Home Posts tagged "Knee Injury"

Who “Kneeds” Normal Knees?

Okay, this subject line was undoubtedly the worst of all time, but I promise that the information that follows will be worth reading. A lot of you were probably hoping that you were out of the woods after I told you how bad your lower backs and shoulders look on diagnostic imaging such as MRIs.  I'm sorry to say that these "normal" structural disasters also apply to the knees. A 2010 review from Flanigan et al. looked at studies that collectively examined the (1,862) knees of 931 athletes (40% of whom were professional athletes) using MRI and arthroscopy.  They found that 36% of these knees had full-thickness chondral defects, but 14% of these subjects had no symptoms when diagnosed.  The researchers concluded that "Over one-half of asymptomatic athletes have a full-thickness defect."


Years earlier, Cook et al. screened 134 elite junior basketball players (268 total knees) for patellar tendinopathy.  At the time, only 19 (7%) of the 268 tendons presented with symptoms (pain) of tendinopathy.  Interestingly, though, under diagnosis with ultrasound, researchers actually found that 26% of all the tendons could be labeled tendinopathy based on the degenerative changes observed.  In other words, for every one that actually presents clinically with symptoms, more than three more go undiagnosed because people either haven't reached threshold, or they move well enough to keep symptoms at bay.  Or they are Kurt Rambis and can just look so awkward that nobody even pays attention to their knee sleeve.


On the "move well enough" side of things, check out this study from Edwards et al.  They showed that these athletes with asymptomatic patellar tendinopathy actually land differently - both in terms of muscle recruitment and sequencing - than asymptomatic athletes without tendinopathy.  Fix that movement pattern neurally and strengthen the right muscles, and those issues never reach threshold.  Leave it alone, and they'll be presenting with knee pain sooner than later.  Mike Robertson does a great job of outlining ways to improve knee health via movement retraining in his Bulletproof Knees Manual.


This is just the tip of the iceberg.  You'll see loads of chronic ACL and meniscus tears that folks never realize they have.  I could go on and on. The take-home messages?  Yet again, diagnostic imaging is just one piece of the puzzle, and how you move is far more important. Related Posts The Importance of Ankle Mobility Healthy Knees, Steady Progress
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Stuff You Should Read: 4/27/10

Here are some reading recommendations for the week: Q&A: Partial Knee Meniscectomy - Here is a great blog from Mike Robertson about training modifications for those who have had a portion of the meniscus removed.  Mike's a brilliant knee guy (definitely check out Bulletproof Knees if you haven't already).  Stick around Mike's site and read a bit; he's been kicking out some great content lately. bpkAre You Inflamed? - This is a good one on the nutrition side of things from Mike Roussell. What Makes Roy Run? - This was an awesome article about Roy Halladay from a few weeks ago in Sports Illustrated.  To be blunt, a ton of professional baseball pitchers are lazy, one-trick ponies who rely on natural talent and don't work hard to fulfill their potential.  Halladay is an exception to that rule: a guy who has worked incredibly hard to become arguably the best pitcher in the game.  This is a tremendously well-written and entertaining piece about the path he took and how he deserves every bit of success that comes his way.  Phillies fans are lucky to have him.
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Great Results for a One-Time Consultation Client

Back in 2008, Ray Bennett made the trip from the West Coast all the way out to see me here in Massachusetts to figure out how to train around some chronic knee issues and get his body right so that he could compete as a bodybuilder at the young age of 41.  After his initial consult and training sessions at Cressey Performance, Ray "endured" four months of online consulting programs with me before we threw him back out into the wild on his own. Recently, the bodybuilding dream came to fruition for Ray, and when I saw the pictures, I was so impressed that I asked if he'd be willing to be somewhat of a "posterboy" for our one-time consultation program at Cressey Performance (and my online consulting set-up) with a testimonial and some pictures.  As the pictures below show, those knees are doing just fine! Check it out: "After meeting Eric in person for an evaluation at Cressey Performance in Boston I travelled back home to Portland, Oregon where I embarked on a new method of training.  I was so impressed with the knowledge and work ethic Eric and his performance facility displayed that I entered into a remote, on line coaching agreement.  For four months Eric programmed all my training, instructed me on proper exercise mechanics and answered all of my detailed questions without fail.  As an aging amateur bodybuilder I found I had hit a plateau in my training and was racking up more injuries than personal bests.  Eric understood that my failure to advance was due to a lack of focus on the core compound lifts and functional movement patterns.  With Eric's help I began making progress again and all of my old aches and pains resolved.  He gave me the tools I needed to rediscover the reasons I go to the gym which are to excel and be my best.  Along these lines he helped inspire me to set a goal of actually competing in my very first contest.  I am in the best shape of my life, able to run and jump with my son pain free and am continually breaking personal lifting records that have stood for 25 years.  I am excited about my newfound viability in the gym and I have Eric to thank for laying the foundation." Ray Bennett 41 year old Natural Bodybuilder (2010 Vancouver Natural Bodybuilding Championship Competitor - 40 and over class)


