How to Initiate Plyometric Training After ACL Surgery

Let’s start by using a case study to help us to better understand the return to plyometric activities. Joe is a high school basketball player who tore his ACL while landing on one leg after shooting a layup. He underwent surgery and has had a fairly straight-forward rehabilitation up until this point. The first 12 weeks of his rehabilitation were centered around regaining his range of motion and building strength in order to create better symmetry between his lower limbs. He has progressed very well, and he is ready to initiate straight line jogging as well as lower level plyometrics. This is a scary task for Joe. He has not performed any form of ballistic movement in almost four months and now we are asking him to perform movements that are beginning to resemble the movement that led to Joe’s injury in the first place.

Guiding Principles

If you have never rehabilitated a post-operative ACL reconstruction before, trying to figure out where to begin with return-to-play progressions can seem like a tall task. Having a set of guiding principles can make the programming process less intimidating. Below are the guiding principles that we will follow for plyometric programming while navigating the return-to-play process:

First, we will progress our athletes from a stable to less stable environment. It is important to note that we are not talking about the surface the athlete is standing on. While the Twitter world loves to debate stable versus unstable surface training, we will steer clear of that today. For the sake of our guiding principles, stable will refer to two foot take offs and landings (jumps) and less stable will refer to single limb take offs and landings (bounds and hops).

Second, we will start with movements requiring low force production and progress towards higher force production plyometrics. We will discuss this concept in more detail to come. In order to provide you with an easy to follow list in one place however, here is the progression we will follow:

· Landing Mechanics

· Non-Countermovement Jump

· Countermovement Jump

· Drop Jump

· Depth Jump

· Continuous Jump

Finally, we will progress our athletes from general movements to movements that are more specific to the sport they play. Don’t overthink this! Think movement direction. We will start in the sagittal plane with vertical plyometrics and progress towards lateral and transverse plane plyometrics that place more rotary and sheer forces on the knee. We will go in more depth on this concept in a future blog post.

Landing Mechanics

Before starting our true plyometric training, we need to spend time teaching our athletes how to land properly. I refer to this as pre-plyometric training. During this phase, we focus on eccentric control and teaching body awareness during the absorption phase. This stage is crucial, as most catastrophic lower body injuries happen in the eccentric phase of a movement. By teaching an athlete how to maintain proper hip-knee-ankle alignment while landing, we set the stage for safe and efficient movement. This provides the athlete with a foundation to build off of as we progress to more challenging movements.

Some of my favorite ways to teach athletes landing mechanics include drop squats and box drops. During the drop squat, the athlete will start on their toes with both hands overhead before quickly snapping down into a mini-squat position. I have found that a great cue for this exercise is to “pretend someone is ripping the floor out from under your feet.” Box drops are performed in a similar fashion, except this time we will step off a box. As you will see in the video below, we are progressing from stable to less stable (two feet to single leg) and low force to higher force (drop squat to box drop).

As we discussed earlier, initiating plyometrics can be a scary task for the athlete recovering from an extensive injury. One of the first mental hurdles we will have to overcome is getting comfortable going into closed chain triple flexion (hip flexion, knee flexion and ankle dorsiflexion) rapidly on the surgically repaired limb. I have found medicine balls to be a great tool for overcoming this barrier. Medicine ball slams force the athlete to quickly snap their hands back, which reflexively leads to triple flexion of the lower limbs. In the video below, we progress from two leg to single limb in the sagittal plane before adding a more transverse plane component. By slamming a medicine ball, we are able to keep the forces relatively low in these exercises.

Medicine ball chop lunges can provide another great stimulus to teach an athlete to load their hips instinctively while going into a triple-flexed position. This can be progressed to a bound as well. You will notice in this video we progress from the sagittal plane, to the frontal plane, and finally the transverse plane. Because the medicine ball never leaves the hand, the forces experienced during these exercises will be a little higher than those experienced during the slams.

Introduction to Propulsion

Once an athlete has begun to demonstrate competency with landing mechanics, we introduce them to the concentric portion of plyometrics. We do this by performing the exercise from a static position, called a non-countermovement jump. The pause before the jump, bound, or hop removes the stretch-shortening cycle component, giving the athletes less variables that they have to control (therefore, this would also be considered pre-plyometric training).

In the video below, we begin by performing a non-countermovement box jump to minimize the forces the athlete must absorb during their landing. We then introduce more force by removing the box and forcing the athlete to absorb more force during their landing.

So far, we have essentially broken the plyometric into its respective parts – absorption and propulsion – in order to force the athlete to own each phase separately before combining them to produce more athletic-looking movements. In my next blog I will go into detail about how to introduce the stretch-shortening cycle as well as how to determine training volume when programming plyometrics (click here).

If you missed my last blog, which covered the naming of plyometric exercises as well as some of the research behind plyometrics and injury prevention, you can find it here.