Latest / The ACL Athlete Podcast / 263 | Quad Size Still Smaller? The Science Behind Persistent Quad Atrophy after ACLR

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263 | Quad Size Still Smaller? The Science Behind Persistent Quad Atrophy after ACLR · The ACL Athlete Podcast

• 0:01
  SPEAKER_00: What is up, team, and welcome back to the ACL Athlete podcast.
• 0:05
  SPEAKER_00: So today we are talking about something a lot of you think about and it's just not discussed very much enough in ACL rehab.
• 0:14
  SPEAKER_00: You hear about strength a lot, you hear people talk about it, but muscle mass itself is not discussed enough.
• 0:22
  SPEAKER_00: Your quad is still smaller and you're months out from the process, and it it's something that can be a little challenging, even if you are nine months out, twelve months out, eighteen months out, maybe, and you're starting to look at your legs thinking, why does this still not match yet?
• 0:40
  SPEAKER_00: And so one thing I want to discuss here today is the first thing is that it's normal, more normal than you think.
• 0:48
  SPEAKER_00: And number two is that I actually want to pull from some of the research to show you some of this from a data standpoint that is showing people don't necessarily always get this back, you know, 100% matching side to side.
• 1:01
  SPEAKER_00: Now you may see the highlight videos of people who are like flexing the heck out of their quads, and it's looking just like the other side.
• 1:08
  SPEAKER_00: The winning stories, the big comeback stories, and yeah, those exist.
• 1:15
  SPEAKER_00: And don't get me wrong, people get their quad sizes back, and we've had athletes who get there.
• 1:19
  SPEAKER_00: But I think the other thing that is important to note is that there are also a lot of people who don't necessarily get it fully back, at least within the nine to twelve months, or even within the first two years, to be completely honest, unless they are just focusing so hard on quad hypertrophy and just being able to work through that appropriately and recover.
• 1:41
  SPEAKER_00: And there are a lot of variables that also layer into this, like genetics or graph type, that will truly influence also getting that size back as well.
• 1:49
  SPEAKER_00: And I'll talk through this today, but first I do want to talk through some of the research that exists to help showcase a little bit of this and normalize it.
• 1:58
  SPEAKER_00: So the thing is with quad atrophy that it starts before surgery, and I remember this so so clearly.
• 2:06
  SPEAKER_00: Like one of the things that I am very proud of is my quads.
• 2:09
  SPEAKER_00: And I remember after ACL injury, my first time and second time, these quads that you have worked so hard for, and I know that many of you will relate to this.
• 2:19
  SPEAKER_00: You look down after the injury, and it's like a day or two later, and you're like, What happened?
• 2:24
  SPEAKER_00: And it's like literally looking like a hot dog, and it sucks.
• 2:28
  SPEAKER_00: And you're just like, Where did all my hard work go?
• 2:30
  SPEAKER_00: Because you're pretty proud of having that muscle there, the definition there, and also the strength there, but especially the size of it, you're just like, Where did it go?
• 2:38
  SPEAKER_00: And so the thing is, is that this happens very, very soon after the injury, and then of course, another trauma after the surgery if you have the surgery.
• 2:48
  SPEAKER_00: And there was a 2024 quantitative MRI study by Anderson et al.
• 2:53
  SPEAKER_00: in 2024 that showed even before ACL reconstruction that ACL deficient limb had reduced quadricep physiological cross-sectional area compared to the uninvolved limb.
• 3:04
  SPEAKER_00: Basically, when they cut that thing across, they showed that there was less muscle mass compared to the other side.
• 3:10
  SPEAKER_00: So it was already smaller before surgery, not weeks after, before ACL surgery.
• 3:16
  SPEAKER_00: So many athletes after surgery already have their muscle mass down prior to going in.
• 3:25
  SPEAKER_00: And that's important context to take into this because the way that I like to think about this is, and I've shared this example before, but it's essentially imagining you know your fitness level, your quad size, everything you equate to, you're standing on the 10th floor.
• 3:39
  SPEAKER_00: When you have that first initial ACL injury, that's gonna drop you down to the seventh, sixth floor, maybe, right?
• 3:46
  SPEAKER_00: And then, of course, hopefully you're doing prehab to help yourself climb back up to a fitness and strength level and range of motion and all the things to get you in a better spot.
• 3:54
  SPEAKER_00: And then you have the surgery again, and hopefully it doesn't knock you down too far.
• 3:58
  SPEAKER_00: So then therefore the climb back up isn't too bad.
• 4:01
  SPEAKER_00: But if you are standing at that 10th floor, you get knocked down to the sixth floor after the ACL injury, let's say you don't really do anything.
• 4:08
  SPEAKER_00: You protect the knee, you rush into surgery, whatever it is.
