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40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com, WHAT OTHER KNEE STRUCTURES CAN BE INJURED WHEN THE ACL TEARS. The meniscus is a crescent shaped cartilage that acts as a shock absorber. between the femur and tibia Each knee has two menisci medial inner. and lateral outer The menisci are attached to the tibia When the tibia. suddenly moves forward and the ACL tears the meniscus can become. compressed between the femur and tibia resulting in a tear The. abnormal motion of the joint can also bruise the bones. There is a second type of cartilage in the knee joint called articular cartilage. This is a smooth white glistening surface that covers the ends of the bones. The articular cartilage provides lubrication and as a result there is very. little friction when the joint moves This joint cartilage can get damaged. when the ACL tears and the joint is compressed in an abnormal way. If this articular cartilage is injured the joint no longer moves smoothly. Stiffness pain swelling and grinding can occur Eventually arthritis can. The MCL and other ligaments in the joint can also be disrupted when the ACL tears This is more. common if an external blow to the knee causes the injury such as if the knee was clipped while. playing football or when skiing,WHAT IS THE INITIAL TREATMENT FOR A TORN ACL. The initial treatment of the injured joint is to apply ice and gentle compression to control. swelling A knee brace and crutches are used The knee should be evaluated by a doctor to see. which ligaments are torn and to be sure other structures such as tendons arteries nerves etc. have not been injured X rays are taken to rule out a fracture Sometimes an MRI is needed but. usually the diagnosis can be made by physical examination. HOW WILL THE KNEE FUNCTION IF THE ACL IS TORN, If no structure other than the ACL is injured the knee usually regains it range of motion and is. painless after six or eight weeks The knee will often feel normal However it can be a trick. knee If a knee does not have an ACL it can give way or be unstable when the person pivots or. changes direction The athlete can usually run straight ahead without a problem but when he or. she makes a quick turning motion the knee tends to give way and collapse This abnormal motion. can damage the menisci or articular cartilage and cause further knee problems. If a person does not do sports and is relatively inactive the knee can feel quite normal even if the. ACL is torn In young athletic patients however the knee will tend to reinjure frequently and. 40 Allied Drive,Dedham MA 02026,781 251 3535 office.
www bostonsportsmedicine com, give way during activities in which the person quickly changes direction Therefore it is usually. recommended to reconstruct the torn ACL,WHEN SHOULD SURGERY BE PERFORMED FOR A TORN ACL. It is best to wait for the pain and swelling to subside and to allow associated injuries to heal. before performing reconstructive surgery for the ACL If surgery is done too soon after injury. rehabilitation is more difficult In fact the knee may get stiff and have permanent loss of motion. The athlete will usually get back to sports much more quickly if the knee is allowed to recover. from the initial injury and to regain its full painless range of motion usually about six weeks. before performing surgery, In addition regaining full motion prior to surgery allows an accelerated rehabilitation program to. be used after surgery With accelerated rehabilitation continuous passive range of motion CPM. is used for the first 2 weeks following surgery The knee heals feels better more quickly resulting. in better initial joint function, The best treatment following acute ACL injury is usually to protect the joint apply ice and use. crutches for several weeks As the swelling and pain subside and the patient can put weight on. the leg then the brace and crutches can be discontinued The emphasis is on regaining knee. motion Resistive exercises to build up strength should not be done during this time to prevent. damaging the knee cap and causing chondromalacia patella. If the knee also has an injured medial collateral ligament MCL it is best to allow the MCL to. heal completely usually six to eight weeks before reconstructing the ACL The torn MCL. usually does not need to be repaired surgically unless its healing is incomplete. There may be instances when immediate surgery is indicated following injury Examples are knee. dislocations in which multiple ligaments are torn Tears of the outer knee ligaments lateral. collateral ligament often require timely surgical repair Individual decisions need to be made on. whether or not to reconstruct the ACL soon after injury in such instances where immediate. surgery may be required,DO ALL ACL TEARS NEED SURGERY.
