Episode 155 | How to Build and Structure a Dynamic ACL Rehab Session

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today is episode 155 and we’re talking how to build and structure a dynamic ACL rehab session. This is a fun one where we get to talk about the dynamic components of ACL rehab, but before we do that I do want to talk about our mentorship. If you are a provider listening to this, a physical therapist assistant, any type of therapist, athletic trainer, chiropractor, a performance coach, strength and conditioning coach, anyone who works with the ACL rehab or ACLers, this is for you. We are starting our cohort two on February 5th. We have wrapped up cohort number one, and it was an absolute blast. It was awesome. We had clinicians and coaches who were so dialed into the process, such good conversations, and going through our material. It was awesome to just share our framework and our processes and to just dig into case studies and to be able to help our ACLers.

This is something that we are launching on February 5th. Enrollment is open this Sunday, January 21st at 1:00 PM Eastern. If that is something of interest you get on our waitlist, there is a link in the show notes. To give you a little insight on this, it’s based on principles, that’s our focus. We are teaching you how to go from rehab to performance, taking an ACL or from prehab, post-op all the way to full return of performance. This is our way of showing you we go through needs analysis, planning, periodization, and a framework to walk this athlete through the process and individualize it. And then we teach you our return to the running process, all the on-fuel type stuff, dynamic work that we’ll talk about today, your coaches, return to performance and testing. We go through that entire process. It’s research-based, digging into the science, but ultimately based on principles. We have 20 spots available and this is going to be something that we are releasing some bonuses for you guys for cohort two. So, if this is something that you are interested in, get on the waitlist it’s in the show notes. 

We are so pumped to be able to do this and continue to grow. That’s the goal with this podcast, with what we do is to be able to continue to serve our ACLers and to make sure that we can help elevate the standard. Because right now we know that that needs some help and that’s what we are trying to do. So join that waitlist if that is something that is interesting to you. Otherwise, we’re going to hop into it, how to build and structure a dynamic ACLrehab session. 

First, we’ll typically have a theme for these types of sessions, depending on the block that the athlete is in. This could be in the earlier stages. It could be more so pre-running a return to running phases. And then once we’re opening up more change of direction on field or on-court type work, right? The early phases have a lot of technical work, working on mechanics and trying to get this athlete ready to start running. Alongside, of course, really solid strength work, conditioning work that’s of course taking place, especially in the gym. 

And then we are trying to add in more of these dynamic elements, the more and more this athlete is becoming more and more grounded in their foundations, getting that strength up, range of motion, developing some of those power components, and then making sure that we are able to expose the athlete back to what they need to be exposed to. Especially when we talk about a skier or a soccer athlete, a lacrosse athlete, football, basketball, BJJ (jiu-jitsu). These are all different athletes that we will run into. And that’s just a drop in the bucket of the variety of things people are trying to do. There’s rock climbing, there is snowboarding, there is hiking, there are a bunch of other activities and sports that are involved with what people either tear their ACL, or maybe they tear it a different way. But then they’re trying to get back to doing something more active. It’s our job to make sure we expose these athletes back in a very progressive way, but also making sure we do our due diligence with that. 

When we go to think about these themes, there are different ways that we can divide up these types of dynamic sessions. To make it really clear when we think about dynamic, think about a field-based session. We are going out on the turf. And if you have the luxury to do that, that’s awesome. You might have to just kind of combine with the space you have in your clinic to be able to get some of these elements in. And of course, you might be combining that with strength work in the same day. But today we are talking specifically about dynamic days. There will be days where I just focus specifically on this with my athletes, because maybe another session we did, gym-based work, or they’re have some work that they’re doing on their own, with themselves or with a team.

