ACL Rehab Update and the Latest Workout

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The last post I sent out was sort of screwed up. Something was wrong with the code. Here’s the new and improved version.

Thursday was a full week since my ACL reconstruction and it was the day of my first PT appointment. According to the PT, I’m weeks ahead of schedule in terms of strength, mobility and gait. This was fantastic news and I’m completely convinced that my pre-surgery workout routine was the key.

The current thinking on ACL reconstruction and recovery is to engage in what’s known as prehabilitation (as opposed to rehabilitation) prior to surgery. Surgery is a type of controlled injury. Though the overall goal of surgery is to improve function and “fix” an injury, the immediate outcome of surgery is pain, poor movement, weakness and maybe instability. The aim in prehab is to make the involved area as mobile, strong and highly functional as possible so as to minimize the impact of surgery.

My prehab consisted of lots of squats and single-leg work, deadlifts, walking, and bicycling as well as various stretches and plenty of upper body and trunk/core work. Most of my work consisted of sagittal plane (front/back) movement. This was the most stable plane of movement available to me. I also did some frontal plane (side-to-side) work but only a little work in the transverse (rotational/twisting) plane. A torn ACL typically results from way too much twisting so I was very careful not to twist and I used anti-rotation exercises in which I worked to resist forces trying to twist me.

On Friday I did my first workout.  Here’s what I did. Take note of the single-leg work. This was a big part of my prehab and will be a huge part of my rehab.

Super set 1

    • Barbell press: 65 lbs. x 5 reps – 75 lbs. x 5 reps – 85 lbs. x 5 reps – 95 lbs. x 5 reps – 105 lbs. x 5 reps – 115 lbs. x 5 reps – 120 lbs. x 5 reps – 120 lbs. x 5 reps – 70 lbs. x 12 reps
      • That last set was a back-off set. I’ll be employing back-off sets with various exercises and I’ll probably discuss back-off sets later.
    • 1-leg exercises: Watch the video for an explanation
    • Toe raises (aka heel raises or calf raises): 2-foot x 30 reps – 1-foot x 10 reps.  I alternated this pattern throughout the super set. I only used my body weight.

Super set 2

  • Leg lifts: 12 reps – 10 reps – 10 reps
    • Haven’t done these in forever.
    • I got sore and tired in the abdomen very quickly!
    • Might be sore tomorrow
  • Band walks:
    • Went to exertion in the hip abductors
    • I was very careful to keep my right knee from caving in, which is an example of working to avoid transverse plane movement as I mentioned above.

    Finally, I was able to just turn the cranks on a recumbent bike. I couldn’t generate much force with my leg but still, to get a full revolution was good news. I figure I’ll be on a real bike in maybe a week.

Worth Reading: What Makes a Great Personal Trainer? Recovery, Pronation, Bringing Up Your Weak Spots

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What makes a great trainer?

The Personal Training Development Center (PTDC) has a lot of useful, informative articles for personal trainers.  Are Personal Trainers Missing the Point is a recent piece with which I agree. The key observation is this:

“The ability to correctly coach exercises is slowly becoming a lost art in the training world, despite that it’s the most fundamental component of being a personal trainer/coach.”

The article advocates for trainers to teach the squat, deadlift, bench press, standing press and pull-up.  (I would ad the push-up to the list.) It’s also suggested that trainers learn to teach regressions and progressions of these exercises. These exercises are the essentials. They have been and still are the basic building blocks of effective exercise programs and they offer the most return on investment of a client’s training time. Read the article to learn three steps to becoming a better coach.

Running recovery

Alex Hutchinson writes for Runner’s World and the Running Times. He recently wrote an article called the Science of Recovery.  He briefly discusses six methods: antioxidants, jogging (as during a cool down), ice bath, massage, cryosauna and compression garments. Anyone who trains hard–runner or not–may find the article interesting.

