Episode 166 | Do You Have to Be a “Gym-Person” For ACL Rehab?

What is up guys and welcome back to another episode on the ACL Athlete Podcast. Today, we are answering the question: Do you have to be a “gym-person” for ACL rehab? And this is a question, honestly, one of those where you think it is very straight forward. But one, we have to tackle with expectations with the ACL rehab process, especially for those that say “I’m not a gym-person” and I get that. 

But first, I want to provide some context around this. While we think naturally about this process and this injury, we think it already happens to those people who are already those gym type people. We think about the organized sports, like soccer and football and lacrosse, all the different ones that we see through, whether it’s social media. The way that people usually find out about ACL injuries and the general public is through sports. But the thing is, ACL injuries do not discriminate. It happens to this athletic population or ones with organized sport playing. But it also happens to a whole host of other people, whether it’s sports or activities, less inclined to have weight training as a part of it or just thinking about everyday activities, and just things that you’re doing on the normal existing as a human. 

Let’s talk about some people this can happen to. It can happen to, of course, the typical sports, soccer, football, lacrosse, basketball, handball, all the things that have any type of cutting, pivoting, decelerating, jumping, any of those things, especially at higher velocities, especially with other people you have to avoid or move around and it’s unpredictable. Those are the things where we see majority of the ACL injuries. 

And then we have some less typical ones that you would assume but still can happen quite often — martial arts, BJJ, tennis, pickleball, other activities like skiing, rock climbing, skateboarding, hiking. And then there’s the category of accidents, literally something like a car accident or like a bike accident. We’ve had people who have fallen off scooters who have torn their ACL, thinking about construction workers, something kind of messes up and they fall from a height, falling off of a chair, literally, trying to put a light bulb in and someone fell off of a chair, misstep on a stairs, tripping over a kid. And then think about those youth athletes who never really lifted weights before, because they’re just young. They’re playing sports. It’s usually not the biggest priority, especially in your single digit years. And then as you get into early teenage years, that’s something that it just kind of depends on the culture you’re around, the type of organizations, the schooling, all those things kind of play into it in terms of being in the gym or having weight training and resistance training as a part of the process. 

I list all of these because we have had people from all of these injuries work with us, literally, every single one of these. You can check the box and we’ve had ACLers from every single category. Of course, majority of people will kind of fall into this, more organized sports kind of population or activities that do require the knees a lot which is something like skiing in an unpredictable environment. It’s usually not somebody who’s just cruising on a green. It’s someone who’s doing some double blocks or going through trees and all of these different kind of obstacles or the weather conditions suck and they don’t see a drop-off — you name it. It could be very common in those types of aspects to. I know all my skiers listening are nodding their heads — yes. 

This is the thing that I want to bring up is that, it’s not directly connected with having an ACL injury and you automatically being a gym person. There’s plenty of people listening to this. I know who are like, I never went to the gym. Maybe I lifted some weights here or there. Usually, maybe I do my physical activity and other different ways, maybe you’re a yoga person and maybe you are someone who just like to do orange theory, some circuit based training. Sure, there is weights and resistance that is associated with those things, but we’re talking about like getting in the gym, lifting heavy weights, really stressing your muscles beyond a certain point with external resistance. This is the thing that I want to kind of dive into today because not all of these people are just an avid gym goers. You are faced with this ACL injury. And so then you have to get down to the question that I want to answer today, which is: Do you have to be a gym-person for ACL rehab? And the short answer here is yes. 

Now, let’s dive into why I say yes. I want to provide as much context as I can around this, because I think this is a really important topic that gets overlooked. But before I do, I just want to say that you do not have to be some gym lover or someone who is some gym rat or gym bro.You don’t have to be obsessed with going into the gym and lifting weights. But there is no way around this for ACL rehab until something new in technology or some sort of medicine that comes out and maybe 50 years. Until now, you just have to lift weights to get stronger, that’s the only way to get stronger. This is based on science and medicine and research and biology and all the things we know about the human body. There is no way to truly get stronger unless you actually have external resistance to do that. Unless you have some sort of genetic predisposition to be able to gain strength just inherently, but that is still going to be such a small, small percentage of the population. That unfortunately us normal humans have to lift weights in order to gain strength. 

