Episode 73 | Mechanics, Consistency, Intensity in ACL Rehab

What is up my ACL athletes? Today is episode number 73, and we are talking about mechanics, consistency, and intensity in ACL rehab. What is all of this and how is it related to ACL rehab? Well, I am a huge fan of this hierarchy, if you will. If you can imagine with me this pyramid, at the base of this pyramid, there are mechanics. The next level above the pyramid is consistency, and at the top, or at the point is the intensity. And this is something that’s kind of like a ground-up type approach, and it’s something that could be really helpful and I use it with a lot of our athletes, both remotely and in person. These concepts and principles are going to be so key and something that could be really helpful to guide you while you’re on your journey, especially early in this process. But it works through the entire process. 

And this is something that I’ve learned from the principles of strength and conditioning, sports performance, and CrossFit, put it together in a nice little package a long time ago that I want to talk to you guys about today. And now before we talk about, oh, well, CrossFit, anyone can have their opinions on it, about CrossFitters and the sporter CrossFit. I’ve worked with CrossFit games athletes the everyday CrossFitters. This is something that they love and enjoy and it ends up coming down to the gym and the way that they program. Some of you may roll your eyes, but this is an incredible sport. And if it’s done well, you see some incredible athleticism.

And this is something that I think in these principles can be really packaged well, in order to give you a good understanding of movement. And it’s all about the principles rather than inserting any style of movement or training. But I do want to give CrossFit headquarters credit for this simple framework. And at the end of the day, you have to earn the right to move forward on this continuum with this progression. And time itself doesn’t count, especially for my ACL athletes. Just because we’re at three months does not mean we get a green light to go run. We need to earn the right to run, we need to earn the right to jump. Part of that is allowing our bodies to heal, but also making sure that we apply these scientific and research-based concepts into our programming to make sure we are prepared for any task that we’re about to take on.

Let’s dive into the mechanics, consistency, and intensity. For mechanics, remember at the base of that pyramid is essentially, thinking about your technique and moving your body and any external object in an efficient, effective, and safe manner. If I tell someone to squat, there are going to be numerous ways. If I line up 10 people, whether they have had ACL rehab or are going through it, or just people who are squatting without any injuries. You’re going to see tons of different ways that people squat. And you’ll see this in the gym all the time. Everyone’s got their own experience and definitions based on their own past history of understanding the movement itself. We want to make sure that the mechanics and the technique of it are fit to that person based on their anatomy, based on their goals. But making sure that when we squat we’re doing it in as efficient and effective manner, and making sure that they’re safe. 

With ACLs, initially, when we start to squat, we’ll typically do the mini squats into increased depth and then progress towards maybe goblet box squats to front squats, and back squats. That’s if that’s in your programming or rehab, hopefully, at some point. And this is something that is going to look different for each person. But what we will typically see, because the knee is what has been injured or reconstructed that we will avoid loading the knee, loading the quad, and what we’ll do is shift our butt back or shift to the unoperated side.

Susan Sigur did a study a few years ago. She talked about how at three months there is a compensation to the interlimb side. So that means on the unoperated or uninvolved side. We’ll shift that way because we don’t want to load the ACL side. And we want to have our unaffected side do most of the work, which makes sense. And then what we’ll do is we’ll shoot our butts back in order to avoid loading the knee and the quad as much. We’ll load our hamstrings and our glutes. The same thing could be said. When they looked at five months, and these same people who are squatting, instead of seeing an interlimb, to the opposite side compensation. We saw a same-side compensation, so that’s called an intralimb. And this is an episode we’re going to be doing here soon to talk about this. But this is a very constant thing we see in ACL rehab where people will shift. The squat will look even, but maybe they’re shifting their butt back or they’re compensating in some sort of way.

