Addressing Quad Inhibition in ACL Rehab

Hi guys, I’m Mai-Linh Dovan, Certified Athletic Therapist and Founder of Rehab-U Movement and Performance Therapy. 

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In this week’s video, we’re going to talk about quad inhibition in ACL rehab. 

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Now we know that the quad is an important focus in ACL rehab: quad inhibition, quad strength. These are important focuses of ACL rehab. Now one thing that we often forget, is that quad inhibition can persist for a lot longer than we think.   Early on in the rehab process, we’re very good at doing some isolated quad activation exercises and then later on some isolated quad strength. But then we forget to continue to bring that focus to the quads through later phases of the rehab process. 

What we’re going to do in this video is we’re going to show you how to make your quad inhibition or I should say quad activation exercises, a little bit more challenging, yes, but also a little bit more functional as you progress an athlete in the further stages of ACL rehab. Before I show you these exercises, let me introduce Virginie. So Virginie is a soccer player and she’s actually had three ACL tears. So you can imagine that for her, quad activation has been a very important aspect of her rehab and we’ll see where maybe there were some gaps in her rehab.

Understand that for an athlete, a soccer player, like Virginie, who played at a high level, an ACL injury can be career-ending, so it’s a pretty traumatic and dramatic experience. So let’s see where we can optimize some of the things in her rehab. 

Very early on in the rehab process quad sets are usually the “go to” exercise to reactivate the quads. Now I’m talking about really early on where you know she would actually even have trouble pushing the back of the knee into the rolled-up towel.  As athletes move further along we start to do short arc knee extensions. Right? Where we can have a bigger towel, we can have a little bit more range and we’re doing short arc knee extensions. So those are the pretty classic early quad activation exercises then we typically move on to TKEs, or terminal knee extensions, where we have a band at the knee. 

So this is a good progression because now Virginie is weight-bearing. So closed kinetic chain and she’s going to integrate that terminal knee extension. So she’s extended on the one and she lets that other knee flex, and then comes back and extends against the band. So, this is obviously more functional than what we saw on the bench with the quad sets. So an interesting progression and what would you say, you remember doing these quite a bit, right? So Virginie remembers doing these two quite vividly, but there are ways where we can progress. 

Because remember, quad inhibition persists a little bit longer than we think. So what we want to do from there instead of having now a very internal focus on, I’m extending against that band, I’m hands on my hips, I’m very focused on my quad. Can we start to bring the focus a little bit external for one and can we start to make it even more functional? 

For example, athletes are going to need that terminal extension to get tall. For a soccer player like Virginie, she’s gonna have to jump to head a ball. She’s going to need to get tall and that’s where that terminal extension is going to come into play. And if she’s only focused on extending over here, she may not make that transition or the quad may not make that transition to contribute to that movement. 

So we can have her do an overhead push with the ball where her idea is to get nice and tall so she’s reaching as high as she can with that ball and we leave the elastic band there and then later on maybe we even remove it so we make sure she doesn’t have that feedback from the elastic band, but she’s still getting tall and she’s do still doing that terminal extension. Okay, so now we’re bringing a task into play, continuing to progress, and continuing to focus on quad inhibition. But we have a bit more of a quote-unquote “sport-specific task”. 

Then we can increase the intensity of these exercises. So we can do a retro step back. Now as opposed to standing flat-footed, we’re going to start to incorporate the foot in there where she’s rolling off the toes. So rolling from the toes up onto the heel and then off towards the toes and decelerating towards the front again with the resistance of the band, right? So we’re still really targeting that quad but we’re making that movement a little bit more like a backpedal, something that’s a little bit more specific to what she might have to do on the field.

Then we can progress to a forefoot deceleration. So now she’s standing on that forefoot and she’s decelerating into the band and then extending.  So having that weight on that forefoot and decelerating with the band pulling and then pushing against the band. So again, it’s kind of a TKE exercise, kind of a terminal knee extension but we’re incorporating that into something that’s more functional and sport-specific. 

So these are all ways in which you can take your very basic rehab elements, quad sets, terminal knee extension, make them more externally focused for one, so there’s an outcome like getting tall  or standing tall, and then make it more intense as far as how it it solicits the quad, and then make it more specific to how athletes are going to move on the field of play. 

Because remember that quad inhibition can persist for a long time. For Virginie, she remembers doing quad exercises early on, the first couple that we showed, you the classic ones. But the gap in her rehab is more when she started to do or where she didn’t start to do more functional exercises with a quad focus.  We need to target quad inhibition because so long as the quad is inhibited, it’s not going to be able to contribute to functional movement, and if we try to do functional movement, we will likely create compensation. But once we’ve reactivated that quad, we need to kind of have that progression in order to get the athlete to where we want it to be. If we limit ourselves to isolated quad inhibition exercises that are not very functional and then we try to do functional exercises like walking lunges, step-ups and things like that, we may not have as good of a transfer of that quad inhibition will persist. So, hopefully that gives you guys some ideas on how to better integrate quad activation quad focused exercises in your activation sequences in your rehab. 

Obviously, there are strengthening exercises that you would integrate in there as well, but make sure that you keep on that quad inhibition for probably a lot longer than you think.

Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U