Progressing Through Strength Training After Knee Surgery

        Last week, Dr. Anthony Falco discussed the role of the meniscus in the knee and when you should consider getting surgery to repair a meniscus tear. This week, I will discuss some things you should implement into your training program following knee surgery and how you can further progress after you have completed working with your physical therapist following surgery. Following any knee surgery it is imperative to build back adequate muscle mass in the quadriceps, re-establish proper landing mechanics and force absorption of ground forces during high power activities and solidify sprinting mechanics.
 
 
Eccentric focused exercises are your best friends
 
            After knee surgery it is common to experience atrophy (diminished muscle mass) of the quadriceps of the repaired leg. While your physical therapist more than likely focused on building back lost mass, it is imperative to continue this focus once you have moved on to strength and speed training.
 
            While I have no problem with seated leg extensions early on in the rehabilitation process, I believe other alternatives should be utilized in strength training protocol. Essentially, seated leg extensions limit activity of the hamstring while the quadriceps is contracting. This never really happens in sports. So, I prefer the terminal knee extension (TKE), as a quadriceps building exercise that allows the hamstring to work in addition to the quadriceps. Basically, anchor a band and place it around your knee. Slightly flex your knee forward before pulling it back into extension and contracting your quadriceps. While many other quadriceps dominant movements can be performed to build muscle mass (lunges, split squats etc.), here are my general hypertrophy guidelines to follow:
 

• Eccentric Tension
  • The eccentric (think moving back to flexed position in the knee extensions) portion of the range of motion of any exercise is the number one area to build muscle mass as it is responsible for the most torn muscle fibers (main contributing factor to hypertrophy).
• High Repetitions
  • Repetitions in the 12-15 range are perfect to build muscle mass. Go any higher and you will begin instead working on muscular endurance.
• Adequate Time Under Tension
  • Time under tension is basically the total amount of time a muscle spends in a contracted state (sum total of the time spent in all areas of the range of motion). Aim for 30-50 seconds of time under tension to build muscle mass

 
Absorbing forces, re-conditioning tendons and ligaments and sprinting technique
 
            While building mass back in the quadriceps you should also focus on re-introducing your tendons and ligaments to power movements such as jumping and sprinting. It is important not to jump right in to high intensity jumps and sprints as your body may not be ready to handle the demand places on the knee and surrounding areas.
 
Extensive Plyometrics
 
                  Extensive plyometrics are lower intensity jumps that are essentially “hypertrophy for jumping.” Meaning, they rid of use of the stretch shortening cycle (reactive stretch reflex of the ligaments and tendons involved in maximum intensity jumping and sprinting). We accomplish this by implementing pauses or performing short rhythmic jumps. The main goal is to re-condition the tendons and ligaments and prepare them to handle higher intensities. Also, it teaches them how to behave again so performance is maximized later on. During these exercises the focus should be on sound and clean landing mechanics. Here is what you should look for:
 

• Absorbing ground forces with the “entire foot.”
  • Many knee injuries occur due to inability to absorb ground forces with the entirety of the foot. Failing to do so can shift pressure anteriorly (forward) and leave the ACL susceptible to injury. Cue your athlete to land on the ground, box etc. by maintaining contact with the entire bottom of their foot.
• Arm use
  • The arms are a neglected portion of power development and jumping effectiveness. Proper use of the arms can help load timing. Ensure that the athlete lowers their arms into their lower half load.
• Proper External Hip Rotation (Avoiding Valgus)
  • Aim to avoid “knock knees,” (knees moving inward upon pre-loading, load, or landing. If this cannot be done it may be best to take a step back and sure up the posterior chain.
• Land in proper squat position
  • This is an easy cue to use to help landing mechanics. We want to maintain proper spine alignment upon landing and avoid further damage to our back.

 
Low Intensity Sprinting Start Types
 
            Lastly, it is extremely important to reaffirm good sprinting technique while not exposing an athlete to sprinting variations that produce too much power. That is, low start types (push-up, mountain climber, etc.) or start types that involve excess power building via medicine ball throws.
 

• Falling Starts
  • Start type where good acceleration angle is drilled via a forward fall (without flexing at the knees or hips).
  • Considered the most basic of starting types due to the more upright positioning of the body as it moves into the sprint.
  • Use this before you progress into more advanced types that place the athlete at a lower angle. A lower angle is conducive to higher power output.

 
             Overall, it is important to progress through movements with a plan once an athlete has moved through a full rehabilitation program and can begin training!
 
            
Gerry DeFilippo