plyometrics in space, being able to change direction, being able to open up multi-directional speed, and things of that nature. So that’s where the fun begins. But first, we got to get him there to run in order to open that door. 

Now, the goal is to give you insight into what one of these days looks like within his training block. But I’m going to zoom out for a second just so you can see the big picture of how we structured it for him. He has four days that he’s training in his week that’s dedicated to this specific block based on his schedule. Two days are gym-focused days. One is a quad-dominant day, and then the other day has a hamstring-dominant compound lift day. But there’s obviously still a lot of quadricep work built in. One other day is a muscle pump and dynamic focus day, and then there’s a fourth day that is purely just dynamic focus.

When we say dynamic, it’s basically just thinking about movement in space. It’s not a lot of strength-building necessarily, but it’s a lot of movement coordination, getting him ready to be able to prep for running. Think of it as just pre-running movements based on mechanics and just getting into the grove of feeling like he can do that stuff again. So that’s how we structure things. Side note also this structure itself is highly dependent on where each of our ACLs are within each phase of our 4R system. But then also their athlete schedule, the equipment access, the goals that they have, all these factors are going to play into it. This is how we just structured it out for this specific guy, Jake. 

For this block, we’re going to focus on addressing a lot of these issues and cleaning things up that he’s experiencing in order to attack these rate limiters, the roadblocks that he’s dealing with in order for us to move him forward and get him running. 

Let’s dive into one of these days based on the framework provided. And if you guys missed that, that was something that I posted on Instagram that just showed a little bit of that framework of just kind of the big picture. But today, I want to dive into a specific use of it and its practical application. What I had shared was basically assessing the symptom profile. Every session, each athlete, the goal is to be able to assess how they feel before, during, and after. But especially before because you need to know what that baseline feels like in order for us to make sure that we keep track of that after the session and especially into our next day. This is a part of our feedback loop system that we share with our athletes and coaches. This is just something that’s really important because it’s going to help monitor and create a feedback loop for us to adjust the consecutive sessions and training. 

We’re going to assess the symptom profile. So that’s going to be pain, swelling, some soreness, any of those pieces. And then we’re going to go into the session. We’ve got movement prep, we’ve got technical and movement skill, we’ve got power, max strength work, accessory strength and hypertrophy work and then we’ve got conditioning work. These are all the buckets or the flow of the session. 

I’m just going to roll through it. We have movement prep, which is basically just getting the body ready for the session. We want to get our heart rate up. We want to get the joints moving. We want the body to feel good. And if there’s anything I’ve learned as an ACL or two times myself working with other ACL athletes.

There’s nothing like going cold into a session and feeling like trash. You need to warm up and you’ll see all this stuff about warm-ups. They take away from time in the session. If you got 20 minutes, yeah, don’t warm up for 15 minutes. But look, the knee is going to not feel so hot, especially when you’re in the early parts of this process.

And so the last thing you want to do is go and do a max lift without warming up. It feels like trash. And it’s one of those things where, especially with our ACL rehab, with our knee, get some good movement prep in, get the fluid going, get things feeling good, and then that way you can really build some momentum going into the workout. So that’s my belief in terms of doing this. Now, this doesn’t take away from this session. But there is emphasis and importance on doing this and structuring it in a way to essentially add up to work on certain pieces we’re trying to improve. In this movement prep, for example, we’re going to get the heart rate up and work on some positions.

For example, we’ve got a reverse treadmill walk to get the quads going and get the heart rate a little bit more elevated. Then we go into this three-piece where we’re working on mobility. It’s going to be an assisted knee drive forward holding at end range, lateral hip strength where we’re doing a star plank hold, and then we’ve got another mobility movement that’s going to be basically an isometric combo where you’re doing a split squat with a target forward. And then there’s going to be a rock back to load that back leg with that quad while it’s being on the stretch. Guess what, we’re going to be targeting that donor site as you know it. 