My goal in saying this is that if I tell people to squat, they’re going to find a way to do it. And it doesn’t necessarily matter how it’s done. Because that’s not what is processed in most people’s brains when they’re doing these types of movements, especially whenever they’re fresh post-op. I mean, you’re essentially just trying not to fall over and feel like you’re going to die. We’re essentially just trying to squat and it feels like a big milestone, but how we do it and the way we do it is going to be so key. And that’s where these mechanics come into place; the technique of it. We want to make sure that you are in a good position to move your body and then any type of external object as well, we want to make sure we’re efficient and we’re effective and we’re safe. Mechanics at the base, you have to learn the proper form, skills, movements, the fundamentals before you can start to ramp on the weights or the intensity, the speed of things. And you got to do it consistently. And this is going to apply to any type of movement that you do in your ACL rehab.

So think about any type of movement you’re doing, whether it is a squat, a hinge, or a deadlift. You’re doing any type of lunge or split squat variation, single-leg stuff. And then this starts moving towards even the dynamic stuff. You’re talking about jumping, running, cutting. You got to essentially relearn how to do all this stuff and then knee has to relearn to do it along with this. Walking is a very good example. We’ve walked all of our lives. And you have to relearn how to use your leg again to walk. And it’s not uncommon for me to see people later down the road when that hasn’t been focused on. And then all of a sudden, they start walking and we start working on these gait drills and you’re seeing some limping or some issues that arise and we have to take a step back. Instead of them running, we might have to work a little bit on some of the prerequisites, like making sure the range of motion is there. But then also patterning and getting the mechanics of their gait right. Because you have to learn how to walk before you can run. So mechanics, learn the proper form, skills, movements, and fundamentals.

The next layer on the pyramid is consistency. Let’s say we have the mechanics in place and we’ll keep working with the squat because that’s always a good example. You can squat well. There’s no compensation that we see. It feels good to you. It feels even, I know a lot of you probably listening are like, man, that would be the dream. Keep working on it. But if we’re talking about consistency here, this next level that is the progression here, it has a twofold meaning. Number one, consistent in performing the proper mechanics of a movement. For that squat, we need to make sure that that first movement is the same as rep number 15 and not just one to two movements. Sometimes it can look pretty one to two movements, but we want to make sure we make that consistent.

And this is going to be ultimately important for performance to move well, to distribute forces well, to use the right muscles, and not compensate. This is a big reason why we focus on this. So consistent in performing the proper mechanics of a movement. And the second point here is consistent with moving often. Both are going to be very necessary and you can’t only do something one time per week expecting this skill or the mechanics of it to improve. You have to be consistent in both and how you perform the movements and the appropriate frequency. A lot of times, we’ll call this capacity. We need to build the capacity up in order to make sure we can move towards a higher intensity. But we need to make sure we move well first. And then you want to make sure that you do it with repetitions and do it often.

A good example again, is the squat. If we only squat one time a week, then that is going to be difficult to master, as opposed to intentional time to focus on it maybe three, four times a week with enough spaced-out recovery. And think about this with any other skill that we’re going to try and learn, whether you are trying to cook, whether you are trying to play the guitar, whether you are trying to learn a new sport like soccer, you’re going to need to practice a lot in order to get used to that specific skill. But it’s not only doing it well, you have to practice it often and be consistent. So that’s one of the things that will be important with any movement, including the squats or lunges or the dynamic work. Is being good with your mechanics, good with the consistency of it, of the proper movement from rep 1 to rep 10, as well as consistently with the frequency, three times a week, four times a week, as opposed to one time a week.

Last but not least at the top is intensity. Once, one and two are mastered, you own the mechanics of the movement and the skill essentially and can do it for repetitions consistently. Then you can add intensity via speed or distance or load to increase your capacity and to increase your ability to essentially do more, to be more powerful, to go for longer periods of time, to be faster. And you want to do it right and then you earn the right to make it harder. That’s going to be the biggest piece here. What I will often see is that people want to jump to the intensity really fast because that’s where it’s kind of fun. You’re starting to feel more like yourself. But then whenever it doesn’t look too great, you might look like Bambi or Phoebe from Friends running around. It’s not going to be great for you to add intensity to that because then forces are going to be in certain places, and you’re probably going to get a grumpy knee.

