I’m F, 4’11/4’10 and 50KG’s, Im newish to the gym and wanting to make sure I’m on the right track for everything.
I’m currently in a calorie deficit and eating around 1,600 per day and eating between 80-100g of protein - I’m running 3KM’s twice a week and then doing glute focused days twice a week which consist of hip thrusts, KAS glute bridges, RDL, Bulgarian split squats and glute hyper extensions (I might change this to cable kickbacks). My goal is to ‘lose weight’ / lean out but have big glutes as I naturally have bigger legs and the weight tends to go everywhere such as my quads, calves and hamstrings but my GLUTES hence why I’m trying to only focus on my glutes - I used to be 45KG which uneasy to maintain for long periods of time for me, so I am trying to stay around 47/48KG’s as it’s easier to maintain.
So the question is, amI do everything correct? or is there anything I should tweak - I know 1,600 seems too little of calories but I think some people underestimate how short being under 5ft actually is! my lifestyle is pretty sedentary outside of working out as I work 40 hours a week in the office.

I originally made this post in another subreddit to talk about current best practices for ACL management and how I rehabbed my own injury! Unfortunately, that subreddit does not like literature or evidence so I thought this could conjure up some good discussion here among those that do.
For context, I am a 22-year-old male. In December of 2023, I suffered a complete midsubstance tear of my ACL, a peripheral vertical tear of my lateral meniscus, and a bucket-handle tear of my medial meniscus with a fragment that was displaced into the intercondylar notch, all within my right knee. I have kept track of important dates, and I am going to provide a timeline of my recovery process as well as some considerations for deciding on surgical vs. nonsurgical treatment with references. I would like to offer some hope to others dealing with a bleak situation and discuss the main things I would have wished to know when initially getting hurt, while debunking a lot of the most common myths as I have seen a ton of misinformation about the nonoperative route. For those who don’t want to read a novel, I think this 10 minute video is the best concise resource about making a decision regarding surgery. This decision aid is also a very useful tool in figuring things out, but this is going to be a bit more detailed. TLDR at bottom.
12/9 – full ACL tear and partial meniscal tears; surprise injury while bouldering where I jumped down from only a few feet up on the wall; I was immediately able to walk with some discomfort and had a little bit of swelling
12/11 – visited sports medicine clinic and talked to an orthopedic surgeon; had Lachman test performed which revealed greater joint laxity in my right leg compared to my left; X-rays were inconclusive, so I was referred for an MRI, but was told I could continue to do leg strength training
12/16 – had MRI
12/19 – met with surgeon to discuss MRI results and was told that reconstruction surgery was the only way I could ever return to the sports I wanted; I disagreed, so my surgeon suggested I get a second opinion (referred me to another surgeon of course)
12/23 – did a full sissy squat pain-free
12/26 – hit a new squat PR of 275x4 ass-to-grass pain-free
1/4 – met with a physician at a regenerative medicine clinic that specializes in nonsurgical treatment of ACL tears, particularly with experimental platelet-rich plasma and bone marrow concentrate injections; she confirmed my belief that reconstruction was unnecessary for me given my knee function and referred me to a physical therapist
1/9 – had a consultation and movement screen with my physical therapist who also confirmed that reconstruction surgery was not indicated for me; he helped me come up with a plyometric exercise progression plan
1/18 – ran a 10:00 mile on a treadmill pain-free
1/23 – PT visit
2/6 – PT visit
2/10 – returned to alpine skiing with a Donjoy knee brace; had no issues except for sucking at skiing and dealing with icy conditions (East coast), and I stayed on the easy green trail the whole time as I got used to skiing again
2/25 – ran my first Spartan 5k race
After I had my initial consultation with the surgeon in December, I began obsessively researching ACLs. For hours every day, I read research about treatment and rehabilitation through different methods in addition to numerous podcasts from experts. I believe there are currently five approaches worth considering when it comes to a complete ACL tear:

1. ACL Reconstruction – Long considered the gold standard, autografts remove your native ACL and use tissue from your own patellar tendon (which is actually a ligament), hamstring tendon, or quad tendon to connect your femur and tibia. The bone-patellar tendon-bone graft is the strongest of these. Allografts use tissue from cadaver tendons to attach these bones. Cadaver grafts are often irradiated to prevent transmission of infection, but the exposure to radiation causes the graft to be weaker than if not treated this way. Some of the potential downsides of reconstruction include long-term or permanent loss of range of motion and strength, a longer return-to-sport timeline than other treatments, deep vein thrombosis (DVT), Hoffa’s fat pad impingement, and long-term or permanent weakness and pain in the joint and grafted tendon. It is also usually suggested to avoid weight-bearing for weeks after surgery and depending on which knee it is, you may be unable to drive for weeks as well. These are potential complications from successful surgeries, and there is a myriad of other possible complications from poorly performed surgeries.
2. ACL Repair – Less invasive but uncommonly recommended surgery. Instead of harvesting tissue from anywhere else, the ACL is instead just reconnected to bone. Limited evidence supports the use of repair over reconstruction in proximal tears where the ACL is ripped off the femur (van der List et al., 2021).
3. Bridge-Enhanced ACL Repair (BEAR implant) – Only being approved by the FDA in 2020, it is a somewhat recently implemented technique, so there are not many surgeons performing it. BEAR makes use of bovine tissue to reattach the ends of the torn ligament, and the implant is injected with the patient’s own blood to form a clot. Over time, the bovine tissue is resorbed into the bloodstream, leaving only the native ACL, and allowing it to heal naturally. Reconstruction surgeries remove ends of the torn ACL, never giving it the opportunity to heal. The major downsides to this surgery are that it must be performed within 50 days of injury, and it is more challenging to find surgeons capable of the procedure.
4. Regenerative medicine – Regenerative medicine clinics strive to heal your ACL/menisci using minimally invasive platelet-rich plasma and/or bone marrow concentrate (stem cell) injections. While I do not know about the efficacy of these treatments for other injuries, one of the leading physicians in this field, Dr. Christopher Centeno, has published two articles in the last few years regarding his company’s methods in treating partial and complete ACL tears (listed below), however the evidence supporting its use is weak in my opinion. Their 2018 study failed to implement a control group against which they could measure results, meaning that there’s no way to know if ACL healing occurred as a result of treatment or if the body would have healed it on its own. Their 2022 study was a randomized controlled trial where they divided 30 patients who had completed three months of rehabilitation without surgery and still complained of pain and/or instability. The control group did a quad/hamstring/hip abductor exercise therapy program and was measured against a group using PRP, BMC, and an exercise therapy program. The nontreatment group was given the option to cross over into the treatment group, and all of the participants crossed over before having follow-up MRIs. Again, this means it is impossible to conclude whether the ACLs healed through time and exercise or as a result of the treatment, which defeats the purpose of an RCT. The major downside of this treatment is its cost: I was quoted $2,000 for PRP treatment (used for partial tears) and $7,000 for BMC treatment (used for full tears). This treatment is not covered by health insurance in the U.S. as it is considered experimental. Depending on your imaging, you may also not be eligible for this treatment if the ends of your ligament have greater than 1 cm of retraction like mine did.
5. Nonoperative management – In the last decade, there has been a substantial amount of research published on ACL healing as well as individuals functioning with an ACL deficient knee, known as “copers.” Not every ACL is capable of healing, and it seems that not everyone is capable of coping and some deal with persistent instability, but the current literature suggests that over 50% of ACL deficient people can cope with good knee function at the 2-year mark (Grindem et al., 2018). This method involves a progressive physical therapy/strength training program and may be more effective with some early bracing protocols.

