Rehabilitation Against the Grain : Fixing My Knee Without Conventional Wisdom

rehab knee

July 17th 2012 I underwent my first surgery. You can see pictures from inside here. The surgery included the following procedures :

  1.  Left knee arthroscopy with debridement of advanced grade 3 chondromalacia of the patella.
  2.  Removal of 2-cm (large) loose body.
  3.  Medial patellofemoral ligament repair (imbrication with reattachement to correct patella mal-tracking)

It was also discovered that one my bursae had a hole in it that never healed, likely from one of my dislocation events in high school. Which means I have had little to no synovial fluid in that sac for many years. It is unclear to what degree this contributed to the chondromalacia, because it has also been confirmed that my non-operative, never-injured knee also has chondromalacia, to the same or similar degree.

The surgery itself has been a success. My kneecap is tracking properly, my knee no longer “crunches” when it extends/flexes, and I no longer have a “loose body” floating around my knee, causing trouble every few months. The kind of trouble that prevents you from walking, and causes you to question whether or not your knee will simply invert (pro tip : scary stuff).

In addition, the more I research the surgery itself (on the MPFL), the more certain I am that my doctor’s decision and my consent to the surgery was the correct set of choices. Modifying the MPFL to correct for mal-tracking appears to be the most effective, least invasive, safest way to go about this problem, with the lowest chance for permanent side effects. Compare ligament repair to sawing part of the bones in my lower leg.

No thanks. I cringed pretty bad just at the thought of permanently modifying bones in my body. This procedure, thankfully, also happened to be well out of my price range, since I paid cash.

Rehabilitation Against the Grain : Throwing Conventional Wisdom Out the Window

Not only could I not afford physical therapy sessions as they are typically offered at rehabilitation centers, I was not the least bit interested in taking part in them, even if I could find a way to pay for them. It was apparent to me pre-surgery that conventional wisdom permeates the field of physical therapy as much, or more, than any other related field. I concluded that I would be infinitely better off nursing my knee back to health on my own, than with any number of physical therapists available to me in Florida.

As I’ve discovered in exercise and nutrition, doing what is popular is not only one of the dumbest, least effective things you can do, it is also likely the most dangerous, with the most short (and long) term negative consequences and risks. A predicable result for following the unthinking-masses.

As a result, I decided to do my own research, and rehabilitate my knee back to health.

After consulting with a few friends through e-mail, reading Framework for the Knee (a result of the former), and doing internet searches to the point of nausea, I made a few decision about how my rehab work would look.

In the interest of making this a little less “dry”, I’ll spell out exactly what was involved first.

  • Nautilus Nitro Leg Press – Dual Leg
  • Nautilus Nitro Leg Press – Operative Leg Only
  • Nautilus Nitro Leg Press – Non-operative Leg Only
  • Nautilus Nitro Hip Abduction
  • Nautilus Nitro Hip Adduction
  • Congruent Body Weight Single Leg Heel Raises
  • V-ball exercise
  • Operative leg stability work (60-120 seconds, soft lock, standing on trampoline)
  • Static Belt Squat (video)

Notes :

1. All of the leg press exercises have been performed through a limited, small range of motion. This includes dual leg presses as well as single leg. It was only 8 weeks into rehabilitation that I began increasing the range of motion even by the tiniest margin. This was done both under the advisement of my doctor as well as by my own judgement (in independent agreement with his).

2. All of my leg press exercises that involved my operative leg were done with multiple, sub-failure sets. Usually a starting dual leg set, followed by three operative only leg sets, followed by a heavier dual leg set, followed by a final non-operative leg set (closely approaching failure). Rest between sets ranged from 1-3 minutes.

3. The rehabilitative strength training that involved my repaired MPFL was never performed to failure, however the strength training involving hip ad/abduction was performed in a single-set-to-failure fashion from day 1.

4. The static belt squat was taken to failure, however I only began performing these approximately 5 weeks into rehabilitation. And as seen in the video, they were performed at a very small level of flexion.

5. The heel raises were single-set-to-failure. These were not incorporated until ~5 weeks into rehab as well.

6. On occasion, I performed static holds on the leg press exercises in the place of dynamic work. I suspect it was a good alternative to the dynamic work, but even so, not quite as good of an option as the dynamic work (more in a moment).

