Home Posts tagged "Knee Pain" (Page 3)

Newsletter 161

I have the normal weekly newsletter posted below, but first a quick announcement: Mike Robertson, Bill Hartman, and I just filmed a new DVD set!  Those of you who have enjoyed all of our products individually can now see what happens when the three of us collaborate.  For more information, check out today's blog post: A Sneak Peak at the New Project.
The Law of Repetitive Motion: Part 2 In last week's newsletter, I talked about the first three component of the law of repetitive motion: "I" (injury/insult), "N" (number of repetitions), and "F" (the force of each repetition, expressed as a percentage of maximal strength).


This week, I'll discuss the "A" and the "R" of this equation.  To begin, amplitude, stated simply, is range of motion.  If we spend our entire lives in limited ranges of motion, we run into problems.

Obviously, this refers to those who sit too often and too long - particularly in poor postures.  I'm a big believer that the best posture is the one that is constantly changing, so I always encourage people to try to get up and move around every 20-30 minutes whenever possible.  If not, I love the idea of simply "shuffling" positions at your computer.  Complement this constant fluctuation of posture with some good training to open up the hips and thoracic spine, and strengthen the upper back and glutes, and you'll find that being stuck in a job with a small amplitude is a "manageable" problem.


Amplitude can also refer to only doing certain exercises in the gym, particularly those who exercise through a partial range of motion.  It might be people who simply press too often and pull too infrequently, or those who perform a lot of bilateral exercises, but nothing unilateral.  We aren't just talking about ranges of motion at the joints; we are also talking about the muscles recruited and type of muscle action - concentric, eccentric, isometric - that takes place.

Lastly, working at a specific task for extended periods of time can be a huge issue for some.  Just ask musicians, factory line workers, and even baseball pitchers.  These issues can all impose huge asymmetries that must be addressed both directly (soft tissue work, flexibility training) and indirectly (training the contralateral side, or just exposing the individual to a broader excursion of movement outside this specific task).

So, all that in mind, improving amplitude is all about increasing range of motion in one's daily life.  Of course, this must be specific range of motion.  You wouldn't, for instance, want to increase lumbar spine range of motion in most back pain patients, but you would want to optimize hip and thoracic spine mobility.

Rest, the "R" in our equation, is pretty straight-forward: if a tissue is angry, you need to give it time to settle down.  However, just stopping all exercise isn't always the best bet.

Often, it's simply a matter of keeping the stress on the tissue below its capacity for loading.  As a great example, a lot of manual therapists with whom I've worked actually like people to go out and lightly load tissues that have just been worked in order to teach the tissue to "deform" properly.  For instance, I got a little "Graston Loving" on my biceps a while back, and spent the rest of the day lightly loading the tissues and doing some prolonged stretching sets.  It worked like a charm.


Taking it a step further, though, much of the time, it's about redistributing stress.  For instance, someone with anterior knee pain may not be able to do a more quad-dominant squat, but instructing that same lifter to sit back into the glutes and hamstrings more can markedly take down the stress on the anterior knee.  Sure, it changes the muscular recruitment of the exercise, but the lifter derives great benefit and keeps the loading on the affected tissues below capacity.  And, in this particular case, he's strengthening the posterior chain muscles that almost always help to prevent anterior knee pain in the first place.

That wraps up our look at the law of repetitive motion.  It's certainly not an exhaustive review, but my hope is that it got you thinking just enough to consider how this law applies to the issues you see on a daily basis, as well as those you want to prevent from ever reaching threshold.  For more information, check out the Building the Efficient Athlete DVD Set.


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The Law of Repetitive Motion

Back in early May, I published a newsletter discussing some alternatives I've used as replacements for traditional interval training.  Basically, the goal was to show that one can work to address inefficiencies while still getting some good energy systems development training. One of the key concepts I briefly outlined in this newsletter - and also thoroughly in Mike Robertson and my Building the Efficient Athlete DVD Set - is the Law of Repetitive Motion.  This law is expressed as the equation I=NF/AR.  In this equation, injury equals the number of repetitions multiplied by the frequency of those repetitions, divided by the amplitude of each repetition times the rest interval.


