Episode 150 | The High-Low Approach in ACL Rehab

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today is episode 150 and we’re diving into the high-low approach in ACL rehab. The high-low approach is something that was popularized by a famous track and sprint coach, Charlie Francis. He’s one of the OGs of strength and conditioning in the field of performance, in general. And he falls along the lines of Verkhoshansky and all these people who have really helped to set up the field, especially from a performance standpoint to help athletes at their best to be able to perform at their best. And so we’re just going to dive into this concept of a high-low approach. This is something that is a common framework if you will use in the strength and conditioning world and something we apply to our ACL rehab, especially as we approach those mid to late stages of rehab because it’s just going to look like good training. That’s essentially what we’re doing with these athletes once they get out of that acute post-op phase or post-injury phase, it’s just good, old strength and conditioning. We use this approach quite often and even in those earlier phases to be able to make sure we are balancing things as best as possible. Let’s dig into what this is about and how it can apply to you and your ACL rehab. 

Charlie essentially used this based on the CNS or our central nervous system and the output related to that. So you can associate high as high-intensity days with a high CNS or central nervous system demand. Something like sprinting, jumping, explosive power work, heavy lifting, max effort type movements. And then for low, low days with low CNS demand, you can think of this as like technical skills, lighter weights, easy circuits, active recovery, easy tempo runs, mobility type work stuff. That’s essentially low demand. You can think about this as your CNS, like a battery. Essentially, you have this full battery. And essentially when you’re are using it on these high days, you’re draining that battery more. And then on low days, you’re able to recharge that battery back up to full you’re not stressing that battery out. You’re not draining it completely. 

And the idea here is to alternate between these two days. The aim is to allow for roughly 48 hours between high days or sessions to maximally recover. The low days allow you to get work in and get quality reps in without always taking them completely off. You don’t need these full off days all the time. You could just do some activity or things that are still going to help to move the needle, but at lower intensities and the aim is to get rid of what we call moderate days as they don’t give you as much from either end good recovery or high outputs while they’re still can be married to it.I still believe that this can kind of fit into the realm of our training and rehab and shame conditioning. This is something that can impact, especially the higher day outputs. 

In order to get stronger, we need to lift heavier weights; in order to get more powerful and explosive, we need to move heavy and light things really fast; in order to get faster, we need to sprint. These require high output. It’s hard to touch this if we only go 70% to 80% effort, most of the time. Can you make progress? Sure. And we can still get by with doing things like that by better allowing yourself to hit these higher efforts, if possible, as that will move the needle more than what we call sub-max efforts on days like this.

We want to make sure we’re hitting that high intensity or with any of those types of movements that I talked about with high days, being able to hit those higher thresholds, that’s gonna allow you to improve from a tissue standpoint, from a muscular strength standpoint, endurance from a peak strength standpoint, from a rate or power standpoint, and especially connecting all those pieces to be more athletic, especially being able to be more elastic. And so these are important things, but it’s a lot harder to develop these if we’re going to sub maximally. This high-low approach helps athletes to balance their training intensity, and then it also helps prevent burnout. 

And the most important thing is that we’re able to maximize long-term performance outcomes and gains. We’re playing the long game here. If we try to go hot out of the gate too fast, one, you can run into issues like over-training, but especially, things can start to nag at you, especially injuries. Whether it is related to the knee itself and is starting to get achy, painful, swollen, or it could be other areas that are taking on the load and not distributing that. It’s because there are not enough high-low days in the mix or enough high-intensity days, and then low-intensity days to balance out the recovery, in order to allow for those long-term adaptations we are looking for. 

So an example of this very simply, it could be thinking about your Monday is a high day, Tuesday as a low day, Wednesday as another high day, Thursday as a low day and then Friday high day and then Saturda low day. And then you could take Sunday completely off and disconnect from it. So you’ve got your seven days of the week. The first six days, if we were starting with Monday it just alternates high-low, high-low, high-low. And this allows you to have three really amazing days with pretty solid outputs. 

