T Nation

Squatting After ACL Reconstruct

This is a question geared toward readers with either a physical therapy background or have experience with an ACL/MCL reconstruction. I understand that it’s extremely hard on the MCL to deep squat, thus being only 8.5 months out of reconstruction I’m implementing a box squat only program.

My questions are, how long does it take to get back into squatting? Also, is it safe for me to be doing box-squats so quickly out of surgery? I’ve been comfortable with this ROM until last week, when I felt pain in my knee.(I immedietly stopped lifting)

My squatting numbers are much lower than before, I’m only squatting 205 5x 5 at box height! :S

If it helps here’s my Post. Chain routine:

Deadlifts 5x5
Box Squats 5x5
High Pulls 5x5
Ab Cycle

I had my ACL reconstructed back in '03 with the harvested middle third of my patellar tendon.

I squat ass to grass, 5x5.

Your knee is going to hurt, it’s never going to be the same. However, you need to know the difference between when you’re hurting and when you’re really injured.

Box squats seem ok to me in order to help build confidence in squatting again. The mind-fuck is a real thing and I’ve been there. I guess I’m just saying that ass to grass squats can be done after a reconstruct, just make sure you take it easy and don’t overdo it.

My progress was definitely hindered by going straight to deep squats right away.

Good luck dude.

B.

[quote]mj_gk wrote:
This is a question geared toward readers with either a physical therapy background or have experience with an ACL/MCL reconstruction. I understand that it’s extremely hard on the MCL to deep squat, thus being only 8.5 months out of reconstruction I’m implementing a box squat only program.

My questions are, how long does it take to get back into squatting? Also, is it safe for me to be doing box-squats so quickly out of surgery? I’ve been comfortable with this ROM until last week, when I felt pain in my knee.(I immedietly stopped lifting)

My squatting numbers are much lower than before, I’m only squatting 205 5x 5 at box height! :S

If it helps here’s my Post. Chain routine:

Deadlifts 5x5
Box Squats 5x5
High Pulls 5x5
Ab Cycle[/quote]

I am by no means qualified to give information on this subject, but I did have a major knee injury (completely torn ACL, partial tears of PCL and MCL, and meniscus damage) in 2002.

I had an ACL reconstruction done. The surgeon used semitendinosus tendon for the operation. Rehab was a bitch. I didn’t notice any major improvements until I started squatting with moderate weight. I started squatting with 135 lbs. about 3 months after the surgery and was back to squatting my regular weight about 10 - 12 months later. Four years later later, I’m squatting significantly more weight than before the injury. There is no pain in the knee when I squat below parallel. When I try to go ass to the ground I do feel some stiffness in the joint.

I now have a few degrees less for range of motion (knee flexion) and the hamstring on the injured side is still weaker. I think this is because the semitendinosus tendon was used. I can really see and feel the hole where the surgeon cut into the tendon. Personally I think he did a shitty job on me. Good luck with your rehab.

I tore my ACL and MCL in highschool football, wayyy back in Fall of 1998. I didn’t have it reconstructed until late 1999. I had been walking around without my ACL because they had somehow only thought that I had torn the MCL. I was squating 315 prior to the hamstring graft.

It took me a while to get back to squating that. I think I waited about 6 months before I tried to get hardcore about legs again. I have since, been up to 405 for 10 reps, but that was a couple of years ago.

In my experience, I’d say that the way you are going is good. You have to take it slow and feel it out. Don’t do anything crazy until you are fully confident in your knee. Also, make sure that your knee is nice and warm when you work it.

I am currently squating 405 for 4 or so and don’t have any trouble. I have had problems with things like hack squats and the leg press, but not lately. I also felt some pain from power cleans when I was up to 225. I am not sure why. So, uif the doc did a good job, you should been fine.

hey, I had my ACL reconstructed about 20 months ago, which is around the time the knee should be completely healed.

Yesterday I went out played some soccer with the boys from work the next morning and today I could barely walk when I got out of bed. Its the first time I’ve had such a reaction to my activities. However, I haven’t been working out, I been sitting in an office all summer with next to zero activity. But I guess thats not the point of this subject.

I started working my legs out about 3 months after my operation with no weights. I’d squat, I’d do some leg extensions with about 20 lbs. I kept it extremely light. From what I’d heard around the block, if you get into it too fast, too soon your asking for future knee pain when it comes to the change in weather (pressure, etc.). So, I didn’t start using heavier weights (not even close to what I should be doing, 2x own weight) until about 8/9 months after the operation, thats when the doc said I could start playing aggresive sports again.

