July 17th 2012 I underwent my first surgery. You can see pictures from inside here. The surgery included the following procedures :
- Left knee arthroscopy with debridement of advanced grade 3 chondromalacia of the patella.
- Removal of 2-cm (large) loose body.
- 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)
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.
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 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.
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.