Post-ACL and the QUAD

…….from a very excellent strength & conditioning coach that I know well and greatly respect his work…………

I have a good relationship with a very well known knee/shoulder guy in the area. He sends me tons of patients, sometimes I feel they need someone more qualified but the Doctor loves us and says we get better results than most PTs…………. 
…………We get lots of Post rehab ACL people, usually 3-6 months post op after PT. I am told by him that they need quad strength but cant squat or lunge………….What should my main focus be?
…………In these specific cases is the leg extension, which he says is a good choice, the right option?
…………Also as I am sure they are weak in the Post Chain how should I structure the program in terms of balance? More quad work, even, more post chain?

Perhaps this is the knee surgeon in question talking about quads, isokinetic testing, and lateral release.

1. To start this off, this physician is an idiot.
I’m sure it’s an article unto itself, but why there is any assumption that a surgeon is also expert at rehabilitation is just bizarre.  They may very well be expert, but to assume that doctors or surgeons know more or better than PTs and trainers is just ludicrous.

So if these folks are directed by Dr. Dumbass to not squat or lunge, then how are they going to get in and out of a car, a chair, take a dump, go up and down the stairs, pick something up off the ground?  Need I go on?  I mean even walking is a model of lunging when there is double stance.

2. My experience is that doctors don’t give a rat’s ass about patients’ ultimate success, but rather their immediate happiness.  Immediate in the case of ACL surgery is about 9 months.  I don’t think most surgeons care about anything past 9-12 months even, and anything not right after that point, the surgeon is out of the picture, and the athlete or parents chalk it up to some form “I guess this is the best it’s gonna be as good as it’s gonna be.  I had surgery.”

I think f your kids come back with a strong quad, and their parents are happy, I don’t think this buffoon doctor is going to care if you did with squats, lunges, or rubbing your tummy and patting your head at the same time.

3. If squats and lunges are out, how about Deadlifts, 1-leg deadlifts, and spit squats? Those are technically not squats or lunges, are they?

Dude, you can’t be serious.

4. The quad “weakness” is a reaction to the knee pain/surgery.  This arthogenic inhibition was not the problem before the surgery. I think there is fair agreement among those that are not retarded that the ACL is jeopardized by limited stability in the frontal and transverse plane, not the sagittal plane. While I don’t think this is suggested by your idiot doctor, the posterior chain that controls the valgus collapse should be the primary focus, not the quad.

Perhaps this study will demonstrate that stupid “intensive” rehab does nothing to your little quad problem?

Quad girth or isolated extension strength is meaningless when you can bury a 1-leg squat or have great form in the 5-Hop Test.  These are 2 measures that have very positive correlation in outcome studies at least 2 years ago when I wrote my DPT project on the latest evidence on tests in Outcome studies in the literature.

I will suggest that I will and have used version of Russian e-stim at any point in the training process where tone is below minimum standard.  I am not very educated on its nuances, but it appears the Compex devices are very worth looking into.

Probably something there with this thing.

5. If you never isolate knee extension, I think you will be fine. In fact, one of the more successful interventions to increase isolated quad performance is manual therapy through the proximal hip flexor attachments @ ASIS and AIIS.  The quad is in “safe mode” even though the surgery is healed. The quad is still trying to protect the knee, and the right type of manual therapy can release that tone.  Quad contour will change immediately.

6. If you insist on isolating knee extension, the best option, which is not completely isolation, is the standing TKE. You can use a band or a cable machine. I have used sets of 25 for this movement in conjunction with an anterior core and/or WBV training.  But this is probably just keeping as much of the bath water as possible without puking.  This clearly can not be a go to move or something “quad strengthening” is based upon.

“This is the best you NBA guys got for the best PG in the world?”

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19 Responses to “Post-ACL and the QUAD”

  1. Bruce Kelly says:

    Charlie,
    Say what you really think!?! LOL.
    Bruce Kelly

  2. Charlie,

    I think I know a few other doctors that were classmates of this dumb dumb of a surgeon. One if the core classes they took in Med School was squat and lunge hateology. Most of these surgeons haven’t learn a thing about functional anatomy since they graduated in the early 80’s and the seated knee extension must have been all the rage at the time.
    Since reading an article that Bret Contraras wrote recently about how ACL safe the forward lunge is and how very little if any tension is placed on the ACL during the forward lunge, I’ve confidently programmed FL variations in post surgery ACL athletes and have had great success. The difficult part is convincing the athlete that these are safe motion beacuse, just like this surgeon you’re talking about, they never fail to mention that squats and lunges are “no-no’s”. Here is a lunge variation and SL squat series that I like to use as a preventative measures as part of warm-ups and when they’re ready, post surgery:

    http://www.youtube.com/watch?v=3dmMPsV5oyo

    http://www.youtube.com/watch?v=MconB74KUU4&feature=relmfu

    I’d love to hear what you think about them.