• 4:11
  SPEAKER_00: Then essentially you kind of stay at that sixth floor, maybe you drop even a little bit more, and then you have that surgery, and then it drops you down even more.
• 4:19
  SPEAKER_00: So then you're at the third floor and you gotta climb back up to the 10th floor to get there, right?
• 4:23
  SPEAKER_00: And so what I'm saying is that it just makes the climb a lot harder because you're gonna get hit twice typically.
• 4:29
  SPEAKER_00: You're gonna have the injury, and then oftentimes people are going to have the surgery.
• 4:33
  SPEAKER_00: So that's just one thing to recognize here that it starts before the surgery.
• 4:38
  SPEAKER_00: The surgery itself can accelerate the muscle loss rapidly.
• 4:42
  SPEAKER_00: An ultrasound study by Williams et al.
• 4:45
  SPEAKER_00: in 2020 measured quad thickness one hour before surgery and again 48 to 72 hours after ACL reconstruction.
• 4:53
  SPEAKER_00: They found a significant decrease in vaso intermediate thickness in the reconstructed limb within just days.
• 5:02
  SPEAKER_00: So that's one of the four quadriceps muscles.
• 5:05
  SPEAKER_00: That whole my quad disappeared right after surgery feeling.
• 5:08
  SPEAKER_00: You know, that's backed by physiology.
• 5:10
  SPEAKER_00: There is research to show this, and that's the other thing, too, is that as soon as people have the surgery, let's say you do prehab or you know, you have the atrophy that happens, it's going to happen again after the surgery.
• 5:22
  SPEAKER_00: It's just a byproduct of the surgery.
• 5:24
  SPEAKER_00: That's why we try to get that muscle active.
• 5:26
  SPEAKER_00: We are trying to reduce the risk of atrophy after surgery as much as possible.
• 5:31
  SPEAKER_00: And that is where these interventions and rehab is going to be such a key point of starting day one.
• 5:36
  SPEAKER_00: We have athletes day of surgery doing stuff.
• 5:38
  SPEAKER_00: Quad sets, getting that leg active and moving as much as we can to be able to minimize the drop in the size and the strength.
• 5:48
  SPEAKER_00: Even at return to activity, for example, that the quad often has not fully recovered in size.
• 5:54
  SPEAKER_00: And this was an ultrasound study by Thomas in 2020.
• 5:59
  SPEAKER_00: Tracked quad cross-sectional area, pre-op, nine weeks post-op, and at return to activity clearance.
• 6:05
  SPEAKER_00: And what they found was the rectus femoris cross-sectional area decreased early after ACL surgery.
• 6:11
  SPEAKER_00: That would be to be expected.
• 6:13
  SPEAKER_00: At clearance, the uninvolved limb returned to preopsize.
• 6:18
  SPEAKER_00: That's great.
• 6:19
  SPEAKER_00: The involved limb did not return to preopsize.
• 6:23
  SPEAKER_00: So the uninvolved limb got there, but the involved limb did not necessarily get to the preopsize.
• 6:30
  SPEAKER_00: So when people get cleared to activity, again, based on the definition of this study, the quad size isn't necessarily there yet.
• 6:38
  SPEAKER_00: And so, like, let's talk about six to twelve months.
• 6:42
  SPEAKER_00: So there was an MRI-based research summarized by Leppley in 2015, and this is a pretty popular study here, showed approximately 7% quadriceps volume deficit in the reconstructed limb at 6 to 12 months.
• 6:55
  SPEAKER_00: Now, I'd probably say like 7% difference isn't awful.
• 6:58
  SPEAKER_00: Like a lot of you would be like 93% symmetry, cool.
• 7:02
  SPEAKER_00: But the deficits were still present at 12 to 18 months, even though they had decreased a little bit.
• 7:08
  SPEAKER_00: But it's one of those things that still can be visually noticeable, and that's the average.
• 7:13
  SPEAKER_00: Some people are more, some people are less, right?
• 7:16
  SPEAKER_00: Persistent asymmetry years later is still consistent too, because there was an ultrasound study by Quenz Quenz, I always never know how to say this name.
• 7:26
  SPEAKER_00: K-U-E-N-Z-E.
• 7:28
  SPEAKER_00: 2020 examined individuals around 50 months post-acyl reconstruction.
• 7:32
  SPEAKER_00: And they found persistent vasus lateralis, that's the muscle on the outside of the quads, the one to the furthest outside, cross-sectional area deficits in the involved limb.
• 7:45
  SPEAKER_00: That's over four years out.
• 7:46
  SPEAKER_00: Again, not everyone, but enough for it to matter and for them to say this.
• 7:50
  SPEAKER_00: And then there's a subgroup that doesn't necessarily fully regain symmetry.