For example, and they’re getting in the strength worker and they’re hitting the numbers they need to, then maybe we just show some focus during our sessions for some dynamic focus, which is something they want to get back to. This is where we are looking at, that field-based session, if you will, or court, and we’re going to potentially look at some themes. We can have a direction of travel. So it could be linear-focused or straightforward in line. It could be a lateral focused or frontal plane or sideways from what we can kind of look at. Still can be kind of a linear focus in a sense, but we could divide it into linear, that frontal plane or lateral. And then there’s multi-directional so that’s really just having all the different elements forward, back, rotating out to the side. I said basically there’s no limits with that one. And so it just kind of depends on the intent. And that’s where you got to come back to, what are the goals? What are the focus of the phase and what you’re trying to develop? But these are one ways to be able to create these themes. And then there are other ways to look at this too, right? Maybe it’s quality development, those physical qualities. Maybe we’re looking at a deceleration focus day or theme, along with a change to direction focus. Those two tend to go really well together because when we’re working on deceleration work, usually that is a component of change of direction or agility work. You’re going to accelerate, you’re going to decelerate and then typically reaccelerate again. Those go together really well. We might have a max velocity or speed day, which is very vertically oriented. So this is thinking about high speed, sprinting, thinking about short ground contact times. So that is a way to kind of bucket those types of themes. And then you have an acceleration focus theme. So that’s more horizontal in nature. You have longer ground contact times. And so these are ways to kind of think about ways to theme your days. And this can help with having more focused intent with each and every session that you have with your ACLer. 

And one of the questions you might have is, well, when do I know to put these types of sessions in play? How do I know when I need dynamic sessions? How do I know when I need to kind of organize and plan my schedule around these things? Well, this is all going to come back to doing a performance needs analysis. You need to find out where your ACLer is, where they need to be and what is the next step to get there. That comes back to that ABZ framework. Your ACLer is at point A, you’ve got your Z, which is their end goal. And then B is just that next step. What are we aiming for? This is something that we end up finding out through testing and understanding what are those main rate limiters or the bottlenecks currently the athlete is dealing with. What are the goals that we have ahead for them? And then we need to connect that with some criteria that is specific to those goals in order to make sure we keep this athlete moving forward. So we’re just trying to fill in that gap. To get them to that point B and closer to the next step to their end goal. And so then this is where we have to have a framework understanding what we’re progressing towards. 

It can’t be just this like general protocol because doing neuromuscular work or doing just agility work isn’t enough. We have to have an approach and understanding of what are the needs for our athletes, what are those demands and getting them exposed to those and being able to do that gradually. 

I think that’s the other thing too, is that we just have these random exercises. We throw at people without really digging into the intent behind it. Are we trying to really work on certain cutting directions? Are we trying to work on reactive abilities? Are we trying to work on maybe some contact? Or, there’s a lot of just different pieces that especially are in this dynamic element and it’s very new to a lot of clinicians and coaches, especially. But as something that we need to have a good grasp of, if we want to get our ACLers back, especially to being able to be on a field or court or any dynamic type activities. 

The goal here is to provide a general view of how I structure my dynamic days with ACLers. In contrast, we have our gym focus days that we have, especially early on. And then even through the process, the gym is still a big part of this entire ACL rehab journey because we got to get strong. Strength is the foundation for us to be able to be dynamic, for us to be explosive, reactive, elastic, all the pieces that we are looking to build upon strength as a foundation of that. We will still have our gym days and this comes back to zooming out with our planning and our goals. 

But if we zoom in a little bit, the other thing that can be combined with this, as I had mentioned earlier, is finding that appropriate balance of gym and dynamic. And you might have hybrid days based on your gym, your model, the schedule that you’re working with ACL, or this is something where you might have to do both in the day, which is very common. I do that with ACLers as well, depending on our weekly structure and what we were looking for. But that is where you might just do some of the dynamic pieces that are focused for the day. And then you might do some strength work at the end. So maybe you have 30 minutes of dynamic work and then 30 minutes of strength work. So you can make sure that both areas are elevating as best as possible. 