7. All exercises were done without momentum, very, very slowly.

8. I performed my rehabilitation sessions 2-3 times per week, continue to do so, and will do so until my knee is above it’s original baseline.

~~~

The conventional wisdom I “threw out the window”, at least in HIT circles, was limited, single set, and to failure training for any exercise directly related to the operative tissues, with the exception of a late, shallow, static squat, as loaded through the pelvis. To the contrary, all direct exercises for the knee were done with an enormous amount of repetitions, sets, and moderate to low resistances, compared to how I usually trained.

My mantra has been : high reps, high sets, low force, low weight.

Perhaps there is wider thinking on this issue in HIT than I understand, but in all cases, I had zero interest in taking my recovering knee to failure. I saw no necessity to it, no potential benefit, and instead, potential risks.

In addition and for clarity, I was not interested in a low volume, high intensity approach.

Rehabilitative Strength Training vs. Hypertrophic Strength Training

I like what Ken Hutchins had to say on strength training as it relates to rehabilitation.

“Strength training — especially Super Slow Protocol in cooperation with manually-resisted movements and negative-only protocol — are not adjuncts to therapy. Strength training is the therapy.

This has been my experience nursing my knee back to health. Hot therapy, cold therapy, professional massage, nutrition, supplements, and so on, seem to help. But not very much, and/or not for very long. From my experience, they are in a sense, “the icing on the cake”. The “cake” has been without a doubt in my personal experience, strength training.

Ken however, like many others, does not appear to draw a distinction between rehabilitative strength training, and hypertrophic strength training. Sure there is special consideration for recent surgery, and SuperSlow™ protocol is anything but dangerous in and of itself.

Never the less, strength training appears to be a monolithic term in scope, with no consideration for context.

Whenever surgery, or a traumatic injury of some kind have occurred however, the context in which strength training is being performed has been fundamentally altered. No longer is someone experiencing strength training from a neutral baseline.

They are starting from a dug out hole. Well below baseline, some cases more, or less than others.

The difference between R strength training and H strength training then being that while both share the common goal of stimulating hypertrophy in certain muscles, one is doing so strictly above, and beyond, baseline.

In contrast, R strength training is (properly) an attempt to restore someone to their previous baseline of health and function, or in the case of corrective surgery, to a new baseline as determined by the surgery and it’s success there of (hopefully higher than when the patient went in).

It is in part because of this that I saw no “default” relevance of single-set-to-failure training for rehabilitative purposes. In fact, it appeared quite useless for rehabilitating my knee itself.

Why?

Mobilization as the Antidote to Immobilization

 The stimulus for muscle growth is high tension motor unit recruitment and fatigue. Muscle atrophy also has a stimulus, and that stimulus is immobilization. Even some limited ROM will limit atrophy so that you won’t have to reclaim as much when you start rehab.

Doug McGuff M.D. 

Doug said this in response to me on the BBS blog in July of this year. What he said about immobilization is no secret, but it was a welcomed reminder just after my surgery.

What Doug said also got me thinking : what is the opposite of immobilization? The answer was obvious, mobilization. To mobilize.

This was important for my surgery and rehabilitation thinking because my knee was immobilized for 4 weeks after surgery via a simple brace. And during those four weeks Doug’s comment really got me thinking : what if meaningful mobilization is the answer to my need for rehabilitation?

My quadriceps and especially my VMO atrophied quickly and dramatically after surgery, in spite of my pre-operation workout to hinder this effect (72 hours before surgery).  In hindsight, this is of little surprise, considering the following factors :

  • 4 weeks of immobilization
  • the trauma of arthroscopic surgery
  • the trauma of major ligament repair
  • consequent inflammatory/swelling response over the entire area

And boy did I swell. 200 cc of blood had to be removed 2 weeks after surgery.

Back to mobilization … this fit quite well with the distinction I was beginning to draw between R strength training and H strength training.

I didn’t want to get stronger — I wanted to return to baseline/my new baseline as quickly, safely, and effectively as possible. Getting stronger is not the real objective. It is a by-product of the rehabilitative process.

