In this blog, I teach you everything you need to know about Phase 3 of ACL rehab, also often referred to as the Mid to Late Stage.
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Phase 3 Entry Criteria & Goals
Phase 3 will focus on running, jumping, landing, and plyometrics.
The title of this blog suggests that these movements will be initiated at 4 months, which is actually somewhat of a conservative estimate compared to many protocols you’ll find online. I structured it this way for several reasons:
- Separating strength and conditioning into one blog, and running and plyometrics into another, allowed for better organization and ease of understanding, while reducing the length of each blog.
- I didn’t want the importance of a good strength and conditioning program to be overlooked as it prepares you for these movements.
- I understand that many individuals may be using this series as a substitute or supplement to in-person guidance due to a variety of barriers, such as restricted time, inadequate resources, and limited accessibility. However, if you’re not doing so already and it’s an option for you, I highly recommend working with a sports physical therapist who has access to a suitable training facility.
If you’re truly 16 weeks post-surgery and you met the objective criteria I provided in the previous blog, you should be more than prepared to initiate the entry-level exercises in the next section.
If not, a simple rule of thumb to begin bilateral landings from Buckthorpe et al is that you “have attained at least one times body mass (single limb) and two-times body mass (double limb) for [a] set of eight repetitions on the leg press.” This means if you weigh 150 pounds, or 68 kilograms, you should be able to move that much weight for 8 reps with your involved leg using the leg press.
Their rationale is that “Typical forces during bilateral landings can be around 1.5-2 times body mass depending upon the height of the landing (which represents around one times body mass per limb delivered at high rates of loading).” This highlights the importance of a good strength training program.
Before demonstrating the movements, I want to point out that there are an infinite number of possibilities and progressions. What I’m going to discuss is not an all-inclusive list or the only viable method. My recommendations will focus on simplicity, optionality, and safety.
Simplicity and optionality relate to consistency. Regardless of the exercises you choose to do, regularly incorporating these movements into your routine will improve your likelihood of success. Safety refers to an emphasis on eccentric control during landing and decelerating, sometimes referred to as “force absorption” or “building the brakes.”
Line Hop & Pogo Progression
Line hops are an easy starting point because most of the work is coming from your feet and ankles, especially if you focus on quick hops with your hands on your hips.
Here is an 8-level progression:
- Double Leg in Place
- Double Leg Forward & Backward
- Double Leg Side to Side
- Double Leg Figure 8
- Single Leg In Place
- Single Leg Forward & Backward
- Single Leg Side to Side
- Single Leg Figure 8
I am differentiating pogos from line hops because there is a bigger emphasis on technique for pogos within the sports performance world. For example, you might be told to “attack the ground” and “lift your toes up” with each repetition.
Here is a 5-step pogo progression:
- Double Leg
- Staggered Stance
- Alternating
- Front Foot Elevated
- Single Leg
Keep in mind that this progression is more variable because it is dependent on your effort or intent. For instance, high intensity pogos at a slower cadence are more demanding than low intensity pogos at a faster cadence.
As with the line hops, you can incorporate different directions. Also, your hands can be on your hips, at your side, or you can let them assist in driving each jump.
Lastly, if you’re a fan of jump roping, you can throw it under this category.
Horizontal Jumping Progression
Here’s a 4-step progression:
- Submaximal Broad Jump
- Maximal Broad Jump
- Single Leg Submaximal Broad Jump
- Single Leg Broad Jump
Between steps 2 and 3, you can try one of these options if needed:
- 1 leg to 2 legs to practice jumping off one leg
- 1 leg to the other leg
After step 4, some options include:
- Single Leg Triple Hop
- Single Leg Crossover Hop
- 2 legs to 1 leg to increase landing forces
All types of bounding can be used in this category as well.
Vertical Jumping Progression
For vertical jumps, I’m going to provide 5 different options, starting with a countermovement jump progression:
- Submaximal Countermovement Jump
- Maximal Countermovement Jump
- Repeat Maximal Countermovement Jump
- Single Leg Submaximal Countermovement Jump
- Single Leg Maximal Countermovement Jump
- Single Leg Repeat Maximal Countermovement Jump
An advantage of countermovement jumps is that the landing forces required are dictated by how high you jump rather than an arbitrary box height. However, you can split countermovement jumps into separate landing and jumping exercises.
For landing, start with a Drop Landing from a low box.
Then you can gradually increase the height, switch to a single leg, or do both.
For jumping, start with Box Jumps to a low box.
You can gradually increase the height, switch to a single leg, or do both.