No some knees function reasonably well despite having a torn ACL Good knee. function without surgery is more common in older patients who are relatively inactive in. sports Patients who are younger regardless of activity level tend to have problems with. instability and frequent episodes of giving way Therefore surgical reconstruction of a. torn ACL is usually recommended for these patients. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com,TREATMENT OPTIONS FOR A TORN ACL. I NON OPERATIVE, Some patients can function well even if the ACL is torn However it may be necessary to modify. activities and avoid high risk sports such as basketball soccer and football The key to prevent. the knee that has a torn ACL from giving out is to avoid quick pivoting motions Wearing a knee. brace can help to prevent re injury The main effect of a knee brace is to be a constant reminder to. be careful, However a brace will not completely stabilize a knee that has a torn ACL Exercises that restore. the muscle strength power coordination and endurance will also improve knee function and help. stabilize the knee However a fully rehabilitated knee that has a torn ACL can still give way if a. quick change in direction occurs,II LIMITED ARTHROSCOPIC SURGERY.
Many knees in which the ACL is torn have additional injuries such as torn menisci or fragments. of articular cartilage that are displaced creating a loose body and a defect in the articular. cartilage These associated injuries can cause symptoms of pain swelling and locking in. addition to symptoms of giving way due to the torn ACL Arthroscopic surgery to remove torn. menissci or to remove loose bodies can improve pain and eliminate locking However. arthroscopy alone usually does not eliminate symptoms of instability i e giving way. III ACL RECONSTRUCTION, Surgical reconstruction of a torn ACL involves replacing the torn. ACL with soft tissue called a graft usually a tendon or ligament. from another part of the knee The graft is then placed into a position to. replace the function of the torn ACL The most commonly used graft is. taken from the middle third of the patellar tendon the tendon connecting. the knee cap to the tibial bone Hamstring tendon grafts taken from the. inner thigh on the back of the knee are also used Occasionally tendon. grafts are taken from cadavers referred to as allograft. For most of these procedures the operation is done arthroscopically instead of. making long incisions The knee is examined arthroscopically and associated injuries such. as torn menisci loose bodies etc are treated If the middle third of the patellar. tendon is used a small incision is made on the inner side of the leg just below. the knee to take the graft this results in numbness on the front of the knee. While viewing the inside of the joint through the arthroscope guides are used. to create bone tunnels in the exact positions to allow anatomic placement of the. graft The graft is then pulled into the bony tunnels Absorbable screws are. placed in the tunnels to wedge the bone graft against the wall of the tunnel to. give immediate stability and allow healing of the bone graft. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com, Postoperatively an accelerated rehabilitation program allows the. most rapid return of function This necessitates using a continuous. passive motion CPM machine for at least 10 hours per day for the. first week following surgery The patient can get up whenever. he or she wishes for short periods of time using crutches and a knee. The CPM is typically arranged by Dr Gill s office It is a small device that sits on the bed and. very slowly moves the knee continuously The knee actually has less pain and regains its function. much more quickly if CPM is used If the knee is taken out of the CPM for periods of time it. becomes stiff and more painful Therefore it is best to devote the first week following surgery to. continuous use of the CPM at home Two weeks after surgery the sutures are removed and the. patient can walk bearing full weight on the leg Crutches are used from 1 6 weeks depending on. the type of graft that was used for the reconstruction. WHEN CAN I EXPECT TO RETURN TO SPORTS FOLLOWING SURGERY. Within two weeks after surgery most patients are walking on level surfaces without a limp. Typically a stationary bike can be used on post operative day one Most patients can be in a. swimming pool after their sutures are removed at 2 weeks When the knee has full range of. motion usually at six to eight weeks muscle strengthening exercises are done At four months. jogging is permitted in a sports brace Full sports competition is allowed once strength has. returned usually between 6 8 months Full recovery takes approximately one year. WHEN CAN I EXPECT TO RETURN TO ACTIVITIES AFTER SURGERY. Most people can get back to desk work or sedentary activity one or two weeks after surgery If. the right knee has been reconstructed it may be several weeks before the knee is strong enough to. drive safely For heavy work it may take 3 6 months before the patient is medically cleared to. return with no restrictions,WORK RETURN,Sedentary Desk 1 to 2 weeks. General Office 2 to 3 weeks,Light 6 to 8 weeks,Medium 3 months.
