ACLR Post-Op Diary – Week 1

Introduction

So far, 2022 has been the worst year of my life. ’20 and ’21 were shite in and of itself due to the COVID scenario and governments displaying fascistic tendencies. But I must admit that ’21 was a great year for me: I started riding Enduro, spent quality time with my son on the beach and in the mountains, and met my girlfriend. Things began to deteriorate drastically by the end of 2021.

Unfortunately, my mother died in February ’22 after concealing her sickness from the rest of the family. My relationship with my girlfriend ended soon after. Back in the spring of 2022, the only light in the tunnel was motorcycles riding. I spent some time on the MX course with both my motorcycles, a KTM 250 EXC and a 890 ADV R. I couldn’t wait for the Enduro season to start (we were still waiting for the snow to melt on the mountain).

Figure 1: Around March, 2022

The season eventually began in mid-April. I was very excited to ride now that I had more experience. Unfortunately, on the second day of riding, while I was also guiding a visiting party of father and son from Spain, on the way back to our starting point, myself and the visiting lad began going faster and having fun. We were speeding around a blind turn while driving through a dried out river bed. I completely forgot that on the way there, we came across a fallen tree that entirely blocked the entrance save for a one-meter-wide gap between the branches. When I saw it, I was already going too fast for my abilities, so I decided to break while avoiding slipping and try to pass through the gap between the top of the fallen tree and the rocky side wall. I assumed the branches would merely brush against me, but one of them was heavy and caught my hand-guard on the handlebar. This caused me to lose control of the bike, thus catapulting me. I still don’t recall the fall. I was lying on the ground with some left knee discomfort, and the elder Spanish guy and the other two guys were leaning over me. I apparently had a bad collision, stood up, grabbed the bike, and wanted to ride. Of course, I have no recollection of this. The elder Spanish man (who is a horse agility course trainer) then observed my blank face and asked what month it is and how we arrived to this spot. I stated it was November (it was actually April) and that I had no idea how we got there.

Figure 2: First and second day of the Enduro season 2022, just moments before accident

Of course, I had a concussion. They kept me warm on the ground until my friend Nebojša arrived with the car to fetch me up. Fortunately, we were in one of the few places that could be reached by automobile. I sensed knee discomfort and kept repeating, like a broken record (as is frequent with concussions), that I had all of my equipment, which I did. I was well protected, with knee braces and a neck brace.

I’ve lost three months of my life’s memories. The most painful thing was that I had forgotten about my mother’s death. I recall asking my friend Nebojša, who took me to the hospital, which of my parents had lately died. He said it was my mother. So I went through the ordeal of learning that one of your parents had died, twice. It was more difficult to bear than the knee injury.

I was in the hospital for two nights. They needed to see if the brain would enlarge after a concussion. My recollection gradually returned, although the accident remains hazy. During the night, my knee hurt so much that I couldn’t get up to pee.

I drove back to Belgrade a few days after being discharged from the hospital. I went to visit a physio, and he requested an MRI because he suspected ACL tear. An MRI revealed that I had torn the ACL, lateral ligaments, and meniscus.

Pre-op

It was decided to postpone the operation until the Fall in order to restore as much mobility, strength, and muscle mass as feasible, as well as to avoid being completely fucked up during the Summer. I saw the same physio twice in the first week and we had knee aspiration/puncture twice. This aided in the restoration of knee mobility as well as quad activation. I began training as normally as possible and gradually included running – but it was terrible. However, it gradually improved over the next two months. I went to visit the surgeon and opted to perform my own pre-op and follow up with him later in the year.

My girlfriend and I reconnected in May, and we went enduro riding together again. I put on the same braces and went for a leisurely riding. The first day was entirely fine. My knee did not swell, and I was able to run for a short distance in the morning.

The next day, near the end of the ride, I was completing training ground loops when my bike slipped slightly in the bend, forcing me to place my left foot on the ground. Even with the braces, my knee collapsed instantly, and I was in severe pain. I couldn’t even move my leg. I was able to walk again after a few minutes, but the “knee slipping” set me back two weeks in therapy. I think I managed to tear the meniscus even further, but I’m not sure.

After several months, I decided to get the procedure. The knee was “quiet,” and I performed isometric and dynamometry tests (which I shall document in my journal). This functioned as a baseline to compared against during recovery. I booked the operation shortly after moving to a new apartment in another part of town to be closer to my kid.

