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T=R: The ACL Edition

What is your opinion on when athletes should return to strength training following an injury?…..not talking about the…..acute or subacute phase….but once the athlete engages in physical training, and the goal of the rehab becomes strengthening?

I'm really literally LOL.

I’m really literally LOL.

I think strength training starts relatively immediately, as in later in the day of surgery maybe if they aren’t groggy.
Think of the simple rules that we would always use….
1) Does it look good (as in good form)?
2) Does it hurt?
For the ACL rehabilitation, there are obviously some other rules regarding protecting the graft for a few months depending on the surgical procedure used, but the answer to when strength training starts is more similar to the answer to any environment of strength training.
Does it look good, and does it hurt?

Basically as soon as the manual therapy to the structures around the knee, basic teaching of self-ROM and overpressure, Russian e-stim, assisted squats and weight shifts on and off the Vibraflex, stepping as competent are all put in place, I want to get to as much of the full program as possible beyond these local approaches.
An interesting piece perhaps is that a big week 2 goal for me is pull-ups. There is absolutely no reason why someone recovering from an ACL procedure can’t do pull-ups or any upper body exercise if………1) it looks good, and 2) it doesn’t hurt.
Now if a little girl or her mom is scared as all get out of her hanging up there, we’re not going to do it, but it’s not wrong. I really like that risk-reward in terms of feeding the nervous systems inputs that tell the brain, “We are fine.  We are ready to go.” That message translates to the knee, and the knee isn’t even loaded.
We can get to medball work and chops and lifts in the supine position. As much upper-body work as possible is in the mix.  I recently demonstrated this at my T=R seminar in NYC where we used explosive chop and lift medball throws from the supine position in the context of recovery from serious knee surgery………….if 1) it looks good, and 2) it doesn’t hurt.
One of the terminologies I’ve made up in trying to help define does it hurt with a surgery is “reverb.”  So for training upper body with an ACL or any lower body procedure, it obviously can’t hurt in the upper body, and the pressure and vibration from the movement can not lead to any symptoms in the knee.

Example of Rope Lift out of supine. Can be done with Bar, Rope, Band, or Medball.

Example of Rope Lift out of supine from functionalmovement.com. Can be done with Bar, Rope, Band, or Medball.

And when you talk about speed and agility, I believe that all starts with weight shifts with centrated lower extremities and the most mild of step matrix patterning to push loading and backside mechanics.
I’m at the very least THINKING of all of these things on Day 1. There is no onus to get anything performance-based in any time frame, but the sooner the better.
The more efficient stress that can be exposed to the body during this injury healing process will allow for the central mechanisms of GPP to be often nearly as effective, and without a doubt these fitness qualities positively affect the healing process.  But also, the no-mans-land of when an athlete is medically cleared and then ready to train and/or ready to play can be minimized if a lot of conditioning is already in place.

This is what can happen when bad rehab folks own the athlete when he is "injured."

This is what can happen when bad rehab folks own the athlete when he is “injured.”

 

For instance, ACL surgery 5 months out…should an athlete have a limit on load predetermined?
………some MD’s release to train while others hold…some PTs still have SAQ going on while others have athletes performing one-legged squats on an Airex or Bosu but ban Rack Pulls because “heavy weights cause too much stress…..

There is NEVER a pre-determined load.  That is nonsense.  How would any training environment be spoken to with some arbitrary limit, particularly without prior context?
Getting strong with a compromised knee is based on the rep scheme you want, perfect form, in this case lots of vertical tibia, and absolutely zero pain, and satisfactory recovery.
At 5 months, there should be some fairly well loaded squats and deadlifts, both single and double leg, if you moved progressively early on.  And even if you didn’t, the loads should still be challenging. Heavy is always just relative.

When we get into surgeons and PTs that have these nonsensical approaches, you’re basically just talking about just very under- or mis-educated individuals.  They don’t know what they don’t know, and it’s a shame.  But I’ve recently come to verbalize that it’s not that these poor messengers exist that bother me.  It’s that people actually listen to them, look up them, read and follow their stuff.

And they do ACL rehab on wobble boards.

And they do ACL rehab on wobble boards and with leg raises.

Some of my most proud stories in all of my career are the young high school aged females tearing their ACLs and getting into training for the very first time.  Some of their lives have been changed forever from these horrible-at-the-time life events.
We’ve had 110# girls sumo DLing 225 with perfect form in month 2-3. Now is that a risk-reward I champion today? Maybe not as much as I did a few years ago, but these girls by month 5-6 were sumo’ing most of the time double body weight, squatting at least 80% bodyweight for reps, 1-leg squats or even pistols with load. We had one girl who had to weigh less than 120 bury 5 ATG 1-leg squats off the side of a box carrying 2 17.5# DBs. And this was WELL before 6 months.
The knee is centrated, the foot is grounded and short, and there was no pain. There is absolutely no reason NOT to do this.
And yes, I’ve also had some of these girls that have retorn their ACL and hurt their back and other things that I nor anyone is immune to during serious training.  Did any of these things happen because we went T=R too aggressively?  Who know?  I don’t think so.

ACL rehab is an exciting thing because for most kids, it’s a free pass for them to learn how to train the right way without the sport or metabolic demands getting in the way.
When we hear about silly unstable surfaces and limits on loads and exercises outside the south range of intelligent training which includes knowledge of pathology and precautions, you really are just quoting clowns, Champions of the Stupid.

Progression is mandatory. Longer phases of ownership of the progressions are mandatory. Zero pain outside of ranging is mandatory.
Training hard all the time is mandatory.

Telling me why you shouldn't or don't intelligently train hard during a surgery is telling me that you just don't know how.

Telling me why you shouldn’t or don’t intelligently train hard during a surgery is telling me that you just don’t know how.