Pronation

Pete Larson at Runblogger.com gives us Do You Pronate? A Shoe Fitting Tale. Here, he describes overhearing a conversation between a confused shoe store customer and the mis-informed employee who tries to educate her on pronation. Contrary to what many of us believe, pronation is not a dire evil problem to be avoided at all costs. Larson says it well:

 “The reality is that everybody pronates, and pronation is a completely normal movement… We might vary in how much we pronate, but asking someone if they pronate is like asking them if they breathe. I’d actually be much more concerned if the customer had revealed that no, she doesn’t pronate. At all. That would be worrisome.”

If you’re a runner then I highly suggest you learn about the realities of pronation.

Supplemental strength

I love strength training. I love all the subtleties and ins & outs of getting stronger. One area that I’m learning about is supplemental work (aka accessory work). This is weight training used to bring up one’s strength on other lifts (typically the squat, deadlift, bench press or standing press).  With supplemental work, we’re looking to find weak areas and make them stronger.
Dave Tate at EliteFTS is one of the foremost experts on all of this. Thus, his article Dave Tate’s Guide to Supplemental Strength is very much up my alley, and it should be up yours if you’re serious about getting stronger. He discusses several categories of exercises and how to incorporate them into a routine. Below, the term “builders” refers to exercises that build the power lifts (squat, bench press, deadlift):
  1. Always start with the builders. Do not start with the main lift.
    Examples: Floor press, box squat. Sets: 3-5. Reps: 3-5.
  2. Move to supplemental exercises — exercises that build the builders.
    Examples: 2-board press, safety-bar close-stance squat. Sets: 3. Reps: 5-8.
  3. Accessories — Either muscle-based (for size) or movement-based (for strength). Use supersets and tri-sets, as needed.
    Examples: DB presses, biceps curls. Sets: 3. Reps: 10-20.
  4. Rehab/Pre-hab — Whatever you need, nothing more or less. Examples:
    External rotation, face pulls. Sets: 2-3. Reps: 20-30.
This is just a little bit of the article. It’s very detailed. There may not be much here for recreational lifters but for coaches and those of us who have gotten a little deeper into our lifting, it’s a superb article.

Relatively Good ACL News & 4/3/14 Workout

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ACL News

I saw a non-surgical orthopedist yesterday and he walked me through my MRI. It wasn’t the worst news in the world. There were no bad surprises. I do have a grade III sprain aka a fully torn ACL. I have a grade II sprain of my MCL. No surprises there. The good news is my minisci are intact and undamaged. That’s great news! There’s also no bone damage. I’m really happy about both of these things. Surgery will be required but this injury could’ve been quite a bit worse.

I told him about my activities (staying as active and mobile as possible so long as I’m not in pain) and he approved. He said most people who get this type of injury sit down, prop up their leg, and move as little as possible. The muscles whither and their movement suffers. They go into surgery in bad shape and they come out worse. Recovery takes much longer under these circumstances.

This is no good. I’ll meet both meet with a surgeon and start physical therapy in two weeks. Some people have expressed exasperation and frustration at the pace of this process. I’m not one of them. I’m not the only guy wandering around Denver with an injury and this isn’t life threatening. I’m grateful that I have insurance, I don’t have some awful, exotic injury or illness and I’ve got people around me who can help. Anyway, the doc said surgeons typically wait on the surgery for two reasons: 1) We want to reduce swelling as much as possible and 2) We want to restore as much range of motion as possible. This stuff takes time and there’s no way around it.

4/4/14 Workout

  • Good morning: 135 lbs x 6 reps – 145 lbs x 6 reps – 155 lbs. x 6 reps x 3 sets
  • Super set 1
    • pull-ups x 4 reps
    • push-ups x 4 reps
    • goblet squat x 4 reps: I worked up from 16 kg to 20 kg to 24 kg
    • I accumulated 74 reps on pull-ups/push-ups but I didn’t time it.
    • My squat depth is getting better and I’m very happy about that. My knee is tolerating the movement well.
  • Super set 2
    • windmill: 16 kg x 5 x 2 sets – 20 kg x 5 – 14 kg x 5; What’s the windmill? Watch the video.
    • stability ball leg curl: 13 reps x 4 sets

    All’s well. Might get in a bike ride today.