I decided to take the ACL graft from the same leg’s hamstring, as well as to remove the section of the meniscus that was bothering me and locking my knee (this had happened a few times prior to surgery).

It’s been precisely one year after the surgery, and I’ve chosen to post the training log/diary that I kept over the first few months. The leg is now entirely good, and I am riding and sprinting again, although it take more than a year to regain full flexion (it still hurts a little in the extreme ranges) and hamstring strength. I’ve also had low-back pain (LBP), which I believe was caused by a change in movement mechanics (but I am speculating). I am now in a two-month-long episode. However, things are improving. It might be due to age:)

In any case, the following diary may be useful to anybody contemplating or undergoing ACL reconstructive surgery or rehab. Over the next few installments I will publish my daily writings. Enjoy!

25-Nov-2022 Friday

Day of the surgery – finally! I was scheduled to go to the private hospital Euromedic around 11, so I took the time to unpack the rest of the boxes in my new apartment. Showered, shaved my leg around my knee (and managed to make a small cut, idiot) then called the taxi. Wanted to walk there, since it is around 20min walk from my new place, but didn’t have the time.

I haven’t eaten anything since last night (friend came over and we had a large Chinese dinner) and I haven’t drink anything since 9:00 (when I had a 0.75L water with a bit of salt).

Upon arrival, I did the now-standard COVID test, which was negative. So they took me inside, gave me the pajama, flip-flops and put me to bed. Surgery was planned for 13:00. So they did all the preparation – surgeon Rajko Vulović visited me few times to check me and the knee, anesthesiologist came to check up on me as well, the assistance surgeon also visited and explained to me the procedure that they will also give me local anesthesia in my groin (if memory serves me well). Then the nurse put the infusion needle in my wrist, wrapped my other leg with elastic band, for some reason she tried to explain me, but I did not get (Figure 3). I just hoped they will operate the left leg.

Figure 3: Chillin’ in my room waiting to be operated

Went to surgery around 13:30. It took around 3 hours to finish. The waking up from a total anesthesia was not a pleasant experience – I was very cold and shaking like crazy, since it was damn cold in the operating room. I remember switching beds in a semi-conscious state.

When I woke up in my room, I was unable to move my leg at all and I had a drainage tube in my knee as well (Figure 4).

Figure 4: Post-operation drainage

I didn’t feel much pain, since I was having a local anesthetic as well. I couldn’t move my leg to save my life. No chance I could recruit my quads. But I did a bunch of “ankle pumps”, or simply moving your ankle.

Surgeon Rajko Vulović paid me a visit and informed me about the success of the operation. He was happy with the graft strength (9/10 rating I am not familiar with), but also informed me that my meniscus was in vorse shape than indicated by the MRI (probably due to knee collapsing the second time). Both medial and lateral sides have been torn, and he had to shave 1/4 of my meniscus. Well, I guess I should continue lifting and being physically active (as well as reducing my body weight) thorough the rest of my life to avoid osteo-arthritis. Not sure how I will handle that (pun intended). Can’t wait to get back to training and motorcycle anyway.

I have four holes in my knee – one big cut where they took hamstring graft and used it to drill the tibia, one hole for the camera, one hole for the needle in the femur to tie down the graft, and one hole for the drainage.

I used this time to chill. I was having IV and other drugs via my infusion needle multiple times, including Fraxiparin injections to the stomach (actually to the subcutaneous area in the stomach). I had to pee in the bottle, which was not fun, and I had to get used to peeing while lying on my back, since I couldn’t move to any other position. Of course I peed myself. Multiple times.

I tried to watch TV, but decided to read my colleague Olja Knezević’s book on ACL recovery (Figure 5) as well as to refresh my knowledge by reading Randall Cooper and Mick Hughes Melbourne ACL Rehabilitation Guide 2.0.

Figure 5: Olja Knezević book on ACL reconstruction and recovery

Visits are unfortunately not allowed, otherwise I would have my son visit me. But we spoke and I also rang the rest of my family to inform them I am alive and well.

Reading and watching TV was everything I was doing. I was also starving, since the last meal I had was the night before. Finally, hospital food arrived, and I asked for one more serving later on. Fat fuck. Physio therapist arrived later in the day and wanted me to stand up and walk using that “walker” thing. I managed to move, attached the drainage system to the walker and managed to get out of bed and walk to the room exit. Physio explained me the “mechanics” of walking with the “walker” and later with the crutches. Unfortunately, after reaching the room door, I found myself heading toward collapsing into unconscious world again, due to anesthesia still in my system. Luckily I notified the therapist I feel unwell and was about to fall asleep, so he called for help and they managed to get me in the chair just before I collapsed. It is shit feeling – cold sweat, heavy breathing. After a minute or so I felt good again.