And this is the thing where you might be able to do a few reps, but if you tried to add high intensity to not such great movement, and with a knee that isn’t necessarily in the best place for it, that’s going to be really tough. And it’s probably going to look sloppy. Let’s be for real. Everyone knows what that feels like. And the only caveat I’ll give is that it’s not your first rep needs to be perfect, it just needs to be consistent and executed in a similar fashion rep over rep over time. And that’s going to be really key here. And so you have to really earn the right to dial up the intensity.

And this is a conversation I have with so many of my athletes. It’s so important. We got to make sure that before we start to add a lot of speed or power or weight to it, we got to make sure that we master it first. And then we can add intensity to it if they’re doing it right. This could be something as simple as moving from a goblet squat towards a front squat, or it could be something where you’re adding more weight to your front squat. It could be something as simple as doing a squat jump. We’re working more on power, or maybe we’re doing accommodating resistance. There’s a bunch of different options, but you got to earn the right to be able to build the intensity. 

One other flow or idea that I want to bring out here is for the dynamic work, I talk to a lot of my athletes about this three Ps method. And we’ll use this a lot with acceleration or speed work. But it follows a very similar flow as the mechanics, consistency, and intensity. And these three Ps is posture, pattern, and power. We want to develop the good postures or the mechanics of it, making sure that we are getting into good technique. We want to pattern that really well, so we want to be consistent with it. We want each and every single rep to look very similar, and then we add power to it. The power is essentially the intensity. Whether that’s adding weight or the speed or whatever it is that we are trying to make it more difficult, it’s these three flows that you can use, similar to the mechanics, consistency, and intensity. 

I’m going to leave you guys with this example. If we have a movement, let’s say the squat, you are post ACL injury or surgery and you’re limited. A lot of this will depend on your range of motion and your baseline strength. But for the sake of this example, let’s assume you have adequate strength, and motion for the movement. If we’re working into the mechanics of it, it might be a progression like this. Assisted mini squat to a target, air squat to a target, a counterbalance to a target, goblet squat to a box/ target, and goblet squat without a box or a target. 

And then the tempo is going to be huge here. We can essentially just manipulate the range of motion, and control the tempo, and that’s going to be the biggest thing to help get the mechanics of it well. You don’t feel like it’s a very daunting movement when there’s no target behind you. Maybe the strength isn’t all the way there. You want a safe space, and then you could still load it and get some strength-building within that range. And then if we move into the consistency, focusing on training this pattern, the squat, two to four times per week intentionally for a certain amount of reps and sets, then accumulating more over time until this feels strong, controlled, and fluid. Then, if we’re talking about intensity, we’re talking about strength. Maybe we’ll go weight-wise as I’d mentioned earlier, a goblet squat where there’s a kettlebell or dumbbell in your hand to a barbell, maybe front or backloaded. 

And then we might move into power-based work, which is the power to speed. This is moving the weight faster. But just remember, in order to be powerful, force is a very big component of this. We need to make sure we are strong and therefore we need good mechanics and capacity or consistency in order to add intensity. That’s going to be really key here. You guys are probably tired of hearing these words, but it’ll help so much to understand and see this concept. And man, it will make your ACL rehab and your return to sports training so much easier if you allow yourself to give yourself some grace and know that you’re not just going to throw on a ton of weight, initially really quickly. Because our bodies are very good at learning how to move, even if it’s not moving well. At the end of the day, if I told you to walk from point A to point B, you’re going to do it. It might not look pretty if you’re early post-op, but you’ll do it. So that’s where it’s going to be really important to hammer this home and understand the concepts.

And the biggest fault that I will see is that not doing one and two correctly and wanting to move too fast. And sometimes this is not at your own fault. It could be at the physical therapist or trainer or whoever you’re working with. They might be using a protocol and so they might just be like, ah, it’s good enough. When you move forward and you don’t get enough time to spend in each of these, but then also maybe not the proper guidance or maybe there’s some sort of issue that’s going on that doesn’t allow you to work on this specifically. But yet it’s still following a time or protocol basis.

