GSP and the doctors who helped him, reflect on the ACL injury that almost ended his MMA career in 2012, and how he came back stronger than ever.

Around 10 weeks before Georges St-Pierre was due to defend his title, at UFC 154 in November 2012, the reigning UFC welterweight champ wasn’t sure he could, or even would again. For the best part of a year, he had been recovering from an anterior cruciate ligament tear in his right knee (incurred training for a bout against former Strikeforce 170lb king Nick Diaz) and the sometimes career-threatening surgery that resulted. 

Was it strong enough for competition? The fight had been penciled in for months, but as Georges’ head trainer and confidant, Firas Zahabi, recalls, whether the 23-2 French-Canadian would compete in front of his Quebec fans hinged on one single training session.

“During training camp, we have a meal every day after the first practice,” says Zahabi, who has known Georges for near enough 10 years. “We sit, we talk every day. Talk about training, where we’re at. We still weren’t sure if he was going to accept the fight or not, and there was one practice where we said, ‘OK, today is do or die. If the practice goes well, you call the UFC and tell them you’re doing it. If it doesn’t go well, tell them you’re not doing it.’” 

With the weight of expectation of the UFC and its fans resting on this handful of hours in the famed Tristar gym in Montreal, Zahabi and St-Pierre patiently assessed. And? “The practice went extremely well.” As did the fight. 

A third-round knockdown aside, over five rounds St-Pierre dictated the action and punished his opponent – dangerous interim title holder Condit – both on the ground and feet. All despite concerns from many that his afflicted knee may fail to prop up the same St-Pierre that last left the Octagon way back in April 2011. 

What is an ACL?

ACL is short for anterior cruciate ligament, and it’s what’s knocked GSP and fighters like Dominick Cruz and ‘King Mo’ Lawal off the mats and into the operating room. In basic terms, it connects through your knee joint to your thigh and shin bones and prevents hyperextension. GSP tore his, which is common in athletes, and had to have part of another knee tendon removed to replace it.

Dr Neal S. ElAttrache, the California surgeon who replaced St-Pierre’s ACL with a portion of his patellar tendon, said he never would have allowed Georges to compete had he not been entirely satisfied with the joint’s recuperation. 

“I was very pleased with everything I saw,” says Dr ElAttrache, of GSP’s physical state in Montreal. “You really couldn’t tell any difference at all, as a spectator, looking at him: the way he fought, the way he moved, when he was on the ground, when he was standing. He looked very natural and very strong. To me, he looked as strong as ever.” 

And Coach Zahabi agrees: “The structure of the knee is sound. It was tested; it was strong. The question was Georges’ coordination, Georges’ comfort, Georges’ trust in the knee. I had no worries the knee would heal as normal. It was really the pilot I was worried about. The pilot inside Georges’ head.”

If there was something other than the physical that could fail Georges prior to UFC 154, it was the mental. A cerebral competitor who thinks perhaps even better than he fights – evidenced by his ever-flawless preparation for nine sequential title bouts – Georges revealed to Fighters Only earlier in 2012 he sees himself as a fight strategy geek of sorts. 

“I am obsessed by martial arts and I am always thinking, practicing, reading, visualizing, dreaming about it,” Georges said. “(My managers) see me as a researcher in his basement working on a particular project (for) days and nights.” So often his ally, there was a chance Georges’ propensity to overthink could lead to a lack of confidence in his knee, and therefore a stunted performance. So too could his time away from the mental rigors of an MMA gym – by fight night he had been away from the Octagon for over 18 months. 

“He was very euphoric about coming back to training,” reveals Zahabi. “But of course, once he started doing the live training he hadn’t sparred in a long, long time – over a year. He was in supreme physical condition but he was getting tired early on. And it’s normal because you’re not efficient, you’re not relaxed, your muscles are tight, you’re nervous, you’re thinking about too many things, you’re not just letting things happen. 

“It takes time to regain that experience… He’s been competing since he was six or seven years old so I wasn’t surprised that it came back out. But there was a shaky time there where I had to talk to him, stay in his ear, and make sure he believed that those instincts are still down there, deep down inside. You’ve just got to pull them to the surface.”

ACL recovery

It’s a testament to the results of Georges’ physical rehab that the majority of his team’s concerns weren’t centered on the joint’s welfare when the opening bell rang for his UFC 154 main event. That’s thanks to the Kerlan-Jobe Orthopaedic Clinic’s Dr. ElAttrache, who also repaired the knee of superstar New England Patriots quarterback Tom Brady. 

And to the team at GSP’s rehab HQ, Sports Science Lab in Orange County, California. Gavin MacMillan and his crew worked Georges through a unique program designed to rebuild the capabilities of Georges’ knee in a way that was complementary to his physical makeup. “I had the best rehab people, the best surgeon,” Georges told reporters recently.

Dr. ElAttrache, who operated on Georges in California in December 2011, explains the theory behind good ACL recovery. “Many people go their entire life as great athletes and they use their quadriceps and hamstrings solely to power their knee – they don’t have the natural mechanics provided by the gluteal muscles to protect their knee.” says Dr. ElAttrache, adding he encourages ACL patients to work safely on regaining their full, safe range of motion as soon as possible after the procedure. 

