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Fitness Corner: ACL recovery

Texans strength and conditioning coach **Dan Riley** writes his popular Fitness Corner column for Riley and assistant strength and conditioning coach **Ray Wright** will continue to post selected answers to your questions throughout the year. Join in by shooting over an e-mail to ****.
Here's Dan...

I am a redshirt freshman DB at the University Wisconsin River Falls. I recently (March 12th) had bone-to-bone ACL reconstruction on my right knee from a basketball injury I suffered February 5.  How do I regain all my lost strength and how do I know when I am ready for competition again? Are you involved in the rehab of your players? What can I do for my uninjured left leg to keep the strength that I have and also gain more? What else do you recommend for rehab that my therapists may not suggest that is a little more football specific? Thanks for your help! Go Houston!

-- AJ Bautch

The best advice I can give you is to continue following the guidelines given to you by your therapist. I do have some thoughts in the area of rehabilitation I will share with you based upon the many hours I have spent helping athletes regain lost strength after an injury.

Early in my career I spent a significant amount of time in the area of rehabilitation. Strength training did not have the widespread acceptance it now has among the coaching community and the medical community. Most trainers and therapists only had a superficial understanding of how to regain near maximum strength levels. It wasn't until the advent of the Cybex knee unit that strength training became an accepted and important component of the rehabilitation process.

Here with the Texans we have a medical staff with the knowledge and expertise to coordinate our players rehab from post surgery until they are back on the playing field.

Kevin Bastin is our head trainer and the medical liaison for any rehabilitation involving our players. He coordinates any and all information to and from our doctors, to the players and the coaches. Assistant trainers Jon Ishop and Tom Colt work with Kevin as part of the rehabilitation team. Tom is also a physical therapist and according to our players, the best in the business. Rehabilitation is a tedious and time-consuming process. Having our medical staff coordinate all phases of injury rehabilitation allows Ray and I to focus on our healthy players.

During the rehabilitation of an injury Kevin will let Ray and I know where a player is in his recovery and tell us what things a player can do and what things a player must avoid. We rely totally upon the instructions of our trainers when it comes to the recovery process of our players and I suggest you do the same. Our trainers conduct the majority of our player's rehabilitation. We get the "mop up" duty.

My philosophy (from a strength coach's perspective) regarding rehabilitation is the following:

A player is not fully recovered from an injury until he:

  1. Recovers from surgery (if the injury required surgery).
  1. Experiences no pain or swelling.
  1. Regains full range of motion.
  1. Returns to pre-injury maximum strength levels in every muscle affected directly or indirectly by the injury. This must include both multi-joint and single joint (isolation) exercises. To accomplish this the athlete must perform exercises with a fused movement arm (both arms or legs contribute equally to lift the weight) and also with a non-fused movement arm (each arm or leg is forced to lift the weight independently -- photos 1 | 2). Equal strength must be developed between the affected limb and the non-affected limb.
  1. Regains requisite game speed fitness levels. If during the season this must include position specific fitness levels.
  1. Regains the position specific skills used to play their position.
  1. Participates in practice and games.

Once Kevin releases a player to us our goal is to help him regain maximum strength levels based upon our pre-injury records.

We keep accurate records on a wide range of exercises. Each time our players lift we document seat settings, the amount of weight lifted, and the number of properly performed reps completed.

We have a computerized program to keep records of each exercise performed during every workout. On the computer sheet they print for each workout are several columns of information.

