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- More Than Quads...
Quads get all the love and attention when dealing with ACL injuries, and for good reason, but they can hog the spotlight a bit too much as well.
There are more pieces to the puzzle.
This is particularly true in the early stages, when you can't load the quad as much, and in the mid to late stages, when quad strength is getting pretty close to where it needs to be.
Everything is important when it comes to return to sport, but there are two regions I am particularly interested in for ACL's:
Foot and ankle
Hamstring
I wanted to emphasize that last point because it drives me crazy how much some PT's obsess over the glute medius. Doing endless clamshells and monster walks but their athletes still can't do a 2-inch step up exercise without using their hips to cheat because their quads are so weak.
Anyway, rant over.
So first and foremost, any athlete I work with coming off an ACL or other knee injury I am going to blast their calves and tibs. High reps, low reps, different variations and ranges of motion, I want all my athletes to be not just good, but freakishly strong in this area.
Think about it the feet are the foundation. The structures upon which everything else is built. If these are not strong and functioning properly nothing else on top of it can work as well as they're supposed to.
This is key for both improved sport performance (sprinting, jumping, and agility) as well as protecting the knee from injury. In fact we know that the soleus in particular plays a key role reducing load on the ACL during deceleration (1).
That means that the more we can increase the strength of this muscle, the more protection we will have for the knee! The opposite is also true however: failure to develop adequate lower leg strength in the recovery process means you'll have even more load being placed on the knee and ACL when you try to go back to sport-related activities.
So for practical applications that looks like a lot of standing calf raises, yes, but also calf raise variations with the knee bent to work the soleus (the deeper calf muscle that connects to the Achilles). Seated calf machines are great as well as standing variations against a wall but keeping the knee bent to around 90 degrees to maximize the load on this particular calf muscle.
Another key area to focus on is the hamstring. The hamstrings also play a key role in unloading and protecting the ACL (1) and can take a very long time to fully recover. In fact some studies still show strength deficits in the hamstring 2 years after surgery (2)!
Now a key point I want to highlight here is how we train the hamstrings during various stages of the recovery process. In the initial stages you will see a lot of 'knee-dominant' hamstring exercises: towel curls, eccentric hamstring slides, machine hamstring curls, and things like that.
As athletes progress to the mid and late stages of their recovery you start to see a lot more 'hip-dominant' hamstring exercises: RDL's, single leg RDL's,…
My concern with this is that the distal part of the hamstring (closer to the knee) does not get trained as hard, or strengthened to the same degree as the proximal hamstring (closer to the butt).
But we're talking about ACL recovery here, the ligament that attaches right behind the knee like we mentioned earlier. I want that area to be freaskishly strong to give my athletes as much protection as possible when they go back to sports.
This is why with all of my athletes I prioritize exercises like the Nordic Hamstring Curl as one of our primary strength exercises and use RDL's as accessory movements.
The Nordic has two key features that I want to take advantage of:
Overload the eccentric: the eccentric portion of an exercise is primarily responsible for hypertrophy (muscle growth). This means we can more effectively build the strength and muscle tissue around the knee joint that is going to make it stronger and more protected.
Heavily knee dominant: If you've ever tried a Nordic you know that the feeling like your hamstrings are going to tear off your leg is concentrated mostly right behind the knee. That means that's where you're going to get the most adaptation!
Getting very strong on this exercise in particular is one of the key factors that allows our athletes to come back with so much strength, speed, and most of all, confidence.
Just to be clear, I am not saying these are the only two areas of the body other than the quad I want my athletes to train. Yes the hip flexors, adductors, low back, and of course, glutes are all important as well.
However, I consistently find disproportional benefit from putting a great deal of intent into training the foot and the hamstring to a high degree.
If you want to see exactly how and why I apply this in my training drop me a message and I can talk about it more in depth and with visuals on YouTube.
You can always see smaller examples scattered across my Instagram Page as well.
If you're looking for help with your own knee recovery send in a training application and we can talk face to face about where you're at and how I can help.
As always you can connect with me on social media @zakwoodwardatp to see examples of this in action, ask me a question, or let me know what topics you'd like to see covered in next week's newsletter.
Otherwise I'll see you in next week's article.
Till then, bye ✌🏼
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