Knees, PT and Iron Manual...a little help???

[FishrCutB8]

Went to the doctor about my knee and I have knees that are beginning to tighten up on the outside of the knee, pulling on the patella and causing the knee cap to point outward. Also, my quads and hamstrings are tighter, which is causing unbalanced pulling on the knee cap.

The goal for my PT is to loosen my quads where they connect to the pelvic area, and to stretch out the hamstrings and calves. The doc ordered four weeks of Physical Therapy. At PT, I got the news that squats are contraindicated...NO SQUATS?!?!?!! JUST STICK A KNIFE IN MY EYE!

I am on Iron Manual, PHASE II. I can still do good mornings and swiss ball hip extensions, and calf raises with weighted sit-ups. What can I substitute for squats and leg presses (if anything) that will help me maintain what I have worked for?

It pisses me off because I just broke through a plateau (mental and physical) and was back on track. Any help would be great....thanks fellas.

[poopy pants]

What reason for contraindication was given?

[poopy pants]

Do you EVER do any stretching?

[FishrCutB8]

Of course I stretch...I do yoga, remember?

[FishrCutB8]

For the record, the official name is Patellofemoral pain syndrome....

[poopy pants]

Originally posted by FishrCutB8:
Of course I stretch...I do yoga, remember?

Oh yeah, duuuh. [img]tongue.gif[/img]

[Bill Hartman]

Okay...here goes...

I am assuming you have anterior knee pain or patello-femoral pain.

Knees don't suddenly tighten up for no reason. I'm assuming the doc is referring to your lateral retinaculum. The lateral retinaculum does not produce tension but rather translates it. That means any true lateral tracking (which can be best identified during a surgery) is probably due to some sort of mechanical glitch in your technique.

If you are performing full range movements (squats?) and assuming you are not exceeding your natural flexibility, then the flexibility issue in quads and hams is probably not the cause. By the way, the only part of the quads that attach to the pelvis is the rectur femoris. While this could encourage some patellar compression, tight RF usually causes an anterior pelvic tilt which then influences the entire kinetic chain as you squat (back to the mechanical problem).

Here's the $64,000 question: Did your doc or PT watch you squat as your would during a workout (loaded)? If not, then all the static stretch tests, palpation, special ligamentous and patellar function tests are all questionable. Function during dynamic activities, especially under heavy loads, is different than that during static clinical tests.

Did they check your hip and ankle/foot during closed chain (walking, step up, squat) for variation? If not, another ?????

Most injuries are due to faulty technique (not your fault everyone has adaptive technique problems at some point), overloading (too much weight too frequently), training the same movement too frequently, and limited training variation.

Now, if the RF is tight (but more likely your psoas is the culprit...have them do a Thomas test for diagnostic purposes), as you squat the femur will internally rotate slightly which in turn causes a valgus force at the knee and increased subtalar joint (ankle) pronation. This can cause some lateral force production because of the line of pull of the quadriceps tendon.

You need to do several things:

1. Stop doing the activity that causes pain. If it's squatting, stop squatting. There may be some form of lunge, step up or any number of other leg exercises you can do.

2. You also need to be evaluated for your technique in the exercise that causes the most pain. If it's a squat, find someone that knows their shit when it comes to weight training. Most PT's don't know dick when it comes to proper technique. There is most likely some sort of asymmetry which will be identified. If not, then consider your loading parameters for possible cause. (consider video taping yourself to ID any symmetry problems)

3. Heal. If it's patello-femoral pain, it will take a while. Don't train through it.

4. Question your cookbook training program (whatever Ironmanual is). The loading parameters may not be for you.


If you post your symptom pattern (where it hurts, what makes it worse, what makes it better), we may be able to provide more info.

Bill Hartman, HARTMAN certified since 1966

[FishrCutB8]

Most of the pain is in a horseshoe around and under the knee, with most of the pain occurring below the knee cap (bottom of the horseshoe).

What hurts: lunges--a lot; climbing and descending (more than climbing) stairs; flexing quads while sitting or standing.

