The anterior cruciate ligament (ACL) is the most commonly injured of the four main knee ligaments, and operations to reconstruct it are becoming more common. An extremely painful injury and one that can destroy a sporting career. I should know as I tore my ACL only 5 months ago! A complete rupture will require surgery as the knee will be exposed to massive instability and without repair will lead to chronic arthritis and a lifetime of pain. But what if you partially tear the ACL? Is surgery still the best option? Well this depends on many factors but what I will share with you here is that regardless of whether you have surgery or not, have a partial tear or a full rupture adopting a Functional Movement Strength Training Program is an absolute must! Unfortunately most of the programs and information you can look up about how to do this is really bad at best and actually can make you worse not better. I read several books and became an ACL research fanatic for months looking for answers to my own questions and came up with a set of key exercises and strategies I am about to share with you. It is important to note here that these are also great ACL Prevention exercises and if you had adopted these before the injury you would not be reading this article. I had never hurt my knees in over 30 years of competitive sports, and became lazy with my training, thinking this will never happen to me. And even though I had great movement skills, strength and fitness for a 42 year old, I still should have been completing some of these exercises more consistently to ensure I prevented this painful injury.

Does The ACL Heal On It's Own?

This was one big thing I learned after injuring my knee earlier this year. I have broken many bones (20+), torn hamstrings, ankle tendons and shoulder muscles many times before and never needed surgery. With the right rest, physical therapy and rehabilitation I was always able to get back to full strength and go back to sports. But this injury I was to find out is a lot different. Unlike other ligaments the ACL is entirely within the knee joint. It's unique anatomical position is what allows for it to play a crucial role in pivoting and twisting turning movements and secondly it's very poor healing ability! Because it is inside the knee joint itself, it sits within a pool of synovial fluid along with all the other structures of the joint. And because of this it receives a very minimal amount of blood supply. And anything that does not receive a good blood supply will not heal effectively. Meaning that the ACL does not heal very well at all.The importance of strengthening muscles supporting the joint becomes more important than ever!

Approximately 70% of all ACL injuries are classified as non contact situations where the person landed from a jump or tried to chase or evade a player only to fall to the ground in agony. ACL tears or full ruptures occur when you plant your foot on the ground and attempt to rotate your body in relation to that planted foot, placing a huge amount of weight on it. I did mine trying a crossover move in a basketball game. Exactly the movement I just described. Whereas many AFL Football players like Nic Naitanui it was from a single leg landing after a jump to mark the ball. In Naitanui's case his was a full rupture requiring surgery and a 12 month rehabilitation program. But does this mean surgery is required for a torn ACL, knowing that it does not heal well on it's own? Not necessarily.

What is needed if you just tear the ACL, or you have a full reconstructive surgery, is:

"The need to strengthen all of the muscles involved in leg movements and identify and correct any faulty movement that led to the cause of the injury!"

Surgery Does Not Treat The Cause And Does Not Mean The Knee is Fixed

Understand that once you tear your ACL your knee is never going to be the same, even if you have reconstructive surgery. And remember surgery is just treating the symptoms or the end result. Surgery does not treat the original cause which in 99% of all cases you can trace to faulty movement patterns and muscular imbalance. This is why you see so many professional sports players repeatedly tear the ACL, as they rely on the surgery to fix them, rush through a strength program  but not really address the poor movement patterns and postural problems that are still in place. All surgery comes at a risk too, and with ACL reconstructions this is so true. I have a young AFL football player who had the reconstructive surgery and the graft for the ACL was taken from the hamstring. This year he has suffered multiple hamstrings tears and missed another year of football as a result. You cannot steal from yourself and be the same.

You only have to look at recent examples in the AFL of Alex Johnson from the Sydney Swans who has had 5 knee reconstructions and Daniel Menzel from Geelong to see that although surgery is needed, it does not "fix you" and it definitely does not address the real cause of your problem. I am always amused at seeing how many sports players get the end of season arthroscopy to "clean out the knee" instead of addressing their running technique, muscle imbalance and poor movement patterns that is stressing the knee. In the book "Surgery The Ultimate Placebo" by Dr Ian Harris he describes how useless this surgery is.

"For knee arthroscopy, the bottom line is that if you have pain and degenerative changes in your knee (like mild arthritis or an undisplaced meniscus tear), then regardless of the kind of symptoms you have (mechanical or not), regardless of how bad your pain is, and regardless of whether or not the MRI scans show your meniscus to be torn, and of whether or not you have an MRI at all, having an arthroscopy will not increase your chances of getting better, compared to a sham surgery. Nor will it reverse the degenerative changes in your knee. Believe me, I would love for arthroscopy to work (it is a great operation and pays well) but for arthritis and degenerative tears in the meniscus which is most patients with knee pain it doesn't."