  1. Column one lists the exercises in that workout.
  1. Column two lists the seat settings for any piece of equipment with an adjustable seat. Once the seat is adjusted we want to make sure it is in the same position every time they perform that exercise. Moving the seat can provide a leverage advantage (or disadvantage) making an exercise easier (or harder). If a player lifts more weight or reps, we want it to be because he has gotten stronger, not because he made the exercise easier by changing his seat position.
  1. Column three and four list the athletes' best effort (weight in pounds and number of good reps performed) ever on that particular exercise. This serves as a barometer for us if a player is injured. Our goal is to return a player to his best effort on every exercise and if possible try to increase his strength. We do not formally test and compare our players on how much weight they can lift. This is meaningless information for us. Comparing a player to himself from one workout to the next is invaluable for the player and for us especially when a player is recovering from an injury.
  1. Column four and five list the amount of weight used and the number of reps they performed the last time they completed that particular workout.
  1. Column six lists the amount of weight they will use the next time they perform that workout.
  1. Column seven provides a space to record the number of properly performed reps for each exercise for that particular workout.

At the end of the day we go through each workout sheet and update any changes. If you haven't already, I would suggest you keep accurate records of all your workouts. It is most important during rehabilitation.

I can provide you with some of the methods I used when I was actively involved in the rehabilitation process. Should you consider using any of these techniques I would strongly encourage you to consult with your therapist.

Listed below are some of the questions I am asked regarding rehabilitation. The assumption is the athlete is pain-free and has full range of motion. Also the head trainer has released the player to begin regaining lost strength.

How much weight should be used?

Be conservative. Safety first. I always start with a weight I know is too light. The intent on the first day is to take the athlete through the full range of motion provided by the exercise and wait until the next day to determine if there is any aggravation. Keep accurate records. If there are no problems I will increase the weight during the next workout. The amount of increase will depend upon the exercise performed and the equipment used. Two and one-half pounds may be too much on one exercise and ten pounds may be too light on another. I will continue adding weight each workout until the athlete is unable to complete the designated number of reps for that day, or until he has returned to his pre-injury maximum strength levels on all exercises involving the knee, hip, and ankle.

How many reps should be performed?

In the early phases of rehab I use our slow-rep technique. I would use a stopwatch and sound off with a verbal cadence of eight seconds during the raising phase and an emphasis on the lowering phase. I start with ten reps and reduce the number of reps to eight when heavier weights are used. A major advantage of using slow reps is the amount of weight used is reduced significantly, which decreases the shearing forces and stress to the joints. After several weeks of exclusively using slow reps I would have the player begin to alternate workouts using slow reps one workout and normal reps the next workout. Our rep range for the hips and legs when performing normal reps is twelve.

While performing normal reps we adhere to the following protocol while performing each repetition.

  1. Eliminate momentum during the raising phase. No sudden, jerky, or cheating movements. Raise the weight in a smooth and deliberate manner.
  1. Pause momentarily (for a count of 1001) in the muscles contracted position. The Sliding Filament Theory tells us the greatest numbers of muscle fibers are recruited in this position. Little or no strength will be developed in the contracted position if the player doesn't raise the weight and stop. By pausing momentarily in the contracted position all available muscle fibers will be activated and it makes for a smoother transition from the raising phase to the lowering phase.
  1. Emphasize the lowering of the weight. The same muscles are used to lower the weight. One half of the exercise is lowering the weight. Because of gravity and intracellular friction, we can lower a great deal more weight than we can lift. Under ideal conditions more weight should be added while a player lowers the weight and the extra weight removed during the raising phase. This is impractical therefore the only safe and productive alternative is to take more time during the lowering phase. Unfortunately most athletes have been programmed to focus on how much weight they can lift and are only preoccupied by lifting the weight with little or no concern for lowering the weight.
  1. Rep reproduction. We stress performing each rep at the same speed. It makes it difficult to document strength gains from one workout to the next if haphazard lifting and lowering techniques are used.
  1. Raise and lower the weight through the muscles full range of motion.

How often should a player lift?

In the early phases of rehab I would train a player on consecutive days. I would do this because the starting weights were very light and the athlete could easily recover by the next day. I would continue this protocol for several weeks until the athlete began using meaningful weights or he was showing signs of not fully recovering from one workout to the next. At this point I would decrease the number of training sessions from five workouts per week to three (Monday-Wednesday-Friday). As his strength progressed closer to his best efforts I would decrease the workouts permanently to two a week (Monday-Thursday).

