N=1; A Guide to ACL-R Recovery

This is all to set the stage for what, in hindsight, was at the same time the greatest, most soul defeating failure of my life as well as perhaps the best thing I ever did. A last minute invite came my way to play with Monmouth Rugby Club at the annual Saranac/Lake Placid CanAm tournament, essentially one of the largest rugby tournaments in North America. It was one week before I was due to fly and resettle my life in Montana. If you think 22 year old Alec could smell the danger from doing something that stupid then you truly overestimate me. A last minute schedule change bumped Monmouth up from the social "just have some fun" division to the club "we're here to show out" division. I still remember seeing the shorts of my opposite number in the first game that had the logo for Old Glory RFC (the professional rugby team in DC) and thinking "maybe I don't belong here". I'm an OK rugby player, some nicer folks might even say good, although at that point in my life, I was in over my head. Twenty minutes and one bad carry later and my ACL had been torn into two, as well as some minor meniscus damage. Life = changed.

I'll write more in a future article about the significance of all of this in my life and the psycho-social battle that dealing with any injury entails, although below I will lay out some of the lessons learned in my own recovery in regards to training. REMEMBER: N=1 here. Although I have coached well over a hundred athletes (rough estimate) who were in ACL reconstruction at various stages, I'm mostly speaking about my own recovery here. There is plenty of great literature out there that details the best ways to train after a major orthoscopic surgery like mine, although the scope of this writing is merely what worked for me back then.

Step One: Where are we?

A needs analysis for an ACL reconstruction is pretty easy at first: I want to walk again. Then I want to drive again. Then I want to run again. I want to be able to get up and down stairs with no problems. I want to be able to demo exercise for my head coach on both of my legs. I want to be able to go out with my friends and not need to sit down every fifteen minutes. Eventually, my goal was to play rugby and compete in olympic weightlifting again, as well as all of the other random athletic endeavors I undertake (climbing, hiking, running, etc.). We are starting at square one: waking up in a bed without the use of 25% of my limbs. I have a fairly strong left leg that not long ago helped me qualify for USAW nationals and be apart of a collegiate rugby team that finished #2 in the country, although next to that leg is a withered, obscenely atrophied right leg that is locked at full extension. 

Step Two: Where do we want to go?

Simple, mostly outlined above. I'm not calling it quits on my identity as an athlete. Winston Churchill, in speaking of Britain's survival through the Blitz and awaiting American aid, famously said "if necessary for years, if necessary alone". It's not cheerful and it doesn't exactly inspire hope, although it's true and important. Most ACL patients I've worked with rehab for somewhere between nine to twelve months post operation and even then might not feel "100%" in a lot of ways. Look into the rate of re-tear rates in ACL reconstruction patients and how those taper off month by month post operation past two years and you'll get a wicked dose of reality regarding the time constraints an injury like this puts on a person. That being said, luckily I was already out of college, I was never really hurt during undergrad or even high school for that matter, and I am still pretty young. This is going to take time although that doesn't mean that any doors have been permanently shut to me. 

Step Three: Walk - How To Make Progress Right Off The Operating Table (and influence people)

The best way to become a film critic is to get surgery or a disease that slumps you in a bed for an extended period of time with not much to do besides scrolling Netflix. During breaks from your extended film viewing in the first few weeks of recovery you might take the time, as I did, to plan out the early stages of your recovery. Why? Because I want to crush this. I want this to be the best ACL-R recovery ever seen by gods or men, whatever that means. Here are some of the ways I was able to be successful early in recovery. To repeat, N=1 here. This worked for me. I can't speak for anyone else and these are not recommendations. 

• Tip #1: Collagen Supplementation

  • Even when healthy I struggle to get enough protein. This is mostly due to my food drive being fairly low and not liking to dedicate time to eating/meal prepping when I could be doing other things. Putting the weight (specifically muscle) back onto the affected leg is imperative. Furthermore, the connective tissue in the ACL must be rebuilt. Enter Costco's collagen powder. It mixes easily into water, is relatively tasteless, and gives arguably the most important structural protein for the development and health of connective tissue. Small investment for great returns. Mix into a large bottle of water in the morning, drink plenty of fluids throughout the day, and we'll get there. 

• Tip #2: Vitamin E Oil

  • That scar needs to heal, that surrounding musculature needs some TLC, and that knee is going to take a beating from three PT sessions a week, not to mention all of the at home work (more on that later). Enter the vitamin E oil bottle that my mom bought from the local pharmacy. Cheap, feels nice, makes massage on the freshly pain stricken leg feel more tolerable, and also smells pretty good. Look elsewhere for an in depth explanation of the effectiveness of vitamin E oil for treating various conditions although for the needs of this article, it worked well. Plus it was pretty funny to see my physical therapist get mad and say "what the hell is this" when he touches my knee and finds some strange and unexplained golden ectoplasm over my scar. Sorry Dr. Miller, it's vitamin E oil, I use it every morning to massage my knee and right now it's making my knee feel great.

