# ACL Rehab: Phase 2 | 8 To 16+ Weeks (Strength & Conditioning Exercises + Mistakes To Avoid)

## Метаданные

- **Канал:** E3 Rehab
- **YouTube:** https://www.youtube.com/watch?v=0r4jJMxIKew
- **Источник:** https://ekstraktznaniy.ru/video/43023

## Транскрипт

### Segment 1 (00:00 - 05:00) []

In this video, I'm going to teach you everything you need to know about phase two of ACL rehab, often also referred to as the mid-stage, as defined by Buckthorp and Deliva. The three primary goals of phase 2 are muscle strengthening, movement training, and fitness reconditioning. The authors go on to state that this stage also considers knee factors such as joint range of motion, eusion/swelling, control, pain management, and joint stability, as well as considering the psychology of the athlete such as motivation and apprehension. These additional considerations highlight the need for rehab to focus on function, not time. Accomplishing the goals of phase 1 significantly increases your likelihood of success in phase two. Each phase prepares you for the next. This is not to say that you can't initiate phase two if you haven't fully completed the goals of phase one because rather than being distinct entities, these phases exist on an overlapping continuum. However, if you're still struggling with restoring your knee extension, range of motion, or managing your swelling, those previous goals should be your priority. In the title of this video, I suggested that phase 2 will last from roughly 8 to 16 weeks. Based on what I'm going to discuss, this timeline is actually somewhat conservative compared to some protocols you'll find online. It's important to recognize though that these protocols are often carried out by expert clinicians on highle athletes in research settings with a lot of resources available. I say this to reiterate the importance of focusing on your function, not time. As long as you are doing the right things and giving your best effort, don't worry about comparing yourself to others. Plus, these phase 2 goals are consistent throughout all of rehab. If your strength isn't where you hoped or expected after 16 weeks, the plan might change or evolve, but the goal doesn't. I'm going to outline exercise options for each body region, explain the rationale for their selection, and provide a sample program. But I want you to keep these four things in mind. One, don't get overwhelmed by the number of exercises I'm going to demonstrate. You're not going to do them all in a single session, and you likely won't even do them all after 16 weeks. I'm simply providing options. Two, don't get discouraged by the difficulty of the exercises. Many of the exercises will seem unrealistic at first, but your capabilities will drastically improve over the course of rehab. You can view some of these exercises as eventual goals. Three, pain and swelling management are still key. Nothing will limit your strength and overall progress more than frequent flare-ups. In general, exercises should be challenging but tolerable. If an exercise doesn't feel tolerable or you're experiencing lingering joint discomfort, you probably need to scale back your activity levels. Muscle soreness, on the other hand, is normal and expected. Four, the main priority here is still safety, especially as it relates to any precautions or restrictions provided to you by your surgeon. For example, if you had a hamstring graft, the introduction of hamstring strengthening will likely be delayed to allow for appropriate healing. For that reason, this information is not meant to replace a consultation with a physical therapist or overrule any information provided to you by your physical therapist or surgeon. Okay, let's get into the exercises. If you want to improve your function and reduce your risk of reinjury, strengthening your quads needs to be a top priority. Here are three progressions that I like. Option number one, squat progression. Level one, bodyweight squat. Gently tap your butt to a bench, chair, or box and stand back up. If it's too challenging or painful, shorten the range of motion or use your hands for assistance. Increase the difficulty by removing the bench, chair, or box. Aim for three sets of 20 repetitions. Level two, goblet squat. Aim for three sets of 15 reps using a kettle bell or dumbbell. Level three, barbell, back squat, or front squat. Aim for three sets of 6 to 12 reps. Keep in mind that there are known limitations with squats. Research by Sigward in 2018 found that 3 months after ACL reconstruction, individuals performed interlim compensations during a squat. This means that if they had surgery on their right side, they loaded their left side more, which is often associated with an observable weight shift to that left side. However, the participants also demonstrated intraim compensations. This means that in addition to favoring their non-surgical leg, they offloaded their affected knee by working harder at the ankle and hip on their surgical side. Five months after surgery, the participants no longer demonstrated interlim compensations, but they continued to have intral compensations. So what the researchers found was that

