In the second part of this series on training injured athletes I’d like to look at what is likely one of the worst athletic injuries I’ll ever experience as a coach. The athlete in question was one of the top football players on one of the top football programs in the country. He was also a fairly accomplished track and field athlete, having qualified for 2 high school National Championship meets. This athlete came to me 5 months post-op from a surgery to repair a complete rupture of his ACL, MCL, and LCL, partial rupture (80%) of his PCL, and a complete rupture of the hamstring tendon. The injury occurred as a result of taking a collision to the knee and having the foot ‘stick’ to the ground. He had surgery to repair the hamstring tendon, ACL, MCL, and LCL and then PCL was allowed to repair on its own with the help of platelet rich plasma (PRP) injections. This is as close to a complete knee reconstruction as one can get. In many cases, people in these scenarios may have difficulty walking without a limp much less running again. At 8 months post-op I am glad to say that this athlete has not only returned to, but in some cases has exceeded, his previous weight room and sprint bests; and should he choose to take the risk is physically capable of playing football at the level he was playing before.
Here are some of my notes on where we started, where we finished and what we did to get to where we are today:
- The athlete had nearly full range of motion in the knee, and no noticeable compensations at the ankle, hip or pelvis when he started.
- Strength was very compromised from before the injury. The athlete had a previous deep squat best of 330 lbs and power clean best of 220 lbs at a body weight of 175 lbs. In the 5 months post-op, the athlete lost about 10 lbs of body weight and had a guesstimated (we didn’t test early on) squat best of around 130 lbs. There was no way of estimating his power clean capacity since we couldn’t do it for 6 weeks of training.
- When the athlete came to me he had just been cleared for low-level impact activities but lateral movements were still contra-indicated. He had not yet done anything of impact other than walking without the aid of crutches (roughly 1-1.25x body weight on each leg with each step).
- With most new clients / athletes I like to start with a questionnaire and some physical testing to determine strengths, weaknesses and injury history. In this case I didn’t think it would be wise to do any testing beyond some simple movement screens. In fact, I didn’t do any form of strength or power testing until after about 6 weeks of training.
- We started with non-impact activities. This meant we primarily did in-place warmups using calisthenics, medicine balls, and dynamic stretches. This progressed to some low level skipping, to jogging, to higher level skipping, to running, to jumps on to a box, to buildups, and then to normal training including plyometric work and sprinting.
- Because one of the goals was to be able to handle lateral movement again we did some stability work with a medicine ball where he caught and received standing in slightly off balanced positions. This progressed from double support to single support, low catches (close to hips) to higher catches (over the head / shoulder) and from catches on the mid-line to receiving the ball on either side and then to some easy twisting actions. We did this for about 3 weeks at least 2x per week. Once we were a couple weeks in to low-level impact activities I started including low level lateral impact activities like jumping jacks, side skips, easy cariocas, etc. We then did things like double-support lateral jumps, moving to single support lateral jumps and finally to easier running and cutting and then hard running and cutting.
- We did loaded strength work right from the start. Because even though the athlete had lost a significant amount of strength he was still relatively strong compared to an untrained individual and the knee joint had nearly full range of motion so I figured there should be no problems and the benefits of loaded activities would help. I kept the strength work very conservative with low loads and relatively high reps (10-15) for the first couple weeks. At no time during the first 2 weeks was the athlete pushed to their limit but we were able to progress the loads much more rapidly then I would have expected. I kept the reps and total volume high to ensure that we would strengthen the soft tissue that had been repaired. Recovering soft tissue responds particularly well to higher rep protocols because the soft tissue is avascular and largely relies on nutrient content from blood flow to the surrounding musculature to get what it needs for optimal recovery. Also, the higher volumes would allow us to get the athlete’s work capacity up which was important since he hadn’t trained for 5 months. Additionally we did quite a bit of loaded eccentric work as current research indicates that this is great for tendon strength (remember he ruptured the hamstring tendon). As with the other exercises load progressed fairly rapidly as the athlete adapted so well. This would likely not have been true in someone without a prior athletic history.
- There is not a single machine in my training center so that answers the question of whether any were used. And even if I had machines they would not have been used. We used dumbbells, barbells, kettlebells, medicine balls, body weight, and awkward objects to develop strength and functional capacity.
- Unilateral lower body activities were used in almost a 1:1 ratio with double support exercises to ensure that no imbalances developed as a result of favoring the non-injured leg.
- Although the tendency of many is to strengthen the quad in the case of knee injuries, functional anatomy will tell you that the hamstring is the primary knee stabilizer. As such, we spent quite a bit of time strengthening the hamstring and adductors (which can act as a knee stabilizer and hip extensor) as both knee flexors and hip extensors.
- We started doing some physical capacity testing about 4 weeks in to training. This started with predicted maximums using moderate rep ranges in the squat, a maximal power output test on a C2 rower, and a 1RM on the bench press. Several weeks later, we added 30m sprint and power clean to the mix, and performed the predicted maximum squat test with a higher load and lower rep range.
For the past month the athlete has been doing everything I would program in a normal training plan. His 30m sprint, deep squat and power clean have equaled or exceeded previous marks and his body weight has gone up about 8 lbs. He will definitely be returning to track competitions and is contemplating returning to football although no longer wants to play in college due to the increased risk of re-injury due to an unexpected impact.