But today, I’m going to focus just on dynamic movements. I will do another episode on these hybrid days which we will use very often in our program design because people have limitations in their timing and schedule with structuring and programming. It can come down to an athlete where this is their full-time job. You can have a full-on dynamic session and not need to lift weights in that session. And then maybe you have a PM session or a gym session the next day. Versus there are some athletes who can only get to the gym two times a week or three times a week. Or that focus with being with you in person. And so then therefore, there’s a lot of ways to structure things. And that’s where these gym dynamic and hybrid focus days or combined days can be clutch, coming back to our goals for the particular block and moving this ACL athlete forward.

Let’s dig into the framework of the dynamic focus day. So we’ll initially start with movement prep stands for movement preparation. We will go through a dynamic warmup. This is just some field-based warmup. This will be something where the athletes going through a bunch of different ranges of motion for the different joints. different muscle groups. Being able to ideally do this within a 10 to 20-yard space. If you’ve got limited space, no worries, you can do this literally in place, or you could do it within five yards. But this is something that we want to get the athlete moving, getting their nervous system prepped up, getting their body warmed up for the session ahead. And then we’ll go into some locomotor drills with some reactive components locomotor being, just getting the athlete from point A to point B. It might be jogging, it might be backward jogging. It might be beside shuffle karaoke. We might do open-close hip drills. We might do some reactive components where they react to me or to an app or to a partner. Just to kind of get things going. 

And then next we’ll go into what we call like a technical or movement skill block. And so this is where we’re working specifically on some technical components for the day. So this might be something where we are looking at, let’s say, we’re doing a speed day. We’ll do an A series where we’ll do like a march, skips and those different series, maybe with a dowel to be able to dial in the speed mechanics for the day. Maybe we’ll do like some sort of triple extension or Bosch-type drills where we are trying to really get that co- contraction at the hip. And being able to project the body forward, that could be for our acceleration focus days. So these are ways to work on the technical elements that are going to help us build into some of the more intended movements in the session. 

And then next we’ll have a plyometric block. So this can move from extensive based plyo. So we’re talking low intensity, but maybe more volume towards intensive pylos. So this is higher intensity pylos, but you can’t do those at higher volumes. Otherwise, you’re going to crush yourself and probably pay for it later. If you’re doing intensive pylos, there’s a likelihood, if you could do a higher volume then they’re not intensive enough. So then therefore we might move from extensive to intensive. And then we might have some Pogo variations that we will help build in, especially for extensive variations. 

And then we might build in some kind of locomotor base where we are trying to work on 45 degree bounds, lateral push to base, maybe a crossover step into bounding for heightened distance. And this could also be driven based on the intent of maybe having a vertical focus theme for the speed day. Maybe you have shorter ground contact time focus repliers versus horizontal focus, which might be for acceleration or change the direction and deceleration work, which will be maybe longer ground contact times. So then therefore this is something that you can play around with, based on the block that you’re in. And maybe the intent behind the plyometrics that you’re focused on. 

And then next we’ll go into a deceleration-specific block. And this is something where I think having a dedicated block in sessions to work on deceleration-type work is so often overlooked. We can look at the cutting and the acceleration and speed components. And while in cutting and agility work, there’s deceleration components, for sure. When there’s intention behind deceleration work, you can really focus on that. And so this is something that I think needs to be highlighted more because when we think about the mechanism of injury for ACL, it is usually through an eccentric or deceleration-based type of movement that it happens. 

You go to do a sidestep when you’re cutting and then the ACL tears. Or we’re doing a jump and we land awkwardly and we’re decelerating. We’re hitting the brakes. And that’s where that knee kind of pivots and that injury happens.  This is something that can be tough, honestly, for athletes, because they kinda feel that PTSD. 