So to sum it up, I took it easy. There is no point in rushing it. Its nonsense, getting back into previous form if your knee isn’t going to be. You only have one. So if you ask me, you shouldn’t be using any significant weight for a least a year after your operation. Even if you could squat at least 450 lbs. before.

Your knee will come back to hunt your ego.

After what happened with me today, I’m gonna get back into the gym wihin the next few days so I can go hard on the field.

Take it ez.

C Bad

[quote]C Bad wrote:
I’d squat, I’d do some leg extensions with about 20 lbs. [/quote]
Leg extensions are the worst thing you can do after ACL reconstruction! Didn’t your doctor tell you this?

I’m going to have to disagree with you C Bad. The first few months after your surgery are crucial for the rehab process. You need to work extremely hard to regain your range of motion and strength. I’m not sugesting you go out and play sports, but you should work hard under the supervision of a qualified physiotherapist.

How quick to be able to run that knee thru full power without being scared.

This means able to play basket ball on it, stop, cut, change direction, heavy squat/leg press/extension.

Is there anyting someone can do to minimize damage to acl thru sports?

IE: excercises, knee sleeves, etc?

hey Tpa,

I agree with you, the first few months after the operation are the most crucial and you gotta work hard at your physio. But thats what I’m tryin’ to say is, during physio they didn’t hook you up with a 100lbs+ right away, only 2-4lbs…where’d you repeat a motion for 3-4 minutes. Its a long a painful process that has to been taken with caution. You don’t have to squat anything to get your range of motion and strength back.

As for the leg extensions…physiotherapist from the clinic where I had my surgery done gave me a list of all the exercises I can do…leg extensions with a rubber band one was one. And once I began my physio under supervision I did leg extensions ranging from 2lbs. to 8lbs after a month. No doctor, or anyone said leg extensions are a no-no after ACL reconstruction, why would it be the worse thing you can do, isn’t that something that would most benefit the range of motion of your knee?

C Bad

hey DJRobins,

My doc said around after 9 months you can begin playing demanding sports, ie. in your case, basketball.

But like I’ve been tryin’ to say, its all progress. After physio, your leg routine should progress slowly, going thru higher reps before adding more weight. Once you start playin’ ball again, also a slow progression. After nine months my knee felt good, it felt ready, however, the doc said 18 months before its fully healed so I don’t know how you wanna interpret that.

Just the same way each body reacts to exercise and a diet…each knee is also different and its hard to tell what you should and shouldn’t do.

Key is to keep working your legs. Doesn’t haven’t to be a devasting leg routine, just enough to keep in condition. I wrote before, yesterday I went to play some soccer after sitting around doing nothing all summer and today I’ve been limping around all day.

We’re going to have to take care of our bad fella’s now if we want to be able to move, now and in the future.

Hope my own experience helps.

C Bad

[quote]C Bad wrote:
hey Tpa,

As for the leg extensions…physiotherapist from the clinic where I had my surgery done gave me a list of all the exercises I can do…leg extensions with a rubber band one was one. And once I began my physio under supervision I did leg extensions ranging from 2lbs. to 8lbs after a month. No doctor, or anyone said leg extensions are a no-no after ACL reconstruction, why would it be the worse thing you can do, isn’t that something that would most benefit the range of motion of your knee?

C Bad [/quote]

Sorry, I meant you should avoid heavy extensions on the machine. I was told that it can apply shearing forces to the knee, making it more susceptible to injury. But you’re right, I did tonnes of no-resistance extensions in the weeks that followed my surgery. I just started doing heavy leg extension again 3 years after the surgery…not sure if its a good idea though. But having a massive tear drop vastus medialus is cool.

[quote]tpa wrote:
C Bad wrote:
hey Tpa,

As for the leg extensions…physiotherapist from the clinic where I had my surgery done gave me a list of all the exercises I can do…leg extensions with a rubber band one was one. And once I began my physio under supervision I did leg extensions ranging from 2lbs. to 8lbs after a month. No doctor, or anyone said leg extensions are a no-no after ACL reconstruction, why would it be the worse thing you can do, isn’t that something that would most benefit the range of motion of your knee?