They decided it is enough of walk for today and put me back to bed. Really tried to fall asleep, but not a chance. I had to be on my back, with leg extended. I had intermittent sleep. Tried to drink as much water as possible to get the anesthesia out of the system.

Week 1

26-Nov-2022 Saturday (1st day after surgery)

Nurse woke me up early to give me some drugs and IV. Surgeon Rajko Vulović also paid me a visit to inspect on me and check the drainage. Also made a statement that I should now put pillow under my heel, and not under my knee to get the knee to extend, although I had full knee extension which he was happy with.

After the breakfast, TV watching and book reading, they wanted me to walk using the “walker”. Before trying they informed me to try to sit on the edge of the bed for a while. I took the “walker” and stood up, but was still feeling dizzy, so we postponed it further. Once the assistance surgeon visited as well as the anesthesiologist, I made fun they miscalculated the dosage. They responded they actually gave me less than what was indicated by my body mass.

Anyway, my ex soccer player Marko Stanojević was received in the hospital as well and he paid me a visit. His surgery was scheduled early morning with another surgeon. He decided to do the patella tendon graft method, which was different than mine. As S&C coach, I bet Marko who will run first. Will see. A bit of healthy competition is always good – particularly with your ex player.

I have spent the day in bed, also trying to squeeze my quads. No bloody chance. Later in the day I managed to stand up and walk using crutches. It was REALLY hard. I wasn’t able to put on the or remove the flip flops from my right foot. Walking was very hard, but the physio explained me the basics.

Surgeon Rajko Vulović came in to change my bandages. They did notice that my drainage was leaking and was bloody after my walk attempt. But he was happy with everything, including the amount of fluid drained, which was within standard amount.

I have waited for Marko to get back to his room, so I paid him a visit. I managed to walk on crutches, also practiced climbing up and down stairs. Easy-peasy my ass. Was scary as hell.

My friend Vlada Verebi came over and brought (actually left at the reception, since he was not allowed to get in) some sugar food which I craved. Spent part of the evening with Marko watching football on the TV and talking. I remember Marko being able to actually squeeze his quads. Impressive lad!

Sleep was much better that night since I was able to roll on my left side (I actually asked the docs if it was ok; which they confirmed). Sleeping on my right side was impossible. I managed to use the crutches and wash my teeth and face.

27-Nov-2022 Sunday (2nd day after surgery)

Nurse woke me up again. They told me they will let me out today, around 11. So I have called Dragan Mirkov, my PhD supervisor who offered to drive me to my apartment.

After breakfast, I managed to use the toilet. I know you can live without this information, but it was a real success for me. I also did much more walking around using crutches. Visited Marko few times.

Surgeon Rajko Vulović came in the removed the excessive bandage, as well as the drainage. That was an awkward feeling, but no pain whatsoever. After receiving the outgoing list, I was ready to get home. Rajko mentioned that I should avoid weight bearing on the left leg for the next few days, and keep using both crutches when I walk. He also mentioned that I should try to walk as much as possible. Rajko scheduled bandage change and check-up in 6 days, on Thursday. I asked Rajko about using the Compex NMES and he was fine with it, but told me to withhold using BFR (blood-flow restriction) until I remove my stitches in 2 weeks.

I tried to ring my physiotherapist Milan Todorović, but he was on the road trip. I eventually managed to get a hold of him, and he told me he will bring the ARTROMOT (device for passive mobilization) to my place later in the day or tomorrow. Visited Marco one more time, since Dragan Mirkov came to pick me up. He drive me home and left some food he and Olja Knezević prepared for me. They are amazing.

Spent the rest of the day in bed, with the leg raised up. Also managed to do some mobilization using swiss ball.

Besides doing the mobilizations and elevating my leg, including the knee hypertension (by elevating my heel on an object and letting the knee stretch) and doing the quad activation (which I managed, but barely), I have put the Compex NEMS device, using the Hypertrophy program. I did not have any ice, nor anything cold, so I haven’t done any cooling.

When it comes to NMES, there are protocols that are prescribed, but I tried to finish a gentle introductory protocol without burning my muscles. Just waking them up a bit. Also tried to consciously contract the muscles (i.e., quads) as well. To avoid the knee being in the complete lock, I rolled a towel under the knee.

