ADDuct for the ACL

Recently…attended a seminar put on………..who could come up with the best rehab program for a complete ACL tear in a female basketball player . The three teams were to present on the specif surgery that would be done and how they would handle the case. One of the common themes amongst every one was the use of isometric hip adduction while performing dynamic squats. Essentially they recommended performing a squat while squeezing a ball between there legs.

Good for ACL rehab according to the "literature." Thanks, APTA!!!

This is very foolish and old school.

1) The dated research that links ADDuctor isotonics to VMO cross-sectional area was 1) studied with open-chain movements, and 2) I believe was second to poor soft tissue quality in regards to binding of the ADDuctor Longus to the VM and VMO. That poor soft tissue quality is likely what led to the injury in the first place that warranted a belief for VMO attention.

Keep in mind that the VMO is a player in PF stability, as all knee structures are, however, it’s dysfunction is 100% reactive. A healthy neuromuscular system marked by centration never has a deficient VMO. Focusing on training it up is benign at best.  It is inhibited as a part of pain/injury/threat and recovery there of, while other muscles like the ADDuctors and RF become facilitated. Releasing or relieving the reasons for facilitated tone is the answer for restoring the VMO, not investigated local approaches. This does not work.
The VMO is not the problem before injury, and it is not the problem after injury. It is just the expression to get you to stop hurting yourself.
I mean is there anyone without an old school physical therapy or bodybuilding background that even still talks about the VMO?

It's like building up the floor without worrying about the roof.

2) If you aggressively ADDuct with something in between your knees and feet apart, try to visualize where the femur and midfoot would “want” to go if you removed the ball or pillow. You are cranking into valgus collapse, but there is an illusion of alignment because of the ball in between the knees. This is just straight out dumb.
We know in fact, we should probably be doing the opposite, banding the knees and demanding the valgus collapse be reacted to and met with femoral external rotation and mid-foot rotation.

There are times in which activating the ADDuctors in an effort to prime the core to stabilize prior to a pattern is useful. This hopefully temporary use of a high threshold strategy is supported by the Superficial and Deep Front Lines of Thomas Myers’ Anatomy Trains, mainly he Deep. The ADDuctors have concurrent neurological pathways through the fascia with many of the abdominals, so there is irradiation as a result.
However, in a technique such as the Toe Touch Progression in the FM System, the feet are as close together as possible to create a bony block against pronation and further valgus collapse. This brief approach is also used sparingly, and is reloaded with glute activation as soon as the hip hinge is satisfactory.

Maybe interested in pre- and post-VMO EMG with this…………….

3) Researching concurrent ADDuctor and glute medius activation is not interesting to me. It is typical contrarian nonsense to try to be a renegade and prove everybody wrong. Not everybody needs to be Galileo.
More importantly than that, the laws of reciprocal inhibition will dominate such a study, and dumb people will look at the research and make some silly attempt to rekindle ADDuctor isotonics just because they are “dimmed” when the glute medius is heavily activated.  In fact, we would want the opposite.  Luckily, this notion hasn’t really fallen into the hands of the Champions of the Stupid as much as some other things.
Just make the move look right and have good underlying mobility and stability. Don’t try to reinvent the wheel.  A centrated hip joint will have comparable muscle activation around all aspects of the joint.  A big EMG isn’t always a good one.
And how or why this equates to the VMO does not click to me.

These guys are far more important for the knee than the bogus VMO.

4) Squatting wide with toes out puts the ADDuctors into a better line of pull to be hip extenders and cover up for inhibited glutes. This may be desirable in unique static situations like powerlifting or some versions of KB swings. But this does not support the original idea of more ADD = more VMO.  In fact, it may support bigger glutes, which is really where the money is at in training after an ACL.

To bottom line it, if the knee hurts, and the VMO is soft, leave it alone and use what you know to limit the pain. In the mean time, spare the knee with hip-dominant patterns and core work.  Obviously post-surgically, there is room for Russian NMES and standing TKE, but not much more than that as I see it.

I think Coach Boyle wrote an article that ACL prevention, which is ACL rehab after the ACL is fixed), is just Good Training. I guess the students at the conference must have missed it.

  • December 11, 2011

Leave a Reply 20 comments

Chris Reply

Great article Charlie ! Reply

Champions of the Stupid is priceless! Love it my friend.

mmaxwell Reply

I couldn’t agree more Charlie. It is always shocking when I here of people using these out-dated techniques. Just last week I had a patient come in with a secondary impingement syndrome and AC Joint Arthrosis, secondary to scapulothoracic instability, and the patient had been prescribed EMPTY can exercises! Oh my. I also agree that there is a time and a place for specific VMO activation, but it is limited to post surgical situations.

Elsbeth Reply

Nice. I recently went to a sports med doc for a knee issue and was told that I should do VMO strengthening and otherwise stop all lower body strength training. *sigh* At least now I know that I have to be careful about which doc I refer clients to at that clinic.

Charlie Reply

Empty can as an exercise is grounds for criminal behavior.

Charlie Reply

We go to “doctors” far more than we need to.

Elsbeth Reply

With the doctor visit first, insurance covers manual therapy. And there is a really good doc at this clinic, so I assumed the others were too. Apparently not.

Shannon Reply

Great article Charlie. Sometimes flat out common sense does not make sense to everyone. You are right about the “research” and how it is applied. Thanks for sharing your knowledge and being so committed to this industry. I just do not understand why the “brightest minds” overlook how the kinetic chain works.

Best in health,

Johndee Reply

Well put. Nice tie in with the trains.

Kyle Adams Reply


Great post about importance of joint centeration. I recently had a patient with 100% hip pain who I reduced from 9/10 to 1/10 with MWM plus core/hip progression after ROM improvement. Luckily his MRI showed HNP at L45 and the doc repetitively told me I was wrong. Doc wanted to inject him. Patient asked with a smile…”he’s going to do it in my back isn’t he?” Got a second opinion and has severe hip OA…sometimes it’s scary what I see.

My larger question is how do you reduce tone locally? Will joint centration improve tone following mobs if it is capsular limitation. Are you referring to soft tissue technique? I am a young clinician and have not had success with reducing adductor tone as I would like

Dr. E Reply

Great post Charlie!

I once trained a fellow for OMPT who kept on giving all her knee patients vmo strengthening. It was the usual SLR with ER, I told her to find me one piece of research that showed it was something we should be doing. She couldn’t find one in a month… yet still persisted… sigh… For me, it’s mostly hip mobs, soft tissue work, and ankle mobilizations that do the trick for most knees. I’ll be linking your post on my blog soon.

Charlie Reply

Great work, Erson.
I hope this new PT isn’t allowed to operate heavy machinery.

Bernie Reply

Where can we find what ” ME ” stands for in your training logs?

Charlie Reply

Maximal Effort

Name Reply

Helpful information. Lucky me I found your website accidentally, and I’m surprised why this twist of fate didn’t took place earlier! I bookmarked it.

Phil Earnhardt Reply

Hi, Charlie. Messages like this are tremendously educational. Passion with facts is always memorable.

Have you ever gotten a chance to play with Fitter1’s weebles? They are a pair of single-foot wobble boards. These are somewhat easier to use than a big wobble board; the surprising thing to new users is how much adduction (DFL) is required to balance on them.

Charlie Reply

Paul – I 100% had one of these when i was in Columbus in the NBDL.

Andy Reply

Great post Charlie. Thanks for you passion and taking the time to share your knowledge. What is a staging TKE?

Andy Reply

Meant standing TKE. Damn auto correct!

Charlie Reply

Terminal Knee Extension

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