And then the low days, it doesn’t mean you have to necessarily take them off. You might just keep them at a lower intensity or a threshold in order to allow yourself to recover from those high days. And trust me, if you’re going high on those high days, you’re going to need the low days. I know my athletes, if they’re really pushing themselves, they shouldn’t be able to go back-to-back days, super hardcore. If you think about this, let’s say you have a game or a match or a competition, and they’re back-to-back days. Of course, it depends on the sport and how much exertion. But with that said, if you keep going at high outputs all the time, you’re going to kind of burn out or your performance is going to decrease, but also you’re at risk for potentially reinjury.

The same thing here. We want to make sure that we balance our days as this is going to really help with the stress and recovery. And just how honestly, our body naturally builds, you know, we kind of break it down with training and then the way that it rebuilds, or we are able to improve from a performance standpoint and tissue standpoint is by allowing that recovery to take place and allowing the body to rebuild during that time.  And then being able to continue to do that over repetition, over repetition, over a long period of time. And I’m not saying it has to be one or the other in terms of this high-low. There can be these moderate days that kind of be plugged in into place here. But I think it’s a great training approach and something that we use with ACL athletes trying to anchor to this high-low. And the reason why we care so much about this is, as I had mentioned before, ACL rehab should look like training. It should look like just good old strength and conditioning. 

Early on, of course,. it’s modified and scaled to where the athlete is very quickly. It should start to look like training sessions. You come in, you might do some more isolated exercises for mobility or whatever that might be. But then eventually, you know, you got your movement, prepper warmup. And then you’re going to go into maybe some power work and maybe some main lifts that are strength-based, that is a compound movement, accessory work. And then you might do some conditioning at the end. It should look just like a good training session. This might look a little different in the earlier stages and especially post-ops since you can’t have the super high effort kind of days due to the constraints of the surgery or due to the injury. But this can be adopted pretty quickly once we know we’re out of that initial phase and of this ACL rehab process. 

There can be days where you’re kind of doing a little bit more day-to-day. But usually, this is at low to moderate ish and intensities until we can access the higher intensities without our body saying, “Hey, this is not good for me right now.” When your post-op and post-injury, the last thing you want to do is have high-intensity days on that knee because the knee is just going to be like, I’m good. I’m not ready for this yet. And it’s going to swell up and get painful. And you don’t want to do with that. So you’re going to gradually progress into this. But this is something we want to make sure as we start to adopt it. We want to make sure the high day stays high and the low day stays low. 

And what I love about this is that it allows you to have high output and make it count on those days. And that’s what we really want is to make sure that we can hit those thresholds that we want to, in order to really focus on building what we’re intending to build, whether that is the strength or the power or the elastic abilities, or our ability to just move in space, things of that nature at higher outputs. So that’s something that we want to make sure that that high output counts versus if you think about Monday through Friday, all being kind of moderate output days, it’s not as helpful to move the needle because you’re not really touching high outputs and you’re not really staying low. So then you’re just kind of doing submaximal stuff all the time. And the way that we were actually going to improve is making sure that we kind of have this high-low approach. 

And the thing here is that for me, I would like to have three solid high days of output versus four to five moderate days. Plus it’s less time in theory, you get really solid breaks when you have breaks. And then therefore you’re able to go into those days and really know, all right, this is my high day. I’m going to make sure I put a solid output on it. We create themes for our athletes often depending on these days and the focus of sessions. This is something that could be really helpful to help organize our training, especially as we were trying to kind of balance and figure out which buckets are, which qualities we want to improve in this ACL rehab process, especially from a performance standpoint. 

