Coming out of ACL surgery can be quite shocking. Even though you were injured before you went in, you weren't debilitated. Coming out, stuck in a whole-leg brace, it can feel like you are light years away from getting back to playing your sport, running around without worry or even just walking normally. The purpose of Physical Therapy is to restore normal function of your surgical leg and guide you until you are fully ready to return to sport with minimal risk of re-injury.
The first thing you need to understand about your ACL rehabilitation program is that there is a ton of research regarding how to successfully return to sport from ACL surgery. That being said, each sport has different demands, each athlete has different characteristics (age, strength pre-surgery, athletic career, etc), and each physical therapy practice has different means of delivering therapy. It is vital that you find a physical therapist you can trust to understand the demands of your sport, is willing to work with you, your strength and conditioning staff, and any coaches that may have a stake in your rehabilitation outcome, and set you up for a successful comeback.
Here are the most important things to consider when choosing the right place for to perform your rehab program:
-Does this physical therapy clinic work with a lot of ACL rehab patients?
-Does the therapist you have chosen, or been paired with, understand the demands of your sport?
-How many physical therapy visits does your insurance company agree to cover per year?
-What timeline are you expected to progress through?
Let's break these down.
Does this physical therapy clinic work with a lot of ACL rehab patients?
If you look around the clinic's website, are there pictures of athletes or elderly people? Do you see people like yourself or do you see people you wouldn't want on your pick-up team? This is key because not every clinic is set up in terms of staff training and equipment to best serve the athletic population. For many, it makes sense to perform rehab at the clinic in the same building as the surgeon's office, but this is not always the best route. The reason being could be several fold.
First, surgeon owned PT clinics tend to outsource there therapy management to a private equity company. These companies are not owned by physical therapist, a surgeon or Doctors of any kind. Instead, they are a billing machine. They typically place 3-5 patients on one physical therapist's schedule at the same time and utilize unlicensed technicians to perform treatments. This dramatically decreases the effectiveness of the therapy and therefore requires patient's to come in to the clinic several times per week. To jump ahead to bullet point number three, if you only have a set amount of PT visits per year, you may blow through these in the first couple months of rehab.
I see up to one high school aged patient a month come in from an in-network office without a single visit left in their insurance policy while they are only 4 months out of surgery. The therapist never consulted with the parents regarding the plan of care and the potential to max out their insurance visits in just a few short months was a total shock. Now the family is forced to pay cash for what their insurance used to cover.
Does the therapist you have chosen, or been paired with, work with a lot of ACL rehab patients?
It is a physical therapist's job to see patients and progress them through an exercise rehab program. However, that does not make every therapist an expert in ACL rehab. Often times staff clinicians will accept a patient they are not fully confident with just because they are expected too. It is the patient's who suffer. ACL rehab has specific milestones that need to be met, especially in the first month of rehab. For return to sport there are assessments (although not backed 100% by research) that indicate whether a patient is ready physically to return to sports. If your clinician is not familiar with these protocols, your rehab program may not be as successful as you expect. To put it frankly, you may get re-injured because you did not complete a full ACL rehabilitation program.
How many visits does your insurance company agree to cover per year?
As we talked about above, it is vital this information is laid out on the table day 1. The athlete, the athlete's parents (for minors), and the therapist need to be in agreement about what the long term goal of rehab is and how we are all going to get there. If your policy says 30 visits max, we cannot do 3 times a week for four weeks. This would exhaust nearly half of your visits in the first month. ACL rehab realistically lasts a minimum of 9 months. If an athlete and his/her family intend to only use insurance coverage for rehab, then the visits need to be appropriately spaced. The first month of rehab is where the greatest risk of negligence occurs, and therefore most individuals will be seen twice per week. After the first month the timeline is much more flexible and more can be done at home to improve function. A detailed home program is absolutely necessary for all ACL rehab programs but even more so for success in situations where rehab visits are limited.
What timeline are you expected to progress through?
A true ACL rehab program is 9 months. 1 month of pre-op swelling and range of motion rehab, 2 months of core, hip, quad, hamstring, and calf strengthening, 1-3 months of compound strength training, 2-3 months of agility and return to sport training. This is a very general timeline and is by no means set in stone. However, shortening the timeline comes with a greater risk of re-injury. The research would advocate for 9 months being the minimum before an athlete returns to sports and one year is even safer.
We have all heard about Adrian Peterson and his incredible return to football timeline following ACL repair by Dr. James Andrews. It's important to understand that Adrian Peterson is a paid elite level athlete. His job is to get back to football. His rehab was 5 days a week lasting for several hours at a time. He was taken off the PUP (physically unable to play) list at 8 months post surgery. That is only one month ahead the minimum we (and the research) advocate for at Human Function and Performance. Therefore, it is clear that we take a rather aggressive stance when it comes to rehab. We expect our athlete's to be dedicated to getting back what they have lost. That being said, when things are not progressing along the time table we expect, we maintain open lines of communication with the athlete, parents and all other parties involved to avoid any unexpected setbacks.
For many athlete's the 9-month return to sport may not be realistic. We make a point of describing a rather grueling rehab process for this timeline. If you want to make it back for the start of next season, you are going to have a substantial amount of programming to complete daily. There is no way around doing the work if you want to get better fast. To combine cost effectiveness with great outcomes, we provide detailed programs to athletes with videos depicting proper technique and feel. This allows athletes to perform the bulk of their program at home, rather than in the clinic.
To summarize, ACL rehab is a lengthy process. Mismanagement can have serious consequences impairing return to sport timelines and putting athlete's at risk for re-injury. If you are getting your ACL repaired and want to know if Human Function and Performance is the right fit for your recovery, click here and schedule a free 15-minute consultation.
Want to know more about what ACL rehab progression looks like? Click here to read our ACL Rehab Expectations
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