Return to Sport ACL Rehabilitation/Training

The goal of this blog post is to talk about a specific rehabilitative technique that has been proven to reduce re-injury rates and return to sport at the same level of competition, as prior to your injury.

This technique is called perturbation training.

Perturbation training is a technique that teaches you to stabilize your knee by using your muscles.  It allows you to form a better connection between your body and brain.  The treatment consists of balance exercises in which an external force is added in a specific manner, causing you to isolate and activate the muscles around your knee.  The difficulty is gradually increased as you get better to more closely simulate the demands sport may place on your knee. 

Pertubation training is effective for people that have had surgery (ACL reconstruction) as well as those who choose to avoid surgery.  Click here to read about non-operative management of ACL tears.

The most frequent question I get is “When can I start perturbation/return to sport training?”

I do not use a timeline to answer this question instead I look at certain strength and power criteria:

Full range of motion and has completed “beginning stages of ACL rehabilitation”

Quad strength (Dynamometry) of at least 80%

Single Leg Hop Testing of 90% of greater

Pt has started a jogging progression

Once your leg is strong and power has returned, you can begin sport specific perturbation training.  Watch this video below to see how I assess power of your leg with hop testing.

While you may be in a rush to return to sport, you should know that most re-injuries occur in the first year. This is worse if you do not have a strong quadriceps muscle and you show poor lower extremity power as compared to your non-involved leg. 

Perturbation training is completed over 10 visits and should take place over a period of time no longer than 5 weeks. 

Perturbation training is completed by using a rocker board, a roller board, and a stationary platform to complete a series of 5 different exercises. Each exercise is completed 3 times for 1 minute with a short break in-between.

The first exercise utilizes the rocker board.  The rocker board rolls along its semicircular bottom tilting from front to back.  

While you are standing on the board, I will be tapping on the front and back.  This results in your body responding by turning on the required muscles to stay upright!  

 Next, we turn the board so that it rocks left and right.  This is important because our knee does not just operate in one plane of motion.  You need to keep the knee stable in multiple planes to avoid re-injury.

When you get really good at these we can turn the board diagonally to work both planes simultaneously.  We can also add distractions such as kicking a soccer ball, throwing a ball, or whatever demands your sport requires.

The next exercise involves standing on a stationary platform as well as a platform that moves!  


This exercise is completed with your injured (or healing!) leg on the board that moves.  I will then move the board.  It is your job to react and oppose the movement.  If things are going well there should be little overall movement of the board.  As you get better, you will be able to turn on, only the muscles you need, rather than squeezing everything to stop the board from moving. 

Just like the rocker board, we start easy with slow predictable movements and as you get better, we make the exercise harder.

We then switch legs, so that your non-injured leg is on the board.  You would be surprised how much work the leg on the stationary board actually does!

Finally, you will balance on the roller board, using only your injured leg.  

The board will be moved, causing your body to react and stay upright while only using your injured leg.  Just like the other exercises we start easy and progress to more difficult movements.

Perturbation training is a pivotal part of safely returning to sport and lowering your risk for re-injuring your knee. 

Training is always supplemented with agility and strength training to maximize results. 

It has been proven that individuals who combine return to sport perturbation training in addition to normal ACL rehabilitation have better odds of returning to sport at the same level as prior to injury.  It also results in lower risk for re-injury!

Patellofemoral Pain Syndrome

If you are having pain in the front of your knee, it may be coming from your knee cap. If you are having pain coming from this area, we call it patellofemoral pain syndrome!

Patella is the proper name for your knee cap.  Femur is your thigh bone.  Your knee cap sits in a groove on top of your femur.  If your knee cap does not track through this groove properly it can cause pain.

             Anatomy of the knee


This pain tends to be worse while sitting, going up or down stairs, squatting, bending, and after exercising. 

The type of pain is typically described in a vague manner and it is often hard to pinpoint the exact location. It is often described as "surrounding the knee cap" and it may feel like it moves around. Less commonly, it can be sharp and focal.

