Post-ACL and the QUAD

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

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!!!

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.”

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.

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.

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

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.

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.

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.

“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!

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!

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.

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?

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.

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.

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.

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?

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?

Agreed on all of this.