In this blog, I teach you everything you need to know about Phase 4 (6-12+ months) of ACL rehab, also often referred to as the Late Stage.
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Phase 4 Goals
Phase 4 will focus on sprinting and change of direction drills as you prepare to return to sport.
As with the previous blogs, I want to highlight the importance of your function, not time. Whether you’re 6, 8, or 10 months out from surgery, what matters most is that you’re ready to perform the movements I’m going to present.
How do you know if you’re ready?
Well, hopefully you’ve adequately prepared yourself by gradually progressing through the prior phases and striving to meet the objective criteria I recommended. This includes, but is not limited to:
- No pain or swelling
- Full range of motion
- 80-90% symmetry on strength testing
- Strength training and plyometric exercises 2-3 times per week
- Completed a walk/jog progression
The symmetry on strength testing is a somewhat variable percentage because different drills in this phase require different levels of strength. 80% is a reasonable starting point, while 90% should be the goal before initiating the most challenging tasks. Your performance on the jumping, landing, and plyometric movements should also be approaching 80% symmetry or higher.
I cannot overemphasize the importance of your strength and plyometric training, especially if you haven’t achieved the symmetry percentages I just mentioned. Running, sprinting, and change of direction drills are often viewed as the fun aspect of rehabilitation, and I promise you they are more fun when you feel confident in your capabilities because you didn’t skip any steps along the way.
If you haven’t already, make sure you’re working toward lower repetition, higher intensity sets in your strength training (at least some of the time). For example, doing heel elevated front squats or deficit rear foot elevated split squats for sets of 3-5 reps with maximal intent to restore your strength and power.
Similarly, if you haven’t already, make sure you’re working toward the single leg jumping, landing, and plyometric exercises from Phase 3.
Okay, let’s start with…
Sprinting
Most sports don’t require sustained running for long periods of time. Instead, they require short, high-speed bursts. Think about basketball, American football, and soccer (or football for the rest of the world).
For that reason, ACL rehab usually doesn’t focus on long distance running. Plus, long distance running is additional load on a knee that is already struggling to recover from strength training, plyometrics, and, soon-to-be, sprinting and change of direction drills. If you’re concerned about your aerobic fitness, you can improve that through other means, such as cycling on a stationary bike, swimming, etc., as well as through the gradual reintroduction of playing your sport.
For returning to maximal effort sprints, there is no universally accepted protocol because your function, sport, position, and even the space you have available will dictate how you implement this information. With that in mind, here is a useful “criteria-based return to sprinting progression” from Lorenz and Domzalski in 2020.
As you can see, it is split into 3 stages, with each stage having 4 steps. Stage 1 begins at 50% intensity with a 1:3 work to rest ratio, while stage 3 builds to 90-100% intensity with a 1:7 work to rest ratio. Although it appears fairly straightforward, this is a progression that may take you several months to achieve because, realistically, you might only be doing this 1-2 times per week.
Keep in mind that you don’t have to force yourself to progress to the next step or stage every single session. Sometimes repetition in training is beneficial to prove to yourself that you’re able to tolerate and recover from a certain task, especially in the context of the rest of your program. And once again, you may need to adjust the volume or distances depending on your specific needs.
Lastly, you can consider including acceleration and/or deceleration phases to mimic sporting activity by ramping up to a desired speed for a set distance before slowing back down. Practicing deceleration is an important component of trying to reduce the risk of reinjury.
Cutting, Pivoting, & Change of Direction
For cutting, pivoting, and change of direction, there are 3 main principles for progressing exercises:
- Speed. Like the previous recommendation, you can start at 50% intensity and gradually progress to 100% over the course of several months.
- Cutting angle. Start with softer angles, such as a wide curve, and progress to 45°, 60°, and then 90°. 180° is also a consideration.
- Sport-specific. Initially, drills should be preplanned. This means that all exercises are done in a predictable, controlled manner. However, in order to replicate sporting demands, it’s important to eventually incorporate reactive movements that require effective decision-making and more complex interactions with the environment.
Here’s a helpful visual representation by Buckthorpe in 2021. Exercises are plotted by their intensity and complexity, with a 90° reactive cut being shown as the most demanding movement on this graph.
You can also just think of progressions in this category as following a continuum, with slower speeds, softer angles, and controlled and predictable movements on one end, and faster speeds, sharper angles, and chaotic and reactive sport-specific movements on the other.
Be aware that you aren’t going to progress all three variables simultaneously. Instead, you will likely master the speed and cutting angles before including reactive movements.
Let me show you an example of how to use these 3 principles using 4 cones set up in a Y shape as depicted.
Start at the first cone, run forward to the second one, and then cut toward your right at a 45° angle (or less if needed). Jog back and repeat, but this time cut toward the left. Start at slower speeds and gradually increase as tolerated.
As you might expect, you can also make the drill harder by increasing the angle up to 60° and 90°.
Finally, once you can perform these preplanned cuts at various angles and at full speed, progress to reactive movements. For instance, you can run toward the middle cone and then have someone point in the direction you should cut.
There are unlimited options available, but here are 2 more drills commonly used as part of ACL rehab.
Option 1: T Drill
- Set up cones in a T shape pattern as shown and then perform the following sequence: Sprint forward for 10 yards, shuffle to the left for 5 yards, then to the right for 10 yards, back to the left for 5 yards, and finally run backwards to the starting point. Rest, and then repeat, but start by shuffling to the right first.