What helps: Ice, ibuprofen, glucosamine and chondroitin (only a little though, it seems).

[Bill Hartman]

From your description, it would seem to be more patellar tendonitis (jumper's knee) than patello-femoral. True patello-femoral feels like it's behind the knee cap (knee cap rubbing on femur).

Do you have any crepitice (crunchy sounds) in the knee?

Patellar tendonitis is a tuffy as well but a much easier go than patello-femoral.

The "no squats" may be a good call for the time being. The way to progress may be with very low step ups (2-3") and then increase the knee flexion angle very slowly as long as you don't reproduce symptoms.

If the patellar tendon at the attachment at the inferior pole of the patella(actually patellar ligament if you want to get technical)is point tender, some ASTM may be warranted to stimulate some new fibroblasts for tissue regeneration. A lot of times this is degeneration of the tendon rather than inflammatory depending on how long you've had symptoms.

The chondroitin and glucosamine will have little effect on the tendonopathy if you have one. If it's wear on the chondral surface, it may help. If the ibuprofen helps, you may have some true inflammatory symptoms. Try Aleve. It works better at theraputic doses (about 2x what's on the bottle, but I'm not telling you to do that Are we understood on that count?)

Let me know what your PT says.

Bill Hartman, busier than a one-legged cat in a litter box.

[poopy pants]

If the ibuprofen helps, you may have some true inflammatory symptoms. Try Aleve. It works better at theraputic doses (about 2x what's on the bottle, but I'm not telling you to do that Are we understood on that count?)

I can confirm that this dosage works quite well. After a hernia operation, my surgeon said to take 800mg of Advil to keep the pain away. It did. It worked better than the Pecocet.

[FishrCutB8]

Originally posted by Bill Hartman:

Do you have any crepitice (crunchy sounds) in the knee?

...some ASTM may be warranted to stimulate some new fibroblasts for tissue regeneration.

The chondroitin and glucosamine will have little effect on the tendonopathy if you have one.

Try Aleve. It works better at theraputic doses (about 2x what's on the bottle, but I'm not telling you to do that Are we understood on that count?)

Cruchy sounds = Yes...mostly from the ligament that goes over the outside of the knee...

ASTM = coming up

Glucosamine/Chondroitin...kind of what I thought.

Aleve = will do...though I didn't hear that from you...


Thanks Bill
FishrCutB8...quicker than a long-tailed cat in a room full of rocking chairs...

[FishrCutB8]

Out of curiosity, why Alleve as opposed to Ibuprofen?

[poopy pants]

Originally posted by FishrCutB8:
Out of curiosity, why Alleve as opposed to Ibuprofen?

i'm betting cuz of the effect on the liver and you aint gots to take az many

[wauhawk]

At least with my dealings with Aleve is that it takes longer to "kick in". But does seem to last all day long. The first time I hurt my back I was told to take two morning and night and if I wanted to continue the Advil every 4-6 hours. I found that one dose of Advil in the morning with the first of Aleve gave me both quick and lasting relief.


Another thing to think about is perhaps Vioxx or Celebrex. This is like Advil on roids. You take one little pill and it works quick and all day long. I have found that if I take a Vioxx and do not feel relief then it's more than inflamed muscles and get my butt to the Dr.

I pulled my neck once. High dose of Advil did nothing. Next day still couldn't move my neck took a Celebrex with in an hour I had full range of motion. Took that stuff two more days and was back to normal.

[bryanc]

I had meant to reply to this on Friday when I got back from vacation, and I did start a reply, but then everything crashed and I lost a good chunk of it and was just too angry to type it all out again. Our lab did a randomized control trial on PFPS (patellofemoral pain syndrome) a few years back (I don't know if the paper has been published or not). We looked at four treatment arms: 1) a home exercise program, 2) a patellar brace, 3) a patellar brace with a home exercise program and 4) a fake patellar brace with a home exercise program. What we found was that there wasn't any difference in terms of knee cap pain after 12 weeks between any of the groups (even though we theorized that the brace + exercise would do better). So, in a classic evidence-based fashion, everyone who is diagnosed with PFPS in the clinic is initially put on the home program. And here it is (warning, it's LONG):