Common Myths
· ACLs have no blood supply and therefore can’t heal
The ACL is vascularized primarily by the middle genicular artery (Duthon et al., 2006), although its blood supply is not abundant as a result of the synovial fluid covering it that restricts the formation of a blood clot that is needed for healing. Additionally, the formation of synovial tissue around ends of the ACL can prevent the ends of an ACL from reattaching (Murray et al., 2000). Despite this, healing of human ACLs has been demonstrated through MRI and arthroscopy (knee cameras) since at least 1996 (Ihara et al., 1996; Costa-Paz et al., 2012; Ihara & Kawano, 2017; Razi et al., 2020; Pitsillides et al., 2021; Blanke et al., 2022; Filbay et al., 2022; Filbay et al., 2023; and many others I have not even read or do not wish to purchase access to)! Blanke et al. (2022) showed 54 of 381 patients, confirmed by arthroscopy, had a healed ACL in 6-9 weeks of doing range of motion exercises in physical therapy. These patients were given a support brace for their knee and allowed to weight bear as tolerated, and 51/54 of those with healing only had partial ruptures. The results of this paper indicate that tears at the femur (proximal) are the most likely to heal, followed by tears in the middle of the ligament (midsubstance/intraligamentous), and then a poor prognosis for those torn at the tibia (distal), but also confirmed with cameras that 3 ACLs had healed from complete tears, and it wasn’t even a rigorous physical therapy program! Filbay et al. (2022) carried out a secondary analysis of the Frobell et al. (2010) KANON trial which confirmed through MRI that 16 of 54 (30%) completely ruptured ACLs healed at two years with a rehabilitation program, and when excluding those who opted into reconstruction surgery before the two-year mark, 16 of 30 (53%) had healed. Filbay et al. (2023) made use of a novel “Cross Bracing Protocol” where the knee is immobilized at 90° of flexion for 4 weeks and range of motion is gradually increased until 12 weeks, where the brace is then removed. This angle places the origin and insertion of the ACL closer together, making torn ends more likely to reconnect. 80 patients participated in this bracing protocol with physical therapy for the entire 12-week duration, and 72/80 (90%) had healing from complete ruptures. Of the 8 ACLs that did not heal, 6 of them attached to the lateral wall or PCL, which can also provide knee stability. Participants in this protocol were prescribed anticoagulants to mitigate the risks of DVT or pulmonary embolism that may arise as a result of knee immobilization. A major limitation is that there was no comparison arm/control group to compare these results to, so this paper is one that is highly contentious. Ironically, no control group is an incredibly common issue with the research on ACL reconstructions, yet it is still considered the gold standard. To me, this is abundant evidence that ACL tears, even ones with complete discontinuity, have the potential to heal. ACL reconstruction is a $7 billion industry annually, so it makes sense that there is little incentive for orthopedic surgeons to consider nonoperative care practices, and you will often see pushback where they deny that ACLs have any healing potential.
If you’re worried that the ACL will heal but forever be weak, worry no more! Davis’s law is a principle in physiology that states soft tissues will adapt when mechanically stressed. Myrick et al. (2019) measured the changes in volume of ACLs over the course of a soccer season for 17 Division I women. Significant increases in volume were measured in both legs with a more notable difference in the athletes’ dominant legs. As the ACL is the most stubborn knee ligament when it comes to healing, I think this suggests that the other ligaments of the knee with greater blood supply could have greater potential for adaptation. This is also excellent news for people who do not experience healing in their ACL, as the more vascular MCL plays a role in limiting internal rotation of the knee and resisting valgus (knee-caved) forces that load the ACL. The other ligaments can also play a role in resisting anterior translation of the tibia in the absence of an ACL, so with enough training stimulus they can adapt and protect your knee for when your muscles aren’t able to absorb force. Having strong passive structures is important for sudden impacts as muscles are not able to react to forces instantaneously, making ligaments the last line of defense. Plyometric training is necessary for this reason, regardless of how strong the muscles of your lower body are.
· Deep squatting is bad for your ACL
https://www.aaronswansonpt.com/the-deep-squat-part-1-the-good-the-bad-the-not-so-ugly/
This is an article about deep squatting in general. It has a very easily digestible diagram about shear forces on different ligaments during the squat with plenty of references, and it shows that peak shear forces on the ACL occur between 15-30° of knee flexion while the PCL takes on more load as you get lower than 90° in a squat. Since the moment arm from your knees to the barbell is short near the top of the squat, there will be little load on the knee at 15-30° of bend even if you’re squatting heavy. For best quad (and glute) growth and strength, squat as deep as you comfortably can.
· Open kinetic chain exercises (leg extensions) are dangerous if you’ve had a tear
https://www.youtube.com/watch?v=nMAOtXkGXfs&t=527s – video summary on leg extensions from E3 Rehab, discusses the papers I reference here
This myth is one of the biggest misconceptions limiting recovery for ACLs, and you may encounter a surgeon like mine who tells you it’s dangerous for your knee or will loosen your graft and that you should opt for something “functional” like a squat. First of all, all strength is functional. While there is a benefit to choosing exercises that are specific to your sport, the idea that a leg extension isn’t “functional” because we don’t do that movement in daily life is nonsense. Getting your quads stronger on a leg extension has the same overall effect as getting them stronger through a squat, there are just slight differences in where your quad grows the most. So far, data has found no differences in joint laxity between ACLR patients avoiding open-chain exercises and those that implement them in rehab (Fleming et al., 2005; Perriman et al., 2018). Despite plenty of evidence disproving this idea of graft loosening, even the British Journal of Sports Medicine published an article suggesting that reconstruction patients should delay open-chain exercise for 4 weeks post-surgery without any evidence to support (Noehren & Snyder-Mackler, 2020). Noehren and Snyder-Mackler (2020) also make the point that ACL strain is 2-3 times greater when walking than it is with 30 Nm (22.1 ft-lbs) of torque at a 15° knee angle. As a squat involves both knee extension and hip extension, it is easy for people to move in ways that make a squat more hip-dominant by bending more at the hip than the knees, and you may not even notice yourself doing this. You cannot truly know if your quads are prepared from multi-joint exercises; with a leg extension, there are no other muscles to compensate for quad weakness. It is good practice to do these unilaterally so that your healthy leg doesn’t hide the weakness of your injured leg.
One other important thing to note is that one of the quads, the rectus femoris, is a biarticular muscle since it crosses both the hip and knee. As you descend in a squat, both your hips and knees flex, making it so that the rectus femoris doesn’t significantly change in length and it is inhibited from producing enough force to grow substantially. It is for the same reason that squats do not sufficiently grow your hamstrings. Leg extensions isolate the quads and allow you to grow all of them well. They are also a great way to begin a training session as the strong quad contractions facilitate a lot of blood flow to your knee and this often provides temporary pain relief. Isometric (static) holds are going to be the least aggravating way to begin doing leg extensions, and this is a commonly used protocol for quad/patellar tendinopathy as well. A suggestion from Portland PT Erik Meira, who is a pioneer in ACL care, is to avoid the top range of motion on these machines – not because it is dangerous for an injured knee, but because you can load significantly more weight by skipping out on the last few degrees of knee extension, and this will be more beneficial for rate-of-force development. Training at this longer muscle length will also likely stimulate more hypertrophy (Oranchuk et al., 2019; Wolf et al., 2023). 60-90° of knee flexion is a good range for leg extensions starting out as there is no additional strain on the ACL with 45N (10 lbs) of force applied to the leg relative to a relaxed muscle state (Beynnon et al., 1995). I do still think it is worthwhile to eventually implement full range of motion on this exercise as strength is somewhat specific to the joint angles that you train in (and you want to be strong near extension where ACLs tear most often), but it may be more tolerable and even beneficial to begin with a partial range of motion.
· You can’t return to sport without an ACL if you don’t get surgery
One of the most common things people like to say is “you can run in straight lines without an ACL, but you need surgery if you ever want to go back to other sports.” And we have seen that this is absolutely false both in literature and anecdote. DeJuan Blair, an NBA center who tore both ACLs in high school and had failed repairs, had a physical that revealed that his ACLs had deteriorated and were no longer connecting his bones shortly before being drafted. He continued to play from 2009-2016 without further reported injury. Mitch Short was a professional rugby player who tore his ACL in 2018 and remained confident in his knee. He went on to play in his next match two weeks later and won a man of the match award. Short made use of the Cross Bracing Protocol and had a follow-up MRI in January 2020 that showed his ACL had healed. Jets quarterback Joe Namath tore an ACL in college in the 1960s (before surgical options were a choice) and braced for a few weeks before going on to have a Hall of Fame career. Notable Steelers wide receiver Hines Ward played his entire football career missing an ACL. Weiler et al. (2015) discusses professional soccer player Alou Diarra’s ACL tear in 2013, after which he returned to play in just 8 weeks of training. Diarra had no prior strength training experience and refused to perform squats as he did not like the feeling of a barbell on his back, but his medical team found other quad exercises he would comply with, paired with electrical stimulation, blood-flow restriction training, and eventually implemented low-level plyometrics before he made his return to the field. Grindem et al. (2012) conducted a comparison of return to pivoting sports a year post-injury with a surgery group and a nonoperative treatment group. The return to sport rate was identical between groups in the cohort of 138 people (68.1%) and the nonoperative group actually performed better on hop tests and had higher scores on knee function scales. Myklebust et al. (2003) found the following in a 6-11 year follow-up of professional handball players with torn ACLs: “Among the 57 operatively treated patients who returned for follow-up, 33 (58%) returned to team handball at their preinjury level, compared with 18 of 22 (82%) in the nonoperative group. Eleven of the 50 players (22%) who continued playing reinjured their anterior cruciate ligament when playing team handball.” Hurd et al. (2009) demonstrated that 63/88 (72%) of those that met the coper criteria returned to sports without reinjury over ten years. Grindem et al. (2018) implemented 2 years of progressive strength training for injured athletes and 52/97 (54%) had very successful outcomes regarding knee function. If you’re more interested in this study, check out this free lecture on Physiotutors (you just need to sign up). One limitation of these papers is that they often exclude people with concomitant injuries such as a tear in another ligament or meniscus (but not always); however, we know that both lateral and medical meniscal tears have the potential to heal as well, even the more serious bucket-handle tears (Rabelo et al. 2013, Han et al. 2015, Green et al. 2022). Menisci have three regions of varying vascularity that can influence the tear’s healing potential: the red-red zone (outermost layer), the red-white zone (the middle), and the white-white zone (innermost layer).
Dr. Kieran Richardson also discusses in this article from a few years ago: “It is almost unfathomable that a recent review by Kay et al 2017 revealed that only 1 of 412 ACL randomised controlled trials actually compared ACL reconstruction (ACLR) to structured rehabilitation for acute ACL injury, with essentially all other studies comparing various ACL surgeries and graft types to one another (Culvenor and Barton 2018). This single RCT, the famous KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) trial by Frobell and colleagues (2013), recommended that their ‘results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.’”
· Your risk of osteoarthritis is higher if you don’t get ACL/meniscus surgery
In 2018, van Yperen et al. retrospectively evaluated 50 patients. 25 patients who had unstable knees after 3 months of rehab were treated with surgery and 25 patients who had stable knees after 3 months were of rehab were treated without it. In a 20-year follow-up, osteoarthritis was found in 80% of the operative group and 68% of the non-operative group, a difference deemed statistically insignificant. This study is severely limited by the number of patients (n=50) and by it being a retrospective analysis. However, in an umbrella review evaluating 13 systematic reviews and meta-analyses, it was determined that having a surgical reconstruction does not reduce the risk for the development of osteoarthritis long-term, and an estimated 1/3 who have had ACL surgery will experience OA (Webster & Hewett, 2023). Three other reviews found no significant differences in pain, knee function, symptoms, return to sport, future meniscal tears, and OA, with slightly higher incidence of OA in operative groups (Delincé & Ghafil, 2012; Smith et al., 2014; Monk et al., 2016). Keep in mind that not all OA is symptomatic, and it is often related to how much cartilage remains in your joint and your physical fitness. Risk of OA is greater in those with quadriceps weakness (Øiestad et al., 2015, as cited in Filbay & Grindem, 2019). Meniscectomies remove some or all of the meniscus, leaving you at a greater risk of OA than if you had your meniscus repaired instead of removed (Migliorini et al., 2023). In fact, partial meniscectomies on degenerative menisci have been shown to do nothing more for knee function than placebo at 5 years (Sihvonen et al., 2022), and osteoarthritis has been reported in up to 89% of meniscectomy patients (Rangger et al., 1997). Additionally, some evidence supports the idea that meniscal tears are overtreated and leaving an injured meniscus alone results in equal or better results than meniscus repair, especially since meniscus tears are often asymptomatic (Shelbourne, 2021). Shelbourne also believes that weight-bearing is important for healing as it pushes the cartilage against the joint capsule and avoiding it may cause permanent loss of range of motion and strength. Meniscus trephination is a newer technique that’s been shown to be very effective for treating degenerative/torn menisci, but research on this is limited; the procedure involves poking holes hardened meniscal tissue with a needle in order to soften it to allow it to compress when walking, and the insertion of the needle attracts blood flow to the area to promote healing (Shelbourne 2021; Tfayli et al., 2023). The major takeaway here is that it’s the ACL injury itself that increases the risk of OA, not your surgical decision. While there’s not been shown to be a statistically significant difference in rates of OA with surgery vs. nonoperative care, it’s my suspicion that reconstruction leads to greater rates of radiographic OA, and rates tend to be slightly higher in the research for ACLR patients.
· You’re at greater risk of a meniscus tear if you don’t get surgery
From a recent systematic review written by both surgeons and physiotherapists, the authors concluded, “There is insufficient evidence that choosing early ACL reconstruction over non-operative treatment with optional delayed ACL reconstruction helps patients avoid new meniscal tears” (Ekas et al., 2020). Three other literature reviews also found no significant differences in rates of subsequent meniscal tears between surgical and non-surgical interventions (Delincé & Ghafil, 2012; Smith et al., 2014; Monk et al., 2016). Dr. Kieran Richardson discusses how the current literature suggesting risk of meniscal tears is greater is of poor methodological quality and fails to use a valid comparison arm here around the 5:00 mark. Studies will compare a group receiving surgery and excellent rehabilitation to a group receiving no treatment whatsoever and then jump to the conclusion that the risk of a meniscus tear is higher in nonoperative patients. Meniscal tears are also a much smaller trauma to your knee than an ACL reconstruction that drills into your bones and removes tendon tissue, so even if it were true that the risk of a meniscus tear is greater, it would still make sense to me to postpone or even forego surgery.
· Surgery should be done as soon as possible
Current best practice for patients receiving knee surgery is a 12-week period of strength training/prehab. Filbay & Grindem (2019) states, “As the only randomized trial on the topic did not support a superior outcome with early ACLR, it is prudent to suggest a period of rehabilitation before surgical decision-making for most patients with ACL rupture. This strategy is also supported by the findings that preoperative rehabilitation improves postsurgical outcomes in those who go on to have an ACLR. There is clinical agreement that patients who have functional instability after rehabilitation are likely to benefit from ACLR. The rationale behind this is that frequent instability episodes can be prevented by an ACLR, thereby reducing potential damage to the menisci and cartilage.” Since motion and strength are significantly limited immediately after reconstruction which results in atrophy, it makes sense to put in at least 3 months of consistent effort toward strengthening the tissues around the knee.
My Routine
After receiving my diagnosis, I resumed strength training immediately. Due to a lack of swelling, I never lost any range of motion or strength in my leg and was able to walk out of the climbing gym right after tearing my ACL and both menisci. I implemented partial range of motion leg extensions (60-90° of knee flexion) at the beginning of my workouts, followed by deep squats, stiff leg deadlifts, leg curls, calf raises, and hip abduction. The quads should be prioritized in ACL rehab, but the hamstrings, calves, and gluteus medius also have a bit of importance in unloading the ACL during different movements. I was training my legs twice a week, and on days that I didn’t train legs, I would do 2 sets of 30-45 second isometric holds at anywhere from 60-90° on the leg extension machine as heavy as I could since these aren’t very fatiguing, nor do they cause much damage/soreness. The idea was to contract my quad as hard as possible to promote blood flow to my knee for faster healing and pain relief; I would do these unilaterally to ensure my healthy leg wasn’t covering up my injured side. For those dealing with muscle inhibition, it should also lead to some improvements there as well. After some weeks of strength training, I gradually increased my speed on a treadmill to get back to running. Starting with an incline before moving back to flat ground will be a lot easier on your knee as the load on the joint is lower when moving uphill (van Hooren et al., 2024). A slight bit of pain is expected and usually necessary when recovering from such an injury; your joint becomes overly sensitive to things that aren’t harming it, and if you avoid pain entirely, it may be challenging to promote the adaptations needed to make a recovery. Listen to your body and dial it back if pain is not very tolerable. If you are dealing with a ton of knee soreness following a training session or even the day after, it is probably a sign that you should scale back either volume or intensity of exercise a little. I have now progressed to depth jumps pain-free and I am going to begin training change of direction with slower speeds soon. One thing to note is that I also had a few years of strength training prior to this injury, but we have evidence of someone with no prior strength training (pro soccer player Alou Diarra) overcoming this injury without surgery too.
Other Important Considerations/Fun Facts
· Muscle Inhibition
Arthrogenic muscle inhibition is a common response to joint injury as a byproduct of excessive effusion/swelling, and this limits the activation and strength of the affected leg. AMI should be expected in reconstruction too as surgery is itself a traumatic knee injury. Cryotherapy, eccentric exercise, and electrical stimulation may be effective treatments for AMI (Pietrosimone et al., 2022). This can impede recovery significantly by making it difficult to load the quads sufficiently, which makes training using blood-flow restriction to induce the same hypertrophic results with less load very appealing. Laurentino et al. (2022) showed that while blood-flow restriction training did not induce gains in size and strength through hormonal changes, there was a greater growth hormone response in those using occlusion than those who didn’t. Admittedly, I’m not very familiar with this area of the research but it is something that my evidence-based Doctor of PT mentioned could facilitate faster healing.
· Cross-Education
As a result of AMI, one of your quads may be weaker than the other. Especially after surgery, training your injured leg is going to be very painful and that leg will likely not see enough load to ward off atrophy that will make your knee even more vulnerable and sensitive to movement. Cross-education refers to the effects of training the uninjured side to its full potential while your injured leg lags behind. Training the good side has been shown to be an incredibly effective tool in strengthening the quads of your injured knee (Harput et al., 2019), and an LSI (Limb Symmetry Index) of greater than 90% dramatically decreases risk of sustaining another injury (Grindem et al., 2016).
· Women
It’s pretty commonly known that women are at far greater risk of tearing their ACL than men. In part, this is due to biomechanical differences such as a greater Q angle. Women’s menstrual cycles can also impact the incidence of ACL tears. Due to elevated levels of relaxin, a hormone that allows for the loosening of muscles and ligaments to support pregnancy and childbirth, women are at a higher risk of ACL injury during their period in the follicular phase as well as the ovulatory phase of their cycles (Denghan et al., 2014; Herzberg et al., 2017).
· Muscle Agonists/Antagonists and Force Vectors
The most important muscles in protection against injury when it comes to the ACL are the quads, gluteus medius, soleus, and hamstrings. While the quads and calves are able to gradually absorb force when landing, the glute medius (and minimus), soleus (deep calf muscle), and hamstrings are able to oppose anterior tibial shear forces and valgus/varus forces that load the ACL (Maniar et al., 2020). The hamstrings are also most capable of producing torque with a more bent knee, which can explain why ACLs are often torn when the leg is relatively straight (<30°). Men often neglect the glute medius, so hop on that hip abduction/bad girl machine ASAP! Banded clamshells work too, they are just harder to progressively overload than a weight stack.
Part 2: https://www.reddit.com/physicaltherapy/comments/1b57pgp/complete_acl_rupture_how_i_safely_returned_to/