Keep in mind that a higher box isn’t necessarily better. The box is meant to decrease landing forces, so pick a box height that accomplishes this without significantly altering your technique.
The next vertical jump option is a Drop Jump, which can be performed double leg or single leg at different heights.
Drop jumps are meant to develop a specific adaptation, known as Reactive Strength. To calculate the Reactive Strength Index, or RSI, divide jump height or flight time by the ground contact time.
This means you want to be quick and explosive when you land, while jumping as high as possible. This also means you want to try to build up to a box height that provides you with the best RSI. Heights might range from 8-24 inches.
A similar looking exercise is a Depth Jump except your ground contact time will be longer to maximize force output and allow for an even higher jump. Heights may range from 12-30 inches.
Split squat jump variations are popularly used in this category as well.
Lateral Jumping Progression
Here’s a 5-level progression:
- Lateral Squat
- Lateral Lunge
- Lateral Lunge with Step Back
- Skater Jump
- Repeated Skater Jump
Add a light medicine ball for a different challenge.
Deceleration Progression
For forward deceleration, here’s a 5-step progression:
- Forward Lunge
- Forward Lunge with Step Back
- Forward Step & Land
- Step & Land with Step Back
- Jogging with Step Back
Other helpful exercises here include heel elevated forward step downs and band resisted backward walking.
The next blog will delve into sprinting and cutting, so deceleration will be a bigger focus.
How Much Does Technique Matter?
A lot, for the most part.
Take the drop jumps, for example. If you’re not trying to minimize your ground contact time, you aren’t improving your reactive strength, which is the adaptation they’re meant to develop.
In terms of analyzing movements, you want to view them in the frontal and sagittal planes, which refers to front and side views.
Ideally, you should be able to control the position of your trunk, pelvis, and knee in the frontal plane. There is no cutoff for what’s acceptable, but if you demonstrate significant dynamic knee valgus and trunk side bend while landing on your ACL reconstructed knee but not your other knee, that’s probably an indication that the task is too difficult for your current level of strength.
The sagittal plane can be a bit trickier, but you can compare side-to-side landing strategies to determine if you’re loading your affected knee appropriately. Let’s use the single leg drop landing as an example. If your preferred technique is to land on a straight, stiff knee with your trunk hinged all the way forward, this means that your knee isn’t handling its share of the load.
In the presence of weakness, pain, or swelling, your body is going to try to protect the knee by offloading it, whether it’s a conscious decision or not. This is something you need to be aware of during any of the jumping or deceleration exercises. There are 3 strategies to overcome this:
- Develop the adequate quadriceps strength for the task
- Improve your confidence through consistent training and gradually use the progressions I provided to build up to the task
- Intentional practice
Sometimes a more constrained variation of the movement can be helpful. For instance, a heel elevated wall drop forces you to load through your knees if you strive to maintain your back against the wall.
Some exercises inherently differ in their loading profiles. A study by Kotsifaki et al in 2021 found that both a vertical and horizontal jump will load the hip, knee, and ankle, but the relative contributions from each joint will be slightly different. For example, during a vertical jump, “each joint contributes approximately ⅓ of the total work, both in (takeoff) and landing.” In contrast, for a horizontal jump, “the hip and ankle predominantly drive the movement” while the knee joint is primarily responsible for absorbing the landing. Therefore, variety in training is beneficial.
Programming
To best understand programming, let’s revisit the sample 3 day program I provided in the previous blog:
Monday
- Split Squats (2-3 sets of 8-12 reps)
- Kickstand RDLs (2-3 sets of 8-12 reps)
- Single Leg Leg Extensions (2-3 sets of 10-15 reps)
- Single Leg Prone Hamstring Curls (2-3 sets of 10-15 reps)
- Single Leg Heel Raises with a Dumbbell (2-3 sets of 8-12 reps)
- Side Planks (2-3 sets of 30-60 seconds)
- Y Balance (2-3 sets of 30-60 seconds)
Wednesday
- Heel Elevated Goblet Squats (2-3 sets of 10-15 reps)
- Single Leg Roman Chair Hip Extension (2-3 sets of 10-15 reps)
- Lateral Step Down (2-3 sets of 10-15 reps)
- Single Leg Seated Hamstring Curls (2-3 sets of 10-15 reps)
- Single Leg Hip Thrust (2-3 sets of 10-15 reps)
- Seated Heel Raises (2-3 sets of 8-12 reps)
- 3-Way RDL with Knee Drive (2-3 sets of 30-60 seconds)
Friday
- Single Leg Leg Press (2-3 sets of 8-12 reps)
- Single Leg RDLs (2-3 sets of 8-12 reps)
- Single Leg Leg Extension Isometrics (2-3 sets of 30-45 seconds)
- Double Leg Slider (2-3 sets of 8-12 reps)
- Short Copenhagen Plank Isometric (2-3 sets of 30-60 seconds)
- Single Leg Heel Raises with Smith Machine (2-3 sets of 8-12 reps)
- Standing Fire Hydrant (2-3 sets of 30-60 seconds)
An optional 5-10 minute dynamic warm-up can be performed at the start of each session.