The thing about this process is that sometimes we will get people who say they are not gym people, or they love bodyweight movements as their routine. We respect that we’re not here to make you a gym lover and we’re not here to say like, “Hey, like you have to live in the gym”. Bbut this is also something that as we know with where we currently stand in terms of human biology or physiology science, there’s literally no way around getting stronger than actually loading your muscles with external resistance in order to progressively overload them and get them stronger to a point, to face the demands of everyday life of everyday type situations you will be in. 

When we think about activities and sports, we got to train to be able to tackle those things, especially as we get out of the youth athlete kind of phases. Once you are beyond like those teenage years, we got to maintain to keep those things up, otherwise you will lose it. And so then therefore this is where playing sports, being able to work out in a variety of ways, lift weights is going to help to keep you as robust as possible and prepared for the demands of what you’re trying to do with your body. 

After an ACL injury and surgery, there’s so many things we have to get back, so many things. One of these big bucket items is strength. It’s one of the biggest, biggest pieces that we lose. And based on where we stand, there’s no way to actually strengthen a muscle without stressing it and providing progressive overload, as I had mentioned. This is done by adding resistance outside of just your body weight. You can get stronger with some body weight, you can manipulate tempo, you can add volume to it. These are all of the principles that you can do to add more and more overload to your system. But at the end of the day, you got to add some extra resistance that’s going to push you beyond your limits because that’s what we face in the real world. We’re not just facing certain percentages of our body weight whenever we go to do a cut or a jump and things of that nature. We have to be able to handle more than our body weight of forces to be able to do that. And this is also one of the reasons why your physical therapy clinic that only has going up to 30 pounds isn’t going to cut it in getting you stronger. 

If you walk into your physio or a physical therapy clinic and you see weights that really only go up to 30 pounds, I don’t care if you’re a 13-year-old female athlete, you are much stronger than that. At some point, you will be able to lift more than that. I’ve had young athletes that are able to trap bar deadlift over twice their body weight. These are things that are possible and things that we need in order to make sure we get our athletes prepared for what they need to do. And so with that said, the thing is that these clinics… just know that it will run its course at some point where you will not be able to get stronger because there’s no equipment to help continue to overload you unnless maybe they’re available with other machines and whatnot. But with that said, just know external resistance is going to be very important for this process and to overload your muscles. 

How we get there? The method is a very, very different conversation. This can be done via free weights, cables, machines, and bands. But the point here is to get heavy at some points in the process. Meaning, being in rep ranges where you’re only doing maybe three reps, five reps with only one or two reps left in the tank or what we call reps in reserve. This is based off of RPE as well at  0 to 10 scale, where you are an RPE of 8 and 9 and almost to 10, which is full failure. 

Without getting into the weeds here, if we are truly focusing on strength, hypertrophy is different. Hypertrophy as we currently stand in early 2024. People like Bradshaw and Field and other people and company do incredible research in the hypertrophy world, which basically means how do we get a muscle bigger? There is a way for that to lean into getting stronger, but a bigger muscle doesn’t necessarily represent a stronger muscle. We’ve seen all the small people who can ridiculously lift some heavyweight and we’re like, well, they’re not super big. And sometimes they can lift heavier weights than the person who’s 300 pounds. With that said, there is a lot of things that go into the expression of strength and hypertrophy or the size of a muscle, is one of those pieces. But it does give you the ability to be stronger because you have more cross-sectional area. With that said, hypertrophy, there’s a wide range of rep ranges. And a lot of what we know is like going close to failure with enough volume to be able to hit the right amount of input to the muscle in order to get it bigger.

When we talk about strength, there’s a bunch of different ways to define strength. But if we’re talking about getting the peak force or that peak torque up to a certain extent, which is basically how high of a ceiling can I create for that muscle? We got to work towards lower rep ranges and being able to push heavier weight that has maybe only a rep or two left in the tank. If you were someone who’s doing a three-by-five knee extension, for example, single-leg knee extension. And we say an RPE or two reps in the tank or reps in reserve. That means I want you to pick a weight that you could do only seven times and you’re going to go to five reps. That means you have adequately overloaded the muscle to a certain extent that will help to stimulate the strength gains we are looking for. 