Later in the day, my friend Vlada Verebi came over to chill out with me and brought me some food and prescribed drugs (including Fraxiparin that I have to inject in my stomach in the morning). We ordered a pizza. I did the exercises and went to sleep. It was painful, but not much. I managed to sleep only on my left side again.

28-Nov-2022 Monday (3rd day after surgery)

Today was a usual day – woke up and did some swiss ball mobility, quad activation exercises and Compex NMES one more time. Later in the day, Milan Todorović came over and brought me the ARTROMOT device (Figure 6) and Cryo-Cuf for cooling down. Apparently, I am supposed to do mobilization 4 times per day for 40 minutes, 4 times 20-30 min Cryo-Cuff, and 4 times 20-30 min of exercises:

• Quad activation (straight leg with straight foot)
• Quad activation (straight leg with foot in dorsiflexion)
• Quad activation (straight leg with straight foot) with leg lifting
• Adbuction
• Adduction
• Knee hyper extension holds

Figure 6: ARTROMOT device used for passive mobilization

This is a lot of work, but I do not have anything better to do at this time. Besides, ARTROMOT feels really good. I have started with 90 degrees flexion and went to -5 degrees extension. To be honest, I am not sure I did this much of exercises, but I did as much as I could.

Milan also mentioned that I should load the leg after few days, try to switch to single crutch after 7 days, and walk without crutches in 14 days. He was also bitching on NMES and reinforced the need for active contraction. But there is research showing the benefit of early NMES in ACL reconstruction. One of the legend who got me on the NMES bandwagon during the initial phases is Scot Morrison. We exchanged few Instagram audio messages today and he recommends ramping the intensity as much as possible and doing one to two NMES sessions per day. Once the lifting can start, switching NMES to few times per week. He also mentioned that NMES should be done as long as the leg extension force is “unstable” (i.e., I am unable to control the force).

Also, regarding ice – I would prefer to use compression (using elastic bandage) and elevation. I kept my leg elevated over my heart level pretty much all the time. Thus, I haven’t used Cry-cuff that frequently – only when I felt the knee is swollen and painful. I do not want to “kill” the stimuli with cold application.

Getting dressed and undressed was major pain in the ass. I went to walk outside with the crutches to meet a friend of mine Marko in his gym which is very close to my new flat/apartment. It was very slow and I would say painful – feelings of leg “bloating” was there. Maybe I should use the elastic band to wrap my whole leg the next time?

Later in the day Vlada Verebi dropped my son at my place. He have ear infection, so he will not go to school for the next few days and will stay with me. I managed to make him do some exercises between him playing iPad and doing his homework.

Later in the day friend Maja came over for a visit since she also broke her ACL recently and she is planning to do the surgery after needed pre-op preparation. I think my surgeon will also operate her as well. Here is the video of me trying to activate and lift my leg, which hard (managed the few times, but not on the video). Contracting the quads in the full extension also causes some discomfort.

My son and I watched some TV, I did Compex NMES, ARTROMOT, cooled the knee and went to sleep. Was still sleeping on my left side, particularly due to my son moving around while he sleeps (he is 8 years old).

29-Nov-2022 Tuesday (4th day after surgery)

During the night I had pain episodes, but I was not taking any anti-inflammatory drug nor pain medications. Nothing major – sometimes keeping the knee extended was painful, sometimes, comfortable. So I rotated my sleeping posture from my left side to my back.

In the morning I went to loosen up my knee on the ARTROMOT for 40min, then do some exercises and decided it is time for a walk outside. Niksa (my son) and myself went to have a breakfast in the local Italian Tratoria. Sitting was the most painful – not only because I sit on my hamstring, which hurts like I had a hamstring pull (due to graft donor site being the hamstring tendon), but because you feel knee and the whole lower leg starting to swole.

Once I was home, I couldn’t wait to apply Cryo-Cuff and compress and elevate my leg afterwards.

Before every bout of exercise, I tend to take 30g protein, 10g collagen and 1,000 units of vitamin C, since this was shown to increase the tendon recovery. It doesn’t hurt to take it anyway, so I do it. Sometime I also take it before going to sleep.

My son stayed with me the whole day and helped me out with chores and stuff. Watched a movie, went to sleep.