For context, I am a 22-year-old male. In December of 2023, I suffered a complete midsubstance tear of my ACL, a peripheral vertical tear of my lateral meniscus, and a bucket-handle tear of my medial meniscus with a fragment that was displaced into the intercondylar notch, all within my right knee. I have kept track of important dates, and I am going to provide a timeline of my recovery process as well as some considerations for deciding on surgical vs. nonsurgical treatment with references. I would like to offer some hope to others dealing with a bleak situation and discuss the main things I would have wished to know when initially getting hurt, while debunking a lot of the most common myths as I have seen a ton of misinformation about the nonoperative route. For those who don’t want to read a novel, I think this 10 minute video is the best concise resource about making a decision regarding surgery. This decision aid is also a very useful tool in figuring things out, but this is going to be a bit more detailed. TLDR at bottom.
12/9 – full ACL tear and partial meniscal tears; surprise injury while bouldering where I jumped down from only a few feet up on the wall; I was immediately able to walk with some discomfort and had a little bit of swelling
12/11 – visited sports medicine clinic and talked to an orthopedic surgeon; had Lachman test performed which revealed greater joint laxity in my right leg compared to my left; X-rays were inconclusive, so I was referred for an MRI, but was told I could continue to do leg strength training
12/16 – had MRI
12/19 – met with surgeon to discuss MRI results and was told that reconstruction surgery was the only way I could ever return to the sports I wanted; I disagreed, so my surgeon suggested I get a second opinion (referred me to another surgeon of course)
12/23 – did a full sissy squat pain-free
12/26 – hit a new squat PR of 275x4 ass-to-grass pain-free
1/4 – met with a physician at a Regenexx clinic that specializes in nonsurgical treatment of ACL tears, particularly with experimental platelet-rich plasma and bone marrow concentrate injections; she confirmed my belief that reconstruction was unnecessary for me given my knee function and referred me to a physical therapist
1/9 – had a consultation and movement screen with my physical therapist who also confirmed that reconstruction surgery was not indicated for me; he helped me come up with a plyometric exercise progression plan
1/18 – ran a 10:00 mile on a treadmill pain-free
1/23 – PT visit
2/6 – PT visit
2/10 – returned to alpine skiing with a Donjoy knee brace; had no issues except for sucking at skiing and dealing with icy conditions (East coast), and I stayed on the easy green trail the whole time as I got used to skiing again
2/25 – ran my first Spartan 5k race
After I had my initial consultation with the surgeon in December, I began obsessively researching ACLs. For hours every day, I read research about treatment and rehabilitation through different methods in addition to numerous podcasts from experts. I believe there are currently five approaches worth considering when it comes to a complete ACL tear:

1. ACL Reconstruction – Long considered the gold standard, autografts remove your native ACL and use tissue from your own patellar tendon (which is actually a ligament), hamstring tendon, or quad tendon to connect your femur and tibia. The bone-patellar tendon-bone graft is the strongest of these. Allografts use tissue from cadaver tendons to attach these bones. Cadaver grafts are often irradiated to prevent transmission of infection, but the exposure to radiation causes the graft to be weaker than if not treated this way. Some of the potential downsides of reconstruction include long-term or permanent loss of range of motion and strength, a longer return-to-sport timeline than other treatments, deep vein thrombosis (DVT), Hoffa’s fat pad impingement, and long-term or permanent weakness and pain in the joint and grafted tendon. It is also usually suggested to avoid weight-bearing for weeks after surgery and depending on which knee it is, you may be unable to drive for weeks as well. These are potential complications from successful surgeries, and there is a myriad of other possible complications from poorly performed surgeries.
2. ACL Repair – Less invasive but uncommonly recommended surgery. Instead of harvesting tissue from anywhere else, the ACL is instead just reconnected to bone. Limited evidence supports the use of repair over reconstruction in proximal tears where the ACL is ripped off the femur (van der List et al., 2021).
3. Bridge-Enhanced ACL Repair (BEAR implant) – Only being approved by the FDA in 2020, it is a somewhat recently implemented technique, so there are not many surgeons performing it. BEAR makes use of bovine tissue to reattach the ends of the torn ligament, and the implant is injected with the patient’s own blood to form a clot. Over time, the bovine tissue is resorbed into the bloodstream, leaving only the native ACL, and allowing it to heal naturally. Reconstruction surgeries remove ends of the torn ACL, never giving it the opportunity to heal. The major downsides to this surgery are that it must be performed within 50 days of injury, and it is more challenging to find surgeons capable of the procedure.
4. Regenerative medicine – Regenexx is a clinic based in the U.S. with over 80 locations nationwide, and they treat a host of different issues, including ACL and meniscal tears. They strive to heal your ACL/menisci using minimally invasive platelet-rich plasma and/or bone marrow concentrate (stem cell) injections. While I do not know about the efficacy of their treatments for other injuries, their founder Dr. Christopher Centeno has published two articles in the last few years regarding their methods in treating partial and complete ACL tears (listed below), however the evidence supporting its use is weak in my opinion. Their 2018 study failed to implement a control group against which they could measure results, meaning that there’s no way to know if ACL healing occurred as a result of treatment or if the body would have healed it on its own. Their 2022 study was a randomized controlled trial where they divided 30 patients who had completed three months of rehabilitation without surgery and still complained of pain and/or instability. The control group did a quad/hamstring/hip abductor exercise therapy program and was measured against a group using PRP, BMC, and an exercise therapy program. The nontreatment group was given the option to cross over into the treatment group, and all of the participants crossed over before having follow-up MRIs. Again, this means it is impossible to conclude whether the ACLs healed through time and exercise or as a result of the treatment, which defeats the purpose of an RCT. The major downside of this treatment is its cost: I was quoted $2,000 for PRP treatment (used for partial tears) and $7,000 for BMC treatment (used for full tears). This treatment is not covered by health insurance in the U.S. as it is considered experimental. Depending on your imaging, you may also not be eligible for this treatment if the ends of your ligament have greater than 1 cm of retraction like mine did.
5. Nonoperative management – In the last decade, there has been a substantial amount of research published on ACL healing as well as individuals functioning with an ACL deficient knee, known as “copers.” Not every ACL is capable of healing, and it seems that not everyone is capable of coping and some deal with persistent instability, but the current literature suggests that over 50% of ACL deficient people can cope with good knee function at the 2-year mark (Grindem et al., 2018). This method involves a progressive physical therapy/strength training program and may be more effective with some early bracing protocols.

