“But, what happened to my quad strength?”
You made it through your ACL reconstruction surgery! But now you’re left looking at your post-op leg and start to think “wow, that side is starting to look way smaller than the other”. Not only does it look smaller, but it doesn’t seem to want to move either.
Don’t worry! This is all to be expected following knee surgery.
That shrinking your noticing is called muscle atrophy, and it kicks in very quickly following immobilization.
The feeling that your leg doesn’t want to move isn’t in your head either. It’s called “quad inhibition”.
Your knee has undergone a “trauma” and your body is treating it that way. Your nervous system wants to protect the “injured” area by limiting the movement and subsequent pressure around it.
One of the most notable muscles to go? The quads!
We’ve established what’s happening is normal, but it’s not ideal. Getting your quad strength back is going to be essential for your recovery- so it’s time to get to work!
Quad Sets, Quad Sets, Quad Sets
Ah quad sets. Admittedly not the most glamorous exercise in the world, but they work!
As a matter of fact, they work so well that you will start out doing A LOT of them. I typically prescribe 100 reps/ day in the early phase of rehab.
When performing a quad set you will want start of with your leg straight out in front of you. A towel roll under your knee is fine if you’re early in rehab and full extension is too painful. You can be seated or lying down.
Next, you will squeeze you quad to try to push your knee down to the floor/ towel. Hold for 5 sec, relax and repeat.
Don’t worry- you won’t be stuck with these forever! Once you’ve mastered the quad set you’ll be ready to move on to bigger and better quad exercises. Your PT will prescribe these based on your progress and tolerance.
Neuromuscular Electrical Stimulation
Dealing with that neural inhibition can be both tricky and frustrating. Your brain is telling your quad to “SQUEEZE!” but it just isn’t going anywhere.
That’s where neuromuscular electrical stimulation (NMES) comes in!
NMES helps to give your nervous system an additional “boost” by helping your quad to contact. It provides an external stimulus to help overcome the inhibition keeping your quad from fully contracting.
Your physical therapist will strategically apply two sticky electrodes to your quad; one closer to your hip and one closer to your knee. The NMES device will be turned on and set based on your prescription (time on, time off, intensity, etc).
When the device is “on” and sending stimulation you will be able to see your quad contract. It shouldn’t be painful, but you might experience mild discomfort. Most patients describe it as a strong “buzzing”.
During the “on” time I will have patients perform some kind of muscle contraction on their own (quad set, seated knee extension, etc). This allows the NMES to build on the contraction initiated by the patient. During the off time, you rest.
This protocol is continued for the first few weeks until full quad control is regained.
Blood Flow Restriction
Blood flow restriction training (BFR) has been gaining a lot of traction in the rehab world. It is a great way to improve quad strength and size in the early stages of rehab.
During BFR training, we pair low intensity exercise with blood flow occlusion to mimic the effects of high intensity training. Basically, this allows us to increase the challenge on your muscles without increasing the actual load!
When blood flow is limited by the BFR cuff, your muscles experience the same low oxygen levels and subsequent hormone response that they would during high intensity exercise. This triggers the same strengthening response!
This especially comes in handy when loading capacity is limited either by pain or loading restrictions from surgery (i.e. non-weight bearing after meniscus repair).
What to Expect
Your physical therapist will place the cuff around the top of your leg and inflate it to the appropriate level. This will feel similar to when you’re getting your blood pressure read. Your PT will then take you through different exercises, typically prescribed at 4 sets of 30-15-15-15 reps with 30-60 secs between each of these sets.
Once you are cleared/ able to tolerate heavier strength training, BFR can be stopped. It is most useful during early phases of rehab, but after 12 weeks there isn’t an advantage to using it over traditional strength training.
Going through ACL rehab right now? Follow along @drmichelle.dpt where I post regular tips and tricks for getting the most out of your rehab journey and optimizing recovery!
In the Portland area and in need of a ACL rehab specialist? Schedule with me today!