Which exercises?

* *When I began the rehab process our players had full range of motion. I would select only one exercise on the first day of rehabilitation. The athlete would warm up and then select a weight I knew was extremely light and have him perform several sets. The purpose of this protocol was to determine if there was any aggravation or negative impact (joint soreness) caused by this exercise. This would be evaluated on the next day.

One particular piece of equipment might cause some irritation while the same exercise performed on a different piece of equipment might be joint friendly.

This process would continue each day (adding one new exercise) until we included each of our lower body exercises. If many new exercises or activities are added all at once, and there is soreness on the next day, it becomes more difficult to identify what is causing the soreness.

Single joint (isolation) exercises must be performed for each major muscle group. When you perform multi-joint exercises (squat, leg press, lunges, step-ups) several muscle groups contribute, some more than others. Therefore the strength increases will also be distributed between or among the muscles contributing.

Simply put, the muscles directly involved in lifting and lowering the weight will benefit the most, while the muscles indirectly involved will benefit the least. To restore near maximum strength levels it is essential to target each of the major muscle groups with an isolation exercise. Each of these muscle groups will then be forced to perform all of the work and obtain maximum benefits. A player will not regain all lost strength in each of the major muscle groups unless he targets each major muscle group with an isolation exercise.

The major muscle groups that should be targeted with an isolation exercise:

  1. Hip extensors (hip extension)
  1. Hip flexors (hip flexion)
  1. Hip adductors (hip adduction)
  1. Hip abductors (abduction)
  1. Knee flexors (leg curl)
  1. Knee extensors (leg extensions)
  1. Ankle extension (standing and seated calf raises)

Our basic lower body template includes the following sequence of exercises.

  1. Leg press/Squat
  1. Leg curl
  1. Hip extension
  1. Hip abduction
  1. Leg Press/Squat
  1. Leg extension
  1. Leg Press/Squat
  1. Adduction
  1. Hip flexion
  1. Standing calf raises
  1. Seated calf raises

Which equipment?

* *Once significant strength gains are being generated I recommend alternating equipment with fused movement arms (both legs work together) and non-fused movement arms (each leg works independently). There is an advantage of using both types of equipment.

To regain all lost strength in the injured leg it must be forced to perform exercise independent of the non-affected leg. If you begin the rehab process lifting with both legs simultaneously, the non-injured leg will perform more work. Therefore it is paramount that you begin the rehab process forcing both legs to work independently.

If your facility is limited and you do not have equipment with non-fused movement arms you can perform exercises one leg at a time on equipment with a fused movement arm.

Early in the rehab process I would only train the injured limb. Once meaningful weights were being used, I began training both legs independently. It was at this point that I began alternating workouts using equipment with fused movement arms one workout and non-fused movement arms the next.

At this point there are neurological advantages and disadvantages to performing an exercise with each leg independent of the other and performing each exercise with both legs working together.

Cross-Education (Cross-transfer)

In your question you asked what can you do to continue to strengthen your non-affected (uninjured) leg. You were concerned with maintaining the strength you had in your non-injured leg and if possible continuing to gain strength in your healthy leg.

My advice is do not worry about your healthy leg. It is not the problem and you do not want it to interfere with your rehabilitation. Your non-affected leg will lose some strength if you discontinue lifting during the early phases of rehab. You will regain any lost strength in just a short period of time when you begin lifting with it again.

The problem is obviously your injured knee. You will probably experience significant atrophy (loss in muscle strength and size). You will have to work extremely hard to regain pre-injury strength levels with your injured leg. It will be much easier returning to maximum strength levels with your non-injured limb.

There is an exercise phenomenon called "Cross Education" or Cross Transfer." I no longer recommend this technique. Physical educators teach this concept in exercise physiology courses. I subscribed to this technique early in my career but no longer practice it, or recommend it.