A big congratulations goes out to Ray Bennett for not only an awesome transformation, but also for being living proof that no matter how annoying an injury is, you can always find a way to train around it and get better.

For more information on my one-time consultation service, click HERE.  Or, for online consulting, check out my Services Page.

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Why Wait to Repair an ACL?

Q: I was just curious: why would surgeons have waited so long to repair Brady's ACL? It seems that it would be ideal to do the surgery as soon as possible after the injury to give him more time to rehab and come back. A: It actually has less to do with the anterior cruciate ligament (ACL), and more to do with the associated injuries he (presumably) had. It's widely speculated that he ruptured both the ACL and medial collateral ligament (MCL). A MCL will heal on its own, in most cases, so they'll give it 4-6 weeks to do so before going in to do the ACL reconstruction. Had he experienced a lateral meniscus tear, though (as is common in traumatic ACL injuries), they'd have gone in pretty quickly. ACL injuries that also include the lateral meniscus are typically much more serious and potentially career-threatening. With all ACL ruptures, they'll usually have folks wait at least a few days to allow the swelling to go down. In some cases - particularly with really deconditioned individuals, they might opt for a period of physical therapy prior to the surgery to strengthen the surrounding musculature, reduce swelling, and ensure full knee extension ROM to improve post-op outcomes. If you're interested in learning more about knee function and injuries, Mike Robertson has actually pulled together some great stuff with his Bulletproof Knees Manual. It's definitely worth checking out. All that said, best wishes to Brady for a speedy recovery. Us Pats fans look forward to seeing him back on the field.
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The Best Thing I’ve Seen All Year…