- This is a pre-planned drill that will expose you to a change of direction forward, backward, and side to side. Start with slower speeds and then build up to 100% effort over time.
Option 2: 5-0-5 Drill
- Run forward 15 meters, cut 180°, and run back 5 meters over the finish line. Repeat, but this time perform a 180° cut off your other leg.
- The goal of this drill is to improve your ability and confidence at performing a single 180° cut at gradually increasing speeds.
Programming Considerations
Although I’ve provided guidelines for programming in the previous blogs, it becomes more challenging at this stage of rehab for 3 reasons:
- Some of this information might not be relevant to your goals. If you have no intention of ever doing a reactive 90° cut at maximum speed, it’s probably an aspect of rehab you can disregard.
- 6-12+ months is in the title of this blog. 6 months from surgery is a long time, so there’s going to be significant variability in the function and capabilities of each person reading this blog. The more specific I try to make my recommendations, the more people I will end up excluding.
- 6-12+ months is also a long time, and a lot can change over that time, which makes recommendations difficult for the same reason.
Here are three recommendations I can confidently state:
- If you plan on returning to playing a sport that involves sprinting and change of direction movements, you need to be doing these drills.
- Do not discontinue or de-emphasize strength training, plyometric exercises, and cardiovascular conditioning. This is your foundation.
- If you have the time, resources, and accessibility, please work with a sports physical therapist or someone else who is qualified to help you accomplish these higher level tasks.
Phase 4 Objective Criteria
With regard to Phase 4 objective criteria, here are recommendations from the Aspetar group that specialize in ACL rehab. Bear with me for a moment. Don’t get too caught up in the terminology.
- No pain or swelling
- Full knee range of motion
- Stable knee (pivot shift, Lachman, instrumented laxity evaluation)
- Normalized subjective knee function and psychological readiness using patient-reported outcomes (most commonly the IKDC, ACL – RSI, and Tampa Scale of Kinesiophobia)
- Isokinetic quadriceps and hamstring peak torque at 60°/s should display 100% symmetry for return to high demand pivoting sports. Restore (as a minimum) pre-operative absolute values (if available) and normative values according to the sport and level of activity.
- Countermovement jump and drop jump >90% symmetry of height and concentric and eccentric impulse. Reactive strength index (height/time) >1.3 for double leg and 0.5 for single leg for field sport athletes (higher for track and field).
- Jumping biomechanics – normalize absolute and symmetry values for moment, angles, and work in vertical and horizontal jumps, especially in sagittal and front plane at hip, knee, and ankle.
- Running mechanics – restoration of >90% symmetry of vertical ground reaction forces and knee biomechanics during stance during high-speed running and change of direction.
- Complete a sports-specific training program.
Essentially, you should be aiming to restore your strength, functional capabilities, and confidence.
Your training over the past 6-12 months can give you a general understanding of how you’re doing, but a sports physical therapist can conduct a more detailed assessment that better identifies your readiness to return to sport safely.
I want to highlight their last bullet point: “Complete a sports-specific training program.”
Returning To Sport
If there was a Phase 5, this would be it.
While Phase 4, or the late stage of rehab, will help prepare you for your desired activity, it is important to understand that you are not performing rehab one day and playing your sport at your preinjury level the next. Throughout all of these blogs, I haven’t even mentioned kicking and dribbling a ball, maneuvering around teammates, challenging someone for a header, or doing whatever is relevant to your sport. Return to sport (RTS) follows a continuum that overlaps with the phases of rehabilitation. Here is a popular framework from Ardern et al in 2016:
“1. Return to participation. The athlete may be participating in rehabilitation, training (modified or unrestricted), or in sport, but at a level lower than his or her RTS goal. The athlete is physically active, but not yet ‘ready’ (medically, physically and/or psychologically) to RTS. It is possible to train to perform, but this does not automatically mean RTS.
2. Return to sport (RTS). The athlete has returned to his or her defined sport, but is not performing at his or her desired performance level. Some athletes may be satisfied with reaching this stage, and this can represent successful RTS for that individual.
3. Return to performance. This extends the RTS element. The athlete has gradually returned to his or her defined sport and is performing at or above his or her preinjury level. For some athletes this stage may be characterised by personal best performance or expected personal growth as it relates to performance.”
Here is a different diagram from Buckthorpe et al in 2019:
Rehab blends with on-field or on-court rehabilitation and progresses to return to training or practice, return to competition, and finally return to performance. The on-field or on-court rehabilitation may incorporate sport-specific technical/skill work, sport-specific work with contact, and sport-specific work with fatigue.
Here’s one last return-to-competition progression from Brinlee et al. in 2021:
- Noncontact practice
- Small-sided contact practices (1 vs 1, 2 vs 2, 3 vs 3)
- Full practice
- Return to competition with restricted workload
- Return to competition unrestricted
As you can see, this is a process that requires careful planning and consideration, particularly if you’re a competitive athlete. Like with everything else, timelines will vary, but most people reading this blog can likely expect the full rehab process to take 12 months or longer. However, as I’ve repeatedly said, focus on your function, not time. This is a long and difficult journey, so take it one day at a time and try not to get too discouraged along the way.
I hope this series has been helpful. Be sure to check out our other resources, especially our free resource about the FIFA 11+, which is an injury prevention program that everyone should consider using as a dynamic warm-up prior to on-field training, practices, or competitions.
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:
ACL Rehab Phase 1, ACL Rehab Phase 2, ACL Rehab Phase 3
Thanks for reading. Check out the video and please leave any questions or comments below.