The theory states, as one leg (or arm) performs an exercise the brain sends a signal down the spinal cord activating motor units, motoneurons, and eventually enough muscle fibers, to cause movement in the exercising leg.

When the signal reaches the base of the spine the majority of the signal is sent to the exercising leg. However, some of the signal is split and diverted to the non-exercising leg. This is the purported advantage. Even though the injured leg is immobilized, we can activate a small percentage of muscle fibers and possibly minimize some atrophy.

Keep in mind the strength of this signal is very low. It is not strong enough to observe or feel any muscular activity in the injured leg. Very few muscle fibers are activated.

In my opinion the amount of neural activity is negligible and of little or no value in the overall rehab process.

In fact it creates a new problem. Not too long ago, a player's leg would be immobilized for many weeks with a cast or a brace after surgery. Months passed before he regained full range of motion. Significant atrophy would take place.

My goal was to take advantage of cross-transfer by having the player begin training his non-injured limb as soon as he was able. I would focus on the healthy leg hoping the immobilized and injured leg would benefit indirectly. As you would expect, the non-injured leg developed and maintained near maximum strength levels.

A problem developed every time I utilized this protocol. The imbalance in strength between the legs became so significant it took almost a year before a player could perform a lower body exercise without the non-inured leg dominating. Our players always complained well into the rehab process that the non-injured leg kept performing more work no matter how hard they concentrated on forcing both legs to work equally.

In the classroom cross-transfer sounds good theoretically. It has been my experience that in a practical setting it is ineffective and it inhibits the completion of the rehab process. Before following the advice of someone recommending this methodology, I would ask him or her if they have actually utilized this concept and conducted the rehabilitation from beginning to completion? And remember, the rehabilitation is not complete until the player has returned to maximum strength levels on all exercises.

The medical profession has become more aggressive in their approach to expediting the return to exercise and activity. Today the medical profession recognizes the damage done with bed rest, inactivity, and immobilization. The current trend is beginning some type of activity as soon as possible after surgery.

Do not worry about your non-injured leg. I would recommend you stop performing any strength building exercises with your "good" leg. At some point in your rehab (when you begin using meaningful weights with your injured leg) start lifting with your non-injured leg. Even though you are capable, do not use more weight with your healthy leg. Use the same weights you are using to rehab your injured leg. Eventually your injured leg will catch up to your healthy leg.

Your non-injured leg and past lifting records (prior to your injury) becomes your barometer for complete recovery. You have completed your rehab when your injured leg is capable of lifting the same amount of weight as your non-injured leg.

And remember, once you begin using meaningful weights it is essential that you alternate your workouts with exercises designed to work your legs simultaneously and with exercises designed to work each leg independent of the other.

Leg Extensionsyes or no?

At some point during the rehab process it is my opinion that leg extensions must be performed through the quadriceps full range of motion. This exercise should be performed on equipment that provides isotonic (not isokinetic) exercise.

There are four major muscle groups composing the quadriceps. Each of these muscles contributes as the leg is extended. The muscle on the outside of the leg begins the movement while the muscle on the inside the leg completes the straightening of the leg.

We have learned from past isometric studies that muscles are only strengthened at one fixed point. When a lifter pushes against an immovable object (isometric exercise) and exerts a maximum effort, strength is gained at that specific point. The many other points of that muscles range of motion are unaffected. An appropriate amount of resistance must be provided through the muscles full range of motion if the goal is to regain lost strength.

It is also important for the athlete to pause momentarily in the contracted position while performing any exercise. It is especially critical during knee rehabilitation when performing leg extensions and leg curls. If the athlete bounces in this position there are many muscle fibers that will never be recruited or strengthened.

Some athletes never regain full development of the quad muscle on the inner thigh (medialis). This is because they do not perform leg extensions or they are not pausing in the contracted position.