Heavy 4 to 5 months,SPORTS RETURN,Normal walking stairs 1 to 2 months. Light individual sports 3 to 4 months,Running 4 months. Contact high performance 6 to 8 months,40 Allied Drive. Dedham MA 02026,781 251 3535 office,www bostonsportsmedicine com. WHAT ARE THE RISKS AND BENEFITS OF ACL TREATMENT,NON OPERATIVE.
Repetitive injuries or giving way may cause further permanent joint damage. Inability to participate in sports that require pivoting. Avoidance of potential surgical complications, Permanent numbness in the front of the knee near the incision 100. Other nerve injury 0 5,Patello femoral pain kneecap 5. Flexion contracture stiffness reduced motion of the knee 10. Reinjury knee becomes unstable again 5 10,Swelling 10. Superficial infection 1,Deep infection 0 5,Deep vein thrombosis blood clots 0 5. Delay in regaining motion 5,Vascular damage to blood vessels 0 01.
Return to work and sports with a stable knee,Potentially prevent further injury to the knee. Remain physically active,40 Allied Drive,Dedham MA 02026. 781 251 3535 office,www bostonsportsmedicine com,ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY. Here are guidelines that will help you to prepare for ACL reconstruction surgery. PREOPERATIVE INSTRUCTIONS,BEFORE SURGERY, Dr Gill will see you in the office He will do a preoperative history and physical examination. and complete the necessary paperwork He will write preoperative hospital orders and schedule. an appointment with the pre operative test center if needed You will have an opportunity to. speak with anesthesia and physical therapy It is recommended that you utilize a stationary cycle. to maintain your knee range of motion and improve the overall function of the knee prior to. SEVERAL DAYS PRIOR TO SURGERY, Wash the knee with soap or Hibiclens several times per day to get the skin as clean as you can.
This decreases the risk of infection Be careful not to get any scratches cuts sunburn poison. ivy etc The skin has to be in very good shape to prevent problems You do not need to shave. THE DAY BEFORE SURGERY, Please be in touch with Dr Gill s office to confirm the exact time that you should report to the. hospital for surgery You can have nothing to eat or drink after midnight on the day before. surgery It is very important to have a completely empty stomach prior to surgery for anesthesia. safety reasons This included no chewing gum or drinking coffee If you have to take medication. you can do so with a sip of water early in the morning prior to surgery but later tell the. anesthesiologist you have done so,DAY OF SURGERY, Please bring any crutches brace ice machine or imaging studies that you have received. The operation to replace the torn anterior cruciate ligament will be done arthroscopically A. small incision will be made on the inner side of the knee to take the graft from the middle of the. patellar tendon together with a small piece of bone from the bottom of the kneecap and the upper. part of the tibia mid third patellar tendon graft bone tendon bone The incision leaves a. small area of numbness on the outer side of the upper leg Most of this numbness clears but it. takes a year or two and is not usually bothersome In certain circumstances the graft is a. hamstring tendon or a donor graft from a cadaver allograft. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com,AFTER SURGERY, Prior to surgery a continuous passive motion CPM machine will be delivered to your home. This is a small apparatus that sits on the bed and onto which your knee rests The CPM very. slowly bends and straightens out the knee Once you get used to the machine your knee pain and. swelling will be much less If you do not use a CPM and the knee is put into a splint it often gets. stiff and is more painful Your initial recovery may be delayed although the end result would. likely be about the same, You will be able to adjust the CPM with a hand controlled unit The most important part of.