This ran in my newsletter yesterday, and for those who didn't see it, a) What's wrong with you? Why not subscribe to my FREE NEWSLETTER?!?!?! b) Read on. It's a great product. Last week, I was fortunate enough to get a free copy of Mike Robertson and Bill Hartman’s 2008 Indianapolis Performance Enhancement Seminar DVD Set. To be honest, the word “fortunate” doesn’t even begin to do the product justice; it was the best industry product I’ve watched all year. The DVD set is broken up into six separate presentations: 1. Introduction and 21st Century Core Training 2. Creating a More Effective Assessment 3. Optimizing Upper Extremity Biomechanics 4. Building Bulletproof Knees 5. Selecting the Optimal Method for Effective Flexibility Training 6. Program Design and Conclusion To be honest, I’ve already seen Mike Robertson deliver the presentations on DVDs 1 and 4 a few times during seminars at which we’ve both presented, so more of my focus in this review will be on Bill’s presentations because they were more “new” to me. That said, I can tell you that each time I’ve seen Mike deliver there presentations, he’s really impressed the audience and put them in a position to view training from a new (and better) paradigm, debunking old myths along the way. A lot of the principles in his core training presentation mirror what we do with our clients – and particularly with those involved in rotational sports. Bill’s presentation on assessments is excellent. I think I liked it the most because it really demonstrated Bill’s versatility in that he knows how to assess both on the clinical (physical therapy) and asymptomatic (ordinary client/athlete) sides of the things. A few quick notes from Bill’s presentation that I really liked: a. Roughly 40% of athletes have a leg length discrepancy – but that’s not to say that 40% of athletes are injured or even symptomatic. As such, we need to understand that some asymmetry is normal in many cases – and determining what is an acceptable amount of asymmetry is an important task. As an example, in my daily work, a throwing shoulder internal rotation deficit (relative to the non-throwing shoulder) of 15 degrees or less is acceptable – but if a guy goes over 15°, he really needs to buckle down on his flexibility work and cut back on throwing temporarily. If he is 17-18° or more, he shouldn’t be throwing – period. b. It’s important to consider not only a client/patient/athlete looks like on a “regular” test, but also under conditions of fatigue. There’s a reason athletes get hurt more later in games: fatigue changes movement efficiency and safety! This is why many tests should include several reps – and we should always be looking to evaluate players “on the fly” under conditions of fatigue. c. Bill made a great point on “functional training” during this presentation as well – and outlined the importance difference between kinetics (incorporates forces) and kinematics (movement independent of forces). Most functional training zealots only look at kinematics, and in the process, ignore the amount of forces in a dynamic activity. For example, being able to execute a body weight lateral lunge with good technique doesn’t guarantee that you’ll be “equipped” to handle change-of-direction challenges at game speed. In reality, this force consideration is one reason why there are times that bilateral exercise is actually more function than unilateral movements! d. Bill also outlined a multi-faceted scoring system he uses to evaluate athletes in the context of their sports. It’s definitely a useful system for those who want a quantifiable scheme through which to score athletes on overall strength, speed, and flexibility qualities to determine areas that warrant prioritization. DVD #3 is an excellent look at preventing and correcting shoulder problems – and in terms of quality, this presentation with Mike is right on par with their excellent Inside-Out DVD. Mike goes into depth on what causes most shoulder problems and how we can work backward from pathology to see what movement deficiency – particularly scapular downward rotation syndrome – caused the problem. There is a great focus on lower trapezius and serratus anterior strengthening exercises and appropriate flexibility drills for the pec minor, levator scapulae, and thoracic spine – as well as a focus on the effects of hip immobility and rectus abdominus length on upper body function. To be honest, I think that DVD #4 alone is worth far more than the price of the entire set. It actually came at an ideal time for me, as I’m preparing our off-season training templates for our pro baseball guys – and flexibility training is a huge component of this. Whenever I see something and it really gets me thinking about what I’m doing, I know it’s great. Bill’s short vs. stiff discussion really did that for me. Bill does far more justice to the discussion than I can, but the basic gist of the topic is that the word “tight” doesn’t tell us much at all. A short muscle actually has lost sarcomeres because it’s been in a shortened state for an extended period of time; this would be consistent with someone who had been immobilized post-surgery or a guy who has just spent way too long at a computer. These situations mandate some longer duration static stretching to really get after the plastic portion of connective tissue – and this can be uncomfortable, but highly effective. Conversely, a stiff muscle is one that can be relatively easily lengthened acutely as long as you stabilize the less stiff segment. An example would be to stabilize the scapula when stretching someone into humeral internal or external rotation. If the scapular stabilizers are weak (i.e., not stiff), manually fixing the scapula allows us to effectively stretch the muscles acting at the humeral head. If we don’t stabilize the less-stiff joint, folks will just substitute range of motion there instead of where we actually want to create it. In situations like this, in addition to good soft tissue work, Bill recommends 30s static stretches for up to four rounds (this is not to be performed pre-exercise, though; that’s the ideal time for dynamic flexibility drills. DVD #5 is where Mike is at his best: talking knees. This is a great presentation not only because of the quality of his information, but also because of his frame of reference; Mike has overcome some pretty significant knee issues, including a surgery to repair a torn meniscus. Mike details the role of ankle and hip restrictions in knee issues, covers the VMO isolation mindset, and outlines some of the research surrounding resistance training and rehabilitation of knee injuries in light of some of the myths that are abundant in the weight-training world. DVD #6 brings all these ideas together with respect to program design. I should also mention that each DVD also includes the audience Q&A, which is a nice bonus to the presentations themselves. The production quality is excellent, with “back-and-forths” between the slideshow and presenters themselves. Bill and Mike include several video demonstrations in their presentations to break up the talking and help out th e visual learners in the crowd, too. All in all, this is a fantastic DVD set that encompasses much more than I could ever review here. In fact, if it’s any indicator of how great I think it is, I’m actually going to have all our staff members watch it. If you train athletes or clients, definitely get it. Or, if you’re just someone who wants to know how to keep knees, shoulders, and lower backs healthy while optimizing flexibility, it’s worth every penny. You can find out more at the Indianapolis Performance Enhancement Seminar website.
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How to Train around Knee Pain