The real, objective goal, is to get (my knee) back to normal. Nothing else, nothing more, and nothing less.

My solution to accomplish this was to simply, and primarily (the hip and heel work being a secondary factor) mobilize my knee. This meant two things to me in the negative :

1. Walking, or insignificant mechanical work, was not a viable solution. It would not trigger my body’s adaptive, or restorative response(s).

2. Single set to failure training, or anything approaching this that can be classified as intense mechanical work, was also not a viable solution, because it had nothing to do with the problem at hand — with the problem in the respective, below baseline, context.

My solution was to stay away from either end of the spectrum. (High force not even being included on this spectrum). Walking was useless, as was high tension, no matter how low force. (Pro tip : no matter how slow you go, internal forces are exponentially higher than the weights or resistances you are using).

Staying away from either end allowed for many sets, many repetitions, moderate to low moderate tension, and in tandem with my repetition speed, extremely low force.

This allowed for a few things :

  • A. Precision control over an unstable joint through a limited ROM
  • B. Absolutely minimized risk to the operative tissues
  • C. A nursing or “milking” of my knee, the MPFL, my VMO, and surrounding musculature, back to health
  • D. By nature of a high volume, long duration approach, maximum blood flow to the operative areas. (Good for the muscles, *probably* good for the connective tissues).

It did not allow for poor motor control, high forces, high tension, risk to the operative tissues, or general passivity of the knee. I was using it, using it significantly, and using it often (2-3 times per week).

Ultimately, the prescription I devised for my knee came down to one simple idea I encountered many years ago after finding Body by Science. I do not remember if it was Ken Hutchins or Doug McGuff or Drew Baye who said it, but the quote went something like this …

A person would be better off using a leg press for a long duration, than jogging, running, or sprinting.

The implication as I interpreted it in one sense being that running was just a poor way of using the legs; or even more precisely, a leg press is not a better form of exercise than running, running is a poorer form of physical activity than a leg press.

What I am trying to say here is that a leg press is the standard by which running should be judged, not the other way around. Running as exercise is at best dangerous, stupid, and counterproductive. The harder you push, the stronger you get, the faster you go, the more dangerous it gets.

An extreme example.

The Absent Leg Extension

One thing that seems widespread is an obsession with leg extensions, especially when the VMO needs to be strengthened. Personally, I suspect the exercise belongs in a museum, that no one short of amputees should be doing it, and that it really has nothing to do with “proper muscle and joint function” in a normal, healthy human being.

Loads should reach the knee through the toes, feet, ankle, entire lower leg, and all muscle, connective, bone, and nervous tissue in between the knee and the load. Loading the knee exclusively through the tibia … seems unnecessary at best, acutely dangerous in some cases, and I suspect cumulatively dangerous in all cases.

Anyway, the leg extension was not used during my rehab journey on purpose, and at no point will it be used. This is a departure from large globs of conventional wisdom, even in my MPFL repair surgery case, which Nicholas DiNubile M.D. thankfully (yet indirectly) calls “x-rated” in Framework for the Knee.

The Results

For all this talk, I have yet to mention the personal results of overseeing my own rehab (with no actual prior experience), and rejecting conventional wisdom on multiple fronts.

In short, the results have been A fucking +.

Almost entirely sub-failure training, high volume, low tension, ultra-low force, and never a single leg extension.

Then how did I rehabilitate my VMO? Simple : a decent leg press, properly performed, moderate-low tension, high volume, frequent training, and a focus on contracting my quad.

This focus is a sharp contrast to the focus that most people have on moving their limbs or moving the weight up and down. I could care less what the weight is doing. I am much more interested in what my muscles are doing, especially one that was recently inflamed, and in a sense, injured, not to mention severely atrophied.

Now, the naysayers are going to say here “Oh, but who cares, his VMO must have been firing just fine when he started, or he got lucky, or xyz”.

To the contrary, my VMO was barely functional leading up to starting rehabilitation. As in, it almost didn’t fire at all. What did I do? I started small.