using the CPM in your postoperative rehabilitation is to get the knee out straight extension. The machine is set to pause for five seconds in extension to allow you to stretch the knee fully. How much flexion bending you gain initially is less important how quickly the machine moves. also is not as important For the first several days just allow the machine to bend the knee as. much as is comfortable and gradually work on gaining more flexion as the week progresses. Set the initial CPM setting from 5 degrees of hyperextension to 40 degrees of flexion. After 48 hours try to have your knee and the CPM bending to at least 90 degrees of. The most important aspect is to get the knee out completely straight. You will be able to adjust the speed at night have the machine move as slowly as. possible and you will be able to sleep better, During the day you can speed up the machine and also gain more flexion. You will be given a prescription for pain medication to take home with you In addition to this. medication you should take one aspirin per day to help prevent blood clots phlebitis for 10. days The pain medication has a tendency to make you constipated. The dressing should be changed the day following surgery and can be removed at two days The. wound is sealed with steri strips small pieces of tape on the skin You can shower on the. second day following surgery but be careful standing in the shower so that you do not fall It is. better to have a small stool to be able to sit on However you can get the leg wet and wash it. Do not submerge the knee under water in a bath hot tub or swimming pool. To help control swelling in the lower leg you should wear the white stockings. after surgery until your first post operative visit If you develop calf pain or. excessive swelling in the leg call Dr Gill s office. The cryocuff is a blue wrap that is put on the knee to keep it cold. You can use this as often as you want to cool down the knee to reduce. swelling and pain Check your skin every time that you remove the wrap. to make sure that it is intact Be sure to stock up on extra ice in your freezer. For two weeks following surgery it is best to be in the CPM at least 10 hours per day You. can get up as needed It is best to get up more frequently for short periods of time If you are out. of the CPM for a long period of time the knee tends to become more stiff and painful This is not. really a problem but it takes a while to get the knee loosened up again and moving in the CPM. Thus getting up more frequently for short periods of time is better than being out for a long. period of time,40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com,ACL Reconstruction Rehabilitation Guidelines. PHASE 1 0 2 weeks after surgery, This handout is to use as a guideline for your rehabilitation after anterior cruciate. reconstruction You may vary in your ability to do these exercises and to progress from one. phase to the other Please call Dr Gill s office if you are having a problem with your knee or. if you need clarification of these instructions,1 Protect the reconstruction avoid falling.
2 Ensure wound healing,3 Attain and maintain full knee extension. 4 Gain knee flexion knee bending to 90 degrees,5 Decrease knee and leg swelling. 6 Promote quadriceps muscle strength,7 Avoid blood pooling in the leg veins. CONTINUOUS PASSIVE MOTION CPM, Use the CPM machine at home as much as possible at least 10 hours per day You may. move the CPM to a sofa the floor or onto a bed as you change positions and locations Use the. CPM at night while sleeping Slow the speed at night to facilitate sleeping Extension knee. straight on the machine should be set at minus five degrees at all times to help your knee. extend It is very important that you straighten the knee completely The CPM should be. programmed to include an extension pause of 5 seconds in other words when the knee is. straightened out it pauses to allow you to stretch it out straight The flexion setting will start. at 40 degrees and should be gradually increased to at least 90 degrees over the next 48 hours as. you can tolerate more bending of your knee When a meniscus repair is done along with the. ACL reconstruction limit knee flexion to 90 Continue to use the CPM after surgery until. your first post operative visit, Do not place a pillow under the knee for comfort This can lead to knee stiffness.
BRACE CRUTCHES, Your knee brace is set to allow your knee to bend and straighten from 0 to 90 degrees Use it. when walking In some cases you may be sent home with the brace locked at 0 degrees fully. straight After you arrive home and the anesthetic nerve block has worn off unlock the. brace to allow 0 to 90 degrees of motion, For patients with a patellar tendon autograft from your own knee put as much weight on your. operated leg as possible when walking You should use the crutches in the beginning but can. discontinue the crutches when you have confidence in the knee to support you In some cases. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com, crutches and restricted weight bearing may be necessary for longer periods Dr Gill or the. physical therapist will give special instructions in these cases. In cases where hamstring tendon autograft or an allograft is used you will be advised to put. partial weight 50 on your leg with crutches and brace for the first 6 weeks after surgery. In cases where a meniscus repair is done along with the ACL reconstruction the brace should. be locked fully straight when walking for the first 6 weeks after surgery. CRYOCUFF COLD APPLICATION, If you are experiencing pain swelling or discomfort we suggest icing for 15 20 minutes with.
