How Do I Get My Quad Back After ACL Surgery?

One of the hardest things to do when coming back from an ACL injury is get your quad back. I don’t just mean ‘passable’ by PT standards… but strong, powerful, popping off your leg.

As is the case for much of the rehab process, most athletes get part of the way there but miss the last step.

This is it.

Think about muscle tissue like armor. It surrounds and protects the joint, absorbing and redirecting forces to lessen the impact on the joint itself.

If we fail to fully regain our strength and rebuild adequate muscle tissue we are going to force the joint to handle more of the burden.

The area we are most interested in is the Vastus Medialis Oblique (or VMO for short). This is the tear-drop shaped quad muscle on the inside of the knee. (picture)

I am interested in this muscle in particular for three reasons:

1. Plays the biggest role in the strength and STABILITY of the knee itself (preventing excessive valgus among other things)

2. This muscle experiences the greatest ATROPHY (shrinkage) after surgery — makes it very important to fully restore and strengthen

3. Has major carryover to athletic ability — running and jumping

So rebuilding strength in your entire leg, but particularly the VMO, is our highest priority at this stage.

It is very important to have a good foundation of movement and circulation FIRST to maximize the effect we are going to get from this training phase. You can learn everything you need to know about that stage HERE 

The key to this phase, the area most therapists get wrong and where we work differently, is focusing on KNEE-dominant rather than HIP-dominant exercises.

A hip-dominant exercise is one that places the greatest amount of load around the hip joint.

Key point here: this doesn’t mean there is NO load on the knee or your knee won’t get stronger, but the majority of the work is not being done by the knee

Examples of Hip-dominant exercises are:

• Box Squats

• Leg Press

• Lunges

Even step ups (at least the way most clinics coach them)

Why is this a problem? Because your body adapts to where it is challenged the most. So if you challenge the hips MORE than the knee, guess where you are going to get strongest…

The hips.

So after a surgery or major injury when there is already a strength gap between your hip and your knee (after all your knee was just cut open and immobilized) you are now making that gap BIGGER instead of smaller by training the hips more than the knee.

This is why I see so many athletes who have done months of PT and made significant ‘strength gains’ that, when tested on a strict knee exercise (like a Poliquin Step Up) still test very weak.

They’re masking weakness in the knee by using their hips

You can only mask this gap for so long, however, and on the sport field there is no hiding.

The body is very good at compensating and will use the path of least resistance to accomplish a task if you let it.

Better to get it right from the start.

You do this by prioritizing KNEE-dominant strength exercises: exercises that put the greatest emphasis on the knee.

Examples of this include:

• Sled drags (forwards and backwards if done with the correct form)

• Step up variations (again form is key)

• Rhythm squats

• Deep squats and split squats (when it’s safe to progress to these)

• (pictures)

These exercises will challenge the strength and stability of both the hip and then ankle, but will be LIMITED by your knee strength.

As you get stronger in these exercises, you will see direct carryover to the strength of your knees! 

When done with proper form (a key detail that can not be overlooked) these exercises give you the ability to precisely build knee strength, observe differences between sides, and create systematic, measurable progress.

Placing a greater emphasis on strength and muscle mass of the knee itself rather than the hips is one of the major differences between how I train and how many PT’s operate.

This is also how I am able to get transformations like this:

Another big difference between how I train and how many therapists operate is that, especially in the earlier stages, I prioritize high REPS over high weight.

This is especially true for our isolated, single leg exercises. I do this for two reasons:

1. You absolutely CAN build strength by working at higher reps (especially when coming off of surgery)

2. Rebuild the NEUROLOGICAL connections (the wiring) between the brain and the muscle

This second point is key and often overlooked. The same way the muscle tissue around the knee will atrophy after a surgery, the connections between the brain and the muscle will deteriorate as well from lack of use.

This is why it is so hard to activate and ‘feel’ your quad working in those early stages (particularly in that VMO!).

By maximizing circulation like we talked about in Phase 1 

And then working high reps (20, 30, even 50+) in Phase 2

We are able to get that muscle switched on and firing on all cylinders and make dramatic changes in size and strength very quickly.

The Poliquin Step Up is really our main emphasis here.

It is fantastic for developing that VMO as well as stability in the lower leg and glute medius (two areas most PT’s obsess over in the early stages).

What’s awesome about this exercise is because we start off with such a small range of motion and such high reps I am able to have my athletes train DAILY.

This means they get 3 - 5 TIMES the amount of work compared to most PT clinics training less reps only 2 - 3 times per week.

This is how my athletes are able to quickly regain full function of their knee and rapidly build strength and muscle mass far beyond most common practices.

We definitely have other areas of interest when it comes to developing high level strength after an ACL injury, particularly the soleus and distal hamstring (down behind the knee).

Our protocols and methodologies here can take up an entire newsletter by themselves, however so I won’t get into them today but know that’s coming too!

So that is the emphasis of the second phase of training for our athletes coming back from ACL and other serious knee injuries:

Rebuild the strength and muscle mass of the knee, particularly the VMO, by prioritizing high-rep, knee-dominant exercises.

The stronger you get here the more protected and more explosive you will be when you get back to full competition!

If you found this information valuable please share it with a friend.

If you’re looking for help with your own recovery fill out my training application here:

This isn’t a commitment or guarantee of training just a conversation starter.

If you want an overview of my entire approach to helping athletes coming back from ACL and other knee injuries check out that article here.

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Till then, peace. ✌🏼