And the other thing I want to make sure I do not leave out is personality. Because I have a lot of, I mean, we’re athletes. I consider anyone who is using their body towards a goal as an athlete. A big part of this is that depending on the personality, we want to push really hard or just kind of push through pain, if you will, or just move forward to get to a task, no matter how much or how bad a hit looks. There are so many people who will try to go on to run, but yet there hasn’t been the initial stuff that’s been knocked out yet. They’re like, all right, it’s time enough, I’ll give it a shot, and I get it, especially with not the best guidance. But it’s one of those things where we need to make sure if we know that our personality is prone to overdoing it or going too fast or wanting to go too hard, especially as an athlete, then we need to make sure we have some guardrails in place and have that in check. And that’s one of the things that I make sure with each of my athletes, knowing them and communicating and telling them, here are the expectations, here’s how we’re going to progress, and that helps you to be able to anchor yourself in this process.

And another thing to think about with ACL rehab. This is just another concept, another thought. And it’s related to this, is times when you can look at it as practice versus maybe a competition. You show up to rehab and a lot of rehab, you could probably say is practice. We’re just kind of getting things progressively going, getting back to really the thing you want to do, which is using your knee confidently, playing your sport or activities. But the way you can visualize this is the practice piece. In practice, there is an opportunity to mess up. It does not need to be perfect. But at practice, you are also learning the skill of a lot of different movements and refining those, and it’s kind of in a controlled environment. And that’s a lot of what your ACL rehab should kind of feel like is you’re practicing. Sure, you’re developing and pushing yourself, but it’s not the competition. The competition will come at times when it’s appropriate, and that could be maybe on a testing week, a testing day, or maybe it’s getting closer to your sport and return to performance. But you are relearning a lot of skills again, and you want to make sure you do it right. Think about it as practice and relearning that stuff. Giving yourself some grace to mess up, if you need to. Just do it safely. 

All right, guys, as we wrap up here, the biggest takeaway is to make sure that you own the mechanics or the technique of the movement. And remember, this is a range. There is nothing that is pristine and perfect. It is a range for each person based on their anatomy, the way that they’re built, and the way that they move. The six-foot-eight basketball player who tore his ACL is going to look a lot different in squatting versus the gymnast who is five foot. So that needs to be considered whenever we’re comparing people and techniques and how they look as it’s arranged for each person. And that’s where a skilled coach can be so helpful in this.

Remember, mechanics, consistency, intensity. Don’t use time or protocol. Earn the right to move forward. And I will tell you guys, the people who take this concept to heart, from the start of their ACL rehab and remind themselves of it, if they work on practicing and owning the base of this, they crush it with intensity. They crush it with the inconsistency. And it helps them so much to not have as many setbacks as well in this process. Because as many of you know, what we’ll do is we’ll move right to intensity, heavy weights, trying to jump, trying to run, trying to really push things forward, maybe because we feel good. But then the knee gets grumpy and we’re like, man, we pushed that too quick. And that could be the athlete inside of us. So take this concept, and really apply it to your ACL rehab. Don’t rush things. You have time and make sure you have a coach and an individualized plan to get you there. That is going to be the main thing here is that anyone can complete movements, but you need to make sure you have the right plan and the right guidance in order to get there.

And if you need help on that end, please reach out. You can email me at ravi@theaclathlete.com. And while you’re here, if you’re listening on Apple or Spotify or whatever platform you listen on, please do us a favor and leave a review. This helps us so much, one, from a feedback standpoint. And that also my wife isn’t continuing to just download this repeat after repeated weeks and it’s actually you out there. And that you guys can help us reach more and more ACL athletes so they can have more understanding, more education to feel empowered in this process. That’s going to be it for today, guys.

Hope you all have the best week. This is your host, Ravi Patel, signing off.