• 7:54
  SPEAKER_00: Walsan in 2022 identified an atrophy cluster of athletes with marked vasus medialis and vasus lateralis thickness asymmetry, even after later stage.
• 8:06
  SPEAKER_00: So some people biologically trend towards persistent quad size differences.
• 8:11
  SPEAKER_00: And that's just something that honestly we have noticed as well.
• 8:14
  SPEAKER_00: There's some people who recover well, there's some people who, for some reason, their quads do not want to join the party and it takes a long time.
• 8:22
  SPEAKER_00: And this even shows in elite athletes as well.
• 8:25
  SPEAKER_00: A MRI study in 2025 by Greenwood et al.
• 8:29
  SPEAKER_00: looked at Division I football athletes approximately 28 months post-ACL reconstruction.
• 8:34
  SPEAKER_00: They found persistent volume deficits, especially in the uni articular quadriceps muscle.
• 8:39
  SPEAKER_00: So even high-level athletes two years out may not have identical quad muscle volumes.
• 8:45
  SPEAKER_00: So that's the research that I want to share with you guys because I think it's important.
• 8:49
  SPEAKER_00: And yes, there's more that exists out there that teases this out.
• 8:52
  SPEAKER_00: But I just wanted to essentially highlight that there is data behind this, so then that way you're not feeling crazy when you are, you know, six months out, nine months out, two years out, and on, and your quad size is not necessarily a hundred percent the same.
• 9:06
  SPEAKER_00: Now there's caveats and context to this, which I will talk about, but real life and real world visual examples, if you'll look at, I know the one that caught headlines was Alfonso Davies.
• 9:18
  SPEAKER_00: If you look at some of his pictures, that quad did not look super happy being five months out, and he had a quad graft.
• 9:25
  SPEAKER_00: So that kind of showcases itself, and those people tend to get hit a little harder with atrophy.
• 9:31
  SPEAKER_00: If you look at Saquon Barkley after he tore his ACL, and the guy has tree trunks for legs, you're talking about massive quads.
• 9:39
  SPEAKER_00: If you look at his ACL side when he is getting back to on-field stuff, you can tell that there is a difference in his quad sizes.
• 9:47
  SPEAKER_00: And there are a lot of athletes that you will see through their training pictures that you will notice that there is a difference in the atrophy of their quads on the ACL side versus the uninvolved side.
• 10:01
  SPEAKER_00: And I see this in other soccer players as well.
• 10:04
  SPEAKER_00: Um, I cannot think of the athlete to date, but there is a US soccer player I remember recently seeing her photo and looking at her quads after ACL, and they were different.
• 10:16
  SPEAKER_00: And the thing is, is that the asymmetry is important for us to understand, but these are also people who are elite athletes, right?
• 10:24
  SPEAKER_00: Going to the highest level of sport.
• 10:26
  SPEAKER_00: And they have also, you know, as we would argue, the best care, right?
• 10:31
  SPEAKER_00: Like they have the most attention drawn to them.
• 10:33
  SPEAKER_00: This is their full-time jobs, and they're trying to make this muscle mass size count, right?
• 10:39
  SPEAKER_00: But the thing is, is that I just want to normalize that with the expert level of care or the high resources available, let me just say that because there is also not necessarily quote unquote expert level care, even though they're on a pro-level stage.
• 10:55
  SPEAKER_00: We know that by Neymar's uh rehab and what we have explored with his ACL and the the media that showed with that.
• 11:03
  SPEAKER_00: Now, I do not have insights on his rehab, but there were certain things with his rehab that you're just like, that is a huge red flag.
• 11:10
  SPEAKER_00: And with that said, so this is really important because just because they're pro-athlete, pro-team, doesn't necessarily mean that they have the best standards, best care, all the things, right?
• 11:20
  SPEAKER_00: They have the best resources from a financial standpoint, typically, but in terms of expertise and care, it typically correlates, but not always.
• 11:28
  SPEAKER_00: And we've seen this time and time again with a lot of athletes we worked with and consulted with.
• 11:41
  SPEAKER_00: And again, there's there's a big caveat here because it's not universal.
• 11:46
  SPEAKER_00: Some athletes do regain full symmetry, like people get it back, and then there is also a large amount of people who do not get it back, um, or it takes more time than the typical nine to twelve months.
• 11:58
  SPEAKER_00: I promise you this.
• 12:00
  SPEAKER_00: And the factors that influence this injury severity, the duration of swelling, for example, that's gonna also key in some AMI artrogenic muscle inhibition, and it's going to delay the quads waking up to be firing and to get more work within the quads.
• 12:17
  SPEAKER_00: I think there's also just a lack of proper programming, hypertrophy-specific loading to be able to influence that muscle volume.