• Tip #3: Intention in Training

  • ACL-R is how countless teenagers every year learn the difference between doing the bro split at planet fitness with their boys and actual periodized training. Immediately after leaving surgery your surgeon will hand you a packet with recommended exercises that can be done at home, typically while laying in bed. Immediately after awaking from an anesthesia induced coma is no time at all to open Excel and start programming, but a day or two later should suffice. I won't write out my own regime because I think it's far more valuable for the average person to figure that out for themselves a bit and the packet from the surgeon is generally pretty solid for post-op care, although keep in mind that the SPORT principles of training still apply here just as much as they do in "regular" training. Many of the post-op bed based exercises are pretty non-invasive and lack intensity so training frequency can be fairly high, every day or even mulitple times a day. Volume should be more cautious because the tissue is still so fresh that muscle damage and fatigue will be felt much more dramatically than normally. 

Ultimately, one needs to, of their own accord, develop a plan to strengthen their knee, regain flexion and extension, and practice stability and flexibility all from the comfort of their own bed. After a few weeks, they can move to exercising on the floor or standing. All of this is supplemental to the actual "in clinic" physical therapy that one will do. These small exercises when done consistently over a long period of recovery will make a huge difference compared to those who only take the time to work on their knee (or shoulder, or hip, etc.) in the presence of their therapist. Great athletes practice outside of practice. A great ACL recovery may entail three in person PT sessions a week and, perhaps, five at home "sessions" of self work a week. Do your homework.

Some examples of at home exercises could be:

•  Dips (miniature single leg squats on the order of 3-12 inches) off of a stair, sturdy box, or as I did, off a pile of CSCS textbooks. One can drop the non standing leg to the side (side dips), in front (forward dips), behind (reverse dips), or in a curtsy fashion (curtsy dips)

• Standing or side lying hip abduction

• Couch stretch - helpful for both quad flexibility as well as getting used to putting the knee on the ground again

• Half kneeling rock backs

• TKEs

• Knee hugs from a sitting position/towel heel drags

• Supine straight leg raises

• Glute bridges (any variation that that the knee can handle; straight legged, single legged, heel elevated, etc.)

• Prone extension hangs (later, more like six months or so post operation so as not to agitate the surgical site)

• Seated knee extensions (basically an LAQ. Bodyweight is fine here and won't even be possible for a few weeks)

• Contractions of the quad; much of the musculature is still reeling from the anesthetic and knee sensation may never even fully come back. Isometrically contracting the quad, or even the calf, hamstring, or tibialis anterior of the affected leg will help to reawaken the neural pathways of the lower extremity

• Nerve glides/nerve flossing

• Deep squats with assistance from a railing, chair, or other stable surface. Fight for that depth, little by little every week

The point is this: even if you're a high schooler and still figuring life out you can probably figure out a basic routine for at home PT, and you should if you want to recover well at all. Make it a part of your daily habits: wake up, brush teeth, eat breakfast, PT. It should be so automatic that you can do it without even looking at your program for reference after a few weeks. Get input from your therapist on the program; they're the expert in recovery. Your orthopedic surgeon is the expert on just that: surgery. 

Step Four: From Walk to Run

There comes a time in every ACL recovery where the person recovering leaves the treatment room and goes out into the wider facility. They will move onto more dynamic exercises, train with the strength coaches, and find a rapid acceleration in the complexity and demand of their work. Likewise, they will encounter progress at an increased rate, pretty soon being able to squat to further depth, handle heavier resistance in things like leg press, goblet squat, or RDL, and even get into some pre-running protocols and basic plyometrics. This is an exciting time where one can really start to feel like an athlete again. Here are some of the strategies that worked for me in this time frame (months 2-9 post operation):

• Tip #4: Overcoming Isometrics

  • Give them a quick google or YouTube search for a better explanation of how they work than mine. Essentially, while hypertrophy takes precedence in early post operative programming to a certain extent, neural gains are also extremely important given the negative effects of the immobilization caused by surgery. Overcoming isometrics are a great way to recover the neural gains lost by surgery, practice the basic movement patterns that have knee flexion/extension, and prepare for many of the tests that PTs with throw your way periodically throughout rehab (looking at you, painful knee extension tests). Some of the overcoming isos I used were as follow:

    • Single Leg Isometric Overcoming Knee Extension into Pin - 4x5"/each leg 

      • Do at anywhere from 45 to 60 degrees, depending on pain tolerance post operation

    • Barbell Isometric Overcoming Squat Into Safety Pins - 4x5"

      • Do on the concentric portion of the barbell squat, at what point in the range of motion depends on comfort/training goal

    • Trap Bar Isometric Overcoming Deadlift into Safety Pins - 4x5"

      • Also during eccentric portion, also at whatever point feels most natural. I'd say for both this and the squat about 50% of the way through concentric ROM

    • Safety Bar Isometric Overcoming Split Squat into Safety Pins - 4x5"/each side

    • Sets and reps are easily manipulated for all of these. I would typically do a superset similar to French Contrast Training in which I would treat the overcoming iso as a neural charge and immediately after the set finished hop into my primary lift for the day (squat, deadlift, etc.), super setting that way for all sets. That works although longer isos can also be used for a greater focus on neural drive rather than potentiation. The point is to drive into an immovable object with maximal intent. With athletes needing visual cues I often liken it to "turning on the dimmer", i.e. imagine the quad is like a light that can be increasingly "turned on" the longer and harder we push.