The thing here that I do want to mention that we see often with athletes is that they are either being underloaded too much or overloaded too much. Often it is something that we see that they are underloaded, but either is not good because we need a certain sweet spot of stress. Enough stress is going to help us to continue to develop what we need to from a performance standpoint. Or if there’s a lack of stress, then therefore that’s going to also impact things as well. We’re just going to underload and you can kind of think about this in the sense of – we have a bunch of low days back to back to back. And this is okay in that acute phase as I had mentioned, as you’re trying to protect the knee, provide a healing environment. But you should slowly start ramping up towards moderate to higher days pretty quickly. And of course, you’re not going to be sprinting right off the bat, but this might be more dedicated to some work capacity or strength-based work. And then eventually power work gets built into this. Maybe some conditioning that you’re going to do that does not involve a ton of loading into the knee. And this is going to be something that will be very helpful in terms of being able to make sure we find a sweet spot with the stress and intensity of our sessions. 

And going back to the idea of this underloading or overloading. One of the things that’s really interesting about this is that when we start to kind of connect the dots with these athletes and start to ask the questions around like why their knee might be bugging them or flare it up from what they were doing before, when they’re coming in to work with us. It’s interesting to hear maybe they were underloaded, so they weren’t getting enough stress. And then therefore whatever they were doing day to day wasn’t meeting the demands of what it is that they were being prepared for. They were being underloaded and the knee wasn’t happy with it. 

Or we go to the other end and they have essentially too many moderate days back to back, or potentially even too many high days without low days in between. Without appropriate recovery and they’re doing too much volume, too much intensity, and maybe the rehab professional or coach they’re working with is giving them too much. And so then therefore there’s not enough time to allow the adaptations to occur. And what typically happens, the knee swells up or there’s a pain or some sort of thing that pops up. Now, this is going to still potentially happen with the most “perfect” programming high-low approach. This doesn’t solve all the world’s problems for ACL rehab, but it is a good way to manage load, manage stress, and being able to program and understand the intent behind different days. And this is just a great approach to general strength and conditioning. 

If we had a non-ACL athlete, let’s say we had an athlete in front of us regardless of whatever they’re dealing with or they’re someone who’s a healthy athlete, just trying to improve their training, we would still take this concept and this approach because it’s brilliant. This is something that works well in terms of helping to redevelop quality for athletes and especially for this long-term training process. And the beauty of it is, is that you can pair this well with a periodization approach called vertical integration. What this essentially means is that you’re working on multiple training qualities at a specific time with different emphasis on those different qualities within certain blocks. It is an incredible combo for ACL program design.

If you’re a coach or clinician listening to this using this high-low approach, which is what we use within our ACL athlete system, as well as vertical integration. Of course, there is more of an emphasis as we get into the mid to late stages because we have more opportunities to open the door for things like that. But you’re still able to work on some of these things like range of motion, strength, peak strength, and being able to work into power. And then eventually, elastic components which is going to be kind of the bouncy springiness of movements. These are all things that we can work on and vertically integrate, which is the meaning behind it. We can keep up with all of these. Just think about each one has maybe a certain percentage of the pie that is going to be a little bit more dominant during certain phases and blocks of this rehab process. 

When you take this approach and you’ve got a good coach and rehab professional with you, you’re able to design things very strategically and make sure that you’re balancing stress and being able to have high-low days and being able to integrate things very well with making sure that you don’t decondition certain areas or lose certain training qualities because you haven’t trained them up. And that’s one of the things we’re always fighting against in ACL rehab is mitigating the deconditioning effect from a global perspective, but then also, especially within the limit itself. This is why we want to apply as many principles as we can and use good frameworks in order to build our athletes up, in order to make sure that it is very sound with what they need at that time point. And that we’re not just throwing things at the wall and seeing what sticks. Sure. Keep it simple. But we can integrate these things with simplicity and allow our athletes to progress forward. 

And the beauty is, is that you have feedback loops or testing and check-ins to be able to make sure things are progressing along, not only from a subjective standpoint but objectively. So that’s going to help reinforce that your plan is working and the exercise that we are doing is making improvements on the things we were hoping to improve. And then therefore, this is where you constantly update and reiterate these things because of the information that you’re gaining.