    I’m a little surprised to hear that you’re a proponent of using stim as a modality but I also know you’re also a fan of doing what works. I’ve had a lot of experience using a stim device called the ARP WAVE with those who’ve had extreme atrophy after an injury, most specifically and Achilles tendon rupture. His calf was reduced to nothing and resistance training wasn’t getting the job done. 3-4 ARP treatments a week for a month and it packed the muscle on and then he was able to resume resistance training and function was restored.

    Happy Thanksgiving!!!

  3. Kyle Adams says:

    We have multiple surgeons in town that tell post-surgical patients to never squat again, and then quote literature regarding a “deep squat” and patellar compressive forces. My approach is to control effusion first, mobilize if needed and begin to hammer the hips. Dynamic motion progresses from saggital to frontal to transverse assuming no funky movement patter problems. Could you expand some time on manual techniques you favor to reduce tone locally? As a younger clinician I sometimes find it hard to control hypertonic tissue that presents as antagonistic “tightness.”

  4. Eric Lazar says:

    Great post! I once heard a podiatrist say that orthopedic surgeons are lumberjacks who fell off the truck in front of a medical school. Perhaps that’s an old saying, but unfortunately it still too often resonates, and the disconnect between orthopods and PTs is perputated, instead of focusing on a true patient-centered approach. Guess I’ll just continue to be a cynical optimist.

  5. Really glad that 90% of the surgeons I work with “get it” when it comes to rehab and I think it is unfair to lump all in the same group on here. I also think there is a lot to be said about orthos who are doing 100+ ACLRs a year who are typically well-versed in the complete picture of the injury/recovery. Maybe I am just spoiled in my market. :-)

    I would imagine some of these ridiculous comments are by the 85% of orthopedic surgeons who are doing less than 10 ACLRs per year.

  6. Charlie says:

    Bruce – It might be nice to hear someone else do it every once in a while.

  7. Charlie says:

    Angelo – Closed chain training is safe and been preferred for many years. Leaving the ground is not until the surgical knee is properly progressed.
    The first Youtube is not something I would do, but the 2nd one is.

  8. Charlie says:

    Eric – I am neither pessimistic or optimistic. When we work with a surgeon that is happy to be part of the team and not worry about rehab, then it’s a pleasant experience with no tug-of-war and a wonderful outcome for the patient.

  9. Charlie says:

    Julie – I too have several surgeons that are both great surgeons and well versed enough in training conversations.
    Unfortunately the reader that sent in those questions has 2 problems…..a foolish surgeon, and a gamet of local PTs that can’t provide standard care at certain time frames.

  10. saulj says:

    “If you never isolate knee extension, I think you will be fine. In fact, one of the more successful interventions to increase isolated quad performance is manual therapy through the proximal hip flexor attachments @ ASIS and AIIS. The quad is in “safe mode” even though the surgery is healed. The quad is still trying to protect the knee, and the right type of manual therapy can release that tone. Quad contour will change immediately.”

    Did you get this through a research article or is this through clinical experience. Great article thanks!

  11. Any particular reason the forward lunge with the lateral disturbance is not something you would do to any athlete or just ACL post op? Your feedback is greatly appreciated!

  12. Charlie says:

    Angelo – Part of the point to challenging the frontal plane is to do it through the whole movement. Pushing on the knee in a static position is only part of the picture.

  13. But how much activity is needed from stabilizer before contact with the ground is made? How about if I would push starting at with the forward step, through ground contact and only release the disturbance after the return push? would making those changes increase the efficacy and functionality(I didn’t want to use this word but it was fitting) of the movement?

  14. Charlie says:

    Angelo – It’s just getting to fancy. Can they lunge keeping their knee in-line? Then load it up. If they can’t, band it. This hand stuff is making it more than it needs to be.

  15. Got it. Thanks Charlie! Most of the athletes I work with are MMA fighters and the are constantly getting their legs kicked and slammed into while under load so I thought it would be a good idea to reinforce keeping a stable knee under load with outside forces challenging the stability. I’ll spend more time with single leg activities that have a stability emphasis. Thanks again for your input! I really appreciate it.

  16. Jack Behne says:

    Reminds me of a Surgeon who did a majority of the ACLRs at the hosp I new gradded in. His 3 month follow-up with patients usually involved telling them that 200-500 SLRs a day would be fine rehab, and never to run again.

    While he wasn’t alone in these kinds of sentiments, most surgeons I deal with are keen for squatting and WB ex as soon as able really.

  17. louise says:

    I am 11 months out of acl surgery, on my left knee. My quads are still atrophy, still in pt, doing acupuncture, what more can I do to get the quads working. I try to run but my left knee starts to hurt after about 1/2 mile. I am a very active person and love to work out. Any idea’s?

  18. Adam says:

    Would you expect squats and lunges to be safe for the ACL-deficient knee? If so, the vertical shin would reduce shear on the knee, by better glute activity and because of the emphasis on a posterior weight shift, right?

    Also, if someone has no ACL but wears a brace to play sports, would oh recommend working out with or without the brace?

  19. Charlie says:

    Agreed on all of this.

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