James Stewart's ACL Repair
by Aldon Baker
|Aren't you glad you race motocross?|
When Tim asked me to do an article on ACL rehab and repair, I thought this would be a nice way to show people first hand, that rehab for a World Class athlete is really no different than what the weekend warrior might experience given the same type of injury. Often times, people think that just because someone is a professional athlete, that the protocol for their treatment is different from the Average Joe. An ACL knee injury is an ACL knee injury no matter whom it happens to. The only real difference being a fit athlete may recover a little quicker due to their initial conditioning and strength. I have been through this process three times now: once with Ricky Carmichael in 04’, Ben Townley in 06’ and James Stewart last season. All the injuries were very similar and even though both Ricky, Ben and James are great athletes, we didn’t do anything special that is not available to every weekend warrior with the same injury.
As with any injury the key to treatment is evaluation: especially with an injury like the ACL. If you have tweaked your knee riding, training, or just playing around the first thing you should do is see a doctor. Obviously, if it is not painful and you only have a little bit of swelling then some ice and time off the leg might do the trick. But if you experience a sharp pain or heard a click or pop when you sustained the injury, the best thing to do is see a doctor; especially if you have limited range of motion and some swelling. Don’t try to self evaluate something like this. You want to see your Doctor as soon as possible for an evaluation. Early treatment is extremely important and an MRI will show any damage and indicate the prescribed treatment.
In my opinion, damage to the ACL is the most critical injury to the knee as compared to the MCL and PCL , especially when it comes to racing motocross. Without an ACL you lack stability. There are cases however, like with James, when the MCL and PCL are strong enough to give decent stability. But I don’t recommend going very long without an adequate ACL though as that will eventually wear on the other ligaments. Riding with a damaged ACL will also start to wear on the meniscus . Once you start to chip away at the meniscus, you get bone on bone rubbing, which was the case with Ricky. Besides being very painful, you don’t want to tear up your meniscus because it takes a long time to heal and can cause problems down the line. Bottom line is you need to get an evaluation from your Doctor as to the severity of the injury and the protocol for rehab.
Surgery and What to Expect
Bottom line when it comes to riding, if you have damage to your ACL there is probably a 90% chance that you will need to get that thing fixed. The ACL provides most of the stability for the knee joint and motocross requires strong, stable knees. If you look at the case with James, he tweaked his MCL and PCL and was able to get by by hanging off the bike a while and resting. Plus the rest of the ligaments in his knee were strong enough to make up for the injured ACL. You can usually stretch the MCL and PCL pretty good and have those ligaments recover with rest. But when you stretch or tear your ACL, you usually don’t have a choice. If surgery is your only path to recovery as it was with James and Ricky, the protocol to follow is pretty much the same.
Most certainly, your doctor will have you follow a protocol that he feels is right for you so follow that first before trying anything I suggest in this article. But generally, once you are out of surgery the first and most important thing you will want to do is reduce the swelling. Almost immediately, you will be able to start doing some light exercises to regain range of motion in the knee. Normally the graft is strongest right out of the gate but the first thing to hold you back will be the swelling and inflammation. Elevating and icing the knee is key and getting movement as soon as possible is crucial. I use Post Kinetic Chain Exercises with deep flexion angles on my guys but with no strain on the graft. Basically, this is done by sitting on a table and swinging your leg out to get full range of motion. You can also do ankle circles and ankle pumps as soon as you get home post surgery. With ankle circles you simple rotate your ankle in a large circular motion and with pumps you simply point and flex your foot.
Rest - Getting off the leg periodically throughout the day and resting the knee on pillows is recommended, to avoid excess postoperative swelling and pain.
Ice - Placing a cold compress or ice pack around the knee controls pain and swelling.
Compression - Carefully placing an ace wrap for compression around the knee is beneficial to control the swelling. Be careful that the wrap is not too tight to interfere with circulation to the lower leg.
Elevation - Lying down with the knee in a cold compress and elevated higher than the level of the chest is helpful in controlling and reducing swelling.
You definitely want to keep the knee in a brace the first few weeks to aid in stability and to keep any strain off the graft. Stretching the hamstring is also important for ACL recovery. Three weeks post surgery you should have some pretty good range of motion; at least 115 degrees which is easily measured by your therapist. Once you hit the four-week mark, you should be ready to lose the crutches and be able to bare some weight on the leg. At this point, you are still primarily concerned with increasing the range of motion. I have found that the most painful and difficult part here is with the reverse angle of flexion due to the scare tissue. This is basically when you are lying on your stomach and flexing the knee behind you. Message, laser treatment, heat and cold, and stretching are the main course of action in this time period. You should also be able to start applying small ankle weights while sitting on a table and extending your foot out in front of you. By doing this you can start to strengthen the quads while having very little strain on the graft.
After four to six weeks , you should be deep into proprioception training. Rather than sensing external reality, proprioception is the sense of the orientation of one's limbs in space. In other words, it is the sense of knowing where your arms and legs are when your eyes are shut or if you aren’t looking at them. Without proprioception, we'd need to consciously watch our feet to make sure that we stay upright while walking. Learning any new motor skill involves training our proprioceptive sense. Anything that involves moving our arms or legs in a precise way without looking at them invokes it — baseball, basketball, riding, you name it. Proprioception is often overlooked as one of the senses because it is so automatic that our conscious mind barely notices it. It is one of the oldest senses, probably even more evolutionarily ancient than smell.