### Segment 2 (05:00 - 10:00) [5:00]

even though the squats appeared symmetrical and normal, the individuals continued to redistribute the load from the surgical knee to the hip and ankle on that side. And this information isn't just relevant to squatting. It shows up in walking, hopping, and running. Our bodies are naturally going to take the path of least resistance. If you have pain, swelling, or significant weakness due to surgery, which is most people watching this video, you'll find a way to work around those issues, whether it's a conscious decision or not. Here are four ways to combat this. One, evaluate and refine your technique over time. Maintaining an upright trunk, driving the knees forward, and striving for deep knee flexion when appropriate are strategies for shifting more of the demand to the quads in a squat. When appropriate is key here. If you have a bone patellar tendon bone graft, overemphasizing this technique might be uncomfortable at this phase of rehab. If you're already experiencing patellofhemeral pain, deep knee flexion might also be inappropriate if you had any meniscus repair. Two, elevate your heels by using wedges, weight plates, or weightlifting shoes. Many of the same reasons and precautions apply. Three, use equipment that allows you to better control your technique, such as a Smith machine. It's not about what looks functional, it's about improving deficits and strength. Four, implement unilateral exercises that make it harder to hide your weaknesses, such as option number two, split squat progression. Level one, make sure you are comfortable with bodyweight squats or goblet squats. Level two, split squat. Start in a stride stance and lower yourself down so that your back knee taps an egg that you don't want to crack. If it's too difficult for your front or back leg, shorten the range of motion or use your hands for assistance. Aim for three sets of 15 reps. Level three, rear foot elevated split squat. The overall technique of the movement and position of your torso should be similar, so use an object to elevate your back foot that isn't too high. The majority of your weight should be through the front leg. Level four, deficit rear foot elevated split squat. You're going to elevate the front leg using a 2 to 4 in object to start. Over time, you can progress the height. Aim for three sets of six to 12 controlled repetitions. Option number three, step down progression. Level one, step up. Use a stair or object stacked six to seven inches high. Don't push off with the back leg. Focus on putting all of your weight through the working leg and just gently tap up and down with your other heel. If it's too difficult, decrease the height or use your hands for assistance. Aim for three sets of 20 reps per leg. Level two, lateral step down. Same exact cues except this movement will allow for a little more knee travel. Level three, forward step down or elevated lateral step down. You can either step forward off the step or continue to perform the lateral step down while gradually increasing the height of the step. Aim for three sets of six to 12 controlled reps per leg. Technique, heel elevation, and equipment usage are considerations for these exercises as well. Other unilateral exercises include kickstand squats, single leg squats, lunge variations, and the leg press. Another simple strategy is adjusting the tempo of an exercise. Performing a slow tempo or paused repetitions, at least initially, allows you to be more mindful of your technique. You can even attempt long duration isometrics. For instance, set up a body weight split squat with the technique you're trying to reinforce and then hold that bottom position for 30 to 60 seconds. This is extremely challenging. Even with all that being said, any compound or multi- joint exercise is still susceptible to unintentional compensations, especially at this phase of rehab. For that reason, I highly recommend including leg extensions. Since no other muscles extend the knee, leg extensions ensure that the quads are being trained adequately. Once again, it's not about what looks functional. It's about doing what is necessary to restore the strength and muscle mass of your quads. And no, leg extensions are not dangerous to the ACL. Researchers have implemented full range of motion leg extensions as early as 4 weeks, resulting in better long-term strength without increasing graft laxity. Like with any other exercise, you'd make sure they're tolerable and gradually add weight over time. However, the purpose of this video isn't to convince you of their safety or defy any precautions you might have. If you're really concerned, leg extensions between 90 and 60 degrees of knee flexion place zero strain on the ACL while providing the same strength and hypertrophy benefits. Therefore, partial range of motion repetitions or isometric holds for 30 to 45 seconds are suitable alternatives.