“We work on detecting if that is a biomechanical pattern in those types of people, and if it is then we really concentrate a lot of that right after the first few months of recovery. And that determines, in large part, their ability to get back to competition quickly.

“One of the things I do with those kinds of athletes whenever they’re going to go back to an ACL-dependent sport that requires jumping, pivoting, twisting, is we put them through some very high-tech testing, with high-speed cameras and force plates on the floor, to see how they land. Are the forces of the knee protected and dissipated by the function of the gluteal muscles? Then we train them to do that. So they can see the way they look on camera, they’re taught the proper exercises to train the pelvic stabilizers and the glutes so that it matches and balances the power of the quadriceps. And this is rather new technology, but it’s been shown you can decrease the incidence of ACL injury, or recurring ACL injuries, if you can balance those forces.”

At Sports Science Lab, where he spent about six months around early 2012 rehabbing, Georges was asked to put his knee through unique exercises that challenged the joint’s limitations. Anything from simple hydrotherapy, to using his feet to push a Super Cat vertical jump machine, which would usually only contact your shoulders.

“Anybody that knows Georges would tell you that he’s got a lot of energy,” MacMillan recently told UFC Insider. “So corralling that is definitely an issue… Somebody like Georges, you actually have to stop him from doing things. He’s constantly pushing the envelope, he constantly wants to push what his body can do, what his leg can do. 

“He had to be monitored all the time to make sure he doesn’t do anything he’s not supposed to do. So that’s why there’s constant communication between his surgeon, me, the other people that have been involved in his therapy process as we restore the strength in his leg.”

During training camp at Georges’ day-to-day haunt of Tristar, back home in Montreal, a dynamic approach is also present at warm-ups. Zahabi tells THFE although he tends to leave the pro fighters like St-Pierre to warm themselves up, they never do typical static stretching at the beginning of a session. He reveals: “He’ll do activation. He’ll do a dynamic type of stretching. Not static stretching, old-school, where you sit down and stretch out your legs methodically, it’s mobility drills to keep that range of functions… 

“Cool-down will be static stretching. That’s the time for static stretching because what you’re doing is you’re activating your parasympathetic nervous system (which stimulates a ‘rest and digest’ state), you’re slowing the system down. You don’t want to do that right before you spar.”

All this new thinking has produced a new Georges St-Pierre. The most dominant welterweight champion in history now uses more recovery time between practices. And, says Zahabi, isn’t “burning the candle at both ends so much anymore.” And for Georges, who famously errs on the side of no weight training, there are more strength and conditioning changes. 

“A lot less strength training, [and] a lot less weight,” says head trainer Zahabi. “So more body-weight exercises, gymnastics exercises, where you use your own body weight – which is safer in my opinion. There’s still a danger factor but it’s a lot less.”

And going forward, the danger will likely be constantly present in GSP’s mind. But, just like Georges, the average Joe athlete can help prevent ACL tears through proper strength training, says Dr. ElAttrache.

“The best thing you can do is a well-coordinated, well-balanced training program that incorporates core strength – that’s very important,” states Dr. ElAttrache. “Core strength and pelvic stability, with gluteal function, abdominals, obliques, that gives you the foundation for strengthening them, the peripheral muscles like the quadriceps, the hamstrings, etcetera. 

“And so a training program that incorporates agility, proper biomechanics with somebody that is adept and trained at noticing a person’s good or bad biomechanics, is very important. Rather than just going into the gym and doing as many squats, or as heavy a squat as you can, or as heavy a hamstring curl as you can. It has to be a well-coordinated, well-balanced training program between the core and the muscles of the lower leg.”

Looking back at his hard therapy regime, Georges said he found his energy by glancing back into the Octagon. “It was tough also on my ego,” he acknowledged. “There is young guys pushing me every day, trying to take my place. That’s how I kept my motivation.”

It must have been some motivation, because the GSP the world watched return to the Octagon back in November could have been the best Georges St-Pierre anyone has ever seen. And that’s something considering he was at the top of the pound-for-pound conversation when he beat Jake Shields in front of 55,000 in Toronto in April 2011. 

It seems that even when faced with career-troubling operations, those who want it badly enough can bounce back. But, just like the multi-faceted approach required by mixed martial arts, effective rehabilitation also demands mastery of multiple platforms: the mental, and the physical.

“I always have doubts, I’m always scared,” Georges added, at a media Q&A prior to UFC 154, discussing whether he was concerned he wouldn’t get back to being the best in the world. “But you know what, my confidence comes from how I prepare myself, and I couldn’t do anything more than what I did. I’m the most well-prepared I could be, that’s why I am so confident. I left nothing, I gave it all, I didn’t cut corners. I did everything possible I could have done to be the best I could be.”

Postscript: GSP would make it back into the octagon for another four fights, all victories. He announced his retirement in 2019, departing the octagon with a mighty 26-2 record, those two losses - to Matt Hughes and Matt Serra respectively - both avenged, indeed he won his last 13 fights. He is considered by many to be the best fighter in the history of MMA.