The drop squat program:

1) Position/Body Alignment
-feet shoulder width apart
-knees pointing straight ahead
-knee caps aligned to drop over your second toe
-squat or lunge to a dept of no more than 45 degrees (1/4) depth at the knee
-bend at the knees and hips, but do not lean forward

2) Speed
SLOW- for the first week to allow you to become comfortable with the action and alignment
FAST- allow your knees to 'collapse' momentarily, then rapidly contract the quadriceps to stop further collapse, then stand slowly

3) Progression
Build-up phase: gradual increase in knee function and decrease in pain
Maintenance phase: to prevent recurrence of injury

The Build-Up Phase
You will perform one exercise session for 5 days out of the week. You can pick your 'rest' days. You can incorporate the exercise and stretches into your regular workout or do them separately. Each week you will have one exercise. You should perform 3 sets of 20 repetitions of that exercise.Stretching should be done before and after these 3 sets of 20 reps.

Week 1: Drop squat (SLOW no weight) (see above for description of SLOW and FAST).
Week 2: Drop squat (FAST no weight)
Week 3: Drop squat (FAST w/5lbs in each hand)
Week 4: Drop squat (FAST w/10lbs in each hand)
Week 5: Drop squat (FAST w/15lbs in each hand)
Week 6: Lunges (moderate speed, no weight, not walking lunges)
Week 7: Single leg drop squat (FAST, no weight)
Week 8: Single leg drop squat (FAST w/ 5lbs in each hand)

Single leg squats and lunges are 20 reps PER LEG.

After reaching the last stage of the Build-Up Phase, Maintenance Phase is just Week 8 (Single leg drop squats w/5lbs) performed 2-3 times a week instead of 5.

You are encouraged to continue your usual sporting activities _WITHIN YOUR PAIN TOLERANCE_. However, modification of the time and intensity of the activity may be required if it causes knee pain.

Stretches

There are three stretches in this program. Strech the hip and quadriceps muscles to the point that it is slightly uncomfortable. Do not bounce. Hold the strech for 20 seconds. Repeat each stretch 5 times on each leg.

Seated Spinal Rotation: Sit with both legs straight out in front of you. Curl one knee up and cross the foot over the straight leg. Turn your torso so that the tricep/elbow of the opposite arm to the flexed leg is resting against the flexed knee. Push against the flexed knee.

Lying spinal rotation: Lie down with your arms out to the side. Bend one knee and then rotate your hips into that knee (i.e. to the opposite side of that leg. If you bent your right knee, rotate to the left). Keep your shoulder blades on the floor.

Lying quadriceps stretch: Lie on your front. Grab the ankle of one leg and stretch your quadriceps. It's like the standing quad stretch. Only you're lying down.

There you have it. Some tips:

1) Your routine should look like this:
Stretch->drop squats->stretch

2) It is quite common to experience some pain in your knees during the Build-up phase. You can continue if the pain is mild, if the pain is severe, go back a stage (i.e. the previous week) for the remainder of the week before trying that stage again the following week.

3) You can do other strengthening exercises (leg press, leg curls) but leg extensions should be avoided.

4) Cycling is a good supporting exercise.

[Bill Hartman]

Bryan,

What's the rationale for the exercise selection other than the squat progression, especially the stretches?

Why stretch before? Dampening the stretch reflex?

Bill Hartman, curious

[bryanc]

You know, I've often asked that question myself (I didn't design the program, but it seems to work). I think part of it may be that the population we studied included people from all walks of life from not-quite-elite athletes to completely sedentary individuals. So some people were more accustomed to exercise than others. I doubt as much thought as, "dampening the stretch reflex" went into the design of the program itself. I suspect it was one of those, "stretching as a warm-up" kind of things. We did this study in 1999-2000, so it was designed before I got there at the end of 1999, and before the body of literature suggesting the stretching before activity doesn't seem to have an injury-prevention role got large enough to notice.