Your knee is densely innervated with pain receptors and there can be a number of structures responsible for your knee pain. Poor biomechanics (the way you move) and poor quad strength are often the main contributors to irritating knee structures.

The goal of this blog is to discuss some biomechanical reasons why you may be having knee pain and show you taping techniques that can reduce your pain while you exercise.  A structured physical therapy program can help improve your biomechanics and provide you specific exercises to increase your quad strength. Taping can be extremely beneficial during this time by decreasing your pain, which will help you to continue working on your physical therapy exercises.

 I utilize the step down test to both evaluate your biomechanics and to determine if patellofemoral taping will help you.  Here is how the test is completed:

Stand with one leg on a 6-8 inch block, place your hands on your hips and lower your body down until your opposite foot touches the ground.

Do not transfer weight to the leg touching the ground. Repeat this 10 times.

During this process, I look at the quality of your movement. Does your knee cave in towards the arch of your foot? Do your knees go over top of your toes? Does your hip drop? 

These are all bio mechanical factors that can be the reason you are having pain.  With proper treatment they can be fixed!

                                                                                  Poor mechanics before and after treatment

If there is pain during the step down, McConnell Taping (also called Leukotape) can be helpful to reduce or eliminate pain (see below).  There are several theories as to why this may help.  Compression of the joint may help to facilitate smoother motion, ensuring the patella stays inside of the groove. It may also serve as external feedback for your brain, allowing you to fire muscles in a different pattern that help to control the movement of the knee cap.  This process is called proprioception or your body’s ability to know where it is in space.

After taping the knee I re-assess the step down test to see if there is any change in pain.  If the pain is gone, I use the medial (pull the tape toward the inside of your knee) taping technique.  If there is still pain, I look to see if using a different technique that pulls the knee cap superior (up) will be more effective (see below).

Once again, I re-assess the step down test.  If there is less pain with this technique, it should be used while exercising to reduce pain. 

Both improving quad strength and the way your body moves (biomechanics) can help eliminate the problem. McConnell tape is extremely effective in reducing your pain while you work to improve your quad strength. This reduction in pain will allow you to increase your activity so you and your physical therapist can work on strength and bio-mechanical deficits so you can fully resolve the pain.

Click here for full uninterrupted video on patellofemoral pain and McConnell Taping!


What Should I Do After Having A Concussion?

A concussion is an injury to the brain that results in neurologic dysfunction.

A concussion is an injury to the brain that results in neurologic dysfunction.


Today, I am going to teach you what you should do if you have sustained a concussion.  I will also explain how physical therapy can be a beneficial treatment to help fix your symptoms.

What is a concussion?

The Zurich Guidelines defines a concussion as an injury to the brain that results in neurologic dysfunction. This is an oversimplification; however, for the purpose of this post, let's keep things simple.  A concussion is a brain injury.

Sustaining a concussion does not always occur on a sports field.  Certainly, sports related concussions are the most publicized, yet concussions also occur from car accidents, slip and falls, or simply “bumping your head.”

It is important to understand that you may have suffered a concussion even though you never hit your head.  You may have experienced a whiplash motion of your neck, which can cause a concussion due to the acceleration forces on your brain.

Many people who have suffered a concussion will develop immediate symptoms of headaches, dizziness, or nausea.  Most of the time these symptoms quickly resolve within 24-48 hours and 80-90% of people will have complete resolution of symptoms within 7-10 days with active rest. I will explain active rest shortly.

The most common signs and symptoms of a concussion are headaches, dizziness, and nausea.  But, there are many other symptoms that you may be experiencing.  Check them out here. Sometimes, you may simply “feel off.”  This does NOT mean that your concussion is less serious.  You should still be properly evaluated by a professional. 

What Do I Do First If I Believe I Had A Concussion?

Current recommendations are to get rest for the first 24-48 hours. It is important to rest your brain and eyes following a concussion.

This does not mean locking yourself in a dark room. You should, however, avoid aggravating stimulus such as loud noise, lights, and computer screens until you are feeling better.