Cardiovascular conditioning and upper body training sessions may be performed on Tuesdays, Thursdays, or Saturdays.
As a reminder, this is loosely how I structured each day:
- Squat Movement
- Hinge Movement
- Knee Extension
- Knee Flexion
- Hip or Trunk Exercise
- Calf Exercise
- Dynamic Balance
There was a lot of nuance that I attached to this sample program, so please read the previous blog if you haven’t already.
Since one of my priorities is simplicity, I’m going to suggest adding 1-3 jumping, landing, or plyometric exercises at the beginning of each session, after the dynamic warm-up. As an example, you might add 2-3 sets of line hops and countermovement jumps on Monday, 2-3 sets of broad jumps and drop landings on Wednesday, and 2-3 sets of pogos and lateral jumps on Friday.
This is not the only way to do it. If you need to change something about the program to suit your needs, such as training 2 days per week instead of 3, that’s completely acceptable.
Similarly, you might remove the dynamic balance exercises to save time since the jumping, landing, and plyometric exercises challenge your balance.
I haven’t discussed parameters yet, so here are 4 guiding principles:
- Always start with less volume. You can do as little as 1 set per exercise and you probably don’t need to do more than 4 sets per exercise. As far as the duration and reps go, you likely don’t need to exceed 60 seconds for line hops, 30 seconds for pogos, or 10 repetitions for anything else. In general, 10-30 seconds and 4-6 reps are safe bets. For example, if you’re just practicing the skill of stepping off a low box for a drop landing, 10 reps is probably fine. On the other hand, you wouldn’t do 10 reps of a drop jump because of its demanding nature. Instead, you might do 5 reps.
- There is a tradeoff between volume and intensity. Since there is a ceiling for what you can tolerate, you don’t necessarily need to push volume and intensity simultaneously, or indefinitely.
- You don’t need to go max intensity every session, even if you built up to the last level of an exercise progression. You typically wouldn’t perform your squat 1 rep max (1RM) every training session, so you don’t need to try to hit a personal record (PR) on your depth jumps 3 times per week.
- Hopefully this goes without saying, but make sure you’re prepared for each task. If you haven’t even tried a double leg drop landing, don’t test out a single leg drop jump.
I should also mention that beginning Phase 3 does not mean disregarding the primary goals and principles of Phases 1 and 2. One of the main goals of Phase 1 was managing pain and swelling. This is just as important now as it was then. There is no benefit to jumping on a swollen knee. Diligently track your exercises and activity levels, and modify your training based on your ability to appropriately recover and adapt between sessions.
With regard to Phase 2, you can progress certain aspects of the program, such as exercise selection and intensity, if you’re now better prepared to do so. For example, you might gradually progress from double leg sliders to single leg sliders or split squats to deficit rear foot elevated split squats.
Similarly, you might vary your exercise parameters to include lower rep ranges and higher efforts, so you are addressing any deficits in strength and power. Lastly, if you’ve built a good foundation with your cardiovascular conditioning on a stationary bike, you can begin mixing it up with longer duration rides, High Intensity Interval Training (HIIT), etc.
Return To Running Criteria & Goals
One aspect of rehab that I haven’t discussed yet is running. Returning to straight-line running is an important landmark and something that most people look forward to.
Once again, if you’re truly 16 weeks post-surgery and you met the objective criteria I provided in the previous blog, you’re likely more than prepared to initiate a walk-jog program. If you’re reading this at an earlier time point or haven’t met that criteria, here’s a few recommendations from well-trusted clinicians.
In addition to having minimal pain, near or full knee range of motion, and minimal to no swelling, here are 3 recommendations from Buckthorpe and Della Villa:
- Display good quality single leg squats and bilateral landings.
- Demonstrate isometric knee extensor strength >70% of the uninvolved side.
- Be able to perform a single leg exercise, such as a leg press, of at least 1.25 times your body weight.
ACL specialists from Aspetar have slightly stricter guidelines:
- Limb symmetry index (LSI) >80% for quadriceps strength. LSI just refers to the strength or performance of your involved side compared to your uninvolved side.