Common Myths
· ACLs have no blood supply and therefore can’t heal
The ACL is vascularized primarily by the middle genicular artery (Duthon et al., 2006), although its blood supply is not abundant as a result of the synovial fluid covering it that restricts the formation of a blood clot that is needed for healing. Additionally, the formation of synovial tissue around ends of the ACL can prevent the ends of an ACL from reattaching (Murray et al., 2000). Despite this, healing of human ACLs has been demonstrated through MRI and arthroscopy (knee cameras) since at least 1996 (Ihara et al., 1996; Costa-Paz et al., 2012; Ihara & Kawano, 2017; Razi et al., 2020; Pitsillides et al., 2021; Blanke et al., 2022; Filbay et al., 2022; Filbay et al., 2023; and many others I have not even read or do not wish to purchase access to)! Blanke et al. (2022) showed 54 of 381 patients, confirmed by arthroscopy, had a healed ACL in 6-9 weeks of doing range of motion exercises in physical therapy. These patients were given a support brace for their knee and allowed to weight bear as tolerated, and 51/54 of those with healing only had partial ruptures. The results of this paper indicate that tears at the femur (proximal) are the most likely to heal, followed by tears in the middle of the ligament (midsubstance/intraligamentous), and then a poor prognosis for those torn at the tibia (distal), but also confirmed with cameras that 3 ACLs had healed from complete tears, and it wasn’t even a rigorous physical therapy program! Filbay et al. (2022) carried out a secondary analysis of the Frobell et al. (2010) KANON trial which confirmed through MRI that 16 of 54 (30%) completely ruptured ACLs healed at two years with a rehabilitation program, and when excluding those who opted into reconstruction surgery before the two-year mark, 16 of 30 (53%) had healed. Filbay et al. (2023) made use of a novel “Cross Bracing Protocol” where the knee is immobilized at 90° of flexion for 4 weeks and range of motion is gradually increased until 12 weeks, where the brace is then removed. This angle places the origin and insertion of the ACL closer together, making torn ends more likely to reconnect. 80 patients participated in this bracing protocol with physical therapy for the entire 12-week duration, and 72/80 (90%) had healing from complete ruptures. Of the 8 ACLs that did not heal, 6 of them attached to the lateral wall or PCL, which can also provide knee stability. Participants in this protocol were prescribed anticoagulants to mitigate the risks of DVT or pulmonary embolism that may arise as a result of knee immobilization. A major limitation is that there was no comparison arm/control group to compare these results to, so this paper is one that is highly contentious. Ironically, no control group is an incredibly common issue with the research on ACL reconstructions, yet it is still considered the gold standard. To me, this is abundant evidence that ACL tears, even ones with complete discontinuity, have the potential to heal. ACL reconstruction is a $7 billion industry annually, so it makes sense that there is little incentive for orthopedic surgeons to consider nonoperative care practices, and you will often see pushback where they deny that ACLs have any healing potential.
If you’re worried that the ACL will heal but forever be weak, worry no more! Davis’s law is a principle in physiology that states soft tissues will adapt when mechanically stressed. Myrick et al. (2019) measured the changes in volume of ACLs over the course of a soccer season for 17 Division I women. Significant increases in volume were measured in both legs with a more notable difference in the athletes’ dominant legs. As the ACL is the most stubborn knee ligament when it comes to healing, I think this suggests that the other ligaments of the knee with greater blood supply could have greater potential for adaptation. This is also excellent news for people who do not experience healing in their ACL, as the more vascular MCL plays a role in limiting internal rotation of the knee and resisting valgus (knee-caved) forces that load the ACL. The other ligaments can also play a role in resisting anterior translation of the tibia in the absence of an ACL, so with enough training stimulus they can adapt and protect your knee for when your muscles aren’t able to absorb force. Having strong passive structures is important for sudden impacts as muscles are not able to react to forces instantaneously, making ligaments the last line of defense. Plyometric training is necessary for this reason, regardless of how strong the muscles of your lower body are.
· Deep squatting is bad for your ACL
https://www.aaronswansonpt.com/the-deep-squat-part-1-the-good-the-bad-the-not-so-ugly/
This is an article about deep squatting in general. It has a very easily digestible diagram about shear forces on different ligaments during the squat with plenty of references, and it shows that peak shear forces on the ACL occur between 15-30° of knee flexion while the PCL takes on more load as you get lower than 90° in a squat. Since the moment arm from your knees to the barbell is short near the top of the squat, there will be little load on the knee at 15-30° of bend even if you’re squatting heavy. For best quad (and glute) growth and strength, squat as deep as you comfortably can.
· Open kinetic chain exercises (leg extensions) are dangerous if you’ve had a tear
https://www.youtube.com/watch?v=nMAOtXkGXfs&t=527s – video summary on leg extensions from E3 Rehab, discusses the papers I reference here
This myth is one of the biggest misconceptions limiting recovery for ACLs, and you may encounter a surgeon like mine who tells you it’s dangerous for your knee or will loosen your graft and that you should opt for something “functional” like a squat. First of all, all strength is functional. While there is a benefit to choosing exercises that are specific to your sport, the idea that a leg extension isn’t “functional” because we don’t do that movement in daily life is nonsense. Getting your quads stronger on a leg extension has the same overall effect as getting them stronger through a squat, there are just slight differences in where your quad grows the most. So far, data has found no differences in joint laxity between ACLR patients avoiding open-chain exercises and those that implement them in rehab (Fleming et al., 2005; Perriman et al., 2018). Despite plenty of evidence disproving this idea of graft loosening, even the British Journal of Sports Medicine published an article suggesting that reconstruction patients should delay open-chain exercise for 4 weeks post-surgery without any evidence to support (Noehren & Snyder-Mackler, 2020). Noehren and Snyder-Mackler (2020) also make the point that ACL strain is 2-3 times greater when walking than it is with 30 Nm (22.1 ft-lbs) of torque at a 15° knee angle. As a squat involves both knee extension and hip extension, it is easy for people to move in ways that make a squat more hip-dominant by bending more at the hip than the knees, and you may not even notice yourself doing this. You cannot truly know if your quads are prepared from multi-joint exercises; with a leg extension, there are no other muscles to compensate for quad weakness. It is good practice to do these unilaterally so that your healthy leg doesn’t hide the weakness of your injured leg.
One other important thing to note is that one of the quads, the rectus femoris, is a biarticular muscle since it crosses both the hip and knee. As you descend in a squat, both your hips and knees flex, making it so that the rectus femoris doesn’t significantly change in length and it is inhibited from producing enough force to grow substantially. It is for the same reason that squats do not sufficiently grow your hamstrings. Leg extensions isolate the quads and allow you to grow all of them well. They are also a great way to begin a training session as the strong quad contractions facilitate a lot of blood flow to your knee and this often provides temporary pain relief. Isometric (static) holds are going to be the least aggravating way to begin doing leg extensions, and this is a commonly used protocol for quad/patellar tendinopathy as well. A suggestion from Portland PT Erik Meira, who is a pioneer in ACL care, is to avoid the top range of motion on these machines – not because it is dangerous for an injured knee, but because you can load significantly more weight by skipping out on the last few degrees of knee extension, and this will be more beneficial for rate-of-force development. Training at this longer muscle length will also likely stimulate more hypertrophy (Oranchuk et al., 2019; Wolf et al., 2023). 60-90° of knee flexion is a good range for leg extensions starting out as there is no additional strain on the ACL with 45N (10 lbs) of force applied to the leg relative to a relaxed muscle state (Beynnon et al., 1995). I do still think it is worthwhile to eventually implement full range of motion on this exercise as strength is somewhat specific to the joint angles that you train in (and you want to be strong near extension where ACLs tear most often), but it may be more tolerable and even beneficial to begin with a partial range of motion.
· You can’t return to sport without an ACL if you don’t get surgery
One of the most common things people like to say is “you can run in straight lines without an ACL, but you need surgery if you ever want to go back to other sports.” And we have seen that this is absolutely false both in literature and anecdote. DeJuan Blair, an NBA center who tore both ACLs in high school and had failed repairs, had a physical that revealed that his ACLs had deteriorated and were no longer connecting his bones shortly before being drafted. He continued to play from 2009-2016 without further reported injury. Mitch Short was a professional rugby player who tore his ACL in 2018 and remained confident in his knee. He went on to play in his next match two weeks later and won a man of the match award. Short made use of the Cross Bracing Protocol and had a follow-up MRI in January 2020 that showed his ACL had healed. Jets quarterback Joe Namath tore an ACL in college in the 1960s (before surgical options were a choice) and braced for a few weeks before going on to have a Hall of Fame career. Notable Steelers wide receiver Hines Ward played his entire football career missing an ACL. Weiler et al. (2015) discusses professional soccer player Alou Diarra’s ACL tear in 2013, after which he returned to play in just 8 weeks of training. Diarra had no prior strength training experience and refused to perform squats as he did not like the feeling of a barbell on his back, but his medical team found other quad exercises he would comply with, paired with electrical stimulation, blood-flow restriction training, and eventually implemented low-level plyometrics before he made his return to the field. Grindem et al. (2012) conducted a comparison of return to pivoting sports a year post-injury with a surgery group and a nonoperative treatment group. The return to sport rate was identical between groups in the cohort of 138 people (68.1%) and the nonoperative group actually performed better on hop tests and had higher scores on knee function scales. Myklebust et al. (2003) found the following in a 6-11 year follow-up of professional handball players with torn ACLs: “Among the 57 operatively treated patients who returned for follow-up, 33 (58%) returned to team handball at their preinjury level, compared with 18 of 22 (82%) in the nonoperative group. Eleven of the 50 players (22%) who continued playing reinjured their anterior cruciate ligament when playing team handball.” Hurd et al. (2009) demonstrated that 63/88 (72%) of those that met the coper criteria returned to sports without reinjury over ten years. Grindem et al. (2018) implemented 2 years of progressive strength training for injured athletes and 52/97 (54%) had very successful outcomes regarding knee function. If you’re more interested in this study, check out this free lecture on Physiotutors (you just need to sign up). One limitation of these papers is that they often exclude people with concomitant injuries such as a tear in another ligament or meniscus (but not always); however, we know that both lateral and medical meniscal tears have the potential to heal as well, even the more serious bucket-handle tears (Rabelo et al. 2013, Han et al. 2015, Green et al. 2022). Menisci have three regions of varying vascularity that can influence the tear’s healing potential: the red-red zone (outermost layer), the red-white zone (the middle), and the white-white zone (innermost layer).