Now volume or the amount of reps and sets you do with that will also play into this. But with that said, this is something that’s really important and seems very simple. But in a lot of places, what happens is that we are given a 3 by 10, 3 sets of 10, the common thing. There’s nothing wrong with that. It’s harder to get stronger at a certain point in the ACL rehab rehab process if we’re not working into lower rep ranges at the right timing and loading the weight up heavier. This is something that is a little bit of a tangent to this episode, but something I did want to share, because we will get athletes who come in and we’re like, “Hey, what has your programming look like from your physical therapist or your coach?” And they’re doing 3 by 20, and they’re in a phase where they’re like, man, I just can’t get any stronger. My symmetry is here. I’m having this pain and they’re doing endurance sets. They’re doing stuff that’s not going to necessarily get them stronger. It’s almost focusing on certain qualities that are not necessarily needing to be the focus of that certain point in ACL rehab. This is where working with a very good qualified healthcare professional, physical therapist, performance coach will really help because they should know their stuff. If they know their stuff, they’re going to be able to dial in a program and assess whatever the gaps are in your current place and what you’re needing to work towards. 

These are things that are really important and foundational elements of this process. And I kid you not, I would say at least 50% to 75% of people who are coming in or who reach out when we do an audit of their programming, a lot of times they’re just not doing the appropriate prescription or the movements combined in order to attain the goal that they’re trying to achieve, which is typically getting stronger. 

This is such an essential part of ACL rehab because you get weak. It’s just a natural part of this process. I remember in both my ACL rehab, my quad shrunk up so much. It was within a matter of days after the injury and then it repeats again after surgery. Everyone knows about this. You look down and your leg looks like a hot dog. You’ve worked so freaking hard to build this thing up and build muscle around this leg and all of a sudden it shrinks up. But you can get it back. It’s just about really dialing in the programming to be able to build that up with hypertrophy. And then of course, alongside that is getting stronger. 

I think the biggest thing here that I do want to share too, is that the gym is where we are going to do that and that’s the point of it. That’s where we can get overload, get stronger, be able to stimulate our muscles and essentially build this knee and this body back up to get you back to the thing that you care about the most, whether that’s your clinic, whether that’s the gym, whether that’s home equipment, etc. 

I think the biggest misnomer that we see is that people think that they can get away with their  “home gym,” that’s like a bike, 10 to 15 pounds of weights. Maybe there’s like a 20 pound kettlebell and maybe some bands. While this can be fine at the start, you’re going to need more. You will. This is literally talking about the smallest humans that will likely tear their ACL, they’re still going to need more weight than this. Because at the end of the day, you think about your body weight that you’re carrying around, you need to be able to express force similar to your body weight and beyond that. And 10 to 15 pounds at the end of the day is not going to get you stronger. This is something that we need to make sure we address. And every single one of our athletes, whether it’s in-person or remote has a gym that they also use, whether that’s a stacked out gym at home or local to them. This is likely something you’ll also need if you’re rehabbing in person, unless you’re going there 3 times per week and it’s a stacked and decked out gym. Even if you’re going 2 times per week, you’re likely going to need another day in the gym to get enough volume. You need to keep making progress in your ACL rehab. It’s just one of those things where it’s like you’re in this current window where you’re having to recover from this injury and this surgery. This is something where there’s just more emphasis on trying to recover and get this knee back to a certain place. And that means there’s going to be more focused input. Think about it when you’re trying to learn something. If you just try to do it once a week, you might be able to get away with doing that. But the more input you give it to a certain extent, the more you’re going to be able to achieve that specific task or that talent or whatever skill you’re trying to learn. 

Same thing here. There’s a certain dosage we’re looking for to get input on in order to really move the needle with your ACL rehab. We have people who can do 2 times a week, but you got to make sure those 2 times per week are really dialed in and there’s a lot of intent behind it. But usually you’re looking at at least 3 times a week of where you are having to do dedicated strength work. And then there’s some mix of other things, depending on the phase that you’re in in order to make sure you keep continuing to progress with your ACL rehab. 

You might need that extra day if you’re only going 2 times per week at your physical therapy clinic. They may have backed you down from visits from 3 visits per week to 2 times per week. You might need to hit the gym another day for your legs, especially if you’re not really getting heavy enough or hitting enough volume in order to make progress in your ACL rehab. As I mentioned, you don’t have to be a gym bro. 