C Bad

Sorry, I meant you should avoid heavy extensions on the machine. I was told that it can apply shearing forces to the knee, making it more susceptible to injury. But you’re right, I did tonnes of no-resistance extensions in the weeks that followed my surgery. I just started doing heavy leg extension again 3 years after the surgery…not sure if its a good idea though. But having a massive tear drop vastus medialus is cool.
[/quote]

Yeah, I got the whole “no leg extensions” speech as well.

I don’t do them becuase they make me sore the following day bigtime and I’ve been post-op for over three years now.

As for pivot sports like basketball, tennis, football, baseball, soccer:

Only you will ever be able to determine how you’ll do. Start light and easy and go from there and see how it feels. Look at Willis Mcgehee, kid blew his knee up against ohio state but ended up pushing Travis Henry out of the starting RB slot for the Buffalo Bills. Then look at Terrel Davis with the Broncos who never really recovered enough to strap the pads on again.

We’re all getting bigger, stronger and faster. Our muscles are bigger than ever before. So what happens as the by-product? Our joints take the beating, namely our knees. It’s something that happens to athletes all the time nowadays and surgeons do these reconstructs all the time.

So, how to prevent it from happening in the first place? I’m not sure. My initial injury was just a freak thing that happened in the blink of an eye but my knee still blew the hell up. Having strong quads and hamstrings is probably the best prevention, along with proper running posture and so forth. But all it takes is one instant where your knee is vunerable to impact or your brain decides to make your body cut left when you’re still moving forward to make the ACL explode.

The major flaw with this injury is how commonplace it is. Ortho-docs and physical therapists deal with this injury so often that it’s no big deal to them. Just another knee that needs rehab. Unbeknownst to them this injury has totally tossed the patients life upside down with chances of never being able to do what they used to do, and that can be a heavy thing to deal with.

B.

[quote]BradTGIF wrote:

Yeah, I got the whole “no leg extensions” speech as well.

I don’t do them becuase they make me sore the following day bigtime and I’ve been post-op for over three years now.

[/quote]

Tpa also mentioned this. This is beginning to concern me a bit. I haven’t heard or read anything about weighted leg extensions being harmful after ACL reconstruction.

Like said, I’m about 20 months post ops, haven’t been in the gym for about 4/5 so about 15 months after my operation, I was doing heavy leg extensions with no pain during or after the exercise. Overall, when I worked out my legs my knee felt great. Adding weight to my leg extensions was where I began to add more weight to all my leg workouts and feel more confident.

I dunno, this could be the same thing we’ve been mentioning earlier. Each body, each knee reacts differently.

I’m going to look into this though.

Thanks for the insight guys, so much more can be learned if you actually participate in these forums.

C Bad

[quote]C Bad wrote:
BradTGIF wrote:

Yeah, I got the whole “no leg extensions” speech as well.

I don’t do them becuase they make me sore the following day bigtime and I’ve been post-op for over three years now.

Tpa also mentioned this. This is beginning to concern me a bit. I haven’t heard or read anything about weighted leg extensions being harmful after ACL reconstruction.

Like said, I’m about 20 months post ops, haven’t been in the gym for about 4/5 so about 15 months after my operation, I was doing heavy leg extensions with no pain during or after the exercise. Overall, when I worked out my legs my knee felt great. Adding weight to my leg extensions was where I began to add more weight to all my leg workouts and feel more confident.

I dunno, this could be the same thing we’ve been mentioning earlier. Each body, each knee reacts differently.

I’m going to look into this though.

Thanks for the insight guys, so much more can be learned if you actually participate in these forums.

C Bad [/quote]

Perhaps it’s not the reconstruction itself, but the type of reconstruction that dictates risk with leg extentions?

Mine was reconstructed with the harvsted middle third of my patellar tendon. I had the choice of using either that or an ACL from a cadaver.

Since leg extensions put a lot of stress on the patellar tendon on the upward swing of the movemet I can see why this would be a bad idea when the middle third of the tendon is missing. However, for the guys who had theirs rebuilt with their hamstring tendon maybe it’s not so big of a deal.

B.

Thanks for all the fast info, guys. I’m taking all the opinions in and am trying to sort it out and make sense of it.

On the topic of Leg extensions after surgery, my physical therapist and ortho-surgeon told me to avoid them for the time being as it places a large amount of stress on the ACL. This must be one of those things that therapist have different opions on and can’t really find a study to prove their point.