• 12:26
  SPEAKER_00: And when we think about the mechanisms of muscle hypertrophy, we usually go through three different methods.
• 12:32
  SPEAKER_00: And that's gonna be something that's gonna be really important for something like this because if we're not necessarily tapping into hypertrophic type specific loading, then therefore we're not necessarily gonna get the stimulus we need, and we kind of move on.
• 12:46
  SPEAKER_00: And one of the things that we have a challenge with in ACL rehab is proper loading and proper programming, other components, protein intake, making sure people eat right, eat enough, sleeping, genetics.
• 12:58
  SPEAKER_00: Genetics are a huge piece of this.
• 13:00
  SPEAKER_00: The people who you know you walk around and they're fit as ever, and they are the people who are some of these people are ones who never work out and they're super fit looking.
• 13:12
  SPEAKER_00: Genetics definitely help some of these people out.
• 13:15
  SPEAKER_00: So, with that said, there are some people who do have genetics who assist them, right?
• 13:21
  SPEAKER_00: To be able to get that back because maybe they are more lean, maybe they are able to just rebuild muscle mass easily, and so then therefore, those things I tend to see with certain people where they're like, Yeah, your quads came back pretty freaking well, but it was to be expected with someone like you versus maybe someone who is necessarily not as born with these pro genetics to be able to rebuild muscle mass.
• 13:47
  SPEAKER_00: Training age plays a big role, being able to train and be able to push your body, the limb dominance, psychological loading tolerance, and graph type.
• 13:56
  SPEAKER_00: I want to make sure we stress this because yes, quad tendon graphs often present with more visible and sometimes longer lasting quad atrophy because the tissue was harvested directly from that extensor mechanism.
• 14:09
  SPEAKER_00: That does not mean it can't recover, but it does mean that the biological stress was greater.
• 14:16
  SPEAKER_00: And I do believe that.
• 14:18
  SPEAKER_00: And again, like I've seen all the different graph types over the years and size, strength, rate of force, power back, and that is proven in the research as well.
• 14:28
  SPEAKER_00: We see this, we see the data, and I do believe we will see data in the next three, five, ten years that will showcase how much of a climb the quad is compared to the patella and to the hamstring graft.
• 14:40
  SPEAKER_00: Now, with that said, pateller tendons are gonna have a harder comeback too compared to a hamstring.
• 14:45
  SPEAKER_00: When you take a hamstring graft, your quads are not impacted.
• 14:49
  SPEAKER_00: I truly believe that my quads would be a little bit more shot if I had a pateller or a quadricep graft compared to I had two hamstring tendons.
• 15:02
  SPEAKER_00: So I had the benefit of sparing my quads from getting a graft because I did not get the patella, I did not get the quad, I got the hamstring grafts.
• 15:12
  SPEAKER_00: And with that came the pro of being able to preserve that a little bit more.
• 15:18
  SPEAKER_00: The downside of it, again, with all grafts, there's pros and cons, is to choose your own adventure.
• 15:23
  SPEAKER_00: With the hamstring, I don't have as strong a hamstrings as most people normally would, just because I did have one of my hamstring tendons taken, and so then therefore, my posterior chain on both legs are weaker.
• 15:37
  SPEAKER_00: And I noticed that when I do certain things with hamstring muscle groups, like leg curls, Nordics, when I try to sprint, I have shared with you guys historically, like I would have strains in my hamstrings very regularly, and it makes sense because I essentially limited one of the muscle groups for my hamstring muscle group that is required to help me do those things.
• 16:00
  SPEAKER_00: And so, yes, that helped me to spare my quads, which I appreciate, but I did have to pay for it on the other end with my hamstrings getting weaker, right?
• 16:07
  SPEAKER_00: Now, that doesn't necessarily mean that any of these are the best, it's just dependent on each person, their goals, and especially knowing what their history is, and then having a very informed decision about what is the best graph type to get.
• 16:22
  SPEAKER_00: Now, the one thing I do want to share with you guys, because a lot of you are like, okay, great, I have a smaller quad muscle.
• 16:28
  SPEAKER_00: Now tell me what I need to do.
• 16:31
  SPEAKER_00: How does this make sense?
• 16:33
  SPEAKER_00: So, with this smaller muscle, again, it's going to be very normal, especially whenever you're within that first nine to 12 months of this process, you're just going to expect for there to be a smaller muscle size, especially early on, because it hasn't had time to rebuild yet.
• 16:48
  SPEAKER_00: But you're hoping for that to increase over time as time goes on.
• 16:52
  SPEAKER_00: And so the way that I want you to think about this, because especially for those of you, because we have athletes who get to nine months, who get to 12 months, and you know, we're continuing to test their strength, we're measuring their quad size, and we're, you know, also visually inspecting.
