Weight Training after ACL surgery

**jenscats5** · 07-30-2006, 01:42 PM

When were you allowed to get back into your normal program of lifting legs??

L7 · 07-30-2006, 02:37 PM

If you are talking leg extensions on a machine the best answer is never.

**Vinman** · 07-30-2006, 02:46 PM

Aside from leg extensions which should be avaoided for the first 1-2 years (time it takes the graft to fully heal/ligamentize etc)

You should be able to do leg presses, partial ROM squats and the like at about 4 months. This may be longer depending on how your rehab has progressed and depending on what else was done inside your knee, like meniscal repairs. In the case of meniscal repairs there should be no resisted flexion past 90 deg for at least the first 4 months. That menas no hamstring curls and no leg press/squatting past 90 deg of flexion.

But if your meniscus was undamaged or they did a partial excision then that would make things a bit faster.

**fez** · 07-31-2006, 01:32 PM

I had a tiny meniscus tear that didnt need repair and a torn acl done in March of this year.

I was doing leg presses and partial ROM (unweighted) squats in my first PT sessions a week post op. and was doing things like woodchoppers (with a 25# plate) as well as leg press and free weight squats (light weights, 50# + bar) past 90 deg by the second month. My ROM did recover much more quickly than other people I talked to at PT and they had me progressing faster through the exercises though.

My PT was adamant about no kicking motions though. no swimming, no leg extensions and worst of all no fishing from my kick boat. the PT told me at least 6 months until i could do that.

At my 3 month check up I asked my doc about the kicking thing and told me that kicking was fine and i could do whatever i wanted. I had no restrictions at all. He told me to up the weights and really get after it.

I still havent hit the leg extension machine but i have been out in the kick boat a time or two.

**jenscats5** · 08-01-2006, 08:49 PM

Originally Posted by Vinman

Aside from leg extensions which should be avaoided for the first 1-2 years (time it takes the graft to fully heal/ligamentize etc)

You should be able to do leg presses, partial ROM squats and the like at about 4 months. This may be longer depending on how your rehab has progressed and depending on what else was done inside your knee, like meniscal repairs. In the case of meniscal repairs there should be no resisted flexion past 90 deg for at least the first 4 months. That menas no hamstring curls and no leg press/squatting past 90 deg of flexion.

But if your meniscus was undamaged or they did a partial excision then that would make things a bit faster.

Hmmm interesting as my PT has me DOING leg extensions....

I had a lateral meniscus tear but no repair done on it.....I haven't been doing squats at all since I hurt myself, but have been doing leg extensions since I started PT.....oh and I'm doing hamstring curls as well....

**fez** · 08-02-2006, 01:29 AM

are you talking about the leg extensions where you push straight out or where you make a kicking motion?

**StokeSmack** · 08-16-2006, 10:08 PM

Haven't posted all summer, but this is an interesting thread... seems like there are a lot of different approaches out there. I'm 4 months post-op for patellar tendon ACL graft and meniscus repair. My PT folks had me doing isometrics right away and then before I was even off crutches I used ankle weights. Within two months post they moved me up to leg presses, extensions, and curls on a stacked-weight machine The machine has a detente that is set to prevent the leg from extending too much which I'm told is the only way I can cause undue strain on the new ACL with the machine. I was told to work it as much as I could stand, and to add 5-10 pounds per week. I should be so sore, I was told, that it hurts the next day, and if I can do 10 reps without feeling exhausted, I need to add more weight - and then do three sets. I swim a lot, and I'm told that's fine, but that it's the weight training that will get me where I need to be.

Three months out they put me on a "p-tex" (or something like that) machine. This has a strap which pins your knee to a bench, and another strap that secures your ankle to a shaft. Then they dial in resistance depending on your weight. The idea is to flail your leg up and down (extension then curl) as hard and as fast as possible first 10 times (to measure strength) and then 20 times (to measure endurance), and they compare the measurements to your good leg, and to your body weight. The first p-tex measurements told them that my endurance was outstanding, but that I wasn't pushing myself hard enough on the extensions and curls. I was being overly cautious with the weights, and thinking that swimming was enough to compensate - so I've been killing the weights for the last month or so.