Dr. Kieran Richardson also discusses in this article from a few years ago: “It is almost unfathomable that a recent review by Kay et al 2017 revealed that only 1 of 412 ACL randomised controlled trials actually compared ACL reconstruction (ACLR) to structured rehabilitation for acute ACL injury, with essentially all other studies comparing various ACL surgeries and graft types to one another (Culvenor and Barton 2018). This single RCT, the famous KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) trial by Frobell and colleagues (2013), recommended that their ‘results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.’”
· Your risk of osteoarthritis is higher if you don’t get ACL/meniscus surgery
In 2018, van Yperen et al. retrospectively evaluated 50 patients. 25 patients who had unstable knees after 3 months of rehab were treated with surgery and 25 patients who had stable knees after 3 months were of rehab were treated without it. In a 20-year follow-up, osteoarthritis was found in 80% of the operative group and 68% of the non-operative group, a difference deemed statistically insignificant. This study is severely limited by the number of patients (n=50) and by it being a retrospective analysis. However, in an umbrella review evaluating 13 systematic reviews and meta-analyses, it was determined that having a surgical reconstruction does not reduce the risk for the development of osteoarthritis long-term, and an estimated 1/3 who have had ACL surgery will experience OA (Webster & Hewett, 2023). Three other reviews found no significant differences in pain, knee function, symptoms, return to sport, future meniscal tears, and OA, with slightly higher incidence of OA in operative groups (Delincé & Ghafil, 2012; Smith et al., 2014; Monk et al., 2016). Keep in mind that not all OA is symptomatic, and it is often related to how much cartilage remains in your joint and your physical fitness. Risk of OA is greater in those with quadriceps weakness (Øiestad et al., 2015, as cited in Filbay & Grindem, 2019). Meniscectomies remove some or all of the meniscus, leaving you at a greater risk of OA than if you had your meniscus repaired instead of removed (Migliorini et al., 2023). In fact, partial meniscectomies on degenerative menisci have been shown to do nothing more for knee function than placebo at 5 years (Sihvonen et al., 2022), and osteoarthritis has been reported in up to 89% of meniscectomy patients (Rangger et al., 1997). Additionally, some evidence supports the idea that meniscal tears are overtreated and leaving an injured meniscus alone results in equal or better results than meniscus repair, especially since meniscus tears are often asymptomatic (Shelbourne, 2021). Shelbourne also believes that weight-bearing is important for healing as it pushes the cartilage against the joint capsule and avoiding it may cause permanent loss of range of motion and strength. Meniscus trephination is a newer technique that’s been shown to be very effective for treating degenerative/torn menisci, but research on this is limited; the procedure involves poking holes hardened meniscal tissue with a needle in order to soften it to allow it to compress when walking, and the insertion of the needle attracts blood flow to the area to promote healing (Shelbourne 2021; Tfayli et al., 2023). The major takeaway here is that it’s the ACL injury itself that increases the risk of OA, not your surgical decision. While there’s not been shown to be a statistically significant difference in rates of OA with surgery vs. nonoperative care, it’s my suspicion that reconstruction leads to greater rates of radiographic OA, and rates tend to be slightly higher in the research for ACLR patients.
· You’re at greater risk of a meniscus tear if you don’t get surgery
From a recent systematic review written by both surgeons and physiotherapists, the authors concluded, “There is insufficient evidence that choosing early ACL reconstruction over non-operative treatment with optional delayed ACL reconstruction helps patients avoid new meniscal tears” (Ekas et al., 2020). Three other literature reviews also found no significant differences in rates of subsequent meniscal tears between surgical and non-surgical interventions (Delincé & Ghafil, 2012; Smith et al., 2014; Monk et al., 2016). Dr. Kieran Richardson discusses how the current literature suggesting risk of meniscal tears is greater is of poor methodological quality and fails to use a valid comparison arm here around the 5:00 mark. Studies will compare a group receiving surgery and excellent rehabilitation to a group receiving no treatment whatsoever and then jump to the conclusion that the risk of a meniscus tear is higher in nonoperative patients. Meniscal tears are also a much smaller trauma to your knee than an ACL reconstruction that drills into your bones and removes tendon tissue, so even if it were true that the risk of a meniscus tear is greater, it would still make sense to me to postpone or even forego surgery.
· Surgery should be done as soon as possible
Current best practice for patients receiving knee surgery is a 12-week period of strength training/prehab. Filbay & Grindem (2019) states, “As the only randomized trial on the topic did not support a superior outcome with early ACLR, it is prudent to suggest a period of rehabilitation before surgical decision-making for most patients with ACL rupture. This strategy is also supported by the findings that preoperative rehabilitation improves postsurgical outcomes in those who go on to have an ACLR. There is clinical agreement that patients who have functional instability after rehabilitation are likely to benefit from ACLR. The rationale behind this is that frequent instability episodes can be prevented by an ACLR, thereby reducing potential damage to the menisci and cartilage.” Since motion and strength are significantly limited immediately after reconstruction which results in atrophy, it makes sense to put in at least 3 months of consistent effort toward strengthening the tissues around the knee.
My Routine
After receiving my diagnosis, I resumed strength training immediately. Due to a lack of swelling, I never lost any range of motion or strength in my leg and was able to walk out of the climbing gym right after tearing my ACL and both menisci. I implemented partial range of motion leg extensions (60-90° of knee flexion) at the beginning of my workouts, followed by deep squats, stiff leg deadlifts, leg curls, calf raises, and hip abduction. The quads should be prioritized in ACL rehab, but the hamstrings, calves, and gluteus medius also have a bit of importance in unloading the ACL during different movements. I was training my legs twice a week, and on days that I didn’t train legs, I would do 2 sets of 30-45 second isometric holds at anywhere from 60-90° on the leg extension machine as heavy as I could since these aren’t very fatiguing, nor do they cause much damage/soreness. The idea was to contract my quad as hard as possible to promote blood flow to my knee for faster healing and pain relief; I would do these unilaterally to ensure my healthy leg wasn’t covering up my injured side. For those dealing with muscle inhibition, it should also lead to some improvements there as well. After some weeks of strength training, I gradually increased my speed on a treadmill to get back to running. Starting with an incline before moving back to flat ground will be a lot easier on your knee as the load on the joint is lower when moving uphill (van Hooren et al., 2024). A slight bit of pain is expected and usually necessary when recovering from such an injury; your joint becomes overly sensitive to things that aren’t harming it, and if you avoid pain entirely, it may be challenging to promote the adaptations needed to make a recovery. Listen to your body and dial it back if pain is not very tolerable. If you are dealing with a ton of knee soreness following a training session or even the day after, it is probably a sign that you should scale back either volume or intensity of exercise a little. I have now progressed to depth jumps pain-free and I am going to begin training change of direction with slower speeds soon. One thing to note is that I also had a few years of strength training prior to this injury, but we have evidence of someone with no prior strength training (pro soccer player Alou Diarra) overcoming this injury without surgery too.
Other Important Considerations/Fun Facts
· Muscle Inhibition
Arthrogenic muscle inhibition is a common response to joint injury as a byproduct of excessive effusion/swelling, and this limits the activation and strength of the affected leg. AMI should be expected in reconstruction too as surgery is itself a traumatic knee injury. Cryotherapy, eccentric exercise, and electrical stimulation may be effective treatments for AMI (Pietrosimone et al., 2022). This can impede recovery significantly by making it difficult to load the quads sufficiently, which makes training using blood-flow restriction to induce the same hypertrophic results with less load very appealing. Laurentino et al. (2022) showed that while blood-flow restriction training did not induce gains in size and strength through hormonal changes, there was a greater growth hormone response in those using occlusion than those who didn’t. Admittedly, I’m not very familiar with this area of the research but it is something that my evidence-based Doctor of PT mentioned could facilitate faster healing.
· Cross-Education
As a result of AMI, one of your quads may be weaker than the other. Especially after surgery, training your injured leg is going to be very painful and that leg will likely not see enough load to ward off atrophy that will make your knee even more vulnerable and sensitive to movement. Cross-education refers to the effects of training the uninjured side to its full potential while your injured leg lags behind. Training the good side has been shown to be an incredibly effective tool in strengthening the quads of your injured knee (Harput et al., 2019), and an LSI (Limb Symmetry Index) of greater than 90% dramatically decreases risk of sustaining another injury (Grindem et al., 2016).
· Women
It’s pretty commonly known that women are at far greater risk of tearing their ACL than men. In part, this is due to biomechanical differences such as a greater Q angle. Women’s menstrual cycles can also impact the incidence of ACL tears. Due to elevated levels of relaxin, a hormone that allows for the loosening of muscles and ligaments to support pregnancy and childbirth, women are at a higher risk of ACL injury during their period in the follicular phase as well as the ovulatory phase of their cycles (Denghan et al., 2014; Herzberg et al., 2017).
· Finding a Provider
I had a lot of trouble finding an evidence-based physical therapist that I knew would help with nonoperative ACL care. I was lucky that the physician I met with at Regenexx gave me a referral to an excellent Doctor of PT who stays up to date with research. For those who are unable to find a PT in their area that is familiar with nonoperative care, I highly suggest working with someone online. Dr. Steph Allen (Instagram: u/stephallen.dpt) and Dr. Kaan Celebi (Instagram: u/acl_academy) are two practitioners familiar with all facets of ACL care, and while I have not worked with them personally, I think they are both excellent options with the quality of information that they put out. Steph Allen runs a cash-based practice meaning it does not accept insurance, but I believe this is a better model (care-wise and cost-wise) for provider and patient which I will discuss in greater detail below. I’m unsure about the details of Kaan Celebi’s practice.
Surgeons are good at surgery – they are not rehab experts and you should not rely on them for exercise prescription. While you should heed their recommendations about early weight-bearing post-surgery (although surgeon preferences vary), I have heard of surgeons giving out terrible misinformation about exercise, saying things like “squats will ruin your knees” or “deadlifts will ruin your back.” The human body is very resilient, and these kinds of surgeons are a few decades behind in exercise science.
· Muscle Agonists/Antagonists and Force Vectors
The most important muscles in protection against injury when it comes to the ACL are the quads, gluteus medius, soleus, and hamstrings. While the quads and calves are able to gradually absorb force when landing, the glute medius (and minimus), soleus (deep calf muscle), and hamstrings are able to oppose anterior tibial shear forces and valgus/varus forces that load the ACL (Maniar et al., 2020). The hamstrings are also most capable of producing torque with a more bent knee, which can explain why ACLs are often torn when the leg is relatively straight (<30°). Men often neglect the glute medius, so hop on that hip abduction/bad girl machine ASAP! Banded clamshells work too, they are just harder to progressively overload than a weight stack.
Part 2: https://www.reddit.com/ACL/comments/1b4ziva/complete_acl_rupture_how_i_safely_returned_to/