I laid my leg out on a bed, and contracted my quad gently, carefully, and cautiously. I did this as intensely as I could, 10 minutes a day, until I was able to actually contract my quad to a meaningful degree.

Then I did the popular “lock and lift” exercise for my quad, 200-500 times a day, in increasingly larger sets. At first I couldn’t do more than 6 without having to rest. Then 10, 15, 20, 30, 50, 100, and so on.

When I was able to “lock and lift” my leg 6 inches off the ground 175 times without stopping, I decided that was enough, and only days later and under my doctor’s advisement, started my self-created rehab program.

I saw my doctor and his PA on November 2nd. My knee far exceeded expectations. They were not even sure I would have full range of motion (as mobilized by the muscles) 8 weeks in. To the contrary, I had it 4 weeks in.

My knee no longer “crunches” in flexion or extension, and I can contract my quad at full extension, as hard as I want, with no discomfort or pain.

My doctor was uncertain if I would ever regain extreme flexion (pulling your heel to your glute with your hand, or sitting on your lower legs).

Less than a week after seeing him, I discovered I am now only centimeters away from extreme, completely comfortable flexion. (As you can imagine, I have ZERO interest in pulling this thing tight).

This was supposed to take in excess of 8 months, or perhaps even “indefinitely”. I am on the brink of achieving it in less than 4 months after laying on the operating table, and a mere 9 weeks after starting rehabilitative strength training. I still proceed with extreme caution … because apparently connective tissue takes a long, long time to fully heal.

But even so, this recent development has been immensely encouraging, and I suspect that I will not only recover assisted/extreme flexion, but I’ll do so months and months ahead of when it was even supposed to be possible.

Lessons from Rehab

  • Pay for your surgery in cash.
  • Do an absurd amount of homework before surgery.
  • Form your own judgements, trust yourself first, do not rush or be pressured into anything (by insurance, work, etc).
  • Exercise extreme caution dealing with “physical therapists” (another reason to avoid surgery covered by insurance)
  • Be really, really patient.
  • Eat well, get lots of sleep, get your Vitamin D levels way up, etc, etc.
  • Seek out real experts, and avoid people who brag about their “extensive experience with rehab”  like the plague.

(These people are interested in confirming above all that their past decisions were correct; your knee/ankle/whatever is of secondary concern, especially if it will require critical thought that may conflict with past decisions).

Faster/More Efficient/More Effective

I suspect some people will read this and say “great, but you could have achieved all that faster and more efficiently and with a smaller time investment/higher tension/less sets/etc”.

I think this is pure speculation, especially considering how fast I recovered once I started rehabilitation. There is little to no basis to even suggest this, in spite of my health markers, my age, and anything else you can cook up.

This was extremely safe, ultra-fast, and simple to apply on my own, never mind with a hypothetical (qualified) trainer. As far as I’m concerned, the entire process was lethally effective.

The fact that I was able to successfully rehabilitate my entire quad including my VMO, with flat-lined risk to my recently repaired mpfl, should be at the very least, startling.

About Anthony Dream Johnson

CEO, founder, and architect of The 21 Convention, Anthony Dream Johnson is the leading force behind the world's first and only "panorama event for life on earth". He has been featured on WGN Chicago, and in the NY Times #1 best seller The Four Hour Work Week.    His stated purpose for the work he does is "the actualization of the ideal man", a purpose that has led him to found and host The 21 Convention across 3 continents and for 6 years in a row. Anthony blogs vigorously at TheDreamLounge.net and Declarationism.com.

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22 Responses to Rehabilitation Against the Grain : Fixing My Knee Without Conventional Wisdom

  1. Matt November 10, 2012 at 8:06 pm #

    Anthony, this post comes at an opportune time for me, as I literally moments ago hit publish on my own post, which included thoughts on how to rehabilitate and restabilize my ankle, not trusting the typical establishment advice on the topic. I was excited when this popped up in my reader only moments after.

    My gut feeling when it to the ankle is that as far as rehabiliation goes, anything more than ankle raises would be overkill. However, I’m curious if you’ve ran across any exercises when researching for the knee that would be effective for rehabilitating the ankle.