My routine now is streching, calf raises, leg extensions, curls, presses, stair-stepping, balance board squats and lunges. (I have a weight machine that I rigged to only go so far when I do extensions.) The only thing that bothers me is my kneecap hurts where they pulled the patellar tendon. I feel like it always will.

(Sort of interesting side note: last time I went to PT the crew there was dissing Carson Palmer's reconstruction - I live near the 'Nati - saying that he had a cadaver hammy graft and that there was no WAY it would hold up over the season and why didn't he get an autograft.... just goes to show, there seems to be no one universally accepted approach to surgery as well as therapy.)

Anyway, I look at it this way - wrecking my knee sucked, but is going to ultimately make stronger than ever and have more endurance then I've ever had.

Hope your PT is going well.

**ctarmchair** · 08-17-2006, 05:31 AM

Originally Posted by StokeSmack

[snip]...Within two months post they moved me up to leg presses, extensions, and curls on a stacked-weight machine The machine has a detente that is set to prevent the leg from extending too much which I'm told is the only way I can cause undue strain on the new ACL with the machine.[snip]...

Same re: rom restriction and the extensions.

Had interesting conversation with the PT first time around where he basically said there's no reason to ever do leg extensions on a machine outside of rehab relative to other exercises, but we're doing this to keep things very controlled for the course of rehab.

**Vinman** · 08-18-2006, 07:16 PM

As far as I know in my 10+ years of doing rehab with athletes I have never had a doc or other PT that I know of doing leg extensions for an ACL recon. The motion i'm talking about, just to be clear is a kicking type of motion with motion occuring only at the knee.

The reason this is not done is that it creates a shear force on the new graft. The new graft has no blood supply for a couple months and does not fully revascularize until upto a year. And it does not become more ligament like until about 1-2 years. The collagen fibers in the graft change from having tendon types of collagen to having a make up closer to that of a ligament.

Don't do knee extensions during ACL rehab. BAD BAD BAD.

**crashmastera** · 08-18-2006, 11:39 PM

I did my mcl and acl 3 years ago in july playing rugby. that winter i rode on shitty midwest hills and pipes with no problem. I returned to college level 1a rugby by march of the next year. the key for me was COMPLETELY AVOIDING leg extensions and kicking movement for 3 months post surgery. during this time i did a minimum of 500 half and then full body weight squats and surgical tubing hamstring curls EVERY DAY. Let the ligament grow and bond but force your self to do as many squats as possible EVERY DAY. I weighed 245 lbs when injured and lost at least TEN POUNDS of muscle from my injured leg alone. The only way to become confident in a repair like a new acl is to become so strong and proprioceptive that small instabilities that lead to injuries cease to exist.

**jenscats5** · 08-22-2006, 11:33 AM

Originally Posted by fez

are you talking about the leg extensions where you push straight out or where you make a kicking motion?

The seated ones where the pad rests on the shin & you kick out till your leg is straight.....

**jenscats5** · 08-22-2006, 11:34 AM

Originally Posted by Vinman

As far as I know in my 10+ years of doing rehab with athletes I have never had a doc or other PT that I know of doing leg extensions for an ACL recon. The motion i'm talking about, just to be clear is a kicking type of motion with motion occuring only at the knee.

The reason this is not done is that it creates a shear force on the new graft. The new graft has no blood supply for a couple months and does not fully revascularize until upto a year. And it does not become more ligament like until about 1-2 years. The collagen fibers in the graft change from having tendon types of collagen to having a make up closer to that of a ligament.

Don't do knee extensions during ACL rehab. BAD BAD BAD.

Hmmmmmmmmm - very very good post!! I told my PT about it last time I saw him & he said that those who disagree with doing leg extensions during ACL rehab haven't read the research correctly and that the shearing force on the graft isn't that great at all....

