Acl and meniscus surgery rehab

I am a 27 year old female. Started lifting 3 years ago mainly for mass building.

6 months into lifting I tore my ACL and meniscus. I continued lifting with a bad knee for about 2 years ( with some minor instability and swelling issues ) and then finally decided to operate.

I had the surgery 7 months ago now and I really struggle with that knee. I have gained back some of my strength ( DL 200lbs, Leg Press400 lbs for reps), slowly working my way into squats and lunges.

The knee still hurts a lot going down the stairs, doing leg extentions- even with no weight on- or trying to kneel down.

I have severe patella luxation issues ( had the patella tendon graft done), the knee still swells up after excersise and has a lot of stiffness going on.

Is this all normal after 7 months of physio and gym? Should I just work harder?

Hi Konstantia,

Sorry to hear about your struggles.

Can you be more specific on the surgical procedure?
You mentioned a patella tendon graft was used? Can I assume it was an autograft? (your own tendon)
How was the meniscus handled?
What did “physio” consist of?
What does your training look like now?
What are your long term goals?

Hello and thank you for your answer :slight_smile:
Yes, the graft was a patella tendon autograft ( bone tendon bone). I had a medial and lateral meniscus tear , my surgeon did sutures for both the tears.

I had physiotherapy from day 10 after surgery to day 50.We did a session every day, just using different machines.
We did 30minutes of CPM ( continuous passive motion) , electrotherapy , ultrasound and laser therapy mashine. Finally we did some cycling just to help me with my walking.

On top of that, I was doing about 100 reps of mobily excersises and quad and hip excersises at home.

My surgeon advised me NOT to work on my hyperextention at that point, nor do any banded leg extentions because they would " loosen up the graft".

I was cleared to use the leg press at 50 days and after that, I was basically on my own.

At month 5 after surgery, I saw my surgeon for one last time. I had full flexion and 0° extention at that point. He said that my hyperextention would become normal again when I gained back my quad strength.

So, that was the first time I did not listen to my surgeon and started doing band and hyperextention excersises.

Now, at month 7, I finally got from 0° extention to 13° hyperextention ( same as the other leg).

I do legs twice a week.
Day1: Single leg press, Hip Thrusts, dumbbell romanian deadlift, back hyperextentions (for hams and glutes) and single leg calf raises.

Day 2: Single leg press, Sumo deadlifts, Lunges , Goblet squats and calf raises

At home I do banded quad isometric holds every day ( they still hurt like hell, did not make any progress on those).

I just want to have a functional knee, be able to lift and to stabilize that patella.

Ok,

Here are my initial thoughts, and should Derek or Michael have input/disagreements/etc, I’m open to a nice dialogue.

There is no clear consensus on exactly how to rehabilitate a post-surgical ACL reconstruction with meniscus repairs. In my zip code surgeons typically use a BTB graft. With the meniscus repair range of motion and weight bearing are put on hold for the first several weeks. They ask for open chain exercises (knee extensions) be held off until for 6-8 weeks (42 days). Some still think knee extensions are a “bad” exercise no to be done ever.

During the first weeks/phase the goal is range of motion, weight bearing, symmetrical sit to stand, stairs, basic activities of daily living. After this point I follow a simple linear progression starting with a single leg press. The goal is building load tolerance.

At the same time, I’ll work on standard squats/sit to stands with the goal of symmetrical loading and technique. Once the individual can tolerate loads in the knee for both a single leg press and squat, I’ll start moving to lunge movements (stationary, step back, step forward, Bulgarian’s). I still use squats and leg presses during this time.

At around 6-8 weeks (42-56 days) I like to start with single leg knee extensions. It is common for BTB folks to have anterior knee pain. I perform a simple linear progression with these as well. Long slow contractions with the goal of achieving similar strength of the right and left quads.

I like squats, deads, lunges, leg presses as much as anyone…but none of those load the surgical site like an isolated knee extension. Another exercise some use is a anterior step down with the goal of eccentrically lowering yourself in a controlled manner. These also load the anterior knee well.

After surgery its easy to compensate and unload the anterior knee structures in multi-joint exercises. A single leg knee extension will give you a clear picture of the load tolerance of your surgical knee compared to your non-surgical knee. It’s also a nice way to improve isolated eccentric tolerance used in stair decent, deceleration, etc.

With the meniscus repairs, any normal protocol is typically delayed several weeks.

Hope this helps…feel free to ask more questions should you have any.

Thank you so much ! :slight_smile:

I will work more on my leg extention then …

Hey Konstantina,
As with pretty much every post I’ve seen from Matt, I’m in full agreement. I may be a little more aggressive in my loading protocol but that is likely more splitting hairs. The big thing as Matt mentioned is it is easy to compensate with double leg exercises after surgery and single leg exercises are an excellent way of assessing any deficits that persist. If you are continuing to experience anterior knee pain single leg extensions are a great way of assessing the difference but another route is to check via a single leg leg press. Here, you are going to get some of the multi-joint compensation that Matt alluded to but you may be able to tolerate the position better.

One thing I really want to reiterate is that at 7 months it is very common to still have a pronounced quadriceps deficit after ACL surgery. It sounds like your rehab was way on the conservative side of things which is fine, but you almost have to think of the training age of your quadriceps after surgery. If you were not cleared for leg press until almost 2 months post operative you’ve only really been addressing the quadriceps for 5 months and being on your own with the programming during that time may have left a little to be desired. This is okay and you will get over it as you re-establish quad strength. What you will likely notice is the symptoms will not disappear but rather become more episodic as you start pushing your knee.

What sets/reps/RPE are you currently running for your single leg press and what would you rate the current difference side to side? This can give a baseline from which to work and start giving you quantifiable goals to work on.

Thank you so much Doc! :slight_smile:

I am currently doing 5 sets of 10-12 reps at RPE8.

But, on good days( once every two to three workouts) I can work to failure, so, RPE10.

The single leg press is my strongest excersise currently, I would say, the operated side is at 90% of the good one.