    • Anthony Dream Johnson November 10, 2012 at 8:26 pm #

      Hey Matt

      I would suggest picking up a copy of “Framework” by the MD I mentioned.

      http://www.amazon.com/FrameWork-Nicholas-A-DiNubile/dp/1594860572/ref=sr_1_1?ie=UTF8&qid=1352596862&sr=8-1&keywords=framework+for+the+ankle

      Like in my knee add on/version of the series, I think there will be useful parts, and some dubious parts. You should have no trouble in picking fact from fiction in the book.

      Beyond that, I suspect simple balance work on a bed, a trampoline, or ideally a Bosu Ball, will be helpful. Definitely do more research into your injury before starting though … that’s simply based on my own experience standing on a trampoline (positive).

      If you do, no need to get fancy. Start with 2 feet, progress to 1. Keep your arms low, don’t use them to balance. Always err on the side of caution, don’t push it. Nurse it.

  2. Robyn bunting November 11, 2012 at 4:22 am #

    Thanks for this post anthony. I also have some ankle issues- fell off a roof decades ago. The ankle has never been ” right” since. I have worked onnheavy single leg calf raises super slow as main exercise, but i like your suggestions on balance work and lighter higher volume controlled work. May iask what is your exact calf routine btw? i am intrigued by bw only, despite the fact you never reported ankle issues.

    • Anthony Dream Johnson November 11, 2012 at 12:08 pm #

      Hey Robyn

      I recommend taking a look at this video from Bill : https://www.youtube.com/watch?v=Ty_Fjh-yXB4

      Technically, in addition to the standing stability work, that’s all I directly do for my calves. They are also used during a leg press and belt squat however.

      I do body-weight only (on a single leg) because I’ve come to realize that’s all I need, When doing a single leg heel raise, my entire body weight is being lifted/lowered by that single, small part of my body.

      I’m 5’9 and weigh 180 pounds, so this is quite significant. I can use up to an 80lb dumbbell in one hand while doing the heel raise, but I’ve found it’s simply unnecessary. It just causes me to have less control over the movement, and do ~8-9 reps instead of 16 or so.

      Even in that case, the bulk of the resistance is coming from my body, not the dumbbell.

      I can also use my ARX machine to do dual leg heel raises … but I just don’t see the point. My calves are thoroughly exhausted using them stand alone and with bodyweight only.

      With such a small movement, I prefer better control and harder contractions over increased resistance any day.

      Hope this helps.

      • Robyn bunting November 12, 2012 at 6:35 am #

        Very helpfu, anthon, thanks!

  3. Richard November 11, 2012 at 5:55 pm #

    Hey Anthony, what’s your opinion on the sissy squat quad exercise? Would you put it in the same ‘risky’ category as the leg extension? Thanks for your time.

    • Anthony Dream Johnson November 11, 2012 at 7:55 pm #

      Yes, they look like a really, really, really bad idea for your knees. If you are really determined to “isolate” the quads, get on a horizontal leg press, open up the seat as much as you can, focus on contracting the quads, and at most, go “light” on the heels, pushing with the mid/front of your feet.

      That or just do static contractions (on a leg press, or stand alone — stay away from the leg extension).

  4. Garret November 13, 2012 at 9:36 pm #

    “Operative” isn’t an appropriate adjective to describe a body part that’s been operated on.

    • Anthony Dream Johnson November 14, 2012 at 2:38 pm #

      “Medicine/Medical . concerned with, involving, or pertaining to surgical operations.”

      Operative tissues are concerned with and pertain to tissues that have recently undergone surgery.

      I win.

  5. Jeroen November 14, 2012 at 5:36 pm #

    Christ what a long post..

    I will give you creds on your time spended researching all of this knowledge. This is how Rehab go’s down here, Austria that is… This stuff is pretty standard now a days.
    What the hell is a physical therapist doing in America?!?!

    • Anthony Dream Johnson November 14, 2012 at 8:27 pm #

      What are they doing? I’ve seen a few dozen at this point. All of them remind me of sheep. They follow each other, with the latest fads and gizmos, accomplishing little, training their clients dangerously fast, and half the time, simply ignoring them.

      I don’t know which is worse, when they pay attention to the clients, or ignore them.

      Are you sure this is standard in Austria? … I’m quite skeptical to be honest.

  6. Jeroen November 15, 2012 at 2:08 am #

    It’s standard in the clinic were i work…. sorry was not specific enough. Did my study in the Netherlands and such a rehab procedure is standard… That is how i worked (with a few non-active treatments) with all of my clients back in NL.

