How to Successfully Recover from an ACL Knee Injury

The most prevalent sports injury

The Anterior Cruciate Ligament (ACL) sprain or tear is an injury as common as it is devastating, cutting short the careers of athletes across sports like basketball, soccer, baseball, rugby, and football. Despite all the research and so-called advanced methods available today, this injury continues to plague athletes with an alarmingly high incidence and a notoriously poor recovery rate. But let’s cut through the noise. My approach to rehabilitating an ACL rupture doesn’t come from some carefully curated study involving five untrained ballerinas. It comes from hard-earned experience. I’ve endured three knee surgeries, including an ACL rupture that shredded 60% of my knee cartilage during an ill-fated basketball game. And yet, through relentless trial and error, I’ve managed to make a full recovery. I’m now able to move, train, and box pain-free on a weekly basis. I squat over 200kg and boast a vertical jump exceeding 78cm, all while tipping the scales at nearly 100kg. Here are my top tips so you can do it too.

Functional anatomy of ACL

The knee joint is fortified by several critical ligaments, each essential for maintaining stability and function. The anterior cruciate ligament (ACL) controls rotation and prevents the tibia from sliding too far forward, while the posterior cruciate ligament (PCL) stops it from shifting backward. The medial collateral ligament (MCL) stabilizes the inner side of the knee, and the lateral collateral ligament (LCL) secures the outer side. Collectively, these ligaments ensure smooth and stable knee movement, enabling the joint to perform effectively under various stresses.

1. Boost your immunity (pre-surgery)

During my physiotherapy studies, I witnessed countless ACL surgeries firsthand. Let me set the record straight: it’s far more akin to a slaughterhouse than a precise, gentle procedure. The surgery itself is highly invasive, and the recovery process is nothing short of grueling. During my time working in a hospital’s orthopedic department, I cared for numerous post-surgery knee and hip patients daily. One critical observation stood out: the stronger your immunity, the faster your recovery. Patients who were fitter, healthier, and had greater muscle mass consistently recovered quicker, regaining strength and range of motion far more efficiently. If you’re gearing up for surgery, ensure your immunity and recovery capabilities are in peak condition. Stock up on vitamin D3/K2, collagen, magnesium, vitamin C drips, and plenty of protein. Your future self will thank you.

2. Regain range of motion (post-surgery)

Right after the surgery, your knee will be swollen, your muscles will feel like they’ve checked out, and the pain will be unbearable. But here’s the brutal truth: you need to push through it and focus on regaining your range of motion as swiftly as possible. While many therapists advocate a cautious approach to post-surgery rehabilitation, I firmly believe that speed is critical. It's imperative to move your knee as much as possible to prevent adhesions and combat muscle atrophy. Don’t be fooled by the slow-and-steady approach; fast, but smart rehabilitation will get you back on track faster.

3. Get strong (pre-hab and rehab)

Whatever Bosu-balancing exercise your physiotherapist is pushing, don’t buy into it. Forget about convoluted routines involving core stabilization, balance drills, imitating animal movements or childs developmental physiology. What you need is straightforward: build strength. Focus on training through a full range of motion with external weights. Adding external weight is absolutely crucial to provide stimulus for gaining strength, muscle mass and improving tissue resilience. Your priority should be to develop muscle in your thighs, calves, and glutes. Strip away the complexity and get to the essentials. Strength and muscle mass are your best allies in recovery.

4. Do squats (pre-hab and rehab)

There's ample scientific evidence showing that powerlifters and other strength athletes have ligaments up to 300% thicker than sedentary individuals. It’s straightforward: when you subject your body to stress, it adapts. Ligaments become stiffer, muscles grow stronger, and cartilage becomes more resilient. But remember, there’s a fine line—too much stress and things can break down. Incorporating squats or any deep knee bending exercises with substantial load is crucial for ligament and cartilage health, and this principle should be a staple in your training regimen, regardless of your age.

5. Train VMO (pre-hab and rehab)

The Vastus Medialis Oblique (VMO) is the medial portion of the quadriceps, crucial for stabilizing the knee joint from the inside and acting as a dynamic stabilizer. The catch with the VMO is that it primarily activates in the final 15 degrees of knee extension and flexion. In other words, to effectively train it, you need to squat all the way down—something most people fail to do properly. This could be one reason why ACL tears are so prevalent. Below is a sample training designed to absolutely annihilate your quadriceps and hit that elusive VMO with precision.

A1. Paused front squats with narrow stance, 6 sets of 3-5 reps with 4401 tempo.

A2. Lying leg curl with toes pointed in, 6 sets of 3-5 reps with 4401 tempo.

B1. Heel elevated squats with narrow stance and 1/4 reps at the bottom, 5 sets of 6 repetitions with 4201 tempo.

B2. Walking dumbbell lunges with maximal knee flexion, 5 sets of 12 reps with 3110 tempo.

C1. Incline back extension, 3 sets of 12 reps with 3012 tempo.

6. Train glutes and hamstrings (pre-hab and rehab)

The chain is only as strong as its weakest link, and for most people, the posterior chain is severely underdeveloped. Hamstrings are critical for knee stability and force production in the lower limbs. I recommend training them with a 3:1 ratio of hip to knee flexion, emphasizing their role as hip extensors. Focus on exercises like good mornings, Romanian deadlifts, back extensions, rack pulls, kettlebell swings, leg curls, Nordic curls, and GHDs. Below is a sample training routine designed to strengthen your hamstrings and glutes through tri-sets.

A1. Conventional deadlift 5,4,3,2,1 (Build up to 1 heavy repetition).

B1. Romanian deadlift, 5 sets of 6 reps with 4201 tempo.

B2. Very wide stance good mornings, 5 sets of 8 reps with 3110 tempo.

B3. Horizontal back extension, 5 sets of 15 reps with 3011 tempo.

Below is a sample training routine designed to strengthen your hamstrings and glutes through tri-sets.

7. Train at high velocity (pre-hab and rehab)

The reality is that most injuries occur at high velocity, not at slow speeds. So how can you possibly prepare for what you don’t train for? Building strength and muscle mass is essential for reducing injury risk, but mastering the ability to express and control strength at high velocity is equally crucial. Train for speed and power. Begin with gentle jumps, then advance to box jumps, plyometrics, and hill sprints. This approach will ensure you’re not only strong but also capable of handling explosive movements effectively.