Even during Covid, of course, we didn’t have the choice and had to be at home. We did the best we could. And we honestly saw athletes plateau at some points because they couldn’t get into the gym and what they had at home wasn’t cutting it. But once it was good to get back in, we made sure it was in the mix. But it’s a non-negotiable for us and for anyone really going through this ACL rehab process. So, if you are someone who is going through this and not a big gym person, that’s totally fine. But just know you need to get heavy and will need to be a gym person, if you will, during this time in your life. It’s what’s needed most importantly, to get you back to a good baseline of health. And of course, to get you back to the thing that you care about the most, especially if that has cutting, pivoting, jumping in a highly intense unpredictable environment. That’s going to be needed. There’s no one that I’ve seen go through this ACL rehab process without stepping foot in the gym and coming back, hitting all the numbers and being able to get back to sport or feeling like themselves. There’s no one I’ve ever worked with. You could probably ask any good PT and coach and they will tell you the exact same thing. This is the thing that is really important here in order to understand if you’re someone who doesn’t necessarily love the gym. 

The other two points I want to mention on this, is how it can be a great, great opportunity for you. Hear me out. First point is that for our health as human beings, resistance training is recommended 2 times per week at the minimum. This is according to the physical activity guidelines here in the States. But as we know, even globally, worldwide — resistance training is healthy for a myriad of reasons. So many things from metabolic health to body mass, to sarcopenia as you age to power, as it is a prerequisite to help build power as well as you can. There are so many different aspects that can be beneficial to have resistance training in this process. This is a great chance for your general health to get immersed in this world, if you haven’t. If that’s not a part of your normal regimen, if you’re just like, I’m not that gym person, that’s totally fine. But even just from a general health and wellness standpoint, it can be helpful for you, to use this as an opportunity to see — how can I kind of build this in at a minimum effective dose where I know I don’t love the gym in time I will. But at the current time, I’m just trying to get through this ACL rehab process. How can I use this as an opportunity to get used to the gym? Even a bare minimum of working just different muscle groups 2 times per week for strength. This is something that will be massively beneficial. And even working with any of my clients in the past, who didn’t have this as a part of their regimen and also adding this in it’s crazy how much better they felt, not only from an ACL rehab perspective, but just general physical wellness and their ability to just take on their days. 

And it’s really cool to see like, Hey, I was able to do that because I dead lifted 150 pounds. I was able to pick up my grandkid off the floor, or I was able to do this thing that I thought I couldn’t do.But I knew I had picked up 150 pounds so I’m like my body’s capable. And that’s what is really cool about this and brings me to my second and last point here is the beauty in this hidden opportunity. 

Strength training is a love-hate relationship. It will challenge you. It is something that is you against yourself. If you compare yourself to others, that’s fine. But I would just say like compete against yourself. This is a beautiful hidden opportunity. I’ve had athletes fall in love with strength training and the gym. There’s nothing like that empowering feeling from beating a personal best or knowing you’re just freaking strong, especially for my female athletes where it’s easy for that stigma to feel present. And current day culture, it’s starting to pick up a little bit more. But we still see the disconnect between especially female athletes and their ability to step into the gym. And part of that is society not welcoming that as much as we can. there are gyms around here where gym bros are constantly staring and it makes it hard. There is certain cultures around the world. My parents are from India, I’m Indian. And so this is something that my mom, literally, it was frowned upon. And for the longest time it was frowned upon. Even if you go to India now, it’s still not something that is like widely accepted. You would assume in other places like here in the U. S. But with that said, there are a lot of differences all around the world, especially for women. This is something that is really important to me, because I think when we look at this, even just from a zoomed out perspective, the reasons that could be leading to an increased risk of injury for female athletes is because we just don’t allow them to get the exposure that they need early on. And then we expect them to get to a point where they’re competing, playing, practicing. At the same levels. And at this point, an increased level of an intensity for our clubs sports, and then therefore we’re seeing more and more injuries happen. While this is a little bit of a tangent from this topic, I do want to make sure that we share some examples here of how this can be such a beautiful and hidden opportunity. 