This process is called active rest. You are allowing yourself some activity, but restricting the amount of exposure.  It has been shown that children who are put on complete rest  ( meaning no talking, no TV, no reading, etc.) may show higher levels of anxiety and even report more symptoms.  This makes sense because they have nothing to focus on except for their injury.  We need to rest our brains, but not shut our lives down.

Also, remember, most people (80-90%) who sustain a concussion do spontaneously recover within 10 days. This means that your symptoms may be gone; however, it may actually take up to 30 days or longer for your brain cells to fully heal.  This has implications for returning to sports too early and will be covered in a separate post.

In many cases people are fearful or filled with anxiety after a concussion.  This makes sense!  You just hurt your brain and are having some crazy symptoms, which you never experienced before.  Do your best to stay calm and not let your emotions get the best of you.  There is hope and there is help!

Speaking of emotions, your emotions may go WILD following a concussion.  This is called emotional lability or dysregulation.  Your emotions live in your brain and as you have learned, a concussion is a brain injury.  You should try to explain this to your friends and family members so that they understand and can help support you.  A brain injury can be an invisible injury and people may not understand what you are going through as they cannot physically see your injury.

Physical therapy can help fix the symptoms from your concussion.

Physical therapy can help fix the symptoms from your concussion.

How Can Physical Therapy Help My Brain?

Physical therapy can help resolve your symptoms and get you back to work, sport, and play!

Physical therapy takes a unique approach to fix pain by addressing the problems where they start.

There are 3 main focuses of physical therapy to help fix the symptoms associated with post-concussion syndrome.

Vestibular Rehabilitation

 Your vestibular system is responsible for balance and eye movement (among other functions not typically affected following a concussion).

 When you read, look at an object and turn your head, or simply follow something with your eyes, you are using your vestibular system!  These activities may reproduce your symptoms due to your injury. 

People sometimes describe a pressure behind their eyes, headaches, or dizziness. There are exercises that your physical therapist can prescribe to specifically target your vestibular system to fix these problems. 

You can think of it just like any other exercise you may perform if you hurt yourself. If you hurt your shoulder or back, you would want to perform exercises to improve the strength and reduce your pain, right? This is no different for your vestibular system.

Cervical Spine

 Your neck can be responsible for many of your symptoms, including headaches and dizziness.  Many people also suffer from generalized neck pain due to the whiplash mechanism of injury.   

You may be feeling a stiff neck and physical therapy can help by performing skilled mobilizations designed to restore natural motion.

There may also be muscular imbalance that can result in neck pain, dizziness and headaches.  Physical therapy will identify your specific needs and design a program to FIX your problems.

Exertion Training

Symptoms may occur when trying to return to exercise, sports, work, or other activities. This can occur as your brain and body are not adapting properly to physical exertion. 

Physical therapy can design a specific exertion program based on your heart rate to get you back to living a normal life.

Where Should I Look To Find The Right Physical Therapist?

The first place to look is the APTA Online Directory.  The ABPTS (American Board of Physical Therapy Specialists) will also be an excellent resource. 

Please notice how I mentioned the RIGHT physical therapists.  Not all physical therapists are equipped to treat the many systems involved with a concussion.  You wouldn’t see your foot doctor for shoulder pain, would you?

In many places around the country you may actually need to see 2-3 different physical therapists depending on your symptoms.  A vestibular therapist to address your dizziness, an orthopedic therapist to address your neck pain, and a sports therapist to design an exertion program.

While this doesn’t sound ideal, if there is not a therapist in your area trained to handle all components of your post-concussion rehab it will be in your best interest to find one of the above and coordinate to get the best care.  I would advise starting with a vestibular therapist.

In my training I have been fortunate to have mentoring and education that enables me to treat all aspects of post-concussion syndrome.  This allows me to oversee the entire course of care without any details falling through the cracks.  

Finally, not every concussion is the same.  When choosing a physical therapist you should be sure to find one that will dedicate their time to you and truly listen to what your specific symptoms are and how they are affecting your life.  This will make all the difference in your recovery!

I hope you found this discussion helpful.

To recap:  You learned what a concussion is, what to do if you suspect a concussion, and how physical therapy can help fix your symptoms.