I know, I remember that first ACL tear, especially when our, I was in an open space and I just cut, did a side cut to go. Get the running back as a linebacker and my knee popped. And I remembered that and it took me a minute to kind of get past that. So when we revisited it at first, I was a little hesitant, but then over time, working on some of those pieces, getting stronger, some of the on-field deceleration work helped me to be able to build that backup. 

This is something that I think can be super beneficial for our athletes is to have a deceleration block, especially when they’re getting into those mid to late stages. What we can see often if we don’t and there’s not a focus here is that they’ll start to lean on the [00:17:00] uninvolved side to come and say to maybe make the movements happen.  Especially if we’re so lacking any requisite strength or capacity. So this is something where you can work on a block specific to the deceleration component. You can do something that is progressing in place, to adding more open space, more velocity different directions. It could be something like a 10-yard deceleration stop into zones. And then progressing into maybe re-accelerations. 

Maybe you do a linear forward and back, and then maybe you do some progressive change of direction work, that is that reacceleration after a decel. And then you add reactive components to it. There’s a bunch of different ways to kind of integrate this in, but essentially we just want to make sure that knee can take on that load when we do slow down our momentum and create that breaking impulse and being able to redirect that in a different direction, because that’s, what’s going to happen a lot of times with sport and activity is that share. 

We need to slow it down, but then maybe we have to speed back up. And that leads me to the next component, which is acceleration. And technically, this can also be like a max velocity block depending on our theme for the day. But we could work on static position acceleration starts. Then we can add some reactive components to it. Love a good tennis ball drop for example, or a. Reactive work with another athlete or a queue resistance sled runs are great here to be able to increase ground contact times. And be able to improve our acceleration component. And then there might be some sprint work. And so sprint work, this is something I also see that as often missed. In late stages, especially if we have an athlete who has sprinting in their sport, right? 

If we’re talking about a soccer athlete football even basketball. Lacrosse any of these athletes, there’ll be doing sprinting to some degree. So we got to make sure that these athletes have the ability to do that again. So this is something that we want to work on. If it’s in submaximal speeds, then we can work that into later components. If it’s more toward maximal speeds, we might bump this up as a number one or number two priority in the session. We want to make sure we, the athlete hits this earlier because they need to be fresh. To be able to really put that high output out there. So this might be after their technical block or after their plyometrics, we hit that sprint work and then we work into some of these other pieces or that might just be it for the day. So this is something that is really valuable to make sure that we are prioritizing these particular qualities and different. ways to express ourselves on the field and then the last couple of components here. 

Change the direction and agility. This is one that typically saves towards the end. Make sure the athlete is still able to get in those positions well, not too fatigued yet. Again, if it’s like a big focus and theme for the day, we might bump it up early. But if we’re getting into this block, this might be something where we work on certain angles.Maybe we work on angles that are a little bit more forward in nature. So let’s say, for example, you got your straight-ahead running towards some of the curves, like towards 45 degrees. And then as you start working towards 90 degrees, you’re going to have to start creating a little bit more deceleration in order to change that direction. 

So then that might be a component where we start working on more breaking and working on the 90 to 180-degree turns. So there are different ways to go about focusing on our change of direction work, and then pairing that up with certain drills to be able to help ingrain that. 

One of the things I personally love. It’s something called a linear eight vector three-step change of direction mouthful here, but this is a great way for us to re-introduce some change of direction, work in space with some varying angles. And so eight vector kind of think about that compass. And then you have the in between, so you have north, south, east, and west, and then you have Northeast and Southeast, and then you have Northwest and Southwest. And so this is something where you can start thinking about, okay, well, if this athlete is prepared in all these different directions, awesome. 

So then therefore we’re going to start integrating movements to be able to re-expose this athlete to those different directions. And so then therefore, this is something that you can start with, like a progressive walk and then use that dimmer switch to bump up and maybe we get to 50% intensity. And then maybe for the day we’re only working on up to 60 or 70% intensity to help this athlete relearn. 