I remember one of my 13-year-old female athlete, Stella. You guys may have heard of her. I’ve referenced her on the podcast, who never lifted a weight. She tore her ACL at 13 years old. That sucks, man. And you don’t realize how much that can impact a 13 year old, who is just kind of cruising in that weird, awkward stage of getting into middle school, all the things. She had never lifted away. And then 8 months later, she was obsessed with trap bar dead lifts. And when she would come in to see me, this was nearing, especially the end of her ACL rehab and getting her back to sport, she would literally get so excited to lift because it made her feel strong and she wanted to push herself. She was like, what did I do last week? Okay. I’m going to beat that today. And that’s really cool. You could just see like the focus in her face, and you could just see how empowered or how strong she felt from that. And it was really awesome to just see how that kind of played into the things that she was doing because she felt strong. That’s because she was able to add resistance training and lift heavier weights in this process. 

The same thing with one of my remote clients, Danni. She used to say that she was scared of walking into a gym because she didn’t know what she was doing, worried about people staring, it’s kind of egocentric place in a lot of gyms. And especially with nowadays with people videoing and selfies, and there’s just a lot of vanity that can come around this stuff. It’s aesthetics. And so that makes it tough, especially for our female athletes who are not familiar with this, stepping into the gym is something that could be very daunting. It can be daunting for anyone even the males and people who aren’t familiar with the gym. I’m not just speaking to female athletes, although I know that this is a subset of this group that I’m talking about that can make it really hard to love the gym because of these factors that play against you. And so then therefore, I remember, she was worried about these things. She learned how to lift. We taught her how to do like kind of the basics of dead lifting. Squatting, using machines, gave her the principles to understand this from a remote aspect, gave her the programming, gave her feedback to be able to dial things in. She was so-so diligent and this was after her second ACL injury. And she got really freaking strong. At some point she was like pressing over 300 pounds, which was incredible. And when she finished, she sent this incredible message. And when we kind of like reflected on her process, she was like, this was such a huge life shift for her. Because now she felt so empowered to step foot in the gym versus feeling scared and felt really strong. That’s awesome. That’s really freaking awesome. This is all to kind of bring around to this topic. 

Do you have to be a gym person? No, you don’t have to be this like hardcore gym addict person. But during ACL rehab, you have to be able to get in the gym to add resistance training to this process, to lift regularly and just know that is going to be a part of it. If you’re going through this, it’s something I highly recommend setting up as proper expectations. 

If you’re early in this process, especially, and you’re like, oh, I’ll just kind of get away with whatever my PT gives me and maybe stuff at home. Don’t settle for that because you’re just going to sell yourself short in terms of what you can achieve in this. The thing is in order to properly succeed in ACL rehab, strength is such a huge foundational component. And most importantly, it’s an opportunity and it’s something where you can do this for your health and getting back most importantly, to the things that you want to do. That’s why you’re here anyways. No one chooses this ACL injury. It just happens to us. So then therefore you have the power to educate. Educate yourself to know, to set expectations now, especially after you have listened to this. And listened to me, talked for probably two accessibly long about this topic. And who knows maybe you’ll love lifting and trying to be able to pick heavy stuff off the ground and put it down. And then feeling a bit more empowered and confident in your process and in yourself while you’re at it. That’s what’s important here. 

My takeaway here for you on this is look at the gym as an opportunity. Look at this as being able to find this into your routine if it’s not common to learn, to be able to maybe shift a few things and see how this plays out and give it that opportunity versus saying I’m not this person. 

James Clear talks a lot about identity and habits. If we’re trying to get back to the things we want to do, and if we want to be able to truly own that, then we got to own the identity of it. We got to say, all right, I can lift weights. I’m a weightlifter. And so that’s something that we’ll own into your identity and then therefore play into the things that you will do in the habits you’ll create. 

This is a call to action to those of you who say you’re not a gym person, that’s totally fine. But find a way to make it an opportunity to maybe incorporate this in your life. And who knows, man, maybe this is something that in 20 years you’ve learned from, and you’re like, I’m still lifting weights and I feel incredible and I’m able to do the things that I want to do because of that. It’s an opportunity, guys. This entire ACL rehab process is an opportunity. So treat it as that versus playing the victim card and saying why me? Because it’s here, you’re in it. You just got to do it right. It’s happened to me twice. I had my moment where I was like, why me? But then I got over that and I was like, let’s use this as an opportunity. Do that today as you move forward in your process.

If you’re listening to this, I hope you have a good rest of your day/night, whenever you’re listening to this. Until next time team, this is your host, Ravi Patel, signing off.