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For the isometrics between 90 and 60 degrees of knee flexion, a machine, strap, ball, or some other immovable object can be used. Another critical component of rehab is improving the function of the hamstrings as they help to decrease the strain on the ACL and reduce the risk of reinjury. Here are two body weight progressions. Option number one, slider progression. Level one, double leg eccentric slider. Bridge up. Keep your glutes squeezed. Slowly slide your legs out, drop down, bring your feet back to the starting position, and repeat. If it's too difficult, just shorten the range of motion. If you can work up to three sets of 12 reps, progress to the next level. Level two, double leg slider. Aim for three sets of 12 reps. Level three, single leg eccentric slider. Aim for three sets of eight reps. Level four, single leg slider. Aim for three sets of four to eight reps. If you don't have access to sliders, an exercise ball can be used. Option number two, feet elevated long lever bridge progression. Level one, double leg isometric. Place both heels on a bench with a slight bend in your knees. Bridge up until your hips are straight and hold this position. Aim for three sets of 45 seconds. Level two, marching feet elevated long lever bridge isometric. Slowly alternate lifting and lowering each leg. Aim for three sets of 60 seconds total. Level three, single leg foot elevated long lever bridge isometric. Aim for three sets of 30 seconds per leg. Level four, single leg foot elevated long lever bridge. Aim for three sets of six to 12 repetitions per leg with or without weight. Other body weight options include Nordic hamstring curls and hamstring curls on the GHD. If you have access to a gym, two of the best options are seated and prone hamstring curls. Not only do these machines allow you to carefully control the load and range of motion, they can be performed one leg at a time. The rationale is similar to leg extensions. Isolated knee flexion ensures that the hamstrings are being adequately trained. If you're limited by pain, range of motion precautions, or something else, these machines can be really useful for implementing long duration isometrics at tolerable or safe ranges of motion. The previous exercises focused on the knee flexion aspect of hamstring strengthening, but their hip extension action is important as well. Here are three exercise options. Option number one, Romanian deadlifts. Unlike conventional deadlifts that start from the ground, Romanian deadlifts or RDL's start from the upright position, which means you get to choose how far you lower the weight based on your flexibility and comfort. They can be performed with dumbbells, a barbell, or the Smith machine. Other RDL variations include a kickstand stance in which one leg is in front of the other, and a single leg RDL. The kickstand RDL, also known as a B stance RDL, is a way to target one leg at a time without compromising your balance. A single leg RDL, can be done with a barbell, dumbbells, or kettle bells, including using a weight in only one hand. However, if balance or fatigue in your ankle and foot compromise your ability to load the exercise, you can use a Smith machine or your free hand to help with stability. Option number two, Roman chair hip extension. Level one is double leg. Level two is single leg and level three is single leg with weight. Option number three, GHD hip extension. Once again, level one is double leg, level two is single leg and level three is single leg with weight. Your calves are important for running, jumping, landing, etc. And similar to your hamstrings, your solius, one of your primary calf muscles, also helps to unload the ACL. Here are two heel raise progressions. Option number one, bent knee heel raise progression. Level one, seated heel raises on flat ground. Level two, deficit seated heel raises. Aim for three sets of six to 12 reps. You can use a barbell, Smith machine, dumbbells, or seated heel raise machine. Most of these variations can be performed double leg or single leg. Option number two, straight knee heel raise progression. Level one, double leg heel raises on flat ground. Aim for three sets of 25 slow and controlled reps. Use your hands for balance as needed. Level two, single leg heel raises on flat ground. Level three, a step. Level four, step with weight. There are other straight knee options as well. If you train at a gym, the two pieces of equipment

