I have a client who has undergone ACL reconstruction surgery on both knees three times. After spending years working with physiotherapists, he has got to the point where he can walk with relatively little discomfort. An ex-bodybuilder, he has approached me because he would like to gain back strength and size back to his legs as he has predominately been training his upper body. During a kinetic chain assessment, I found quite a number of lower-body postural distortions, and he found any of the movement observations that involved knee flexion or moving in anything other than the sagittal plane either uncomfortable or painful.
My question is how should I proceed given that any exercise involving his knees would cause him discomfort. What exercises should I be prescribing?
I'm glad to hear you began with an assessment. It is no surprise that you mentioned anything "that involved knee flexion or moving in anything other than the sagittal plane either uncomfortable or painful" as most traditional bodybuilding exercises tend to lock athletes into the robotic sagittal plane. In a situation like this where pain is still present, there may NOT be a lot you can assign in the way of strength training exercises (i.e., pain -> no gain). Training with pain may only further the cycle of injury your client has been experiencing the past few years.
I would suggest first and foremost staying in very close contact with the client's physiotherapists and getting as much feedback and advice from them as possible. An integrated flexibility protocol should be the cornerstone of your program.
The postural distortions you've mentioned above have a series of muscles that are prone to tightness requiring flexibility training (self myofascial release] and/or STATIC stretching). Here are a few you may want to begin with:
- rectus femoris
- IT band
- latissimus dorsi
- pec minor
(All stretches can be found on PTontheNET's Exercise & Flexibility Library.)
A logical place to proceed next would be a CORE stability protocol. Years of bodybuilding, void of any integrated techniques, has undoubtedly left your client with less than optimal CORE strength. A few beginning progressions may be:
- 4 point drawing in maneuver
- 2 leg floor bridge
- prone floor cobra
- quadruped opposite arm/leg raise
- alternating bridge
- ball DB cobra
And so on...
If your client has the goal of adding a lot of muscle mass after three ACL surgeries, then we may really be dealing with a behavior modification issue. You may simply want to sit down and have a conversation about what the reality of the situation is and what he can realistically expect at this point in time.
Remember, function first, aesthetics later.