The reason you don’t do full range of motion knee extensions (90-0)with any appreciable amount of weight during the first 10 weeks or so following a reconstruction is the stress it places on the graft. Knee extensions past roughly 90-40 cause anterior translation of the tibia on the femur…the lower leg is pulled forward in a sliding motion on the upper leg…which stresses the graft before it reaches full maturation.

The graft is actually very strong immediately following reconstruction, it is 6-8 weeks after surgery in which it is the weakest. Knee extensions in the first 10 weeks can be progressed quite heavily so long as they are in the 90-40 degree range of motion with a progression from eccentrics to single leg motion as this range of motion does not contribute to anterior translation of the tibia.

Regarding squats, you should have been squatting the first time you went to therapy…3-4 days after surgery. Bodyweight squats, single leg press, lunge squats, retro lunges, and bulgarian split squats at about 4 weeks post-op…squatting is about the safest strengthening exercise you can complete following ACL reconstruction as it causes a co-contraction of the hamstrings to protect the new graft by preventing the above mentioned anterior translation of the tibia.

The type of surgical technique used (patellar tendon, hamstring, cadaver) has nothing to do with the use of the knee extension (see above description). You may find it easier to complete the motion early in therapy if you have a hamstring graft versus patellar tendon.

Pain several months after surgery with knee extensions is probably indicative of patellar tendonitis/tendonesis (whatever your flavor) or a loose ACL graft. If you find you really must complete leg extensions, try to return to the protected range of motion (90-40) working eccentrics then single leg then returning to full range as tolerated.

Good luck with the ACL rehab…if you have to have a major orthopedic surgery this is definitely the one to have.

[quote]74 wrote:
The reason you don’t do full range of motion knee extensions (90-0)with any appreciable amount of weight during the first 10 weeks or so following a reconstruction is the stress it places on the graft. Knee extensions past roughly 90-40 cause anterior translation of the tibia on the femur…the lower leg is pulled forward in a sliding motion on the upper leg…which stresses the graft before it reaches full maturation.

The graft is actually very strong immediately following reconstruction, it is 6-8 weeks after surgery in which it is the weakest. Knee extensions in the first 10 weeks can be progressed quite heavily so long as they are in the 90-40 degree range of motion with a progression from eccentrics to single leg motion as this range of motion does not contribute to anterior translation of the tibia.

Regarding squats, you should have been squatting the first time you went to therapy…3-4 days after surgery. Bodyweight squats, single leg press, lunge squats, retro lunges, and bulgarian split squats at about 4 weeks post-op…squatting is about the safest strengthening exercise you can complete following ACL reconstruction as it causes a co-contraction of the hamstrings to protect the new graft by preventing the above mentioned anterior translation of the tibia.

The type of surgical technique used (patellar tendon, hamstring, cadaver) has nothing to do with the use of the knee extension (see above description). You may find it easier to complete the motion early in therapy if you have a hamstring graft versus patellar tendon.

Pain several months after surgery with knee extensions is probably indicative of patellar tendonitis/tendonesis (whatever your flavor) or a loose ACL graft. If you find you really must complete leg extensions, try to return to the protected range of motion (90-40) working eccentrics then single leg then returning to full range as tolerated.

Good luck with the ACL rehab…if you have to have a major orthopedic surgery this is definitely the one to have.[/quote]

Absolutely outstanding post 74. Thank you.

Are there other associated symptoms with a loose graft other than patellar tendonitis such as laxity or sticking, clicking, or popping during ambulation or weight bearing excersizes?

Thanks again.

b.

I tore my ACL and MCL. It took me almost two years before I could squat heavy again, over 500 lbs, not because of instability but my form was off. I lost about 20% of the muscle mass in my left leg before I was able to start training again.

I just started light and worked my way back up after my form was perfect for that weight. Squatting, assuming proper technique, is one of the safest activities when it comes to knee injuries.

[quote]E-Rocko wrote:
I tore my ACL and MCL in highschool football, wayyy back in Fall of 1998. I didn’t have it reconstructed until late 1999. I had been walking around without my ACL because they had somehow only thought that I had torn the MCL. I was squating 315 prior to the hamstring graft.

It took me a while to get back to squating that. I think I waited about 6 months before I tried to get hardcore about legs again. I have since, been up to 405 for 10 reps, but that was a couple of years ago.