While with the Redskins we signed a free agent linebacker from another team. He was a Pro Bowl linebacker and very muscular. During his first workout I noticed one of his legs was significantly smaller than the other. I asked what was wrong with his leg. He said he had knee surgery two seasons ago. During our conversation I learned that he was told not to perform leg extensions.

We began including leg extensions in his lower body workouts. He performed slow rep (8 seconds to raise the weight) leg extensions the rest of his career. It took almost a year to regain most of his size back.

It lacks logic to tell a player he can go out on the field and engage in violent activities yet cannot perform an exercise in a very smooth and controlled manner in the weight room. The leg extension is not a bad exercise, what is bad is the technique many athletes use to perform this exercise.

When can I return to full practice?

Earlier in this article I listed the criteria I used before allowing a player to return to full competition. You must consult those involved in your rehab and you must be part of that process.

My advice to you AJ is to get together with your therapist and let him/her know what date you are targeting to be ready for practice. Now work backwards from that date. How many weeks do you have to regain maximum strength levels? My goal was to have a player return to his best efforts on every exercise (isolation and multi-joint) and have several weeks to maintain that level of strength to insure retention at that level.

You can only train your legs twice during the week if you are training hard. If you have five weeks before practice begins you will only have ten lower body workouts to regain maximum strength levels. You must ask is this enough time? If not you must delay your comeback until you have had enough time to regain all lost strength in a variety of different exercises.

Each rehab is a little different. I would always get feedback from the player and make adjustments based upon how well the athlete was responding, and I suggest you do the same.

Best of luck with your rehab and thank you for your interest in the Texans.

My question is regarding recovery time. I have very low body fat composition and my body puts on muscle very slowly. I am fairly experienced at creating maximum intensity in my workouts, and I am usually sore for several days. While not wanting to over train, I also want to push my strength levels by not letting atrophy occur. Should I take soreness into account while calculating my recovery times between workouts? I have heard you should not work out if you are still sore. I am wondering though if my muscle may be fully recovered and ready to lift again. Is it a buildup of lactic acid that makes it feel sore?

Nick Wyss

San Marcos, Texas

I am fascinated with the area of recovery. I hope that some day we will be capable of accurately monitoring recovery without being invasive (blood or urine samples). You have asked several in-depth questions. I am not sure if I know the answers but I can give you my opinions.

One of the many advantages of utilizing the system we employ (low volume – high intensity) is the ability of our players to physically recover quickly from our workouts (once they have adapted to this style of exercise). The metabolic damage caused by the lifting however will require a full 48 to 96 hours to repair.

I can give you an example of how fast our players recover physically from an intense workout. During this past season David Carr was sidelined with a shoulder injury and was not 100% but was just about ready to return to competition. It was a home game and Tony Banks was starting at quarterback.

David was going to be active for the game in case of an emergency. He didn't plan on playing so he scheduled a workout with me in our weight room at 10:00 a.m., Sunday morning the day of the game. He trained his neck, midsection, upper body, and arms. He finished the work out with a very intense arm routine we call the terrible towel.

Unfortunately early in the third quarter Tony Banks injured his hand and David entered and finished the game. As the game progressed I kept asking him how he felt and he said, "I feel great." And then jokingly said, "We should get a pump before every game."

Do I recommend lifting before a game? Obviously I do not (and please don't mention David's pre-game pump to Coach Capers). However it illustrates how quickly a person can recover from an intense but brief workout.

It is a major mistake some fitness enthusiasts make when they first begin experimenting with high intensity workouts. Initially some fitness enthusiasts feel the need to perform additional exercise, which is a mistake. Extra exercise is unnecessary if the workout was properly performed. At this point adequate rest becomes the catalyst for stimulating maximum gains, not more exercise.

Time and energy is limited for our players. Our goal is to get the absolute best results while expending the least amount of energy. It lacks logic to perform one extra rep if it is not necessary.