• 17:06
  SPEAKER_00: And sometimes people are like, Well, am I ever going to get my quads back to the same as the other side?
• 17:11
  SPEAKER_00: And I say yes, but the thing is, is that we might not get there in the first nine to 12 months.
• 17:17
  SPEAKER_00: Now, does that mean that that's going to also limit them being able to get their strength back?
• 17:22
  SPEAKER_00: Not necessarily.
• 17:24
  SPEAKER_00: And so this is the analogy I want you to think about the cup analogy.
• 17:27
  SPEAKER_00: So think of muscle size as a size of a cup, right?
• 17:31
  SPEAKER_00: Like if you have a cup in front of you, think about your muscle size as that size of the cup.
• 17:37
  SPEAKER_00: Strength is how much water that cup can hold.
• 17:41
  SPEAKER_00: So a bigger cup has more potential capacity to hold more water, right?
• 17:47
  SPEAKER_00: But two cups that look slightly different in size can both be filled to the top, right?
• 17:53
  SPEAKER_00: So imagine those two cups being there, one a little slightly different, a little bit bigger.
• 17:58
  SPEAKER_00: They both can be filled to the top.
• 18:00
  SPEAKER_00: And a slightly smaller cup can still hold a meaningful amount of water, right?
• 18:05
  SPEAKER_00: So muscle hypertrophy increases the potential force capacity generation.
• 18:11
  SPEAKER_00: So that's the big thing here, is that it gives us the potential for more force.
• 18:15
  SPEAKER_00: That's why bigger people tend to create more force, right?
• 18:19
  SPEAKER_00: Because they have more muscle hypertrophy.
• 18:21
  SPEAKER_00: There's a lot of layers to muscle force.
• 18:24
  SPEAKER_00: Like you also see the small humans who are freakishly strong.
• 18:28
  SPEAKER_00: And the thing is, is that it's just not muscle hypertrophy that is the only thing.
• 18:32
  SPEAKER_00: Panation angles make a difference, genetics makes a difference, tendon elasticity makes a difference, the ability for the neurological system to fire, the rate coding, the firing ability is going to influence things.
• 18:46
  SPEAKER_00: The neuromuscular system as a whole is a network, but there are so many different aspects that influence the ability to produce force, the ability to be strong, right?
• 18:56
  SPEAKER_00: And to do it quickly.
• 18:58
  SPEAKER_00: But that neural efficiency, the tenant adaptations, and the coordination determine how much of that capacity is actually used.
• 19:05
  SPEAKER_00: So it's not just a muscle size and strength, are they not this one-to-one.
• 19:10
  SPEAKER_00: And that's the thing that's really important here.
• 19:13
  SPEAKER_00: So you can still get to the appropriate numbers and levels we are looking for, even with a quad size that is a little bit smaller than the other side.
• 19:23
  SPEAKER_00: Just know that.
• 19:24
  SPEAKER_00: And if you don't get there necessarily, that's okay.
• 19:27
  SPEAKER_00: We want to obviously try to get the muscle size bigger while also making sure that from a strength standpoint, your body can withstand the forces needed for all the things you want to do, being able to be in the gym, get in the right positions, to be able to tolerate forces on repeat, to be able to run, jump, cut, sprint, to be able to do that for the duration of what you needed to and tolerate that, right?
• 19:50
  SPEAKER_00: And so that's where training and rehab comes into play.
• 19:53
  SPEAKER_00: And so the thing is, you can still regain strength without perfect visual symmetry.
• 19:58
  SPEAKER_00: Just know that.
• 22:03
  SPEAKER_00: Does that mean that we don't continue to chase it?
• 22:06
  SPEAKER_00: Not at all.
• 22:07
  SPEAKER_00: Like we are going to continue to keep trying to get the muscle size improved.
• 22:11
  SPEAKER_00: And that's where I do want to share just very briefly how hypertrophy is going to be such a big player in this and having particular time points in this process to focus on that.
• 22:23
  SPEAKER_00: And that is something here at the ACL athlete.
• 22:27
  SPEAKER_00: So if you're in our restore and rebuild phases where we are working with our athletes, there is such a huge emphasis on hypertrophy along with strength rebuilding.
• 22:36
  SPEAKER_00: And so the thing is, is we want to build that muscle capacity and that size back.
• 22:41
  SPEAKER_00: And that's going to be really, really important here.
• 22:43
  SPEAKER_00: And that's where we're going to be mindful of making sure we don't push too much intensity, but we are going to try and hit proper volume.
• 22:52
  SPEAKER_00: And Brad Schoenfield has done incredible work in this field along with a lot of other people discussing how beneficial this can be and finding the sweet spot.
• 23:01
  SPEAKER_00: And people think the more work, the better it is.