If you tear your ACL it can take as long as 6 months to regain the strength and skills to be able to go back to playing sports if you choose not to operate. I myself chose not to operate and within only 3 months I was able to run, jump and complete most strength training exercises with loads as good as before. However I do recognize the lack of power and the potential instability from the twisting and turning movements needed to play basketball. What you must understand though that no matter how strong you can make your muscles and improve your movement patterns with exercises I am about to show you, there is a very high risk of injuring your knee again if you go back to pivoting, twisting and turning sports like basketball, football, soccer and netball. If you injure it a second time you will also damage the meniscus and cartilage leaving you with arthritic symptoms and chronic pain. To go back to sports you must be 100% certain you can execute the exercises perfectly below without instability or pain, but even then there is still a risk. You need to be sure if this risk is worth it. If you need to do this for your job then it may be worth getting the operation. And if you are a teenager, which actually is very common in females aged 16-19 then surgery is possibly a good option to prevent instability for the rest of their life.

Okay so let's take a look at what you can do.

What Can You Do To Prevent Further Tear Or Injury

Firstly you must start with a thorough postural assessment. This will help to identify muscle imbalance that most likely set you up for compensatory movements that place stress on joints all throughout your body. With knee pain I find in over 90% of ALL cases that there is significant anterior tilt of the pelvis associated with tight hips and quads. These tight hips and quads lead to weak glutes and hamstrings which is a perfect recipe for an ACL injury. Click here to read our article on Postural Analysis or click here to watch a quick video of how we do this using an app called Posture Screen Pro. Learning how to correctly strengthen your glutes is one big step in the right direction. Far too many people are quad dominant with most leg exercises and their strength program actually contributes to their injury. Read our article on How To Strengthen Your Glutes for more detail.

In the book "Understanding and Preventing ACL Non Contact Injuries" by American Orthopedic Society For Sports Medicine, they found in their research that "quadricep muscles are the major contributor to the anterior shear force at the proximal end of the tibia through the patella tendon. DeMorat and colleagues showed that 4500 N quadriceps muscle force could create ACL injuries at 20 degrees knee flexion."

But just using a strengthening program isolating the glutes and hamstrings is also a waste of time which unfortunately is what many of the rehab programs I found offered. Using Nordic hamstring isolation and machines like the leg press and various other "body building invented" exercises creates more dysfunction. (read the article on Squats versus Leg Press to see why machines create more problems)They can be used sparingly to assist in strength development, but really LEARNING HOW TO MOVE and strengthen in a standing position, and usually in a single leg stance is where your answers will be found.

Our complete program for ACL Injury Prevention and Rehabilitation is the best program for providing you with comprehensive muscle imbalance corrective exercises, stability and strengthening exercises and I would encourage anyone who needs to go through ACL rehabilitation or any type of knee rehab program to get this. Click Here to see more about what is included in this massive report that has over 100 exercises and drills and step by step programs to guide you on putting together the best program to return to sports.

Click here to go straight to the Online Shop.

The closer the exercises mimic the movement that is likely to hurt you, the greater the chance of preventing further injury, if you can execute with perfect form over several thousands of repetitions. In my research quest I found some books and internet sites that did explore this however these provided exercises that were not very coordinated or sports orientated, the concept was there but the lack of understanding of real movement was apparent. Also there was no focus on adding muscle or specific skills with power which is absolutely essential in sports. Performing slow movements with body weight does not compare to playing a high level game of basketball. Below is set of 3 key patterns of movement that will cause an ACL tear or rupture and I will show you how to use an exercise to correct and prevent this.

Key Movements To Learn For Preventing The ACL From Future Tear Or Injury

Learning how to move is critical here and I am going to give you a video and an explanation of each on how you can use exercises to strengthen your body in order to prevent further injury. Below is a video you can watch, which summarizes all of the movements and gives you an overview of what exposes you to more injury.

Firstly you MUST learn how to do a Single Leg Squat correctly. The single leg squat is the king of all leg exercises and in particular for glute strength, (read our article on How To Do Single Leg Squats for more detail on this). In 99% of ACL injuries it is from a single leg pivot or landing. Rarely from a double leg landing. Strengthening your body with this exercise is more than just leg strength, it takes considerable amount of balance, coordination and body awareness to complete this correctly. The glutes are heavily involved in not only providing the strength to complete the movement but also maintain the correct alignment of the lower limb. From hip through the knee all the way to the ankle. If you cannot do a good single leg squat you are never going to be able to play sports without risk of severely injuring your knee again!

Below is a picture of a single leg squat comparison of good form versus poor form. Play close attention to the angle of the leg, when the knee is not directly over the toes and is falling inwards is where the risk increases. It is your job to strengthen the leg in it's optimal alignment not just with the single leg squat in a standing position but also at high speeds and when you are moving sideways. I also provide you with the table of what to look for so you can use this as a test.

Okay so here is the 3 key movements and number 4 is where we begin to put it all together.