*Shrugs* I dunno.....I have no clue.....

All my weight work for legs right now is unilateral - meaning I'm only lifting my right leg to try & catch it up with my left leg....the only bilateral moves I'm doing is squats & SLDLs.....oh and they have me running now 2x a week.....

**Vinman** · 08-22-2006, 06:22 PM

AFAIK it is generally accepted by the rehab community that it is not done. low shear force or not IMPO there is really no reason to do leg extensions during the early stages of rehab. There are certain ranges of motion where it is considered safe to do extensions (where the shear force is low), but I repeat I would not advocate doing this until you are much much further into your rehab.

Maybe ask your ortho the next time you see him/her, maybe there is a reason they have you doing what you are doing.

L7 · 08-22-2006, 07:03 PM

Originally Posted by jenscats5

he said that those who disagree with doing leg extensions during ACL rehab haven't read the research correctly

Of course now we've got the suggestion that some PTs don't read well and it begs the question if it is your PT or the many many others who feel extensions are dangerous for early rehab. Just the fact your PT would slam those with a different opinion would make me very wary.

**jenscats5** · 08-23-2006, 07:54 AM

Originally Posted by Vinman

AFAIK it is generally accepted by the rehab community that it is not done. low shear force or not IMPO there is really no reason to do leg extensions during the early stages of rehab. There are certain ranges of motion where it is considered safe to do extensions (where the shear force is low), but I repeat I would not advocate doing this until you are much much further into your rehab.

Maybe ask your ortho the next time you see him/her, maybe there is a reason they have you doing what you are doing.

My ortho has no opinion on my exercises/rehab, etc - he says it's all up to my PT....says I can do whatever they tell me to do....

And my PT is with a well known University and I'm actually in a study group on ACL recovery, etc......so it's not like the PT dept. is in a strip mall or something.....

Interesting on the diff. schools of thought on the subject......Actually have to do legs today & I'm just not into it....bleh!

**jrredho** · 08-24-2006, 01:02 PM

Originally Posted by jenscats5

Interesting on the diff. schools of thought on the
subject.

So, just to jump in out of nowhere with a side-comment: While there may be
different schools of thought as to the rehab effects, there is absolutely
no doubt that the amount of shear force that must be opposed through your
knee joint is equal to the amount of weight you're lifting. Period. That
fact derives from simple statics-analysis. (Okay, there may be a bit of
dynamics involved if you're lifting in fast motions, but the shear force
will still be close to that number.)

Vinman: ISTR that 20 years ago, many, many ACL-ers did rehab with a Cybex
machine. I don't hear about alot of these being used now. Weren't the
dynamics of that machine such that you had lower forces at full extension
than one might encounter with weighted leg extensions, or do they have
similar drawbacks (in your opinion) to leg extensions? Also, what
PT-related exercises have they been replaced with? (I guess I'm wondering
what you get with a leg extension that you cannot get with a squat...)

thanks,
john

**Vinman** · 08-27-2006, 03:00 PM

The mechanics of a cybex/nautilus machine were to reuce torque at the "sticking points" of the motion. By sticking point I mean the spot in the lift were you must generate the highest amount of force to move the load, typically at around the 90 degree angle point in most joints.

The reason that squats/lunges/leg press are the preferred over leg extensions is that they are considered a closed kinetic chain exercise. In CKC exercises all three joint in the chain move at predictable ranges of motion and the end link(the foot/ankle for the lower extremneity) is planted on the floor or foot plate. In open chain only one joint moves and the terminal link is not fixed/planted.

And for the shear related to a leg extension. I think what you are getting at is eqal and opposite reaction right.... You are correct.

Shear in this case is caused the the quad pulling on the front of the tinia causing it to move anteriorly in relation to the femur the exact motion the ACL is designed to prevent. So after surgery the thing that would be oppsosing that shear is your brand new ACL graft with no blood supply. Not an ideal situation since your new graft would be getting stressed with no way to repair itself causing it to strech out.