• 23:04
  SPEAKER_00: And the thing with this is that sometimes you almost reach a diminishing return.
• 23:10
  SPEAKER_00: And this is where junk volume comes into play because people think, oh, I need to do you know 10 exercises of this and 10 exercises of this.
• 23:18
  SPEAKER_00: And this is where you need to know your own body.
• 23:21
  SPEAKER_00: But then also the other thing, too, is that people try to overcomplicate this.
• 23:26
  SPEAKER_00: And you want to go with less is more, but you want to have good quality reps taken close to failure.
• 23:32
  SPEAKER_00: And so when you take the volume sweet spot, you're usually aiming for at least 10 hard sets per muscle group per week.
• 23:40
  SPEAKER_00: Now, with the ACL rehab, that means for the quads, we're aiming for 10 hard sets for that muscle group in a week, right?
• 23:47
  SPEAKER_00: And for advanced lifters, the sweet spot is around 12 to 20 sets per week again.
• 23:52
  SPEAKER_00: So just knowing that there's diminishing returns after you really go beyond 20 sets, if those are taken to an appropriate intensity and close to failure.
• 24:04
  SPEAKER_00: Now the hypertrophy zone can really range.
• 24:06
  SPEAKER_00: Before we used to think it's like the 8 to 12 rep range.
• 24:10
  SPEAKER_00: Now it honestly ranges.
• 24:12
  SPEAKER_00: It could be low sets, it could be, or sorry, low reps, it could be moderate reps, it could be high reps.
• 24:18
  SPEAKER_00: But the thing that's important is that it is taken close to failure.
• 24:22
  SPEAKER_00: And this is where a lot of physical therapy, a lot of rehab, a lot of PTs, a lot of coaches just do not do it justice.
• 24:30
  SPEAKER_00: And athletes themselves.
• 24:31
  SPEAKER_00: Like we have a lot of people we're like, take this to failure, and sometimes they will sandbag it and they'll do 20, 30 reps of something that they've been doing 10 reps of.
• 24:41
  SPEAKER_00: And you're like, so you've been doing 30% of what you could be doing.
• 24:45
  SPEAKER_00: And so then therefore you're not really taking it to failure or close to, and then therefore we're not getting any of the adaptations we're aiming for.
• 24:52
  SPEAKER_00: So the thing is that we want to make sure for our ACL rehab, if I could give you just a practical rule or advice, right?
• 25:00
  SPEAKER_00: Use heavier loads, you know, anywhere from three to five and getting towards six to eight for compound lifts for certain movements.
• 25:10
  SPEAKER_00: I tend to stick towards lower around five or less, depending on what we're aiming for.
• 25:15
  SPEAKER_00: Um, but then therefore, we're also gonna build in some moderate to light loads for isolation-based movements, like leg extensions, for example, to accumulate volume in the muscle groups without excessive joint stress.
• 25:27
  SPEAKER_00: And that's something that's really key is that we don't want to just go and hammer out a bunch of compound lifts like squats or you know, split squats, because a lot of times what happens is people will compensate.
• 25:38
  SPEAKER_00: It also creates a lot of joint stress.
• 25:41
  SPEAKER_00: And the thing is we want to work that muscle group and we want to minimize joint stress as much as possible, especially when we're on the earlier side of this rehab.
• 25:49
  SPEAKER_00: In terms of intensity effort, we want to aim for reps and reserve where you roughly have two reps left in the tank, one to two reps, right?
• 25:58
  SPEAKER_00: So if you are doing a weight, you want to target, let's say three sets of eight, right?
• 26:05
  SPEAKER_00: And you're doing a knee extension.
• 26:07
  SPEAKER_00: You want to pick a weight that you can only do a maximum of ten times and you only go for eight reps.
• 26:12
  SPEAKER_00: That's meaning that you are leaving two reps left in the tank.
• 26:16
  SPEAKER_00: If you try to do more than ten reps, you could not do a single additional rep.
• 26:19
  SPEAKER_00: That's what anchoring to two reps left in the tank.
• 26:23
  SPEAKER_00: That could also be considered a rate of perceived exertion, RPE eight.
• 26:28
  SPEAKER_00: Now, this is something we teach all of our athletes.
• 26:30
  SPEAKER_00: I think this is the most beneficial and also just it's very smart training.
• 26:38
  SPEAKER_00: Using percentages of weight is really not necessarily as advantageous unless you're working and doing a specific sport where tracking that percentage is important, like Olympic weightlifting or power lifting.
• 26:52
  SPEAKER_00: With rehab and things like this, we're just trying to get proximity to failure, which is going to lead to an adaptation.
• 26:59
  SPEAKER_00: And so this is gonna be super important for us to understand this.