Looking at this equation and understanding each of these factors sheds some light not only on how we can prevent injuries, but also address these issues once they reach threshold.  Truth be told, as I related in another previous newsletter, I'm a firm believer that we're always just see-sawing back and forth, getting closer to threshold when tissues are loaded in excess of their capacity. Providing adequate stability, mobility, recruitment patterns, and tissue quality with the appropriate training loads and recovery measures ensures that we stay below this threshold.  All of these issues are covered in one way or another by the equation from above. "I" is the injury, or insult to the tissues.  In the active restraints - muscles and tendons - this may present in the form of soft tissue restrictions that can be addressed with manual therapy and foam rolling.  In other words, sometimes simply doing some soft tissue work can bring someone back below threshold (one reason why I refuse to refer any athletes or clients to physical therapists who do not put their hands on patients, but that is a whole other newsletter altogether).


"N" is the number of repetitions imposed on the tissues.  This may be working on a factory line doing the same motion over and over again.  It may also be simply sitting with poor posture, which is the equivalent of a high number of reps (constant activation). Or, it could come from doing as many chin-ups as possible simply because your business partner told you that he didn't think you could do it - and the Mudvayne in the background motivated you to action (but I wouldn't know anything about that).

With respect to "N," the general assumption is that simply reducing the number of repetitions is what it takes to reduce insult to the tissues.  That's absolutely true, but not exhaustively true.

Take someone who bench presses with the elbows flared, and teach them to tuck the elbows and activate the upper back and scapular stabilizers.  You may instantly relieve their pain without altering the number of repetitions; you're just redistributing the load.

The same is true of someone with anterior knee pain who has pain with forward lunging, but not with reverse lunges.  So, the lesson to be learned isn't just to modify the number of repetitions, but also the manner in which those repetitions are performed.

"F" is the force of each repetition, and it's important to remember that this force is expressed as a function of maximum muscular strength.  So, in other words, the "F" figure will be higher - and more injurious - on a weak tissue.  This is one reason why resistance training is a big portion of modern physical therapy - including physical therapy that the brighter minds in the PT community wouldn't consider "comprehensive" or "good."

Here's an example.   Average Joe gets anterior knee pain and, of course, he gets diagnosed with patellar tendinitis when it's really more of a tendinosis (but I won't digress on that).  He spends six weeks in PT to really "build up his quads."  It's obvious that the patellar tendon was just weak and inflamed, so strengthening it and knocking back NSAIDs like candy will fix everything.  Riiiiight.

Chances are that the patellar tendon was just overused because Joe had no hamstrings or glutes.  Getting the quads strong just reduces the "F" figure in the equation above.  They push him away from threshold, but not as far as he'd have gone if they'd also worked on recruiting glutes and hamstrings better, optimizing hip and ankle mobility, or performing soft tissue work.  Or, maybe he just got better because they reduced the "N" we discussed above by resting the knee.  Regardless, Joe's not in the clear and very well might be back in PT in a few months if he doesn't address the other issues in the equation.

And, with that in mind, I'll get to the final two components of the Law of Repetitive Motion in my next newsletter.  In the meantime, check out the Building the Efficient Athlete DVD Set for more details.

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Stuff You Should Read: 3/11/09

Here is this week's list of recommended reading: The Mainstream Media Lag - Here's an old blog post with an enduring theme. An EricCressey.com Exclusive Interview with Dr. Jason Hodges - This interview includes a lot of really interesting thoughts from an openminded and forward-thinking radiologist.  I guarantee you'll learn something new - whether it's about shoulders, knees, or just being an informed consumer. Go Barefoot, Get Stronger - This article included a lot of quotes and perspectives from Martin Rooney, who is one of the initial "pioneers" of barefoot training.  We do a lot of barefoot work, and it's absolutely fantastic.
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Healthy Knees, Steady Progress