Once we move through this movement prep, we’re going to go into our technical and movement skill block. This is going to be something focused on something that we’re trying to be fresh for and feel good about. And we want to just improve that skill feeling and maybe some positions. So for this, we’re going to do a Bosch step-up, which is going to work on triple extension and an opposite hip hike. So that’s going to help us to be able to really iron in some good acceleration and sprinting positions later in the road, but especially focusing on that triple extension since that heel pop is feeling not so hot just yet.

And then we’re going to move into our power block. So with this, we’re going to be focusing mostly on plyometric-based work. So we’re going to do some extensive plyos, which are going to be band-assisted pogos for a double leg. And then we’re going to work into some eccentric focus plyometrics where we’re building the brakes as we call it. These are altitude drops into some trap bar or dumbbell deceleration drops. We’re focusing on the eccentric component, or the breaking, or the landing component of a plyometric, because that’s an important piece here as we’re trying to build the athlete back up. Before you try to take off on running, jumping, and all that stuff, we need to know how to break the system.

And focusing on the eccentric pieces will help so much. especially in getting us back to return to running and a lot of the pieces down the road. And this is the thing, in my opinion, eccentric strength, especially of the quads, is probably one of the biggest missing factors that are worked on within this ACL rehab process. This is something where the quad is working at lengthening to be able to slow the body down, to be able to resist the force. And this is something that we don’t necessarily work on because strength is specific. We do want to make sure we work on it from an eccentric standpoint. Especially in the early phases to be able to absorb and mostly accept and attenuate force So that’s where this power block comes in and this is where we’re going to work on a Smith machine split squat with a front heel elevated to allow that knee to go forward, to be able to load and not worry too much about Balance or anything going on?

We’re just trying to put a high amount of force into the ground and load the quad in a single-leg type movement Then we’re going to work into our accessory strength and hypertrophy work. So we’re going to have our barbell hip thrust, that’s going to be working on a good glute pump, but then also some strength pieces to be able to build up the posterior chain and the hamstrings.

And then we’re going to go into our single-leg seated knee extension with a two up one down. Again, an eccentric focus that we like to work on early in the ACL rehab process before we’re running. Then, that way we can accept those forces that I talked about earlier. And then we’re going to work on some seated hamstring curls. Just good old isolated work that’s going to help work on the quads, work on the hamstrings. And then finally, we’re going to finish with some energy system development, some conditioning, which is going to be focused on bike sprints for anywhere from 5 to 10 rounds for 10 seconds on for hard and 50 seconds off, or just an easy RPM. And that’s going to be the main thing that we’re going to do for this session. 

Now, the goal here is driving intent. We’re not trying to list 20 or 30 different exercises. We have very intentional exercises that we are going to focus on here, and there’s intent for this day, this quad-dominant day, to be able to improve a lot of these deficits that we’re dealing with, and the qualities we’re trying to build up in order to get to the next step and milestone.

Now, this is just gym day one of the two days that we have planned in the block, and this is something that is also not including the muscle pump portion of his dynamic day. We’re trying to hit a certain amount of volume in order to promote hypertrophy and frequency. But then we’re also trying to balance that recovery since the knee can get a little bit grumpy. This is where making sure we structure these things appropriately and balance the recovery is going to be so key. 

He’s got two focused gym days. One that’s like a half and half day of a little bit of a muscle pump, and dynamic day, and then another day that’s a dynamic day. Now, there’s so many ways to flip all this, but this is what works for his schedule, and what we optimize best for this particular block, and responding well, too.

And to give you guys an example, day one looks different from day two. We’re working on different qualities. It has a little bit more of a hamstring emphasis day for at least the compound movement. We’re exploring some other different movement options. But it all follows a very similar framework of similar qualities we’re trying to develop, but it’s going to look a little different in terms of the exercises, some of the rep schemes, some of the tempos, and the movements overall, but we’re still targeting the same outcomes.