1. Learning To Pivot Correctly

By far the most common way an ACL is injured. This is quite a difficult movement to explain and I highly encourage you to get the book "The ACL Solution" by Robert G Marx MD as they provide very simple illustrations and instructions on basic movement skills for this. Often tight hips and tight or even weak ankles play a part in creating the pivot or cut that is less than optimal and setting you up for an injury. Learning how to use a multi direction lunge with the trailing leg pivoting can be very helpful with this exercise so I have included a video alongside to demonstrate this (watch from the 1 minute mark).

2. Single Leg Landing

Common to AFL football and basketball players this is very closely related to the single leg squat mechanics. For really landing from a jump is a single leg squat at high speed. If the knee is not maintained in it's optimal alignment and you land from a jump at high speed there is a great chance of you tearing the ACL. Box Jumps and single leg landing techniques are great to use here. I also included a video of one of our sports assessments using a BOSU to enhance single leg stability.

3. Lateral Bound

It is quite ironic that most injuries occur in a lateral (sideways) movement pattern, yet nearly every gym exercise is completed in what is known as the sagital plane, or otherwise known as going in a straight line. Exercises like squats, lunges, step ups etc are all great exercises however they do not teach you how to move in a lateral direction. If you never practice or try to improve your stability and strength in this direction it is inevitable that you will develop a weakness in this movement.

4. Plyometrics

This takes all of the previous skills based approach and placing them into much more difficult situations, at higher speeds, with load and with unpredictable and random instruction. Where most training programs fail is that all of the exercises are performed in controlled and balanced environment where the person can anticipate what to do and prepare the body for the movement. In sports this is rarely the case, it requires the body to make split second decisions on how to move in order to get the ball, hit the shot, absorb the tackle etc and it will use automatic movement patterns called engrams to do this. In order for you to execute perfectly in these situations you need to train in the exact same environment. Use of tools and partner taps, with random instructions is where great gains can be made and the lessons you learned from the previous 3 skills puts it all together. As I mentioned at the beginning this is where I became lazy in my training. I just did not spend enough time working on and developing these exercises. I was strong and even had great balance, but my lack of training at high speed was due to me being too tired and avoiding what I knew I really needed. Looking back now I know if I had spent more time doing these drills and exercises I would still be playing today, and if anything I most likely would have played better!

Below would be an example of putting these skills together to prevent injury and also improve performance. One features a video of myself performing a crossover move in basketball compared to a plyometric jump over the hurdles. The other is a great video of a hockey player simulating change of direction using single leg hopping and the skills of her game all at once!

Lastly don't disregard the importance of good foot stability. This is one area we see a lot of problems originate from and again this is often missed in treating the injury. The foot needs to act like a spring being soft flexible foot to cushion the stress of each step we make, and then instantly become stiff enough to provide enough power to move us forwards or upwards. This is also known as being able to lock the foot at one point and then being able to unlock the foot at the very next part of the movement. Problems arise if we lose either one of these two things, and ultimately lose our spring. This is where injuries like an ACL tear will occur if the foot is weak or too rigid to properly absorb shock. Below is 2 great videos to watch. The first explains foot stability and the second gives you some simple exercise solutions to correct any weaknesses.

Conclusion

I hope this article gives you great insight as to what you can do for training and prevention strategies to either overcome a torn ACL or prevent further damage. Make no mistake it will not be easy, it will take a long time to get the desired results from all of your Strength Training and Stability work. But it will be well worth the effort. Even if you decide to give your sporting career away it is still important to complete these exercises and learn how to move better. You cannot heal the ACL, but you can strengthen all the muscles surrounding the joint. The injury itself will have wasted many of the muscles supporting your joints, so you are already in a weakened position. If you do nothing to correct this, it only gets worse and you will eventually lead to chronic knee pain and arthritis. Stay away from machines like leg extension, leg curls and leg press and learn how to correctly stabilize yourself in a standing position. Lastly make sure you take your time with the plyometric training. Learn from my mistake and make this a big part of your training. Get a good coach or trainer who understands movement patterns to help you. Once you have been able to execute these exercises a few thousand times you will become automatic at them and your chance of injury is dramatically reduced.

Remember to get your copy of our ACL Special Report by going to our Online Shop or clicking the image below. We also have stacks of FREE REPORTS you can get by clicking here.

If you live in Melbourne you can request a Free Movement and Postural Assessment by clicking the image below

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 14 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Movement - By Gray Cook
• Corrective Exercise Solutions - by Evan Osar
• Athletes Acceleration Speed Training & Game Like Speed - by Lee Taft
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Stuart McGill
• Knee Injuries In Athletes - by Sports Injury Bulletin
• The ACL Solution - by Robert G Marx
• Understanding & Preventing Non-Contact ACL Injuries - American Orthopaedic Society For Sports Medicine
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek
• Twist Conditioning Sports Strength - By Peter Twist
• Twist Conditioning Sports Movement - By Peter Twist
• Twist Conditioning Sports Balance - By Peter Twist