30-Nov-2022 Wednesday (5th day after surgery)

Started the day “as usual”: using the ARTOMOT to get the knee moving since the first steps in the morning are the most problematic. I did notice improvements in certain small tasks, like taking flip-flop off, or getting dressed or undressed, or putting the shoes on and off. I have also noticed that I am able to rotate to my right side. Things are getting better and I can slowly feel it.

In addition to the “usual”, since I noticed things are getting better, I immediately did barefoot standing with weight shifting left and right, as well as very shallow squats for high reps. I have used single crutch as a help to get into position. I also tried simple standing with eyes closed. Tried to lift leg when weight shifting. Managed to do that without any problems.

Me being me, I decided to try leg extensions. Performing leg extension in the 30-80 degree range is pretty safe for the graft (besides done without load or ankle weight). Pretty much open-kinetic-chain (OKC) like leg extension should be done in this range, while the closed-kinetic-chain (CKC) exercises should be done up to 60 degrees of knee bend. This way we get the decent ROM targeted without stressing the graft. The objective is to engage the quads, try to minimize the muscle loss, while avoiding loading the graft and provoking the knee.

So I have done sets of 20-30 reps without any weight at the edge of the bed. Me being me, I decided to try BFR – although I am taking anti-blood-cloth medicine (i.e., fraxiparin in the stomach every morning), I wanted to give it a shot without using too much pressure. I tried using it on both leg extensions as well as those shallow squats. It was a bit uncomfortable, so I decided to wait until I at least remove the stitches before continuing with BFR.

My bruising on behind my knee due to hamstring harvest site just become quite obvious (Figure 7). I was putting Lioton 1000 gel few times per day to avoid blood cloths development, as well as using fraxiparin.

Figure 7: Bruising behind the knee

Generally the things started to move forward. I continued with the ordinary protocol without using too much icing. I also tried to use single crutch in my apartment without problems. Was also easier to carry stuff, so I opted for using single crutch.

My son was still with me and we worked out together, watched movies, played games and did his homework (actually only him did it).

1-Dec-2022 Thursday (6th day after surgery)

Started the morning by jumping on the ARTROMOT as usual. My son and myself went to see the surgeon Rajko Vulović to inspect my knee and and change my bandages. I’ve used single crutch, but Rajko told me it is better to use two crutches, since I will be walking straighter which is better for the locomotion retraining later. I agree with this. We have also scheduled stitches removal for the next Thursday,

Besides the usual routine, I performed ground-based work, did some ISO-holds against the wall, light squats, walking in place, ankling, calf raises.

To be honest, I am a bit “afraid” not to do too much too soon. This keeps fucking me in the head – since every success I feel I am able to do pain free, I feel scared that it might be too much. But this is very problematic for the patient – I know it is better to lean on the safer side and not rush the recovery (i.e., rushing and gaining one or two weeks in 6 months return-to-play might not be smart, since only two weeks is not worth the extra risk). For example, most physios freak out by OKC leg extensions, but also on the flip side reinforces walking and locomotion, which also places strain on the graft, even more so. So should I wait until I start walking or weight bearing? How do we know we are damaging the graft? Can we know that? So many questions, and our current understanding and best-practice doesn’t help. I haven’t stumbled on so many opinionated physios and practitioners until I injured myself – some are more aggressive in their rehab, some are more conservative and very cautious (what? you are walking already? you will create laxity in your graft you idiot).

Although I am worried, I said fuck it – dose makes the poison. Even if I do OKC and CKC like shallow squats (while holding on to crutches), the load is very low and the amplitudes are very shallow. Will just do them and progress from there.

My son is still with me and that helps me mentally. I have done the exercises, mobility, NEMS and iced the knee multiple times per day. I also did NMES afterwards, but it felt “painful” – I was not able to withstand the electricity and was not able to keep my leg in place (i.e., leg started extending, and I was not comfortable with that). Should I push it that much?

2-Dec-2022 Friday (7th day after surgery)

Morning as usually more painful, but after few steps of walking things get back to normal quickly. I started the day as usual with 40min ARTROMOT, but since I felt a bit stiff/swollen in the knee, I have limited the flexion to 95 degrees for the few few minutes, then increase it to 105 degrees. This gives me a neat warm-up to start the day.

Managed to get the shower for the first time since surgery. Took the colder water (not Wim Hof cold, but still). Noticed that I still have some blood under patch covering drain hole. Since the patch was having some channels developed, I think water penetrated in. Squeezed gently afterwards, sprayed with alcohol and applied extra patch on the top.

