The key to making a full recovery from any injury is not just correct treatment and healing but also re-strengthening and regaining coordination of the joint and all the movements it is involved with. Any injury requires a certain amount of time for treatment and healing, but once this is complete don't assume that you or your client can start full training and competition immediately. If you are too hasty, you are more than likely to suffer a recurrence.
To bridge the gap between the treatment bench and full competition, without risking another setback, you have to go through a planned and progressive rehabilitation training programme. The aims of this programme are:
(1) to strengthen the muscles involved in the injury to be just as strong as the unaffected side
(2) to regain full proprioception (joint position sense) in the injured joint
(3) to regain power and coordination of all sports-specific movements.
In terms of progression, the programme must start with low-intensity and low-volume work, gradually increasing so that you build up to the full intensity and volume required for full competition performance. This is quite difficult to do, since the training must be tough enough to have an effect but not too tough so that the injury is aggravated. In addition, it is often difficult to remember that while the muscles respond quickly to strength loads, the tendons and ligaments take much longer to gain in strength. This is why athletes must sometimes stick with training loads that feel easy so that the joint will be significantly tested.
In this article I will suggest a planned progressive rehabilitation programme for a knee joint injury. I will assume that a successful healing period has already been completed, that most, if not all, mobility has been regained and that some basic strength work has been performed. This is the time that you may be tempted to go for it, but resist the temptation. Follow this programme instead and you'll find the results bear me out.
Phase 1 (4-6 weeks)
In the first phase of rehab training, you must concentrate on functional strength exercises, balance training and regaining aerobic fitness.
The knee strength exercises at this stage must be closed kinetic chain movements. A CKC exercise involves ankle, knee and hip joints, where all the muscles round the knee and involved in knee stabilisation are recruited, thereby ensuring the exercises are fully functional. It is generally agreed that much less benefit is gained from performing isolated quadriceps exercises since it is important that a hamstring and quadriceps co-contraction occurs during an exercise, so that the correct neuromuscular patterns are trained. For this reason, the squat exercise is chosen as the key knee strength exercise because it seems to be one of the best knee exercises for hamstring/quadriceps co-contraction. In addition, the hamstrings are a priority for strength development because they play a crucial role in knee stabilisation, and the hip muscles must also be trained.
Strength training: 2-3 times a week with rest days between
Barbell squat. 2-3 x 8-10
The technique for this lift is: feet shoulder width apart, barbell across back of the shoulders. Lower down until knee angle is at 90 degrees. Keeping knees behind the toes. Start with a very light weight just to re-train the movement. Get someone to make sure that you weight each leg evenly. As the knee gets stronger, gradually increase the weight each week.
Terminal CKC knee extensions. 3 x 10
Take a strong piece of flexaband, make a loop and attach it around a table leg. Place the other side of the loop behind your injured knee (you may need some padding). Start with your support leg straight and your working leg slightly bent and up on the toe. Then pull back on the band, straightening your knee and flattening your heel down. You should feel the effort concentrated in the quads. Make sure your body is completely still. Re-flex your knee and ankle and continue.
Quarter one-legged squats. 3 x 10
This exercise is performed without any extra weight. Stand on one leg and bend the knee into a shallow squat position. Straighten up slowly and continue. This exercise is as much for balance as it is for strength. Keep the hips level and the knee behind the toes as you squat down. Use your stomach and glutes to ensure you maintain stability and balance. You may find the injured side is less coordinated at first; the aim is to ensure that both sides are performed evenly.
Leg curls. 3 x 10
The standard hamstring isolation exercise, but perform each leg at a time to make sure the injured side catches up.
Bum lifts. 3 x 10
Lie on the floor on your back, with your knees bent. Lift up your bum until there is a straight line from knee to shoulders; pause slightly and then lower down slowly. Surprisingly, this exercise works the hamstrings and gluteals quite hard. As you get stronger, bend the knees less and less until you can perform the movement with straight legs upon a small step. This is a functional hamstring exercise as it involves trunk extension.
Hip adduction, extension, adduction. 3 x 10
Use the total hip machine to ensure all the hip muscles get a good workout.
Include the usual exercises for stomach, obliques and low back to ensure good core stability and strength. Remember, all links in the kinetic chain are important for injury rehabilitation.
Aerobic training: 3-5 times a week
At this stage you probably haven't been able to complete much aerobic training and so may have lost fitness. Now that your knee is pain-free and mobile, you can use the stationary exercise bike with confidence. This would be my main choice for maintaining aerobic fitness. You may also consider running in the pool with a weighted belt. Research into the fitness benefits of pool running for injured athletes has shown that VO2max can be maintained throughout an injury period with pool workouts, and practical experience suggests that the legs definitely get a good workout in the pool!
Balance and coordination training: every day
At this point, it is vital to include some balance and coordination training in your programme. This component is often the one that gets ignored, with a very detrimental effect in the long run.
I would recommend spending a few minutes 2-3 times a day on a wobble board. You should learn to balance both two-legged and one-legged. Once you get good at the wobble board, you should be able to perfect exercises such as catching and throwing a ball while maintaining balance and mini-squats while maintaining balance.
Phase 2 (3 weeks)
Use the following guidelines to help assess when you are ready to move into phase 2 training. (i) Even strength between injured and uninjured sides in the hamstrings on the leg curl machine. (ii) Correct technique and balance during both the barbell and one-legged squats, combined with some strength improvement. (iii) A good level of skill on the wobble board.