• 27:02
  SPEAKER_00: And then in terms of the frequency, you know, this could be spread over two to three times a week.
• 27:09
  SPEAKER_00: Now, the volume itself, it you know, we don't necessarily want to crush like high volume, and that's what's gonna be really important.
• 27:17
  SPEAKER_00: As we can distribute across this better recovery for the knee and for the quads versus trying to just like tank the quad in one day and do 10 exhaustive steps.
• 27:27
  SPEAKER_00: So that's gonna be something that's gonna be really important for this.
• 27:29
  SPEAKER_00: The last thing that I'll mention here from a hypertrophy standpoint, we're learning that lengthened positions are gonna be beneficial.
• 27:36
  SPEAKER_00: So if you're in a seated knee extension, see if you could put that seat back or see if you could put a pad between that knee extension to flex the knee a little bit more or to reduce flexion of the hip, that's gonna allow a more lengthened position.
• 27:50
  SPEAKER_00: And what we're learning is that that stretch mediated hypertrophy is gonna allow for better muscle size and gain.
• 27:56
  SPEAKER_00: And the other thing too, isolate when you can.
• 27:59
  SPEAKER_00: The knee extension machine is your best friend.
• 28:01
  SPEAKER_00: I don't care what surgeon says, it is going to stretch the graft.
• 28:05
  SPEAKER_00: If you do it strategically, you should start from day one.
• 28:08
  SPEAKER_00: That's what our athletes do in order to incorporate knee extensions.
• 28:12
  SPEAKER_00: It is the only movement that isolates the quadricep muscle.
• 28:17
  SPEAKER_00: It is the only movement that isolates the quadricep muscle, the leg extension machine.
• 28:23
  SPEAKER_00: And this is so key, y'all, because people leave so much on the table by not using this movement, and a lot of times it's demonized by surgeons and physical therapists, and it's old school thinking.
• 28:35
  SPEAKER_00: It's old school thinking.
• 28:37
  SPEAKER_00: Walking puts more stress on this than doing a lightweight from 90 to 30 degrees on a knee extension machine.
• 28:43
  SPEAKER_00: That's the research, it shows this.
• 28:46
  SPEAKER_00: And so the thing is that we know from an isolation standpoint, knee extensions isolate the quads.
• 28:52
  SPEAKER_00: If we are trying to build up the quads, guess what?
• 28:55
  SPEAKER_00: We need to do isolated muscle work.
• 28:57
  SPEAKER_00: If I want to get my biceps bigger, yes, I will do pull-ups, but I'm gonna do some bicep curls, y'all.
• 29:03
  SPEAKER_00: Arm for arm, we're gonna try and get the biceps big.
• 29:06
  SPEAKER_00: Let's do bicep curls.
• 29:07
  SPEAKER_00: We're not just gonna bench and do dips and do pull-ups and rows to get our biceps bigger.
• 29:12
  SPEAKER_00: That's gonna help our back too.
• 29:13
  SPEAKER_00: But if you want to get the biceps bigger, isolate the biceps.
• 29:17
  SPEAKER_00: The same thing for the quads, y'all.
• 29:18
  SPEAKER_00: There's no difference in this, and this is where bodybuilding community comes in clutch to learn from them.
• 29:25
  SPEAKER_00: And the thing here is that we just want, if I could just provide a summary, try to hit a weekly volume of at least 10 sets, getting this in twice per week, split across, mix up some of the rep ranges.
• 29:37
  SPEAKER_00: But again, this is gonna be a very much important part of effort to get it one to two reps within failure of intensity, and then if you can kind of get into some stretched positions to load the muscle groups, that's beautiful.
• 29:51
  SPEAKER_00: A squat is not going to stretch your quads because your hip is flexing while you lower, that's gonna create slack on the quadriceps muscle group.
• 30:00
  SPEAKER_00: So just know that.
• 30:01
  SPEAKER_00: So, this is gonna be something that's gonna be helpful for you if you're trying to develop your quad size back and understanding all right, what is it that I can put into play?
• 30:11
  SPEAKER_00: The other thing that I think is valuable that we have our athletes do a lot of times is use BFR, blood flow restriction training.
• 30:19
  SPEAKER_00: Big fans here, the research supports it.
• 30:22
  SPEAKER_00: Yes, we know whenever athletes can train at equivalent loads, that it's better to do just the load without the BFR.
• 30:30
  SPEAKER_00: But man, as someone who has gone through this process, who has had knee issues in the past, who has worked with so many ACLers who just deal with so much joint-related discomfort, incorporating something that will help to mimic the intensities they need to feel in that muscle pump without needing to push heavy weight.
• 30:50
  SPEAKER_00: BFR is such a great tool and option for this.