This is something that I wanted to talk about today because it’s something that we utilize and I think can be helped very simple to implement for you. If you’re someone who is maybe got a huge laundry list of exercises, well, think about if you had 20 exercises to do, which I’ve seen these guys like athletes have come to us from somewhere else and they just have this huge list of 20 exercises. Even if they’re post-op they gotta do 20 exercises in a day. And we’re like, yo, that’s a lot. How do you expect to do 20 things? Very well, you can’t. It’s hard to find the time, especially with someone is busy in their day. And usually, there are other things people have to do outside of just ACL rehab. 

This is where it’s important to make sure we are prioritizing the important buckets and things to do based on the goals. And making sure that on the days there’s organization and priorities. But then also make sure that you can put intent behind every single thing that you’re doing and that might be reducing the amount of things you’re doing. Likely there’s redundancy in a lot of those anyway, but reducing that stuff down and then getting more out of each and every single movement you’re doing and putting intent behind it. And so then that’s where these high-low days can be helpful too, is that you can’t have a high day if you are doing 10 different things, 15 different things. You can only prioritize a certain amount of movements and output because your body is going to empty that battery, as I had mentioned before, a lot faster. Otherwise, your body’s going to naturally preserve energy based on the amount of work you need to do in a session. 

If you have 10 to 20 things you need to do, well, likely there’s going to be a lot less energy you’re going to put towards these 10 to 20 things versus maybe five to eight things that we might want to work on in the session and get a lot more out of it. And the likelihood is that if you just reduce it down and simplify the concept of addition by subtraction, man, we see a lot of athletes improve because they have organization, they have these principles that are creating the foundation of their programming and the way that things work in their ACL rehab process. 

And I’m sure some of you listening are like, wow, this was way more strength, conditioning and science-based and I was expecting, but it’s because this ACL rehab process is not just like any other injury. It’s not just being able to have a shoulder issue and then all of a sudden like, oh, it’s, it’s better in four to six week. Or something like low back pain. These concepts still apply. Don’t get me wrong, as I had mentioned. But ACL rehab is just a unique injury. You have this thing that happens and it takes 9 to 12 months at a minimum to get you back. Sure, non-operative there might be some variation here. But for the most part, with where we stand with current ACL rehab, with injury, with healing timelines, with people needing to redevelop because of how much this injury brings you down. You need at least 9 to 12 months to get back to 100%.

This is something where you need a good foundational program. And one that is progressive and built on principles and scientific backing of evidence and making sure that this is something that is designed in a way to get you back to the thing you want to do. Instead of these arbitrary protocols or template programs. It needs to be individualized, it needs to be something that is dedicated to you. And that is why we put so much time into each and every single program that we designed for our athletes, both in-person and remote because there’s so much that we have to navigate and variables to consider because of the nuances of this injury and how long it is. Some of this might even just be managing burnout for you. 

Some people are going through this for months and months, and months, and even years after. It’s something to just manage burnout, to help them get to the goal that they want to because they’re sat on it. Here is something that I just want you guys to take away from this, is just thinking about this high-low approach. If you’re someone who might be dealing with some later-stage type issues, maybe you’re doing too much, maybe you’re starting to see things flare up. This is something to kind of come back to is looking at your training load and also seeing like, alright, are we kind of approaching this as a high-low, or are we just doing a bunch of moderate days? Or maybe we’re just doing a bunch of high and moderate days? Well, where are the days when you’re going to actually recover and be able to rebuild in order to go into the next session. These are all the things to consider. 

Hope this was helpful team. If you need any help whatsoever, please reach out to us. You can find us at theaclathlete.com. You can send me a message on Instagram. Our details are in the show notes. And if you got any value out of today’s episode, please leave us a review on Spotify super quick, by scrolling up or on Apple podcasts or whatever platform you’re on. It helps us out a lot to be able to just continue to reach more ACLers. That’s the goal to help ACLers feel educated to reach more clinicians and coaches who are serving our ACLers. This is really important to us and our mission so we appreciate you. Until next time team, this is your host, Ravi Patel, signing off.