Q: I've just bought your book Maximum Strength. I think it is wonderful. I've seen noticeable changes in just 2 weeks on the program. The only problem I have stumbled on is my weak knees/hips. My knees get very sore when I do the squats and make a grinding noise when i bend them. I was wondering if there was any sort of stretching or warm up i could do along with the designated one that would strengthen them and help me gain the maximum lower body results. A: Give this a shot for the knee: 1. Do reverse lunges instead of walking lunges in Phase 1. 2. Box squat on both days (easier on the knee) and wait until phase 2 to front squat. When you box squat, do it barefoot or in a shoe without heel-lift (Nike Fress and Converse All-Stars are good) - not in regular cross trainers. 3. Deadlifts, pull-throughs, rack pulls, etc. should be fine. I think you will be okay with the knee, but if you feel any tweaks, skip that exercise, add a few sets to the next one. The foam rolling and mobility stuff in the book should get it on track pretty quickly, but I'd still highly recommend Bulletproof Knees for you as a resource to use in conjunction with Maximum Strength. This would definitely be a useful investment for you, as there are a lot of drills that you can use to complement the MS program to keep training hard as you get healthy. For more information about Maximum Strength, head HERE.
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Waiting to Reach Threshold?

According to Princeton researchers, one in four Americans have daily pain. Unfortunate? Yes. Surprising? It would depend who you ask. I'm a firm believer that most people are just waiting to reach threshold. With so many sedentary folks - and those who are actually exercising doing a lot of moronic stuff (machines, excessive aerobic training), it's just a matter of time until a chronic overuse condition comes to fruition - or something traumatic occurs. Additionally, just because folks aren't symptomatic doesn't mean that they don't have structural defect. It's estimated that approximately 80% of Americans have disc bulges and/or herniations that are asymptomatic, and I'd put the number of spondylolysis (vertebral fractures) right up in that ballpark as well. All baseball players have labral fraying in their shoulders, but not all of them are in pain. A lot of folks have tendinopathy under the microscope, but don't actually present with pain - YET. So what can you do? First off, if you're sedentary, move. Something is better than nothing! If you're already active, when it comes to your health, think "inefficiency" and not "pathology." The conventional medical model tells us to wait until we have pain to get something checked out. To me, a lack of hip internal rotation range-of-motion, fallen arches, and poor scapular stability are all example of issues that you need to address before pathologies present as pain and loss of function. If you've got shoulder or upper back issues, check out Inside-Out and Secrets of the Shoulder. If your hips are tight, check out our Magnificent Mobility DVD. Lower back pain? Try Dr. Stuart McGill's Ultimate Back Fitness and Performance. If it's knee problems, Mike Robertson's Bulletproof Knees is for you. Cruddy ankle mobility? I like Mike Boyle's Joint-by-Joint Approach to Training. A little education and a small financial investment early-on will do wonders for saving you a lot of pain, time, and cash down the road.
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Preventing Plantar Fasciitis

Q: Another guy from my favorite basketball team went on the injured list with plantar fasciitis this week. What can be done to prevent this? A: Welcome to professional basketball! The average NBA player has very little dorsiflexion range of motion (ankle). The only way the epidemic of plantar fasciitis, Achilles tendinosis, high ankle sprains, and patellofemoral pain is going to stop is if the players quite wearing 10-pound high top sneakers and taping their ankles. Or, at the very least, lose the tape and focus on barefoot training, low-top shoes off the court, and plenty of ankle mobility work. Just ask Shaun Livingston:
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The Truth About Leg Extensions Part 2