• Tip #5: Small Gains Every Week

  • Adding five to ten pounds onto squat weight every week in the top set is manageable, cautious, easy to draw back if need be, and fairly realistic for those in recovery who were already competent athletes. If at week twelve of rehab one is able to goblet squat 30 pounds for four sets of eight reps with reasonable depth, good control, and little to no pain, they can safely add on five pounds during a session next week. That same athlete at week 24 (six months post op) if adding five pounds per week will be squatting hopefully with a barbell and handling 90 pounds with relative ease. Some weeks will be plus five pounds, some plus ten, some well more than that. This is a useable rule of thumb that is by no means hard and fast and clearly on the more conservative end. Ultimately ACL rehab will need to prioritize biomechanics over load in these months.

  • Furthermore, little PRs are crucial for keeping someone engaged in a process as long and meticulous as ACL rehabilitation (or any other long form rehab). Going from a single leg squat to a 24 inch box one week to a 20 inch box the next week is tremendous and should be celebrated as such. Every little milestone accumulated is another brick on the pathway to return to play.

• Tip #6: Relative Intensity Based Programming

  • Programming based off of a 1rm (estimated or otherwise) can be a very useful tool for assuring the appropriate intensity and load within a given training session. This can be very tricky with athletes coming out of injury or surgery because, as mentioned above, 1rm and estimated 1rm can change significantly on a week to week basis. I have found that basing a training session on maintaining a mean intensity (that is to say, the average relative intensity of all sets in a given day will be x%) or targeting accumulating a certain amount of volume at a given intensity is a great way to assure meaningful volume within training. This tool can be used in the recovery process although, again, with a grain of salt. Looking back at my training from 2023/24 I maxed out squat, deadlift, and clean at about eight months post operation and used those 1rms to base my training for subsequent months off of. That worked fairly well in terms of maintaining training intensity, volume, and load at certain targets relevant to training goals. I would not have maxed out any earlier and I don't think I would ask any other person I'm training to handle heavy 1rms much earlier than that arbitrary point in time. Again, this is a tool in the toolbox, although not the entire arsenal itself.

• Tip #7: Recovery... with an asterisk

  • I was very lucky to have a cold compression machine for my knee at home as well as Game Ready units at my rehab clinic to help with pain and soreness management around my knee after intense rehab sessions. In hindsight I would choose not to ice my knee at the end of every session as I did back then if given the choice now. While early on in rehab that may make sense to manage pain and stiffness after the early days of rehab when pain and stiffness can be quite extreme, that stops making sense around the five or so month mark. Inflammation and muscle damage are necessary to certain extents, in accordance with general adaptation syndrome, in order to drive adaptation. Throwing ice on an elevated knee immediately after an intense training session will decrease inflammation and muscle soreness which would be great if those weren't some of the very mechanisms necessary for positive adaptations to occur. Recovery has been on the forefront of everyone's mind these past few years with products like Game Ready, Normatec, and Vyper foam rollers becoming widely used and that is a good thing although in this context one should be careful with their use. 

Step Five: The Waiting Game

Those seven or so tips above are really the bulk of "unique" little training tips I have to offer from my experience. When people have asked me what worked for me, those are typically the pieces of advice I offer. Past month nine of rehab (or twelve, or whenever someone discharges), the most important thing really is timing; when will I return to sport in earnest? I did end up moving to Montana, only a year late, and spent that year around rugby merely as a referee. My first game back to playing was almost exactly two years after having surgery, again for Monmouth RFC, in August 2025. I could afford to wait that long because my career isn't wrapped up in my effect on a rugby field or weightlifting platform and I wasn't missing an opportunity like college athletics that won't come around again. Other people aren't so fortunate. 

What I can truly say in hindsight is the most important training tip I can offer is this: take your time. No game you can prematurely play in is going to be worth the agony caused by another surgery and having to restart the entire rehab process. Let the graft mature, build up a HUGE volume of training, stay consistent with some form of physical activity (be it training, running, etc.), and come back when you feel ready. My first hit on the rugby pitch post op (video below) was still a little nerve wracking even though it was two years post op and by that point I was in great shape in regards to training. That being said, if I had rushed in earlier or waited much longer I mentally wouldn't have been prepared. And guess what - after waiting two whole years that hit felt GREAT! I hope to God that you never have to deal with an injury the likes of which I have dealt with although if you do learn from it as I have.