ACL Surgery and Long Term Strength Results

Brian Dick

To start, I’ve had two ACL surgeries in the past 10 years — one on each leg (I also had a partial meniscus removal from my left leg in 2007). My first surgery was in 2002 (left leg – football) and the most recent was in 2012 (right leg – Brazilian Jiu Jitsu). Both surgeries were hamstring reconstruction surgeries, where one of my hamstring tendons was removed and used as the new ACL graft. This type of surgery is in contrast to the patella tendon graft, or cadaver graft reconstruction. I had two separate surgeons, both of which had performed hundreds (if not thousands) of ACL surgeries prior to mine, mostly on athletes.

My biggest fear before and after both surgeries was long term knee stability and leg strength. Following my left ACL surgery in 2002, I performed the prescribed therapy and was released after about 6 months of therapy. They tested my ACL stability with a KT-1000 measuring device, and cleared me for all future activity. However, after a number of years I could tell that I continued to favor, or “protect” my knee in cutting activities and strength exercises. My leg strength returned to baseline, but I noticed my mass of my left leg did not return to the same size. There was also a small divot in my hamstring muscle (I’m assuming where the graft was taken. I must note, however, that my left leg is my non-dominant leg, so a large portion of this size and strength difference could be marked up to that. One thing that did bother me was that if my left leg remained completely extended for a period of 5+ minutes it would undoubtedly lock, and it would require me to open my hips to that side and then flex downward to bend it. It would release, but it gave me a weird feeling and sometimes made a hollow popping sound.

Then in 2012 I tore my right ACL in half guard lock down (for those of you in the know.) When I tore my ACL this time, I also had my left leg re-MRI’d on account of the weird locking sensation that I was experiencing. The ACL graft in that leg was immediately found to be loose with additional (slight) meniscus damage. The graft had evidently stretched out over the course of the past 10 years. The stretching, while concerning to my doctor, did not according to him warrant an additional surgery if my knee was not buckling. I was frustrated to find that it had loosened, but was relieved to find that I would be able to perform therapy on both knees following my right knee surgery. This was intended to strength the muscles around my loose graft to eliminate potential re-tearing.

Following my right ACL reconstruction, I had a similar amount of atrophy that I had following my first surgery. I did find that I was recovering much more quickly though. My right leg being my dominant leg, I feel contributed to my quickly returning strength and athleticism. A small divot in my right hamstring appeared just the same as it did on my left. One interesting thing to note: my therapist after the first surgery allowed me to perform hamstring strengthening exercises immediately following surgery. My second therapist, however, did not allow me to engage my hamstring for 8 weeks (or the proposed healing time needed for the hamstring tendon harvest location.) This was infuriating, but looking back, I think this has helped my hamstring strength to recover more fully and quickly than it did after my first surgery. Another key difference between the two recoveries, was that I had a full-scale metal brace to use during my first therapy term, but nothing my second. While this was scary getting used to balancing and working out without a brace, I again feel that this encouraged a faster and fuller recovery overall. Not having a brace forced me to not subconsciously try to “protect” my knee during and after rehab. I was forced to move naturally and symmetrically. This allowed me to more fully recover strength and symmetry over the long haul. Over time (16-18 months) I was able to return to the same squat amounts that I was performing pre-surgery (4-6 reps @ 365lbs).

Now that I am fully recovered from the two surgeries, I would like to present a few tips and tricks that helped me (and continue to help) build a strong and secure knee:

  1. Hamstrings, Hamstrings, Hamstrings – Whenever I perform hamstring strengthening exercises, my entire knee feels far more stable, and I feel like I can make more athletic movements as this muscle increases in strength. Standard hamstring curls and manual “razors” are my favorites. Razors are when you kneel on the ground with a partner holding your feet to the floor. With your partner pressing down firmly you lower you chest to the floor as slowly as your muscles will allow. Return to the starting position and repeat for a set of 8-10.
  2. Single Leg Squats – Prior to my surgeries I never performed single leg squats, but I wish I did. This is a great way to recognize strength asymmetries. It is critical however to perform these with good form — i.e., sitting back as though you are sitting into a chair and without the knee buckling in towards the center. It is extremely difficult to perform many of these when your first start — but please don’t push it past the point of using bad form. For the more advanced perform these movements on a BOSU ball
  3. Two Handed Kettlebell Swings – During my post-op recovery I happened to read the “Four Hour Body” where Tim Ferriss speaks highly of using kettlebells and the two handed swing in particular. In a fit of post-op boredom, I bought a 45lb kettlebell on Amazon, and waited until I was healthy enough to give it a try. As soon as I was, I quickly fell in love with the simple, but effective movement. It helps to build my core, and more importantly for me, the athletic coordination and explosivity between my hips and knees. I always feel better after performing the exercise and feel more functionally strong and coordinated.

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