247. Split Squat Compensations During ACL Rehab w/ Megan Graham

In this episode of The E3 Rehab Podcast, Chris Hewitt sits down with Megan Graham, a physical therapist and newly minted PhD graduate from the University of Kentucky, to discuss her recent research on compensatory movement strategies during the rear foot elevated split squat (RFESS) after ACL reconstruction. The study, conducted with 25 participants in the mid-stage rehab phase (3–4.5 months post-op), revealed that despite similar hip and knee joint angles between limbs, the ACL-affected side showed significantly less knee contribution (18%) and greater hip contribution (58%), indicating a strong compensatory hip-dominant strategy. Additionally, interlimb compensation was observed when the surgical leg was in front—patients offloaded more weight to the rear leg, increasing load on the non-surgical limb and reducing quad demand on the surgical side. Megan shares practical clinical insights, including the limitations of standard RFESS for quad loading and the value of constrained movement techniques, such as using a wall or squat rack to prevent posterior weight shift. She also discusses how cues like an upright trunk may unintentionally increase offloading, and offers alternatives like foam pad placement under the rear foot to limit compensation. The conversation underscores the importance of movement variability, exercise selection, and awareness of biomechanical constraints in rehab, especially when progressing patients toward sport-specific demands. Key takeaways include: 1) The RFESS is inherently hip-dominant post-ACL, even when performed correctly; 2) Constrained versions (e.g., wall-supported split squat) are more effective for quad-specific loading; 3) Patient-reported sensations (e.g., quad pump vs. glute activation) are reliable proxies for tissue targeting; 4) Load progression should be paired with movement constraints to avoid compensatory strategies; and 5) A variety of exercises—combining constrained and unconstrained movements—is essential to ensure comprehensive tissue loading. Megan also hints at future research on how increasing load affects compensation, suggesting this is a critical gap in current literature. Overall, the episode provides a nuanced, evidence-based perspective on optimizing closed-chain exercises in ACL rehab.