In my experience, I’d say that the way you are going is good. You have to take it slow and feel it out. Don’t do anything crazy until you are fully confident in your knee. Also, make sure that your knee is nice and warm when you work it.

I am currently squating 405 for 4 or so and don’t have any trouble. I have had problems with things like hack squats and the leg press, but not lately. I also felt some pain from power cleans when I was up to 225. I am not sure why. So, uif the doc did a good job, you should been fine.[/quote]

My son tore his ACL this past year in football as well… he was a junior… and planning to return to his senior season and redeam himself… attempting to play baseball although not fully released as of yet
this is his second ACL tear
he has missed out on his soph and jun season… wants to have a senior season to be proud of … he is a good size, strong kid…
his surgery this time around was done using his own patellar tendon of his bad leg…
last surger was performed using a cadever graft… he had a lot of clicking and stiffness
this has been a better choice of a surger this year… he has experienced no clicking or buckling he has gotten stronger and has been more comfortable this time around
the cadaver graft was a tibial graft … dont think it was a particularly good choice…
he is doing front squats … leg presses and leg curls and well as step ups and lunges… he completed a conditioning program at a clinic recently
any suggerstions on helping him get his quad back and strength to get back into sport…
thanks

[quote]BradTGIF wrote:
74 wrote:
The reason you don’t do full range of motion knee extensions (90-0)with any appreciable amount of weight during the first 10 weeks or so following a reconstruction is the stress it places on the graft. Knee extensions past roughly 90-40 cause anterior translation of the tibia on the femur…the lower leg is pulled forward in a sliding motion on the upper leg…which stresses the graft before it reaches full maturation.

The graft is actually very strong immediately following reconstruction, it is 6-8 weeks after surgery in which it is the weakest. Knee extensions in the first 10 weeks can be progressed quite heavily so long as they are in the 90-40 degree range of motion with a progression from eccentrics to single leg motion as this range of motion does not contribute to anterior translation of the tibia.

Regarding squats, you should have been squatting the first time you went to therapy…3-4 days after surgery. Bodyweight squats, single leg press, lunge squats, retro lunges, and bulgarian split squats at about 4 weeks post-op…squatting is about the safest strengthening exercise you can complete following ACL reconstruction as it causes a co-contraction of the hamstrings to protect the new graft by preventing the above mentioned anterior translation of the tibia.

The type of surgical technique used (patellar tendon, hamstring, cadaver) has nothing to do with the use of the knee extension (see above description). You may find it easier to complete the motion early in therapy if you have a hamstring graft versus patellar tendon.

Pain several months after surgery with knee extensions is probably indicative of patellar tendonitis/tendonesis (whatever your flavor) or a loose ACL graft. If you find you really must complete leg extensions, try to return to the protected range of motion (90-40) working eccentrics then single leg then returning to full range as tolerated.

Good luck with the ACL rehab…if you have to have a major orthopedic surgery this is definitely the one to have.

Absolutely outstanding post 74. Thank you.

Are there other associated symptoms with a loose graft other than patellar tendonitis such as laxity or sticking, clicking, or popping during ambulation or weight bearing excersizes?

Thanks again.

b.[/quote]

Thanks for the post… I am the father of a 16 year old high school football player/baseball player… anxiouslyu awating to return to full athletic training… he is doing front squats with light weight for now until he is proficient then I would like to get him into back squats… and deadlifts
have not considered eccentric leg extensions … will have to try those…
he is almost 5 months post-op
any additional suggestions appreciated

Thanks

I had ACL/MCL/PCL/cracked kneecap reconstruction about 20 months ago. I agree with the previous posters, the first few months are CRITICAL for rehab. This is where you have to rehab it very aggressively and thoroughly.

About squatting, my doctor told me to start doing quarter squats about a year after my surgery. I did so, and I’m able to squat more, but not that much. I can only squat about 145 10 times, and even that is painful, with my knee brace on. After about 7 reps, my knee is hurting pretty bad.

My hamstring is still severely lacking as compared to my other leg, and my knee has definitely gotten stronger, but even after 20 months, it’s still not 100%, and probably never will be.

Concentrate on rehab, then do some quarter squats, and then slowly start increasing the weight, but only when you’re comfortable. Might be a few months, might be a couple of years, only you are the judge of that.