This blog is continued from part 1. Rule #4: You can never have too much information. Ask a lot of questions and consider every angle — and know when to refer out to a professional more qualified than you to handle the problem in question. Your Take-Home: It will never hurt to get diagnostics done on your knee from a qualified physician. Some of your problems could be related to a meniscus issue; it would explain some of the problems with weight-bearing exercise (although you would still be able to do some exercises in the standing position). That said, though, you still likely have a big window of adaptation ahead of you, so read on. Rule #5: Think "correct" before you think "different." If an exercise causes pain, stop performing it. Evaluate technique before moving on, though. If performing the exercise correctly alleviates pain, keep it. Chances are that correctly performing the exercise will actually help correct the imbalance. Your Take-Home: Have you considered that it might be the way that you squat that is the problem? Are you breaking the knees forward or hips back first? Perhaps front-squatting is a better option for you now. Is box squatting painful? Rule #6: Make the athlete feel like an athlete — not a patient — both physically and psychologically. Tell them what they can do. Your Take-Home: I can almost guarantee that deadlift variations, pull-throughs, various single-leg movements, and glute-ham raises would allow you to train pain-free in closed-chain motion if you performed them correctly and with appropriate progressions. Rule #7: Before you go changing what's going on in the gym, figure out what you can do to improve what's going on outside of it. Think posture, repetitive motions, sheer lack of movement, sleeping posture, footwear, and even poor diet. Your Take-Home: What is your footwear like? Is it appropriate for your foot-type? Are you taking fish oil? Glucosamine? Are there activities in your daily life that you do repetitively that could be avoided or revised to keep you healthy? Rule #8: Soft-tissue work serves a valuable role in preventing and correcting imbalances, without making any programming modifications. Foam rolling and lacrosse ball work is cheap and effective. Just do it. Your Take-Home: I’m willing to bet that you aren’t foam rolling or doing any work on your calves or glutes with the lacrosse ball. And, I’m guessing that massages aren’t a common occurrence in your life. All three are great interventions (the former two are very affordable, too). Rule #9: Implement mobility and activation work in your warm-up. It only takes 5-10 minutes, which is a lot less time than it takes to recover from an injury. You'll be amazed at what shakes free when you enhance stability through full ranges of motion. Your Take-Home: I’m guessing that you haven’t done anything to improve hip internal and external range of motion, hip extension ROM, or ankle dorsiflexion ROM. You should be. Rule #10: As a last step, modify the training plan — and only on a small-scale, if possible. This is the most "sacred" aspect of an athlete's preparation, so you should butcher it as little as possible. The more you screw with things, the more the athlete is going to feel like a patient. Your Take-Home: I’m guessing that the leg extensions are causing more harm than good. I would try some lower intensity rack pulls and/or pull-throughs, plus some split squat isometric holds. See how it goes. I would also highly recommend picking up a copy of Mike Robertson’s Bulletproof Knees manual. Mike goes into far more detail in several hundred pages than I ever could with a single blog post. Good luck, Eric Cressey
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The Truth About Leg Extensions Part 1

Hello Eric, I just read “The Truth About Leg Extensions.” Because of my standing work , I can`t do any leg exercises that press under my feet (deadlift, squat, and leg press), more that once a week, without getting trouble with my knees. They get full of water and hurt. When training full-body, three times a week, I do leg extensions Monday and Wednesday and then squats on Friday. This way, I don’t have to stand up for 8 hours the day after squats. I just tried to do squats twice a week (Monday and Friday), also with bad results. So I am happy to have the Leg extension. With Friendly Regards from Denmark, Bent A: You know, I can only imagine how challenging your life must be if you can only go to the bathroom once a week. I mean, honestly, not being able to squat down to the toilet more than once every seven days? You must have a pretty strong colon! Kidding aside, I’m the last person from whom you will get sympathy. I regularly train clients and athletes anywhere from 7-13 hours per day – and those are on some pretty hard rubberized gym floors (rubber is on top of turf). I also happen to have supinated feet (very rigid feet that don’t like to cushion the body), so I regularly wear through the insoles I put in my shoes. Still, I do a wide variety of lifts – from deadlifts, to squats, to various single-leg movements – and sprint 2-3 times a week on top of that stimulus. Now, getting to your issue… First off, go check out my article, The Ten Rules of Corrective Lifting, at T-Nation. It will give you an idea of the direction I’m going to take with this reply. I would actually recommend opening it up in another window as I go through step-by-step what could be your problems. Rule #1: Fit the program to the lifter, not vice versa. The best way to correct dysfunction is to prevent it. If you're blindly following cookie-cutter programs, stop. Your Take-Home: Stop reading your favorite muscle magazine; it takes more than leg extensions and squats to build solid legs that are pain-free. Rule #2: Learn to program for yourself. Establish a small group of people who will give you honest feedback on your programming ideas, and then use your intuition when it comes to modifying things on the fly. Your Take-Home: Seek out the help of others who understand the dynamics of your knees better than you do. Rule #3: Some exercises just aren't worth it. Don't bother with them; there are better options available to you. Your Take-Home: Cough…leg extensions….cough. See the rest of this article in tomorrow's update!
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