And so what I want to come back to here, are really those deficits and outcomes that we are trying to tackle. Let’s go back to those. We had mentioned that he was slightly shy of a heel pop. Well, there are things that are embedded in his week to work on this. But specifically on this day, he had the Bosch step-up that we were working on. There are some other positions for him to be able to finish into an extended position with his knee in order to work on that heel pop, but mostly just an active extension piece. Swelling is focused on basically balancing the load management of his entire week and his current block. End range flexion, the mobility work in end ranges with the movement prep was able to tackle this.

Plus, if we get the swelling down, that’s going to help improve the flexion over time. The 47% quad symmetry and the weakness given the donor site and that sensitivity. Well, that is done through that quad strength that we’re working on with the eccentric emphasis, along with that lean back with the isometric to help load that quad tendon to get the rectus femoris at a lengthened position, so we can get some solid quad work for that tendon.

And that donor site for us to get back to running, we have to introduce some lower level plyometrics and being able to accept load. That’s going to be really important in order to make sure that we are going to get back to running because we’re going to have to deal with that. Because running is essentially small little jumps over and over and over and over sure at a lower level, but we are repeatedly doing that. We’ve got to make sure that we prep the system before we actually start running. We’re building that in. And then the other last piece was doesn’t want to drive the knee forward. Well, we’re biasing forward knee movements with that isometric in the movement prep. We’ve got the max strength work where the heel is elevated to drive the knee forward and emphasize the quad.

And not to mention that the other days balanced to work on a lot of these other pieces to move the needle and to get Jake ultimately back to running, and in the final stages back to skiing.  This framework allows us to tackle these deficits based on our needs analysis of Jake and also make sure we’re addressing all the appropriate qualities. And that’s what’s helpful about this is that it allows us to be agile in case something comes up with Jake or any ACLers that we work with. But we don’t get lost in the exercises. We allow the principles that are building these frameworks or even this session, for example, to guide us. And this is just basically good training if you were to look at any good strength and conditioning session.

We’re just making this a little bit more nuanced to the ACL rehab process. Is it perfect? Definitely not. But it could be very adaptable given any situation. And I can honestly show you 10 different ways we can organize this based on the ACLer in front of us. But it’s all based on principles. We need an operating framework that this is derived from, first, in order to make sure we can do that. And it helps us to just make sure to keep a zoomed-out process, but also a zoomed-in process. The micro and then the macro and being able to make sure that we’re helping our ACLer move in this process, move forward. And it’s not just this list of exercises which I know a lot of ACLers get. They come in and they’re like, “Hey, like I’ve got these 20 exercises.” And then they might be unorganized.

And then also there’s no intensity or kind of rep scheme behind them. It’s just like, “Hey, here are the exercises.” But most importantly, the intensity is the thing that’s going to drive the outcome that we’re going to get from it. So we’re trying to rebuild athleticism, we’re trying to address these gaps, tackle these deficits that we’re seeing in the ACL rehab process with any ACLer in front of us. I think being able to come at it from having a system, having an approach that is rooted in the principles, in the research, in the science, is going to help us a ton to make sure we don’t leave any of these gaps and also just not feeling super overwhelmed and unorganized when we are trying to build these sessions and being able to make sure that we’re tackling everything that we need to do over this long, long journey. 

I hope that this was helpful team. I wanted to give you guys a practical application of this framework that I provided on Instagram and also just in this podcast episode, specifically, just to be able to see what it looks like with an ACLer, a specific case, a real-life example. I think it’s easy to talk in general, but I want to always make sure that there’s a practical example that you could take away from this and put in play immediately.

Check out the posts if you want. It’s helpful to see the visual of it. I’ve got it on my Instagram so you can go there. Most importantly, I suggest if you are a clinician, coach, or any provider working with an ACLer, sign up for our mentorship, which is going to be in the show notes below. And I promise it will be worth it. Get on the insider list and we cannot wait to see you guys there. 

Until next time, team, this is your host, Ravi Patel, signing off.