at least a 60 minute break in between Use your cryocuff or place ice in a zip lock bag and or. in a towel and apply to the injured area Never place ice directly on the skin. WOUND CARE, Remove your bandage on the second morning after surgery but leave the small pieces of white. tape steri strips across the incision You can wrap an elastic bandage ace around the knee at. other times to control swelling You may now shower and get your incision wet but do not. soak the incision in a bathtub or Jacuzzi until the stitches have been removed. ASPIRIN ELASTIC STOCKINGS, Take an aspirin each morning wear an elastic stocking TED below the knee and do at least. 10 ankle pump exercises each hour to help prevent phlebitis blood clots in the veins until. your first post operative visit,FREE MACHINE WEIGHTS Upper Body Trunk Only. We suggest that you do not use any lower extremity free or machine weights If you are doing. free or machine weights for the upper body and trunk we suggest a very light resistance of 3. sets of 15 20 repetitions Do not place yourself in a compromising position with your recently. operated knee,40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com,EXERCISE PROGRAM, Perform exercises without your brace See Knee Exercises handout for illustrations.
You can view a video clip of most of the listed exercises by going to the Boston Sports. Medicine and Rehabilitation Institute website http www bostonsportsmedicine com. Days per Week 7 Times per Day 3 4,Quadriceps setting 1 2 sets of 15 20 reps. Heel prop 5 minutes, Heel slides with towel assist 1 set of 5 to 15 minutes. Sitting heel slides 1 to 2 sets of 15 to 20 reps,Straight leg raises 1 2 sets of 15 20 reps. Patellar mobilization very important 1 set for 1 to 3 minutes. Hip abduction 3 sets of 10 reps,Ankle pumps 1 set of 2 to 3 minutes. Prone hang 5 minutes,START PHYSICAL THERAPY, You can start formal physical therapy about 3 to 5 days after the operation.
We ask that your PT follow our written protocol, If your PT has questions please ask them to call us to discuss them. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com,PHASE 2 2 6 weeks after surgery. 1 Protect the reconstruction avoid falling,2 Ensure wound healing. 3 Maintain full knee extension straighten knee fully. 4 Begin quadriceps muscle strengthening,5 Attain knee flexion of 120 degrees or more.
6 Decrease knee and leg swelling,7 Normal gait without crutches. Use the cryocuff or ice bags to decrease swelling for 20 minutes three times a day after each. exercise session,BRACE CRUTCHES, In cases where the patellar tendon autograft is used you can begin placing all of your weight. on the operated leg when you walk unless otherwise instructed by Dr Gill Discontinue using. your crutches when you are comfortable doing so Continue using your brace when walking. outside of the home Within one or two weeks you can usually discontinue use of the crutches. if you have good control of the leg and are sure that you will not fall or get injured. Concentrate walking normally in a heel strike to toe off pattern without a limp Occasionally. every one or two hours practice standing on your operated leg with your knee fully straight. for 10 to 20 seconds, In cases where hamstring autograft or allograft is used you will be advised to put partial. weight 50 on your leg with crutches and brace for the first 6 weeks after surgery. In cases where a meniscus repair is done along with the ACL reconstruction the brace should. be locked fully straight when walking for the first 6 weeks after surgery. Continue using the elastic stockings TED for the lower leg and wrapping the knee with an. elastic bandage ACE to control swelling,EXERCISE PROGRAM. Stationary Bicycle,Days per week 5 7 Times per day 1 2.
Utilize a stationary bicycle to move the knee joint and increase knee flexion If you cannot. pedal all the way around then keep the foot of your operated leg on the pedal and pedal back. and forth until your knee will bend far enough to allow a full cycle Most people are able to. achieve a full cycle revolution backwards first followed by forward You may ride the cycle. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com, with no resistance for up to 10 15 minutes 1 to 2 times a day Set the seat height so that when. you are sitting on the bicycle seat your knee is fully extended with the heel resting on the. pedal in the fully bottom position You should then actually ride the bicycle with your forefoot. resting on the pedal,Water Workout optional,Days per week 3 Times per day 1. Aqua jogger exercise or Flutter kick swimming 20 30 minutes. RANGE OF MOTION AND STRENGTHENING EXERCISES brace off. Days per Week 5 7 Times per Day 1 2,Quadriceps setting 1 2 sets of 15 20 reps. Heel prop 5 minutes,Prone hang 5 minutes, Heel slides with towel assist 1 set of 5 to 15 minutes.