At the knee during a CKC exercise(squat/leg press/lunge) there will be both hamstring and quadriceps muscle activation. The hamstring activity opposes the shear force created y the quads to stabilize the joint, therefore making if safe for a new ACl graft. With OKC motions (leg extension) there is no muscle activity to oppose the shear force created by the quad as it pulls on the front of the tibia causing anterior translation of the tibia in relation to the femur.

Hopefully that helps answer your question. If not let me know and I'll see if I can clear it up a bit.

**Plakespear** · 08-28-2006, 10:43 AM

Follow up ?/partial hijack:
I want to start lifting again this week. In April I broke my tibial plateau (top of tib bone) I still get some pain from it, particularly when going down stairs. In my case, I was thinking that leg extensions might be a good excercise, since it eouldn't be putting weight on the injured bone.

**jrredho** · 08-28-2006, 02:30 PM

Okay, let me know if this is off-topic enough to move elsewhere...

Originally Posted by Vinman

The mechanics of a cybex/nautilus machine were to reuce
torque at the "sticking points" of the motion. By sticking point I mean
the spot in the lift were you must generate the highest amount of force to
move the load, typically at around the 90 degree angle point in most
joints.

Vinman, you're talking about something different than what I was referring
to.

Before Cybex moved on to these Nautilus-style machines, they made their
name with a machine that didn't even include weights at all, as far as I
could tell.

I don't know much about their then-current product line, but the machine
I'm specifically referring to looked similar to a leg extension weight
machine. These machines (1) really isolated the knee joint using velcro
straps on the thigh and calf, and (2) had resistance that was based
entirely on the angular velocity/acceleration (I'm not really sure which)
of the lower leg. At the start, where one's tib/fib were at 90 degrees to
the femur, there was very little resistance (maybe even zero). I think
this was true for full extension position as well. In between was a
build-up/die-off of resistance that was related to how strong your quad
was and how much stress/pain one's knee could handle.

The time I recall seeing this device in action was the mid-80s in the Rice
University varsity weight room. The only folks that I ever saw use this
contraption were rehab'ing, post-op football players.

Originally Posted by Vinman

And for the shear related to a leg extension. I think what
you are getting at is eqal and opposite reaction right.... You are
correct.

My statement on the shear is based entirely on mechanics analysis: One can
draw a free-body diagram of a cantilever beam, i.e., a beam with one end
built into a support wall and the other end free hangin, with a vertical
load applied at the free end to see what I'm talking about. At the
builtin end there has to be both a resistance force and bending moment to
keep the beam in equilibrium. That force has a magnitude that's equal to
the vertical applied load, and the moment is the magnitude of this force
times the distance from the built-in end to the force application point.

How the resistance force and moment is effected is the bio-mechanics; that
is something that I can't speak about. I'm thinking that what you're
saying is that, simply put, the resistance shear force is almost entire
effected with the ACL?

thanks,
john

ps And to all you rehab'ers, keep up the faith and the hard work; y'all
are bad-asses...

**Vinman** · 08-28-2006, 06:42 PM

the device you are talking about is an isokinetic machine. You are correct, with and isokinetic machine, no matter how hard you push against it, it moves at a constant angular velocity. Typically they were tested at slow speed ~60-80 deg/sec or faster at 180 deg/sec. Of which neither of these translates into real world numbers well because almost nothing we do is a angular speeds that slow.

These kinds of devices were typically used for testing only and not for every day rehab. These days they are still used in the research setting. But in the rehab setting I think more and more we are moving towards real world functional types of training and measurement. I imagine there are places that still use them for rehab type testing though.

As for your second point, yes we are talking about the same thing from two different points of view. And yes I mean to say that the shear force generated by the quad as it pulls the tibia forward during a leg extension is resisted by the ACL. I'm sure there are other structures that do take up some of the load but the ACL would be the main one.