Some of these cutting styles get comfortable with changing direction. Again, a very common mechanism of injury for ACL. So having this athlete just kind of comfortably build back into it can be very valuable in my opinion. And you’ll. Start to see some light bulb moments, you know, at first, what athletes will try to do, especially once the angle starts getting sharper and sharper. Let’s say the 45-degree angle, and this is something where the athlete will try to just curve or kind of bend around to do that angle. So then therefore we need to make sure the constraints are there. 

Or we put pieces in play to make sure that this athlete can’t bend or do that curvilinear run. And instead they have to do that sidestep in order to do it. So they’re going to plant on their right to go left versus using their left to go to the left. Which is a curvilinear run. So this is something that can be super valuable and something that is really helpful to work on and making sure you have a progressive framework, even for that change of direction and agility. 

And to be clear here, change of direction means preplanned. You know what the drill is, you know, what’s coming, there’s no reactive components. With agility, there is a stimulus that you have to react to. It is a little bit unplanned. So that is kind of the main determinant there. There’s more weeds within that, but just so you know, those differences have changed direction and agility. They are not synonymous, they are two different things. One is with a non-reactive component. One is with a reactive component. 

And then the last piece to build off of this is the agility, which we will add as mirror drills or it might be using a different app called maybe switched on, is awesome for this where you’re reacting to colors or arrows or, or creating some sort of gamification with it. I love a good partner chase. 

So this is something where you’re reacting to a partner that could be that mirror drill, or you’re trying to almost play tag with the partner with certain drills. So great ways to start building in that reactive component and getting this athlete to start to get comfortable with the movement and be able to think outside of just the drills themselves. Creating a little bit of that automated feel with being able to do some of this work. 

And then the last component here is going to be energy system development or conditioning. So this can be dependent on what you’re trying to work on with the athlete. It depends on the energy system that’s going to be important at the current block you’re in as well as like, what is the specific energy systems at work for their particular goals? A lot of times this moves from aerobic to anaerobic style conditioning, low intensity longer duration to high-intensity short duration. But we need to be able to repeat that. We can’t just do it for one burst. We need to do that for repeated efforts. So that is where it’s going to be important to come back to figuring out what you need to do based on your goals currently and where this athlete needs to go. 

So this is something, let’s say for example, we’ve been working on acceleration work that day. Well, maybe we do some 10 by tens that I learned from Derek Hanson where you’re working on different acceleration start positions, being able to get some conditioning work in, and being able to work on that angle, as we are trying to develop our acceleration from that static start position or maybe slightly moving into accelerating to that max velocity pace. So this is something that can be built in. The world is your oyster for energy system and conditioning work. But this is something where – when you look at this, it might seem like, well, how am I going to fit all this in, in one day? Well, you might not. That’s the thing that’s important. This is just kind of an order of operations if you will. And then therefore you can start to organize this based on your block and your themes and your goals for the session. And then being able to figure out, okay, well, how do we do this? And so if you’re super efficient with your athletes, and let’s say that they’re fairly familiar with some of these drills, then maybe they’re coming in. 

And when you say you have an hour with them, we do a five-minute movement prep. We do 5 to 10 minutes of technical drills. We do 10 minutes of, let’s say, deceleration work for the day, 10 to 15 minutes of acceleration. We have a 10-minute change of direction, agility, and then maybe 5 to 10 minutes of conditioning.  But being able to structure our days and having time allocated to those different buckets. Are going to be important and can be helpful. And let’s say we do have that combined hybrid day that you’re looking for, well, maybe you just do 30 minutes of that particular session for the dynamic work and then 30 minutes of doing some of the gym work. This is something that we will often do, but this is the way that you can kind of strategize these dynamic days, combined with also some of the gym-focused work. 