I like to use wobble boards and other unstable platforms for proprioceptive training. The Indo Board Balance trainer that was reviewed on this site is an example of a good device. The Indo board is nice because you can progressively increase the instability as the knee gets stronger. The key element to watch out for here is instability in the knee as indicated by quivering of the leg muscles. As stability in the knee increases the quivering will decrease meaning that the fibers of the muscle are starting to fire again and is time to start moving on to move difficult moves.
Once you have progressed from the initial stages of proprioception, you will be able to start doing exercises like lateral lunges and lateral step-ups that require a change in direction and balance. At this point, you may also be able to get rid of the total knee brace and go with a knee sleeve. The knee sleeve provides enough stability to be safe but lets the knee start carrying more of the load. The six to eight week time frame is crucial in an ACL knee repair. The graft actually sours a bit at this point, so it’s no time to be risking tweaking the knee by getting rid of the brace all together. At this time the new graft is busy rebuilding itself and is actually at its most vulnerable.
Cycling and Rowing
These types of exercises along with stretching and range of motion will continue for the next several weeks. Cycling is a major factor in all of my training including rehab. At four weeks or as soon as there is adequate range of motion, I have my guys on a stationary bike. The key here is having adequate range of motion to keep your butt in the seat. If your butt starts to hop on the seat due to the knee not bending enough, you can raise the seat so the knee does not have to bend as far to get over the top of the stroke. Then as you gain more flexibility, you can lower the seat. The key to moving outdoors and cycling is being able to obtain a nice, consistence cadence on the bike without any pain. In James’ case, we spent one week on the indoor spinner and on week five we hit the road bike for some light cycling.
ACL Post-Surgical Schedule
1. Phase One (first couple of weeks after surgery)
Goals: Improve range of motion
2. Phase Two (four to six weeks)
Goals: Able to bend the knee zero to 115 degrees.Start the use of a rowing machine or stationary bike.
3. Phase Three (seven to ten weeks)
This phase includes all the former exercises plus a few more.
Goals: Aim to bend the knee from 0 to 130 degrees
4. Phase Four (eleven to fourteen weeks)
Goals: Full range of motion of the knee
5. Phase Five (fifteen to eighteen weeks)
Goals: Lunges, which are appropriate if the knee can bend in a pain-free manner to 90 degrees.
6. Final Phase: Return to Activity
Goals: Fitting of a functional brace for riding
At three months you should be ready to do some advanced moves like hopping, jumping, and plyometrics. You will also start adding more complex lateral moves like running in a figure eight pattern, big circles, straight jogging, and more intense cycling. Beyond six months you should be close to 100% healed. The rate at which you will be completely healed is completely dependent on the individual. Things like your age, pre-surgery conditioning, your bodies’ ability to heal, and the quality of your diet all play a role in how fast you will heal.
To me, nutrition is one of the most overlooked elements when it comes to rehabbing any injury not just an ACL. I have talked at length about MonaVie and its benefits, and this is a situation where I really believe that feeding your body with healthy nutrients is so important. If you aren’t providing your body with healthy nutrients then how is the new graft going to get the nutrients to repair and grow healthy? Check out this article on the link between nutrion and recovery times. If you want more information on MonaVie, please email me for more info.
Getting Back on the Bike
When to get back on the bike is really the big question. After all, the surgery is not only to alleviate the pain but to get us back to doing what we love to do; ride! Some people’s reasons to ride are for the pure pleasure of riding on the weekend while others ride for a living. My advice for both is, even though it is very tempting especially if your rehab is going well, to stay off the bike for as long as possible. With James, as well as Ricky and Ben, I didn’t let them back on the bike until the very last moment: it only takes one slip in a turn to catch your foot in a rut, ruining all the hard work of the past several months. So stay off the bike for as long as possible (6 months if you can) and ride with caution the first couple of times until you feel like you are back to normal and have regained your confidence on the bike.
Drugs and Medication
It is my opinion that the only drug needed during this time is for severe pain. The only other “drug” needed for rehab is in the form of good nutrition. Stuff like Human Growth Hormone and Steroids in my opinion are unnecessary and are just plain crazy. I have taken three of the sports best athletes and rehabbed them with nothing more than good nutrition, sound physical therapy, and hard work. To me all that other stuff is not even an option: period!
For most individuals with a torn ACL, reconstruction will restore stability to the knee and riding your motorcycle will pose no more risk than before the injury occurred. Reconstructed knees are reliable and stable. The knee will not give out unexpectedly and will allow you to return to previous work and athletic activities, usually without any compromises. If you suspect that you have torn or damaged your ACL get it evaluated by a Doctor. And remember this: even though guys like James, Ricky and Ben ride motocycles really fast....when they get hurt they are just like you and me: patients!
That's it for now, until next time, good luck with your training and remember, if you have a question, log on to the Virtual Trainer Expert Forum and have your question answered by a panel of experts. In addition, be sure and check out the Racer X Virtual Trainer archive section. Your complete one-stop information zone for motocross fitness.