Geno Smith and ACL Recovery

The Jets' injury woes continue as quarterback Geno Smith tore his ACL against the Ravens in week 6. This article is a part of my ongoing ACL series, where I already spoke about the recovery protocol and exercise selection during recovery. This article will focus more on the early phases of recovery and the important aspects of rehabilitation.

To recap, the Anterior Cruciate Ligament is a major ligament in the knee that contributes to the stability of the joint during movement by preventing the tibia (aka shin bone) from moving too far forward. Typical recovery takes anywhere from 9-12 months, with jogging starting around the 4 month mark and return to sport starts around the 9 month mark. Towards the latter part of recovery, it is very important to perform exercises that can carry over to everyday activity such as squat variations, deadlift variations, and balance exercises. As a result, not only does the knee get stronger, but the body is better able to move with that recovering knee. When the knee is starting to get stronger and the athlete is starting to regain confidence in that knee, exercises should shift towards single leg strength. Running is a series of single leg bounds and agility requires to jump off one leg while the body is changing directions. The better strength and balance an athlete has with standing on one leg, the more explosive and dynamic he can be on the football field.

Now let's take a step back and talk about the most important aspects of early rehab to facilitate a successful recovery.

1. Minimize pain and swelling

After undergoing ACL surgery, pain and swelling is usually associated with recovery. Swelling is common around the knee because it is inactive and the fluids that usually circulate around the body build up in the knee. An increase in pain and swelling likely results in shutting down the muscles around the knee therefore contributing to these symptoms. Pain and swelling limit a person's range of motion and limited range of motion in the knee severely affects the way a person walks/moves around. Physical therapists (PTs) usually give basic exercises and provide ice along side from manual techniques to subside the swelling and thereby decrease pain.

2. Regain full range of motion (ROM)

Speaking of ROM, it is imperative that the patient restores full knee extension (straightening the leg out) as soon as possible and gradually improve knee flexion (bending the knee) as rehabilitation progresses. After surgery, it is so hard to regain ROM after a certain time period because the muscles and ligaments around the area tighten up and make the joint stiff. Typically, PTs want to get to 90 degrees within 1 week after surgery and around 125 degrees 1 month after surgery.  A decrease in ROM leads to decrease force production of muscles essentially making them weaker. In addition, inability to fully extend/flex the knee impairs walking and running mechanics, making it that much harder for an athlete to return. Stretches are given on top of PTs attempting to gently force more ROM and performing soft tissue mobilizations to make sure full ROM is regained after ACL surgery.

3. Regain strength in quads

Talking about strength, athletes must reduce the amount of atrophy that occurs in their quads as a result from disuse. The muscles around the knee naturally get weaker from the pain, swelling, and loss of ROM however as all of these symptoms improve, strength in the knee must be gradually restored. With restricted ROM, muscles tend to be shortened or stretched instead of having normal muscle length. As a result, the muscle fibers (that make up the muscle) cannot produce the proper amount of force and decreases the total amount of strength of the muscle group. With full ROM restored and strength in the quads slowly returning, the athlete is able to progress through the recovery protocol and eventually start running and completing football-related activities.

4. Maintain patellar mobility

The patella (aka knee cap) rests on top of your knee is important for making sure the knee moves properly. The patella moves up and down when the knee moves and if it loses mobility as a result from scarring, pain, and/or swelling, the knee is unable to fully flex or extend and consequentially strength is reduced. Loss of patellar mobility is one of the main reasons why total ROM is lost in the knee surgery or not.

5. Maintain strength and endurance of the rest of the body

Finally, while the focus of rehab is on the knee, it is important that the upper body and core don't get weak. Once the knee gets back to full strength, it is important that the rest of the body has not gotten weak from not practicing or playing in a game. For this reason, athletes should still try to work out their upper body and core. As the knee gets stronger, PTs should incorporate exercises for the hip and ankle to avoid weakness and assure they are able to compensate for a temporarily weakened knee joint.