### Segment 4 (15:00 - 20:00) [15:00]

specific to calf training that you might find are the standing calf raise machine and the donkey calf raise machine. You can also do calf raises on any leg press machine. They are all interchangeable. The Smith machine is one of the best options for calf training if you can stand on a step or plates to allow for a full range of motion. A lesser known option is performing calf raises in a staggered stance that still involves training one leg at a time. Recent research found that standing heel raises lead to similar growth of the soius as seated heel raises. So if you had to choose between the two for some reason, standing heel raises are likely more beneficial overall. The strength and control of your trunk and hips can affect what happens at your knee. So here are three exercise progressions that train the hip extensors, abductors, and adductors, as well as the associated trunk muscles. Option number one, hip thrust progression. Level one, double leg bridge. Lie on your back, bridge up, squeeze your glutes, lower yourself down, and repeat. Aim for three sets of 20 reps. Level two, single leg bridge. Aim for three sets of 15 reps. Level three, single leg hip thrust. Aim for three sets of eight to 15 reps. Add weights as needed. Option number two, side plank progression. Level one, short side plank. Start on your forearm and knees while keeping your trunk in a straight line. Hold this position. Level two, side plank. Straighten your legs. Stack your feet and keep yourself in a straight line both from a front view and top view. Level three, side plank hip abduction. Position yourself in the same way as the previous exercise, but slowly move that top leg up and down with good control. Aim for three sets of 60 seconds as you work through each exercise. Keep in mind that many of the exercises demonstrated earlier also train the hip extensors and abductors such as split squats, step downs, and single leg RDL's. Option number three, adductor progression. Level one, lie on your back and squeeze a ball between your knees or ankles as hard as you comfortably can. Level two, short Copenhagen plank isometric. Keep your trunk in a straight line and thighs together. Level three, long Copenhagen plank isometric. Same as the previous exercise, but you're going to keep the knee straight. Level four, long Copenhagen plank. Aim for three sets of 6 to 12 slow and controlled repetitions. To progress to level four, aim for three sets of 60 seconds on levels 1 through three. There's also hip flexor exercises you can perform such as standing hip flexion, dead bugs, leg raises, etc. Why include an adductor progression or hip flexor exercises? Well, I want to provide you with a comprehensive program that prepares you for all aspects of your desired sports or activities, not just as it relates to your ACL. Ideally, you don't reinjure your ACL, but you also don't sprain your MCL or strain your groin or sprain your ankle. For that reason, there's no limit to the number of hip and trunk exercises you can do. These are just some possibilities. The last category here is dynamic balance to help address some of the proprioceptive deficits associated with ACL injuries. Here are two options. Option number one, Y balance. Set up tape, cones, or imagine standing on an upside down Y. Stand on one leg and reach in each direction of the Y. Try not to put any weight through the foot that is tapping the ground. Start with small reaches and gradually increase the distance as your balance improves. Begin with three sets of 30 seconds each and work up to 60 seconds. Option number two, single leg RDL progression. Level one, single leg RDL. Stand on one leg while keeping a slight bend in both knees. Hinge at your hips until your trunk is almost parallel with the ground and then return to the starting position. Repeat this movement without touching your foot to the ground. If this is too challenging, use your hands to help with balance. Shorten the range of motion or tap your foot to the ground. Level two, three-way RDL. Reach your arms in three directions, to the left, middle, and then to the right. Then repeat. You can progress either movement by adding a knee drive. Two comments here. One, there's unlimited options for balance. You can incorporate head turns, eyes closed, unstable surfaces, ball tosses, bands, weights, perturbations, etc. Two, balance is part of everything you do in ACL rehab. So, it doesn't necessarily have to be overly complicated or the main focus of training sessions. What I mean by that is if you're doing a comprehensive program that includes split squats, step downs, single leg RDLs, jumping and landing drills, plyometrics, etc., you are regularly challenging your balance.