In this phase you will continue regaining strength as above, but now you can start running again and developing the coordination of sports-specific movements such as jumping, landing and cutting, starting with low-impact exercises.
Continue with the phase 1 routine, increasing weight gradually with each exercise. With the one-legged squats, the range of movement can be increased with a deeper knee bend but only if the correct balance and technique can be maintained.
Continue using the bike and the pool as before. However, now you can try jogging. Start with five minutes only. Take a day's rest and then try a seven-minute jog. If there is no adverse reaction, continue building up the distance jogged every other day until you can jog for 21 minutes. If there is a bad reaction, then drop down the time. Once 21 minutes has been established, continue at this distance but gradually increase the speed up to normal training speed.
Balance and coordination training
You need to retrain the neuromuscular coordination of the dynamic movements involved in sports, beginning with low-impact movements. The following is a sample programme.
Mini hops. 3 x 10 each leg building up to 3 x 50 each leg
These can be performed on the ground or on a trampette. Starting with just a little lift, hop on one leg on the spot. Make sure you flex the knee on landing and contact the ground with the ball of the foot. Use your abs and glutes to ensure good stability and posture.
Lateral double hops. 3 x 8 building up to 3 x 20
With both feet hop from side to side. Use a line or a small object such as a tennis ball to hop over. Again, make sure you flex the knee, contact the ground with the ball of the foot and maintain good posture and stability. As you improve, gradually build up the height of each hop. This drill begins to train the lateral side movement involved in most sports.
Landing drill. 2 x 8
Stand on a 6' step. Drop off it and land on the balls of your feet, flexing your knees to absorb the impact. Step back on the step and continue. The aim of this exercise is to train the coordination of landing. You should be able to land accurately, maintain an upright upper-body stability and quickly absorb the impact with your knees. A good landing should finish with you stock still with knees slightly bent and body upright. With time, gradually increase the step height.
Mini-squat jumps. 3 x 8
Stand with feet shoulder width apart, squat down to the quarter position and then rapidly jump up, land correctly, squat down and jump again. Aim to perform eight squat jumps with good landings, smoothly linked together.
Set up a little slalom course with 4-6 cones. Perform the slalom run at jogging pace 5-6 times with a brief rest period in between. In time, gradually increase the speed of the run but no faster than three-quarter speed at this point.
Phase 3 (2 weeks)
This phase should finally bring you back to full fitness. All the elements in the training programme should come together so that you can complete a full training routine. You should be able to perform the barbell squat with correct technique at a full training weight. You should show complete equality between sides on exercises such as the leg curl, one-legged squats and mini-hops. You should be well coordinated on the wobble board and at the landing, lateral hopping and jumping exercises. You should be able to run for at least 20 minutes pain-free, and have regained full aerobic fitness with the bike and pool workouts. These final two weeks of rehabilitation training should include a gradual re-introduction of all the normal training methods and match play practice.
Lateral double hops
Strength, coordination and aerobic training
Continue with the above schedules half a week for each as a maintenance training stimulus to ensure the knee remains strong and coordinated and that you are fully fit.
Plyometric, sprints and agility training
Having developed basic coordination with the low-impact drills of phase 2, you must now re-introduce the normal plyometric drills. For example, full-squat jumps, bounds, lateral bounds, and hurdle hops. In the first workout, you should perform just one set of each exercise. After a few days rest, try two sets of each and then three. The plyometric exercises
are very important as they develop the eccentric strength of the hamstrings and quadriceps and teach these muscles to contract fast and control the knee joint on impact (but see Nick Grantham's cautionary article about plyometrics in this issue). The co-contraction of the hamstrings and the quads that occurs during plyometric drills is a very beneficial training factor. Remember that when re-introducing plyometric drills it is the quality of technique that is paramount - the speed or distance can be achieved later.
In addition to plyometric training, you must start to re-introduce sprinting at full speed. For the first sprints workout, I recommend performing only six 30-metre runs with a rolling start at three-quarter speed. After a few rest days, try six 30m runs with a rolling start at full speed. If that is okay, progress to six 60m runs with a rolling start and then finally to 60m efforts from a standing start.
Agility drills should also be included at this stage. Lateral runs, shuffles, slaloms, cutting and side-stepping must all be performed. Again, start at jogging speed only and then progress gradually to full-out efforts.
You must also start to model the competition situation. If you're a games player, eg, tennis/rugby, you should begin with a small period of a non-contact game. If you're a track and field athlete, begin with a few throws or jumps or some below-distance race pace efforts. Again, gradually build things up in terms of time and intensity.
Although waiting this long after an injury before starting to play again may seem excessively cautious, it should also instill confidence from the fact that you should suffer no setbacks. By this stage in the rehab process, you should be fully strong and agile with a good level of aerobic fitness, and be feeling that you are not too far from being able to play again. Your patience will pay off, since having done all the correct rehab training you will have ensured that the injury is fully healed and won't recur. Over the whole rehab period, you will need psychological help from your physiotherapist, fitness trainer and coach. Goal-setting at each phase of the rehab process is a good idea so you are clear about what you need to achieve and why you are doing all this training instead of just getting out there and playing.