Straight leg raises 1 2 sets of 15 20 reps,Standing hamstring curl 3 sets of 10 reps. Standing toe raises 3 sets of 10 reps,Hip abduction 3 sets of 10 reps. 1 3 knee bends 3 sets of 15 reps,Wall slides 3 sets of 15 reps. OPTIONAL ADDITIONAL EXERCISES, If you did not have a meniscus repair you can start the Leg Press and Hamstring Curl machine during this. phase under supervision of a physical therapist if you have achieved the following goals. 1 Full passive knee extension,2 Full extension while quadriceps setting.
3 Flexion of 125 degrees,4 Minimal swelling, You can view a video clip of most of the listed exercises by going to the Boston Sports. Medicine and Rehabilitation Institute website, http www bostonsportsmedicine com protocols therapy videos html. 40 Allied Drive,Dedham MA 02026,781 251 3535 office. www bostonsportsmedicine com,PHASE 3 6 12 weeks after surgery. 1 Protect the reconstruction avoid falling,2 Maintain full knee extension.
3 Attain full knee flexion,4 Walk with a normal heel toe gait with no limp. 5 Muscle strength and conditioning improvements, The brace is discontinued after you see your surgeon at your 6 week post operative office visit. Concentrate on walking with a heel toe gait without a limp In some cases use of the brace. will continue if the knee requires a longer period of protection. CRYOCUFF ICE Continue to use the cryocuff for 20 minutes after each workout. EXERCISE PROGRAM,Range of Motion and Strengthening Exercises. Days per week 3 Times per day 1,Quadriceps setting 1 2 sets of 15 20 reps. Heel prop 5 minutes,Prone hang 5 minutes, Heel slides with towel assist 1 set of 5 to 15 minutes.
Straight leg raises 3 sets of 10 reps,Standing hamstring curl 3 sets of 10 reps. Standing toe raises single leg 3 sets of 10 reps,Hip abduction 3 sets of 10 reps. Squat to chair 3 sets 15 reps,Wall slides 3 sets of 15 reps. Single leg strengthening progression see timeline,Stretching Exercises. Days per week 5 7 Times per day 1 2, Hamstring stretch 3 5 reps holding 15 to 30 seconds.
Quadriceps stretch 3 5 reps holding 15 to 30 seconds. Calf Stretch 3 5 reps holding 15 to 30 seconds,Optional Additional Weight Training. Days per week 2 3 Times per day 1 3 sets of 20 repetitions. The following exercises may be added to your exercise program about 6 weeks after surgery. Seated Leg Press Roman Chair,Hamstring Curl Calf Raise Machine. HIP Abductor Adductor Machine Hip Flexor Machine,40 Allied Drive. Dedham MA 02026,781 251 3535 office,www bostonsportsmedicine com. Cardiovascular Conditioning, Days per week 1 2 Times per day 1 Duration 20 30 minutes.
The following can be performed for conditioning stationary bicycle walking rowing. elliptical trainer and water workout,Single Leg Strengthening Progression. At this time it is important to begin the development of single leg strength Begin to follow. the Progression for Single Leg Strengthening included in this packet. Phase 3 Exercise Program Summary, Frequency 3 times a week 3 sets of 10 15 repetitions. Leg Press Hip Flexor machine,Hamstring Curl Single leg strengthening. Wall Slides progression,Roman Chair Hamstring Calf and Quadriceps. Chair Squat stretching, Calf Raises or Calf Raise machine Quadriceps setting 20 repetitions 3.
Hip Abductor Adductor machine times a day with heel prop. If you do not have access to gym equipment the following exercises from Phase 2 can be. substituted using ankle weights Start with one pound and add one pound a week until 5. pounds Straight leg raise Side lying abduction and Standing hamstring curl. Precautions When Exercising,Avoid pain at the patellar tendon site. Avoid pain and or crepitus at the patella,Build up resistance and repetitions gradually. Perform exercises slowly avoiding quick direction change and impact loading. Exercise frequency should be 2 to 3 times a week for strength building. Be consistent and regular with the exercise schedule. Principles of Strength Training, Warm up prior to exercising by stationary cycling or other means. You are warmed up when you have started sweating,Gently stretch all muscle groups next. Do exercises involving multiple muscle groups first and individual muscle groups last. Do aerobic workouts after strength workouts,Cool down by stretching after finishing exercise.

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