Here's your weekly Maximum Strength success story: "Hey Eric, "Just finished the Maximum Strength program and it was awesome! I played college volleyball and and after letting myself get out of shape, I started weight training about 2 years ago. Obviously playing volleyball you could probably guess I have bad knees. Bedsides the typical tendinitis and jumpers knee, I also had a lateral release done on each knee. I never really squatted since I thought it was bad for my knee's, but one of the guys at the gym who is involved in powerlifting got me squatting. Then I found your book and everything in it seemed to line up with the way I was thinking about working out, and I can tell you my knee's feel better now than they ever have in my life. "I'm kicking myself for not doing all the energy workouts, but still stoked with the results. It's been about six weeks since I completed the program and I am already thinking of doing Maximum Strength again. "Thanks for the great book and looking forward to the next one. Me: Male 36 (37 in April) 6"3 Packing Day: Body weight: 216 (13.1% body fat) Broad jump: 98 inches. Box Squat: 365 lbs. Bench Press: 255 lbs. Deadlift: 365 lbs. 3 Rep Chin-up: 254 lbs. Moving Day: Body weight: 226 (14.1% body fat) Broad jump: 110 inches. Box Squat: 395 lbs. (just missed 405, didn't get the depth) Bench Press: 275 lbs Deadlift: 405 3 rep Chin-lup: 268 pounds Larry Quinn"

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Being Up-Front on the Rear

It's been established pretty clearly that gluteal amnesia - or insufficient recruitment of the glutes - is a contributing factor to lower back and knee pain.  Fortunately, lots of people have gotten their act together and worked to get it firing correctly via both dynamic flexibility and activation drills and specific cuing during resistance training movements. Unfortunately, the overwhelming majority of these drills have focused strictly on activating the glutes in the sagittal plane (divides the body into left and right sides).  In the process, a lot of folks have overlooked the fact the the glutes are actually active in three planes of motion.  As you can tell from points of attachment in the picture below, the line of pull of the glutes also allow it to abduct and externally rotate the hip.


With this functional anatomy in mind, I think it's very important for coaches and trainers to implement more multi-planar movements in warm-ups.  For more information on the what, why, and how, check out the Building the Efficient Athlete DVD Set.

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Stuff You Should Read: 2/26/09

This week, I encourage you to check out: 1. Why wait to repair an ACL? 2. 5 Keys to Bulletproofing Your Knees 3. The Agenda and Line-up for the 2009 MGH Sports Medicine Conference at which I'll be speaking alongside some really smart dudes.  While you're checking it out, read over Mike Reinold's stuff; Mike is the assistant athletic trainer for the Boston Red Sox and consistently puts out great material for the physical therapy community in his blog.
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The “Don’t Squat” Recommendation

I always love it when folks come back from doctors with the "don't squat" recommendation.  My immediate response is, "So you aren't allowed to go to the bathroom?" Obviously, I'm saying this pretty tongue-in-cheek, as I know they're referring to squatting under significant loads.  However, I wish we'd get more doctors who would appreciate that certain things (e.g., squatting) are important parts of our daily lives, and that those with knee pain need to learn how to squat correctly, not avoid it altogether. Learning to sit back and hinge at the hip can give a majority of knee pain sufferers relief from symptoms when they do have to do a squatting motion during their daily lives.  Effectively, when one squats this way, it reduces shear stress at the knee and places the load more on the hip extensors: glutes, hamstrings, and adductor magnus.  These muscles have big cross-sectional areas and can easily handle the burden of squatting. I hate to play devil's advocate, but it's a perfect example of a scenario where a doctor only sees pathology and not movements.  It never ceases to amaze me how simply alternating movement patterns can markedly reduce how symptomatic a pathology is - and this is where good physical therapists and trainers/coaches come in.  A lot of doctors are extremely well-schooled in diagnostics, but have little background in terms of mechanisms of injury (particularly for chronic injuries), optimal rehabilitation , and the hugely important role soft tissue restrictions play in the development of pain.  Often, these issues are left unaddressed and an individual still gets healthy simply because the doctor has contraindicated so many exercise modalities that a patient gets better only through resting the irritated tissues. With respect to the knee, Mike Robertson has put forth some great material on this front in his Bulletproof Knees manual.