During my early years as a strength coach I believed in volume. More exercise and more sets (and more time wasted between sets). It took me a long time to realize the key to generating maximum gains for a football player is not how many sets, or how many exercises are performed. The key to generating maximum gains is how each exercise is performed.

Some athletes perform meaningless non-productive sets. The overload principle is pretty simple. To get stronger you must attempt to lift more weight and/or perform more reps. Overload must be provided every workout, while performing each exercise, if additional strength gains are to be generated. You cannot increase strength with sub-maximal weights.

In our program the term, "Today is my light day" does not exist. A "light day" using our system is a non-productive workout and a waste of time and energy if your goal that day was an attempt to increase strength.

Let's assume with a maximum effort you can lift 100 pounds for 8 reps, and you are unable to properly complete a ninth rep. This is your current strength level for that exercise.

If your goal is to increase your strength during your next workout you must increase the weight (105 lbs.) or attempt to perform more than 8 reps. The overload principle dictates this. If you continue to lift 100 pounds for 8 reps you will maintain this strength level if you train twice a week and allow adequate recovery between workouts.

This is the goal of our players. They must continue to add weight each workout, on every exercise, until they stop making gains. The goal at that point is to maintain these maximum or near maximum strength levels from the first day of training camp through the last game of the season.

Nick, you mentioned you are sore after every workout. It is abnormal to be sore as much as you are. No one knows for sure what causes muscle soreness. If you only perform concentric exercise (only raise the weight and do not lower the weight) little or no soreness occurs. If you only perform eccentric exercise (negative only exercise – only lower the weight) extreme muscle soreness can occur.

In exercise physiology classes we are taught that when a weight is lowered the muscle is forced into a stretched position. With a new exercise, or some form of negative-only exercise, the lifter experiences some micro fiber tears in the stretched position. Some edema (swelling) occurs. This swelling put pressure on the nerve endings which cause the pain.

Unless you are performing a great deal of negative-only exercise (with heavy weights) my assumption is that you are performing too much exercise in your workouts and/or not allowing enough time to recover between workouts.

You stated that you were fairly experienced in creating maximum intensity in your workouts. Some lifters try to apply high intensity principles to the more traditional training protocols that incorporate many more sets. Too much high-intensity exercise will prevent complete recovery and lead to strength losses and undue muscular soreness.

I suggest you experiment with a decrease in the volume of exercise you are performing in a given workout. Cut back on the number of exercises and/or sets you perform in a workout.

For example if you are performing three sets of an exercise eliminate one set and only perform two sets. Keep accurate records. If you are able to maintain your strength level after cutting back on your volume, you can assume you were performing exercise that was unnecessary.

If this occurs, continue cutting back on the amount of exercise until you determine how little exercise you need to maintain maximum strength. It is my responsibility to our players to find out how little exercise they need to generate the best gains. We cannot afford to waste time or recovery energy on non-productive exercise

I suggest you do the same. This may eliminate your soreness and possibly produce even better results. When you first begin a strength program you should expect some soreness and the harder you work the greater the amount of soreness. After several workouts the soreness should disappear. You should not experience any new soreness unless you:

1.Perform a new exercise.

  1. Use a different piece of equipment to perform a similar exercise.
  1. (Properly) perform negative-only exercise.
  1. (Properly) perform negative-accentuated exercise.
  1. Perform too much exercise (too many sets and/or too many exercises per body part.
  1. Train too frequently and do not allow adequate recovery between workouts.
  1. Perform additional exercise (running, bicycling, etc.) that combined with lifting becomes too much exercise to recover from.

I can make a player sore the day after a workout. Because he is sore does not necessarily mean he gained strength.

Eliminate non-productive exercise from your routine and make each set as productive as it can be. Perform as little exercise as is needed to get the best results. It sounds like you are a very hard worker. For people like you my advice is, whenever in doubt always perform less exercise.

One half of the fitness formula for generating maximum gains is exercise (at the appropriate level of intensity and volume). The other half of the formula and equally important is rest. Too much of one will limit your gains.

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