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For cardiovascular conditioning, I'm going to keep it very straightforward. It shouldn't be an afterthought, so hopefully the simplicity increases the likelihood of it getting done. The easiest option is a stationary bike. Let's say as part of phase 1, you've been riding an upright bike for 10 to 15 minutes at least two times per week. My recommendation would be to start gradually increasing the duration and frequency of your rides. For example, you could build up to 30 to 60 minute rides two to three times per week. Then, if that's tolerable and manageable, you could increase the intensity of those 30 to 60 minute rides. Just doing that consistently will go a long way. How do you put all of this information together to create a structured routine? Well, here is an example of a three-day program toward the end of 16 weeks. Monday, split squats, kickstand RDL's, single leg extensions, single leg prone hamstring curls, single leg heel raises with a dumbbell, side planks, Y balance. Wednesday, heel elevated goblet squats, single leg Roman chair hip extension, lateral step down, single leg seated hamstring curls, single leg hip thrust, seated heel raises, three-way RDL with knee drive. Friday, single leg press, single leg RDL's, single leg extension isometrics, double leg slider, short Copenhagen plank isometric, single leg heel raises with Smith machine, standing fire hydrant. Conditioning and upper body training sessions may be performed on Tuesdays, Thursdays, or Saturdays. Okay, there's a lot of nuance to this, so please bear with me. I cannot create a program that will work for every individual based on their unique circumstances at every moment in time. However, I can try to teach you principles because principles are more important than any singular program. From an organizational standpoint, this is loosely how I structured each day. Squat movement, hinge movement, knee extension, knee flexion, hip or trunk exercise, calf exercise, dynamic balance. This is not the only way to do it, and the number of exercises may be too many for some individuals at certain time points. More isn't necessarily better if you're unable to recover and your progress is stagnating. And aside from the general structure, here are five things you can change about this program to suit your specific needs. One, frequency. If 3 days per week isn't feasible because of time constraints, your ability to recover, etc., train two days per week instead. Two, volume. If you're only training two days per week, you might increase the number of sets you perform for each exercise. Three, exercise selection. As an example, if you're not prepared to do heel elevated goblet squats, just do regular goblet squats. Four, range of motion. For instance, if you have restrictions from your surgeon regarding your hamstring training, perform isometrics or shorten the range of motion. Five, intensity or effort. Don't push as heavy or hard on exercises that are less tolerable. There's no set rules for most of this. Truthfully, you shouldn't even get too caught up in the exact exercise progressions I provided earlier. It's helpful to have a framework when you're first starting out, but the progressions I provided are somewhat arbitrary. For example, a 100 lb goblet squat, which I labeled as level two, is more difficult than a back squat with an empty barbell, which I labeled as level three. However, I labeled the barbell back squat and front squat as level three because they typically have a greater potential for progressive overload compared to the goblet squat that is eventually limited by the strength of your upper body. Lastly, the intention of the exercises will fluctuate over time. So once again, don't get too caught up in the exact repetition ranges I provided. Early on, you're probably going to stick to higher repetition ranges as you improve your tolerance, endurance, and work capacity. As you progress, you'll likely transition to increasing hypertrophy, strength, and power by manipulating the repetition ranges, rest times, effort or intensity, and speed of the movements. Your parameters should likely range from 3 to 20 repetitions with minimal rest between sets or exercises up to 3 to 5 minutes of rest between sets or exercises depending on the goal. As you become less limited by pain or swelling, the more you should be trying to push exercises to failure or close to failure safely, of course. Here's a practical example of this. When you first try split squats, you're not going to perform a three rep max to failure. Instead, you'll probably do what's tolerable, which might be five or 10 reps, depending on how well you prepared beforehand. When you become comfortable with the movement, and you're not