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Training the Baseball Catcher

Q: I'm a personal trainer who just started training a couple of baseball catchers.  I understand that your facility specializes in training baseball players.  I just want to know if you guys have any tips, or recommend any resources to find out common structural issues that occur with this position.  Perhaps what you guys have found through training catchers?  What lifts they should avoid, more specifically? I have begun doing a ton of research and just wanted some ideas from you guys to help me out.  Any information would be greatly appreciated. A: Well, first, there are certain things that none of my baseball guys do: -Overhead lifting (excluding pull-up/chin-up variations) -Straight-bar benching -Upright rows -Front/Side Raises -Olympic Lifts (aside from the occasional high pull) -Back Squats (we use safety squat and giant cambered bars instead, plus front squats) I could go on and on with respect to the reasons for these exclusions, but for the sake of this blog, suffice it to say that it's for shoulder and elbow protection reasons.  Fortunately, I wrote about my rationale in an old newsletter. Catchers are obviously different than pitchers and position players in that they spend a lot of time squatting, so we have particular concerns at the knees and hips. Whether or not I squat my catchers is dependent on age, training experience, time of year, and - most importantly - injury history.  If a guy is older and more banged up, we aren't going to be squatting much, if at all.  However, if we're talking about a younger athlete who has a lot more to gain from squatting (particularly if he isn't specialized in baseball yet), I definitely think there is a role for it. That said, regardless of age and injury history, I don't squat my catchers deep in-season.  We'll do some hip-dominant squatting (paused or light tap and go) to a box set at right about parallel, but for the most part, it's deadlift variations.  We get our range-of-motion in the lower body with these guys with single-leg work. As for structural issues, always check everything at the hip and ankle, as you should with any baseball player; it isn't just about shoulders and elbows (although you will want to screen those, too, obviously).  Believe it or not, a lot of the pitching flexibility deficits about which I've written also hold true in catchers. Additionally, I've found that a lot of catchers tend to lean to one side (adduct one femur), and over time, it can lead to some noteworthy imbalances in hip rotation range-of-motion.  You'll also see a lot of catchers who lack thoracic spine range-of-motion because they spend so much time slumped over (not necessarily ideal catching posture, but it does happen when you're stuck down there for nine innings). Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
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Random Friday Thoughts: 10/31/08

It's Halloween, and as you're reading this, I'm down in Georgia for baseball stuff. Because I'm actually writing this on Tuesday night, it's hard to get in the mood and be spooky, but I'll do my best. 1. I'll be doing a LOT of baseball seminars over the next few months: November 8-9 (NY), December 14-16 (TX), January 30 (MA), and February 14 (MA). For more information, check out my schedule page. 2. I actually think the Fat Tax is a good idea. While we're at it, can we institute an a**hole tax for guys who curl in the squat rack? My girlfriend was lifting at a gym down in Southern CT this week, and she told me a guy took up a squat rack all morning to do three curl variations - and then proceeded to set up two bars in the rack to do dips. The good news for him, though, is that the Horse's A** trophy he receives partially offsets the tax. 3. When dealing with athletes post-ACL reconstruction, it's obviously important to get range-of-motion back quickly. However, the direction of that ROM can actually tell you quite a bit about what is going on. When someone is struggling to get knee extension, the problems are usually do to scarring. Flexion problems, on the other hand, are usually related to graft tensioning issues. In other words, when there is loss of flexion, it is usually surgical. When there is loss of extension, it is usually rehabilitative. When there is a loss of both flexion and extension, the problem is - you guessed it - Richard Simmons. Yes, he's spooked, spooky, and stupid. I don't want your trick or your treat, Richard; I just want you to put some pants on and get a haircut. 4. Scientists recently confirmed a virgin birth in a shark. Apparently, the baby shark (called a pup, for reasons I can't explain) carried no male genetic material. Immediately upon its birth, the shark started bitching about how it didn't want to get too bulky. Scientists fear for the pup's survival, as it refuses to swim fast enough to catch its prey because it doesn't want to get out of the "fat burning zone." 5. I went into quite a bit of detail on why I dislike the term "shoulder impingement" in my newsletter this week. Check it out HERE. Just five this week, as I've got lots to do. Have a great weekend!
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5 Reasons to Get Excited