Plakes: That is a tough one. I would look more towards partial weight bearing exercise like pool rehab. Rehab in the pool lets you unload the joints while still getting resistance. Not sure if I would have you doing leg extensions or not. Kind of depends on where exactly the fracture ws and how healed it is. I'm guessing that it is almost totally heal bone wise since you are walking stairs.

Maybe try some limited ROM leg extensions with light weight to start. Something like 0 -30 deg (straight - partially bent). Give the pool rehab a thought though too.

**Cono Este** · 08-28-2006, 06:58 PM

One machine, Hip flexor. up/down side to side.

no leg extensions.

**Plakespear** · 08-28-2006, 07:13 PM

Originally Posted by Vinman

Plakes: That is a tough one. I would look more towards partial weight bearing exercise like pool rehab. Rehab in the pool lets you unload the joints while still getting resistance.

Umm... remember where I live? The fact that there's a gym within 20 miles is amazing in and of itself.

**Vinman** · 08-29-2006, 07:15 PM

Originally Posted by Plakespear

Umm... remember where I live? The fact that there's a gym within 20 miles is amazing in and of itself.

you can always go wading in the East Branch of the Delaware River..... or maybe go poach a condo at Hunter.

**jenscats5** · 09-02-2006, 09:29 AM

Originally Posted by Vinman

The mechanics of a cybex/nautilus machine were to reuce torque at the "sticking points" of the motion. By sticking point I mean the spot in the lift were you must generate the highest amount of force to move the load, typically at around the 90 degree angle point in most joints.

The reason that squats/lunges/leg press are the preferred over leg extensions is that they are considered a closed kinetic chain exercise. In CKC exercises all three joint in the chain move at predictable ranges of motion and the end link(the foot/ankle for the lower extremneity) is planted on the floor or foot plate. In open chain only one joint moves and the terminal link is not fixed/planted.

And for the shear related to a leg extension. I think what you are getting at is eqal and opposite reaction right.... You are correct.

Shear in this case is caused the the quad pulling on the front of the tinia causing it to move anteriorly in relation to the femur the exact motion the ACL is designed to prevent. So after surgery the thing that would be oppsosing that shear is your brand new ACL graft with no blood supply. Not an ideal situation since your new graft would be getting stressed with no way to repair itself causing it to strech out.

At the knee during a CKC exercise(squat/leg press/lunge) there will be both hamstring and quadriceps muscle activation. The hamstring activity opposes the shear force created y the quads to stabilize the joint, therefore making if safe for a new ACl graft. With OKC motions (leg extension) there is no muscle activity to oppose the shear force created by the quad as it pulls on the front of the tibia causing anterior translation of the tibia in relation to the femur.

Hopefully that helps answer your question. If not let me know and I'll see if I can clear it up a bit.

Very informative!!

Do you have a list of leg exercises to do?? Would like to compare the list to what I have & see if I can add anything.....

Don't think I'll be doing the leg extensions anymore......what about lying leg curls??

**dogwonder** · 09-02-2006, 04:16 PM

I've rehabbed two torn ACL's, patella tendon graft each time. Dr. Robert Johnson in Burlington repaired both knees, the first in 1993, the second in 1996. Dr. Johnson is a known conservative rehabilitator with 0 PT in the first 6-8 weeks post-op. With that as background, here's my .02

Dr. Johnson was much more active in rehab than it appears your ortho is. I stuck to my PT program and didn't try to do too much too soon. If I remember correctly (and it was a while ago), I started limited leg extensions ~3-4 months after surgery. These extensions were with ankle weights and only from 90 degrees (leg straight down) to 45 degrees (leg half way extended). I was allowed to do leg press & leg curls with very few restrictions.

I didn't start doing full leg extensions until 6-8 months after surgery, ensuring the graft was set (as has been pointed out in prior posts).

So here's my value add. With this conservative rehab program, I have 0 problems after 10+ years on each knee. In those 10 years, I have picked up skiing and mountain biking (never did either before) and for the most part don't notice any difference to my pre-op days. I am a step slower and on cold days, they'll get a little stiff.

Take it fwiw...