Took the injection to the stomach around 9:00 and took my son and my friend Verebi for a breakfast. Sitting in the restaurant gave me a “things are getting swollen” feeling in the knee, but nothing major. I guess I should avoid prolonged sitting with the leg hanging.

After coming back home I applied some ice water using the AIRCAST Cryo Cuff for cca 20-30min. I did notice that I can do knee hangs (hyper-extesion) while applying Cryo Cuff since the cold tends to reduce the pain. So I tend to combine these two together.

Once my son is back to his mom, I went for a walk down the block. It was semi-shiny for December. This was the first time for me to use elastic wrap/bandages (two packs) for my lower leg, around the knee, and upper leg. Might help with potential swelling.

On my surprise, I managed to do few steps without the crutches. I listened to my surgeon Rajko and took two crutches, not to mess with my walking posture, but I slowly removed the support. Eventually, I ended up doing 10 steps, then 20 or more steps forward without the crutch support.

Once I was able to do those, I started playing. I did the same going backwards and sideways. Tried with open and closed eyes. Once I feel the knee “complaining”, I move back to crutches.

I wish I have taken the collagen-vitC-protein shake beforehand, but I had one once I was back home. Knee was not swollen at all, so it managed this new walking load. Decided to write this entry, so I laid down on the ARTROMOT one more time.

Later in the day I did the some squats, balance drills and “ground based” training. I have put my mat on the ground and did:

Standing:

• calf raises 15-20
• “squats” 15-20 (very, very shallow ROM)
• “RDLs” 15-20 (very, very shallow ROM)
• Walking and balance drills (tried to maintan balance using the Stork position, with and without eyes-closed)

On the ground:

• Quad activation set (5x10sec hold)
• Quad activation with leg lifting over obstacle (sock on the ground)
• Lying down, use sock as a slider then side my heel towards my buttocks few times
• Abductors
• Adductors
• Leg lifts
• Few gymnastic “hollow” position, and then small scissors with legs and arms

On my stomach, I did Y-drill, then X-drill (lift the opposite leg and opposite arm), as well as to stretch my lower back (it was great that I was on a 1x1m mat for this since my knee was off the edge and there was no pressure on it).

My son came back later and he congratulated me when I told him I walked without crutches. Little wanker – I love him. His presence in my apartment means so much to me.

In the evening, Verebi came with Matia – kids played Sony PlayStation, I did hypertrophy program (Cycle 2) using Compex without too much discomfort. I spoke with my Slovenian brother-from-another-mother Robert Simonić regarding NEMS, and he mentioned that I should NOT ramp it up as much as possible. So I went easier, but this time discomfort was non-existent compared to yesterday.

Although I mentioned I was avoiding too much icing of the knee, and prefer using compression and elevation, not to “kill” inflammation (that can be “good”, unless too big of course), I am rethinking this for this type of injury. With injuries, icing should be used to manage pain, inflammation, and swelling for the first few days after injury, and should be avoided in later phases of recovery because cooling can blunt the stimuli and needed inflammation. Some even prefer not to use ice at all!

For example, my thoughts were if I workout my quads, and then apply ice, the icing can reduce the hypertrophy stimuli. If I apply ice before working-out, then I can reduce generation of that same stimuli. But then I stumbled on the “arthrogenic muscle inhibition” (AMI) concept in Olja’s book (Figure 8).

Figure 8: Arthrogenic Muscle Inhibition

Similarly to my point in the previous entries, when I cool the knee, it is easier to passive stretch it (i.e., using knee hangs). So it might be interesting to actually try to cool down the joint only (avoiding cooling down the muscles, but that can be easier said than done), which can reduce the inhibition, and quad retraining/activation can be easier. Not sure the hypertrophy stimuli is much needed at this stage (it is, since we want to maintain the strength and muscle mass of the quads, particularly of the VMO) – if you cannot recruit your quads, if you do not have ROM, then screw the muscle mass maintenance. Hence this is something to try – cooling down first to allow one to recruit the quads and extend the knee actively.

I think that the Figure 9 summaries the “Phase 1” of the ACL reconstruction rehab pretty well.

Figure 9: Mick Hughes’ instagram story summarising Phase one of the ACL reconstruction rehab

Friend and colleague of mine, Nenad Trunić called me to come with him to Pecs, Hungary, where we work for the Ratgeber Basketball Academy on Thursday morning. They offered me a place to stay and access to the physios and the gym. Offer I cannot refuse. I had to move stitch removal to Wednesday.