5 Reasons to Get Excited Reason #1: If you’re a fitness professional, the simple fact that you are reading this newsletter puts you ahead of most of your peers. A few weekends ago, Mike Robertson and I went to a seminar where – out of about 175 folks in attendance – the two of us were probably the only non-physical therapists. Truth be told, the seminar organizers didn’t mandate that attendees be PTs – and they haven’t in the 25+ years that they’ve been putting on great events like this. During the talk, one of the presenters remarked (and yes, this is a quote – and it was directed to all the physical therapists in the audience) “there is absolutely no reason for any of you to ever refer out to a fitness trainer. You can do everything they do.” You’d think that Mike and I – as possible the closest things to trainers in the audience – would have gotten a little miffed on behalf of our profession. Truthfully, though – almost as if we shared some sixth sense – we looked at one another, shrugged, and nodded in agreement with him. As a gross generalization, it’s the truth: there are a lot of instances where people would be better off training on their own post-rehab than they would be with a trainer, as a large percentage of trainers are grossly misinformed. We have seen some crazy stuff (I elaborated on a great example HERE). Need proof? The title of the seminar was "A Unique Approach to the Shoulder, Knee, and Spine." I’m pretty sure that trainers deal with shoulders, knees, and spines every day – just like physical therapists. And, I can guarantee that there were more personal trainers with 100 miles of this event than there were physical therapists – yet there wasn’t a single personal trainer in attendance. Then, let’s put it in dollars and cents. If you go to salary.com and compare the median annual benefits, 401K, and salary package total, here’s what you see: Physical Therapist:$97,373 Personal Trainer: $73,692 Fitness Trainer: $55,262 Think about it this way: if you were a physical therapist, would you refer out to someone if you weren’t confident in their abilities to bridge the gap with the work you’d done? If they screw up a post-rehab patient, it reflects back on you and makes you look bad in a doctor’s eyes – and that’s a doctor you’re probably trying to win over – sometimes with expensive marketing pitches! It’s a “safer” play to simply not refer out to a personal trainer, as you can assume that they make less than you, have less education, and don’t understand what you do (as evidenced by seminar attendance like this; you don’t interact with them at all). We know that this isn’t always the case; there are certainly a lot of people out there who break from this stereotype. Still, if you are a personal trainer, it’s to your advantage to get as smart as you possibly can with respect to getting/keeping people healthy – and you should pat yourself on the back for reading newsletters like this. And, to take it a step further, you should work to cultivate good relationships with physical therapists and doctors; I know that it has been a huge part of our success at Cressey Performance. It’s been a goal of mine in my writing and product creation (particularly Building the Efficient Athlete) to do more education for personal trainers and strength coaches. This leads me to… Reason #2: It looks like we’re going to offer mentorships on a limited basis at Cressey Performance. Last week alone, I had three different people (each of whom stopped by to check out our facility for a single-day) tell me that Cressey Performance needs to get with the program and offer mentorships. To be honest, it's something I've been pondering for the past month or so, and we're really thinking about putting something special together. Itt would be tight-knit: no more than 6-8 attendees at a time. If you want to learn about functional anatomy, training folks around injuries, preventing injuries, managing overhead throwing athletes, or a host of other topics, it’ll be a good fit for you. Plan on training hard while you’re in town, too; we don’t coddle people. If you'd be interested in something like this, drop us an email at cresseyperformance@gmail.com and let us know. Our first offering will likely be January of 2009. Reason #3: I had a new article published at T-Nation last week; check it out: 22 More Random Thoughts Reason #4: A Free Research Review Sampler The Research Review Service is an online, subscription-based service for exercise specialists and manual therapists looking to stay current on emerging scientific literature. Each week, these folks review and contextualize a newly published, peer-reviewed article in the area of chiropractic, physiotherapy, rehabilitation, sports injuries, acupuncture, or exercise sciences. All reviews (now over 160 of them) are posted in the growing Research Review Service online database, which is fully keyword searchable. This week, Dr. Shawn Thistle, founder and president, has made a sample available at no charge to our readers. You can download it HERE. If you like it and want more information, visit www.researchreviewservice.com, or email Dr. Thistle at shawn@researchreviewservice.com. Enjoy! Reason #5: New Blog Content Maximum Strength and Interval Training Intermittent Fasting: New Diet Solution or Passing Fad? Random Friday Thoughts All the Best, EC
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