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limited by any sort of symptoms, you might build up to 15 to 20 slow and controlled reps before gradually adding weight. You might even throw in some of the long duration isometrics I mentioned earlier. Then, you might start to add more weight and lower the rep range to 10 to 15 or 6 to 10. As you begin pushing each set to failure or close to it, eventually you may perform that three rep max to failure and push with maximal intent during each repetition. Over time, you'll probably mix up the repetition ranges, tempos, and split squat variations. The harder you can safely push yourself in training, the easier each step of rehab becomes. As a reminder, you might not be performing deficit rear foot elevated split squats or Nordic hamstring curls by the end of 16 weeks. You also might not be performing exercises for sets of three to six reps to failure because of joint discomfort or safety reasons. That's okay. These are goals you can strive to achieve at some point in your strength training routine. You should reference this video frequently throughout your rehab and make adjustments based on your continued progress. Here are four additional programming considerations. One, don't forget to train the uninjured leg hard, early, and often so it doesn't slowly lose strength and muscle mass. Two, you should be including upper body exercises as well, not just for the physical benefit, but also the mental aspect of feeling like an athlete. Three, you should be performing warm-up sets before most exercises, but you can also include a dynamic warm-up prior to your training sessions. There's no shortage of options, whether you prefer sled pushes and pulls, dynamic stretches, band walks, general movement preparation, etc. Four, your flexibility should improve with a comprehensive strength training program, but you can incorporate stretching into your routine if you'd like. For example, you might have full knee flexion range of motion, but decide that you would benefit from a prone quad stretch. What about running in plyometrics? Historically, people were given permission to run after 12 to 16 weeks based on the healing of the graft after surgery. However, it is now highly recommended that the initiation of running is based on your objective function. You want to earn the ability to run through proper preparation. Part of the reason I didn't include running in plyometrics in this video is that it's just easier to split strength and conditioning into one video and running and plyometrics into another. This video is long enough as it is. I also didn't want the importance of a good strength and conditioning program to get overlooked. Without being able to individually assess everyone watching this video, here's my potentially controversial opinion. Let's say you were objectively ready to initiate running at 12 weeks, but waited until 16 weeks. If you were consistently performing and progressing your strength and conditioning program during that time, I don't really think you're going to be worse off. You still have another 8 months of rehab to go, and you took that time to build a better foundation that is setting you up for long-term success. On the other hand, initiating running before you're ready can be problematic if it contributes to cyclical increases in pain and swelling that lead to delays in progress. Additionally, developing the appropriate strength prior to running may help to reduce loading asymmetries that are common as well as reduce the chance of compensatory movement patterns from emerging. If you don't want to wait for the next video, you can easily add short distances of forward jogging, backward jogging, or side to side shuffles into your dynamic warm-up. Similarly, if you're itching to start plyometrics, it's easy to add some pogos or drop landings from a low box into your program. And I will say that I think plyometrics should come before running, but that's a topic for the next video. Before wrapping up, it's important to list the objective criteria you should be trying to accomplish by the end of phase two. I'll use the recommendations from Buck Thorp and Delvia. Zero eusion with minimal activity related eusion. This means your knee should no longer be swollen and have minimal reactivity to your regular training. Full knee flexion and extension range of motion. Limb symmetry index greater than 80% for your knee flexors and extensors. This means that your knee flexion and extension strength should be at least 80% of your non-surgical side. You can get a general sense of this with your single leg hamstring curls and seated leg extensions, but it's best to get this tested by a physical therapist who has access to an isocinetic dynamometer or inline dynamometer. Two other caveats here. One, the 80% doesn't matter as much if you haven't been keeping up with training your uninvolved leg. There's a difference between your ACL reconstructed knee catching up to your other leg and your other leg becoming

### Segment 7 (30:00 - 32:00) [30:00]

weaker to match your ACL reconstructed knee. This can also be measured by your physical therapist. Two, how strong your leg is matters. This metric is known as peak force. How fast you can produce that strength, known as rate of force development, also matters. As I stated earlier, you'll train with a variety of rep ranges and tempos. However, you'll want to include lower repetition ranges with maximal intent at some point in your training to improve your power and rate of force development. At least 125% body mass for eight reps using the leg press or roughly 150% body mass for one rep. This means if you weigh 150 lb or 68 kg, you should be able to move 187. 5 lb or 85 kg for eight reps with your involved leg using a leg press. If this sounds extremely difficult, it is. A lot of this is. It's meant to set a high standard for helping you return to sport safely. Keep in mind that there will be slightly more variability in this test based on the different types of leg press machines, the technique used, the range of motion, etc. Greater than 20 reps of single leg bridges and within five of the other side. Greater than 20 reps of single leg heel raises and within five of the other side. Good movement quality with a single leg squat. For the single leg bridges, single leg heel raises, single leg squats, and most other movements, you can think about trying to achieve at least 80% strength compared to your uninvolved leg. Don't get too discouraged if you don't meet this criteria by the end of 16 weeks. Remember, you're focusing on your function, not time. Keep trying to get a little better each week. When does phase 2 end? I could say phase 2 ends when you've met this criteria, but it never ends really. The goals evolve as you progress, but the concepts of muscle strengthening, movement training, and fitness reconditioning remain constant throughout rehab, which is why this phase is so important. You should revisit this video time and time again. Thank you so much for watching. If you enjoyed the video, please hit that like button, subscribe, turn on notifications, and leave any comments down below. If you are looking for a rehab or performance program, or you are interested in working with us one- on-one, visit our website at e3rehab. com. Peace.