Sonic the Hedgehog. One of the greatest and most attractive characters ever thought up. He can run at sound speed, take out enemies in a flash, and best of all, he's blue colored and knows how to handle the females. Speaking of females, the Sonic universe might also be classified as "Hot Chick Heaven" because there's such a mess of very beautiful and tough women that it will make you love the franchise even more! And since Valentine's Day is around the corner, I've been inspired to make a top 10 list of the most beautiful female Sonic characters. Grab yourself a snack and a glass of orange juice, and try not to reach through the screen because HERE WE GO!
10: Try this question on for size. Who chases and hugs Sonic all the time and wields a powerful hammer? Why it's Amy Rose of course! Though more of a cutie than a hottie, you can't deny the fact that she's still attractive. Two things that make her attractive are the fact that she wears a dress, and when have you ever seen 3 big, very smooth arcs of hair sticking out of a person's forehead? I haven't! So once again, Amy Rose is lovely; that is until she goes berserk and starts hitting stuff with her hammer.
Who's at number 9? It's this alien plant girl from a distant planet. Cosmo, from Sonic X. She arrived on the character's planet to deliver a message saying that the galaxy was under attack by a force called the Metarex. She doesn't do much except tell people to stop fighting and focus on the real matter at hand. The real reason she lands at the #9 is that she becomes Miles "Tails" Prower's sweetheart, something Tails needed for a long while.
Numero Ocho. Cream the Rabbit's mother, Vanilla. She's attractive and the size of an average human mother. What really surprises me about her is that the leader of Team Chaotix, Vector the Crocodile, falls in love with her. Kinda silly, don't you think? She's another character that doesn't do much, but in a season 3 episode of Sonic X, she helps Chris Thorndyke get into space to fight the Metarex along with Sonic and friends.
What number's next? Seven, of course. Wave the Swallow from Sonic Riders. People always root for the good guys, but sometimes, the bad guys steal the show. Her mechanical IQ is equal to Tails. She also happens to be the smartest member of the Babylon Rogues. I wonder why she isn't the leader. Like Jet the Hawk and Storm the Albatross, her specialty is riding the air-boards called "Extreme Gear". With two very long and smooth feathers extending from her head to her calves and droopy eyes, Wave will rock your socks. If only we could see her take wing.
Numero Six. Tikal the Echidna from Sonic Adventure 1. Named after an ancient Mayan city of the same name, Tikal is the daughter of Chief Pachacamac. She's yet another character that hardly does a thing except beg her father to stop being so greedy. She also traps herself inside the Master Emerald so that the water god Chaos doesn't reign terror upon the land. When you're the daughter of a person in the highest power, you need to look your best and Tikal delivers perfectly. That's why she's #6. Number
#1, #2, #3, #4, #5! Ah-Ah-Ahhh! Mina Mongoose from the Sonic Archie comics. How could you go wrong with a girl that looks like this? She can run nearly as fast as Sonic and she went from being a Freedom Fighter to being a popstar singer. Next to Princess Sally she looks more humanoid than the other characters.
Who could top someone who has long mauve hair? This female standing at number 4: Blaze the Cat. One word: Pyrokinesis. How would you like to have that superpower? I mean Blaze could play around in the Himalayas for hours and she would be perfectly fine! Also, 45 degree ponytail makes her look like a Native American. I really like the fact that her love interest is the telekinetic hedgehog Silver. The combination of mind-moving and fire superpowers make these two a reliable couple. But what really lands Blaze in the #4 spot is that her attitudes apparently more different from the other females.
Next up is #3. What's better than having a female with cascading quills? How about a female with cascading quills and hair? Julie-Su the Echidna, another Archie comic exclusive has that feature. She's smart, knows exactly what to do as a freedom fighter, and even trained Amy once. She's also the girl of Knuckles' dreams. Heh, lucky him. Her older self in the series Mobius: X Years Later is just downright hot! Just look at that long ponytail! Now we're talkin'!
1, 2, button my shoe! Princess Sally Acorn. There's a lot to say about this character. She's the heir to the throne, Sonic's first official romance, the only character that used to not wear clothes, brave and athletic, the most humanoid character, and is like a mother to Tails. In the TV show, Sonic SatAM, one Freedom Fighter, the cowardly Antoine constantly tries to woo Sally, but doesn't succeed because... he's a coward! The Princess is also a semi-perfect example of an excellent love interest, although there were a couple of times when she really snapped and acted like a lunatic; in the comics, that is. But overall, Sally Acorn really stands out amongst the slew of females not just because she's Sonic's first official love interest, or because she's the only one who didn't wear clothes, but because in the comics, she grew very long hair, and married Sonic in the future, becoming the Queen.
So, you've seen a pyrokinetic Cat, a swallow, two gorgeous echidnas, and even a princess! Who could possibly top those kinds of females?
Well, get ready folks; this is the #1 hottest Sonic the Hedgehog female character. Rouge the Bat. If anybody denies it, how dare you? This woman can fly, she's as strong as Knuckles, and is a femme fatale, seducing other characters into getting what she wants. Instead of having one love interest, she has two! Knuckles, and Shadow the Hedgehog. Being a treasure thief, she's only interested in one object set; jewels, especially the Chaos Emeralds. There actually have been situations where Rouge's cleavage has been exposed, but it eventually got censored. What a price to pay. I think the best part about this beauty is that she wears three different outfits unlike the other female characters. And who wouldn't want to fly across the landscape via strong as Shawn Johnson, and flirt with any male, anytime, anywhere. These three traits make Rouge the Bat triumph over all of the Sonic the Hedgehog females. My hat goes off to you Sonic Team USA. You oughta be proud.
There ya have it folks. Those were the hottest female chicks in the Sonic universe. I hope you enjoyed it, happy Valentine's Day, and I'll see you later. HERE WE GO!