The beauty here is that you can reduce this down to the theme of the day. And let’s say, for example, you’re just working on certain elements. It could be just deceleration and change the direction of work for the day. Then another day could be acceleration and speed work intended. But just know that there’s no “perfect” structure. But you have to have an operating framework that is adaptable in any given situation. It’s helpful to have this framework to address particular qualities and buckets we’re trying to improve during this ACL rehab process. Otherwise, we’re kind of shooting in the dark and nothing is worse than feeling unorganized or feeling like we’re missing certain areas that this athlete kind of needs at the moment. This is a way to make sure that we’re capturing the things we need to, and there’s a methodical way to do that. 

Instead, what we often see is that people will have a laundry list of exercises from their clinician, or we talked to clinicians and coaches and they’re just like, yeah, this is just kind of what I give it to them. And then they’re doing highly intensive plyometrics at the end of the session, but they’ve already fatigued themselves out. And so then therefore that doesn’t necessarily make sense because if we want high intent with the pylos. We got to do that potentially early in the session. Because by the end of this session, this athlete should likely be fatigued. And then therefore that intent is going to be lowered because they don’t have as much energy to do it. Our goal is to have a rhyme and reason to why we are structuring things the way we do. And the aim is to get the body warm early and prep it, get through some technical work with those higher demanding work. 

Higher demanding CNS-type work is going to be key. So things that are really going to get that nervous system firing. And then we work our way down. This is focused on rebuilding athleticism – sure we got the gym components, which plays into that. But then we want to make sure this athlete is feeling athletic. They can go back to doing the thing. They’re not nervous about stepping a weird way with their knee. They’re not worried about jumping over something. Let’s say like a bear’s chasing them (worst-case scenarios). We just want to make sure that this athlete is able to express themselves how they want to. 

And oftentimes what I will hear is that athletes just don’t get this last end of things. And then therefore they’re just kind of left, not feeling confident if they want to go back to play picking. If they want to go back to playing pick-up soccer, or if they want to go back to playing basketball or running around with their kids. That is something that we’ll have parents literally reach out and say, I just want to be able to like, run with my five-year-old. But right now I’m so scared I’m going to do something. Because my insurance cut me off at three months or my rehab professional didn’t really give me much to work on these areas. 

And so then therefore the goal here is to address these gaps, rebuild athleticism, show these dynamic components, especially during those times when we see ACLers might have built some strength, but it’s not translating over to athleticism and performance. So that’s the goal here. I hope that this was helpful team to be able to showcase and share. Just a little bit of a framework to help organize thinking around a dynamic session. 

Again, there is gray area within this of how you want to organize this. And based on the athlete and the goal you have in front of you. But this is going to be important to make sure that we have intention behind each session and every movement that we’re doing, because every single minute where you’re working with this athlete is an opportunity to move them in the right direction. And we want to serve our ACLers as best as we can. 

Before we sign off here, as I had mentioned, we’ve got the mentorship that is launching February 5th cohort two. Enrollment opens this Sunday, January 21st at 1:00 PM. Eastern. This is something that we are going to focus on the principals. 

Today, we talked about dynamic framework. This is just a drop in the bucket of the things that we will touch on. And the goal is to make sure that you walk away from this feeling confident to work with your ACLers, to improve your skillset and your knowledge. And most importantly is practical application. 

It’s not just another theory course where we just talk only about research and then you’re just like, well, how do I apply this to my setting? We give you the specific frameworks. We were walked through different movements, exercises, progressions, regressions, talk through cases, all the different things, because that’s what’s needed in this space. 

It’s the number one, most research musculoskeletal injury besides something like low back pain. And this is something that we have so much research, but it’s something where we still don’t have all the answers. How can we best set up our athletes to move forward, get back to the thing, and ultimately look back at ourselves and feel fulfilled by being able to get them there. So that’s going to be it for today, guys, if you have any questions whatsoever. Our information is in the show knows that waitlist signup is in the show notes. Send us a message. 

If you have any questions about it. Otherwise, I will catch you on the next episode. Thank you all so much for listening. This is your host, Ravi Patel signing off.