- LSI >80% for eccentric impulse during a countermovement jump, which is essentially a measure of your ability to decelerate during landing.
- Pain-free repeated single leg hopping (pogos).
For the physical therapists reading who are using a dynamometer, Erik Meira suggests 2 Nm/kg of quadriceps torque to bodyweight as a reasonable “bare minimum.”
All of this information highlights that your function is more important than an arbitrary time point as it relates to returning to running. If you think of running as repeatedly performing single leg landings, it hopefully makes sense why I discussed jumping, landing, and plyometrics first. Strength training and plyometrics prepare you for running, not the other way around.
Running can be initiated on a treadmill or track, although the treadmill is often preferred for its control and ease of use. A typical running progression involves walking for .1 miles, jogging for .1 miles, and repeating this for 1-2 miles total based on your tolerance. The next progression is walking for .1 miles, jogging for .2 miles, and repeating this for 2 miles. As you might expect, this cycle repeats for .3 miles of jogging and .4 miles of jogging until you can run 2-3 miles continuously. Then you would alternate jogging and running every ¼ mile for 3 miles.
Arguments against this type of progression are that it is slow and doesn’t mimic the demands of sport for many athletes, which often requires short bursts of running. There’s not going to be one strategy that works for everyone. Your specific plan might depend on your strength and conditioning program, your tolerance to running, your sport, your position in that sport, etc.
Whatever you decide, I wouldn’t start with more than 2 days of jogging per week.
You want to make sure you can tolerate, recover, and adapt appropriately to everything you’re doing. It’s possible you have to scale back the frequency or volume of your strength and conditioning program. The aim is to find a suitable, sustainable, and steady approach to training for you.
As an aside, if you’re working with a physical therapist, they may recommend running sooner in the pool or using an Alter G Anti-Gravity Treadmill.
Phase 3 Objective Criteria
What criteria should you be trying to achieve by the end of Phase 3?
In general, at 6 months and beyond, you’re working toward symmetry. Symmetry in muscle mass. Symmetry in strength. Symmetry in power. Symmetry in movement quality. Symmetry in your confidence in each leg’s ability to perform a task.
However, to the untrained eye, symmetry can sometimes be deceiving because it doesn’t always tell the whole story. For example, if your leg extension strength is symmetrical between sides because your uninvolved leg got weaker over the past 6 months, that’s not ideal. But this happens. This also happens with jumping and hopping tests. Single leg hop tests can appear symmetrical because you unknowingly hop a shorter distance on your uninvolved side. Altered movement strategies that shift the demand to the hip and ankle are common as well.
This highlights the importance of testing from a sports physical therapist or another expert. Not only can they objectively measure the difference between your legs, they can compare your numbers to expected values.
Here are some things a clinician might examine:
- Maximal Strength, known as peak force, of your knee extensors and flexors using an isokinetic or in-line dynamometer
- How fast you can achieve that peak force, known as rate of force development (RFD), of your knee extensors and flexors using an isokinetic or in-line dynamometer
- Single Leg Hop For Distance
- Triple Hop For Distance
- Crossover Hop For Distance
- Side Hop Test, which assesses how many times you can jump back and forth over a distance of 40 centimeters in 30 seconds
- Drop Vertical Landing, Drop Vertical Jump, and Countermovement Jump using force plates or MyJump App to assess a variety of metrics, including reactive strength
In the previous blog, I recommended striving for 80% symmetry or greater for the strength tests. If you accomplished that, then the next goal would be to aim for 90%. The same goal applies to the movements I just listed. However, if you don’t achieve 80-90% by the end of 6 months for most of these tests, don’t stress too much. That’s not unusual because this is a long and difficult process. For most people reading this blog, you should likely expect rehab to take 12 months or longer, so you have plenty of time to continue improving.
For the physical therapists, if a patient has achieved 2 Nm/kg of quadriceps torque to body weight, start working toward 3 Nm/kg.
When Does Phase 3 End?
It doesn’t, really, because it’s going to blend into the next phase of rehab. Realistically, it might take you 6 months to get proficient at many of the plyometric exercises. And regardless of where you’re at in your rehab, you’re going to keep striving for progress with everything I’ve discussed in this blog. For that reason, you should frequently reference this blog and make adjustments based on your continued progress.
Take your rehab and training to the next level by getting started with our 1-on-1 remote consultation and coaching services!
Want to learn more? Check out some of our other similar blogs:
How To Grow Your Quads, ACL Rehab, How To Perform Nordic Hamstring Curls
Thanks for reading. Check out the video and please leave any questions or comments below.