• 30:54
  SPEAKER_00: And especially for my quad graphs, we are hammering BFR to be able to get some muscle size without really pissing off that joint.
• 31:01
  SPEAKER_00: And that's really the game we're playing here.
• 31:03
  SPEAKER_00: Can we train the muscle groups and try to not aggravate the joint itself?
• 31:08
  SPEAKER_00: And that's gonna be so, so key, especially early on in ACL rehab.
• 31:12
  SPEAKER_00: And we focus a lot on this in order to get the muscle size back and try to help build up strength as well.
• 31:19
  SPEAKER_00: And so the thing here that I think is really important is one, just know that the muscle volume size is going to take time.
• 31:28
  SPEAKER_00: If you had a graft that is going to be taken from the front side of the knee, whether it's the patello or the quad graft, especially, it's gonna take even longer.
• 31:37
  SPEAKER_00: And there are gonna be plenty of people who you see who regain their muscle mass size, and there's also going to be a lot of people who don't necessarily get it, especially in that first year.
• 31:48
  SPEAKER_00: And I want you to just evaluate this, don't compare.
• 31:52
  SPEAKER_00: But if I could just put numbers on this in all reality, I would bet you that there is such a high percentage of people who get back within one year.
• 32:02
  SPEAKER_00: If we measured this at the nine and one year mark, especially for people who go through this, I would say more than 50% of people have a quadricept asymmetry by the time they're at nine to 12 months.
• 32:14
  SPEAKER_00: And that is just my pure belief in this, and it takes longer than that to get there.
• 32:19
  SPEAKER_00: And it's something that I want you to also not be, you know, crushing yourself with and knowing how normal this can be for people to not fully get that all the way back within that first year, especially.
• 32:32
  SPEAKER_00: It's gonna take some work, it's gonna take some effort.
• 32:35
  SPEAKER_00: I think one of the biggest crux of this is that people are just not getting proper programming and guidance to be able to do hypertrophic specific work that is gonna help them get that muscle back as well.
• 32:47
  SPEAKER_00: And this is all strength and conditioning, proper programming, making sure we are providing the proper stimulus to elicit the right response and adaptation.
• 32:58
  SPEAKER_00: And this takes weeks and weeks and months and months of work, especially for a quad that shuts down after an injury like this.
• 33:06
  SPEAKER_00: So today I wanted to share with you guys that how this can be normal.
• 33:12
  SPEAKER_00: Um, it's common and there's persistent asymmetry within the first year.
• 33:17
  SPEAKER_00: A subset of athletes, you know, may even have some differences years later.
• 33:21
  SPEAKER_00: So if you're, you know, two, three, four years out, it just depends on the work you put in and continue to put in to regain that difference.
• 33:29
  SPEAKER_00: But the thing is, is that just no, it's not a one-to-one that even if there's a difference, that necessarily strength won't get there.
• 33:37
  SPEAKER_00: Now, will it help?
• 33:39
  SPEAKER_00: Yes.
• 33:40
  SPEAKER_00: But with that said, it comes back to that cup, right?
• 33:43
  SPEAKER_00: And there's still plenty of people who gain high levels of function and performance even without getting that fully 100% symmetry back again.
• 33:52
  SPEAKER_00: So if you're staring at your leg in the mirror right now, thinking, why doesn't it look the same?
• 33:56
  SPEAKER_00: Just know you're not broken, you're not behind, you're not alone, you are dealing with a biological system that went through trauma, surgery, inhibition, and months of altered loading as well.
• 34:07
  SPEAKER_00: And just know that the rebuilding process itself, it's not linear, right?
• 34:11
  SPEAKER_00: So I think that that's something that's really important for us to discuss and to share with you guys and to normalize as well.
• 34:19
  SPEAKER_00: So chase strength, chase capacity, chase resilience, chase hypertrophy, and do it intelligently, y'all.
• 34:27
  SPEAKER_00: I will tell you that that is such a big part of this process is programming it out well and having guidance on this.
• 34:34
  SPEAKER_00: And there's so many different ways to do this through different rep schemes, through different rest intervals, cluster sets to be able to do myo reps, which is amazing.
• 34:43
  SPEAKER_00: There are just so many different methods out there to be able to get the stimulus we want, okay?
• 34:48
  SPEAKER_00: But do not tie your self worth or your progress entirely to the visual symmetry as much as I know it pains you, it pains me, but you can get back there.
• 34:57
  SPEAKER_00: The human body is adaptive, and sometimes performance returns before perfect aesthetics do.
• 35:04
  SPEAKER_00: So just know that.
• 35:05
  SPEAKER_00: Keep on building, y'all.
• 35:06
  SPEAKER_00: Go do the thing.
• 35:07
  SPEAKER_00: This is your host, Ravi Patel, signing off.