    • Anthony Dream Johnson November 16, 2012 at 4:33 pm #

      @Jeroen

      I am still a little skeptical that what I have detailed here is the standard in Austria for rehabilitation after this type of surgery … I mean, what do you think I mean when I say “slow”? Because I mean slow to the point of absurdity for most people.

      I am also taking my hip ad/abduction exercises to failure in a single set.

      Do you really mean to imply that rehabilitation for post-op patients looks like that? I’ve never seen anything even remotely like this in Florida.

      • robyn buntng November 17, 2012 at 1:36 am #

        is a coincidence but i was working out yesterday at the kieser medx gym here in czech republic. A youg chap was rehabbing his knee under doctors orders-1 leg leg-press, super slow, nowhere near failure!

        Jeroen, are you in austria or netherlands?

        • Anthony Dream Johnson November 17, 2012 at 3:50 pm #

          How much did you get to witness?

          A leg press for rehab isn’t necessarily unpopular … it’s doing it at the exclusion of almost all else that is rare. This is even more true when the VMO has atrophied more than any other part of the quad – this is when the leg extension gets “called in” for backup.

          This is one of my major disagreements with conventional wisdom. Not that the leg press is being underused or something like that.

          • robyn November 18, 2012 at 10:13 am #

            I just saw the guy doing extremely slow movements on one leg and asked a staff member whio is a friend of mine. She told me he was using a protocol to rehab his knee. I didnt see anything more than that. It stood out though because of this post and also because kieser are quite anal retentive when it comes to using equipment in anything but the house protocol which excludes one leg leg presses. [nevertheless very good equipment-
            http://www.kieser-training.cz]

  7. Bill DeSimone November 16, 2012 at 11:28 am #

    Good article, man, and I appreciate your subtlety. Which I never thought I’d say about you. Anyway, the sissy squat. If I remember the old muscle magazine version, hips extended, leaning back, flexion and extension only at the knee: what a disaster waiting to happen. Putting the knee aspects aside, at the bottom, as the rectis stretches over the knee and pelvis, it goes taut. The pelvis can’t shift to protect the lumbar curve, so it exaggerates. If the point was to avoid the lower back, it doesn’t work.

    • Anthony Dream Johnson November 16, 2012 at 4:20 pm #

      Hey Bill

      Thanks! Ya I’ll try to keep you out of the cross-hairs when possible going forward. I prefer to take the brunt of the head bashing, blood guts and carnage anyway =).

      Thx again also for the book recommendation and email exchange. It’s helped tons.

  8. craig January 11, 2013 at 11:52 am #

    Hey Anthony, I really enjoyed reading your article as it strikes close to home (dealing with my own chondromalacia w/o surgery) After many hours of research and trial my program seems to be very similar to yours minus a couple variations (Frankensteins for sartorius and hip bridges for glute strength) . I was just curious about a few things Ive been wondering about..

    -what kind of warm up did your perform prior to your leg press sets?

    -did you foam roll/stretch leg muscles prior to or post workout?

    -what type of bracing you used on the injured knee during your rehab?

    -did you put extra thought into your diet post workouts? ie, protein shakes after workouts and recovery days in addition to a balanced diet.

    best of luck in your full recovery! Craig

  9. Tyler February 21, 2013 at 10:04 pm #

    More modern physios, as well as those that keep up on their literature, aren’t using leg extensions for knee rehab much anymore, in large part due to the high shear forces at the femerotibial joint. More commonly, physios activate the VMO by doing limited range squats while having the patient squeeze a ball between their knees.
    As for your experience with physios in America, keep in mind that most of them are probably used to working with a middle-aged to elderly sedentary population. As such, rehab exercises have to be tailored to not only what is most effective, but what we can talk people in to doing. In fact, most of the research into rehab exercise has been done with elderly sedentary patients. It occurs to me that the physios you encountered might not be so much misinformed/out of date/clueless as much as the information available regarding effective rehabilitation exercises targets a different population with different needs.

    tl:dr: Not all physios are terrible. Some actually understand exercise and keep up on newest info and actually incorporate best practices into their practice.

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