POTOMAC

• ‘Real Housewives’ Doesn’t Even Show Half Of Wendy And Eddie Osefo’s Marriage (Taryn Finley for Huffington Post)

MIAMI

• RHOM Star Lisa Hochstein is Still Following Marcus Jordan Post-Split After Larsa Called Out “Friend,” Plus Marcus Faces Rumors of Being on Raya as Insider Shares If They’ll Get Back Together (Reality Blurb)
• See a New Side of Larsa Pippen in Adorable Throwback Photos of Her Childhood (Bravo's The Daily Dish)
• Check Out These Stunning Throwback Photos of Alexia Nepola (Bravo's The Daily Dish)

BEVERLY HILLS

• Board Member Sharon Stone ‘Wanted’ to Call Homeless Not Toothless Organization ‘Something Else’ (US Weekly)

NEW JERSEY

• Real Housewives' Melissa Gorga Is “Very Picky” About Activewear, but She Loves This $22 Sports Bra (E!)
• Melissa Gorga Deletes and Reposts Clip After ‘Forgetting Filter,’ See the Before & After Pics as RHONJ Fans React (Reality Blurb)

ORANGE COUNTY

• Tamra Judge Says Shannon and Vicki are ‘Insanely Jealous’ of her Success (All About The Real Housewives)

SALT LAKE CITY

• Lisa Barlow Addresses Jen Shah Black Eye Claims, Says RHOSLC Costar Hurt 'Every Single One of Us' (People exclusive)
• Lisa Barlow claims Monica Garcia tried to record their off-air conversations before filming ‘RHOSLC’ (Page Six exclusive)
• Whitney Rose Shares a First Look Inside Her New Home (Photos) (Bravo's The Daily Dish)
• Monica Garcia Shares if She Would Return to RHOSLC (Heavy)

NEW YORK

• 'He's the black Tom Ford!' RHONY star Ubah Hassan gushes over sexy and sophisticated LaQuan Smith collection at New York Fashion Week (Daily Mail exclusive)

ATLANTA

• Shereé Whitfield shades ex Martell Holt after breakup as she reveals what she wants in her next boyfriend (Page Six exclusive)

BRAVO

• Phaedra Parks Talks Reality Television And Her Illustrious Career (Black Enterprise exclusive)
• Scheana Shay Spills Details on Working with The 27s and Teases "New Music" with the Band (Bravo's The Daily Dish)
• Vanderpump Rules Star Ariana Madix Talks Broadway Debut in Chicago (Frank DiLella for Broadway Direct)
• Ariana Madix and Nicola Coughlan pose for a photo while staying out "past our bedtime" (Page Six Star Snaps)
• Katie Maloney and Ariana Madix (Finally!) Give a Tour of Something About Her: See Inside (Bravo's The Daily Dish)
• Brittany Cartwright Gives the Rundown on Lala Kent & Kristen Doute’s Feud (Heavy exclusive)
• Paige DeSorbo's Skin-Baring Style for NYFW Just Stopped Us in Our Tracks (Photos) (Bravo's The Daily Dish)

CHESHIRE

• Riyad Mahrez's wife Taylor Ward reveals what living in Saudi Arabia is like after tearful reaction to the shock move... as she opens up on the 'emotional rollercoaster' of leaving Manchester (Daily Mail)

Links to this week's episode discussion posts:

• VPR S11E3 🍸