What Goes Into A Successful ACL Reconstruction? An Interview With Kurt Spindler, MD

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“I really want to know what predicts ACL reconstruction failure or success so that we can improve our outcomes.” – Dr. Kurt Spindler, MD – Cleveland Clinc

In the course of scouring the Internet for any and all information on ACL injuries and rehabilitation, I came across a research summary titled Predictors of successful ACL reconstruction found. The research comes from the Multicenter Orthopaedics Outcomes Network (MOON), led by Cleveland Clinic’s Kurt Spindler, M.D.  Dr. Spindler is the Vice Chairman of Research in the Orthopaedic & Rheumatologic Institute, the Director of Orthopaedic Clinical Outcomes, and the Academic Director of Cleveland Clinic Sports Health. MOON consists of 17 surgeons from seven institutions. The researchers wanted to establish a “gold standard” for ACL reconstruction and rehabilitation. A related project is the Multi-center ACL Revision Study (MARS). I got to speak with Dr. Spindler recently. He gave me a lot of good information on several topics. After speaking with him I feel very well informed on what to know and what to ask as I start to navigate my way to a new ACL.

What are the big takeaways from the research?

  • Choose the correct type of graft. (An allograft comes from a cadaver. An autograft comes from you, either as part of the patellar tendon or hamstring.) There are advantages and disadvantages to both. Age and activity level are important factors. For teenagers and twenty-somethings, the autograft is best. I told him that I’m highly active and I intend to return full-bore to my activities. He said the autograft (either hamstring or patellar tendon) is right for me.
  • First-time ACL reconstructions perform much better than second reconstructions. Be patient. Do the rehab correctly and don’t rupture the repair!
  • Pick a skilled surgeon, one who does a lot of reconstructions and does them frequently.
  • Do the rehab! (I intend to make my rehab a religion.)

To what degree should I stay off my feet and avoid activity? Is it safe to do any type of activity? If so, what?

  • Pain should be my guide. If it hurts then stop.
  • I can exercise to whatever degree I’m able, so long as it’s gentle work and pain free.
  • I can use an exercise bike, paddle around in a pool, do squats (unweighted obviously) and any other sort of work that I can tolerate.
  • Avoid fast movements and twisting.

In speaking with surgeons, what questions should I ask?

  • How many repairs have you done?
  • How many repairs per year do you do?
  • On whom have you done them? Athletes? Kids? Sedentary people?
  • How involved are you in the rehab program? Will I just receive a handout of exercises to do or will you monitor my progress and adjust the program as necessary?

Is there an ideal rehab protocol?

Dr. Spindler said there wasn’t a strict protocol that’s best. Every injury and every individual will progress differently and rehab must be adjusted accordingly. He directed me to the evidence-based MOON rehab guidelines.

How soon should surgery follow an ACL tear? 

  • The knee should have good ROM.
  • Swelling should be down.
  • Good muscle function should be present.
  • The patient should be able to walk.
  • A long wait increases risk of further injury.

What should I know about miniscus damage? In the case of a damaged miniscus, how much can be salvaged?

  • Tissue with good blood flow can be salvaged.
  • Overly damaged tissue without blood flow should be excised.

What should I know about ACL repair using a bioenhananced scaffold technique?

At this time, there doesn’t appear to be any advantage to using this experimental technique.

He told me I had several favorable factors on my side:

  • I’m athletic.
  • I don’t smoke.
  • I have a good BMI.

One variable that I can’t control is the amount of damage to the knee. My MRI said I have a partial tear and some damage to the MCL. I’ll learn more on Thursday when I meet with an orthopedist. Thank you to Dr. Spindler and the Cleveland Clinic for the interview. This has been a huge help to me and I hope it helps someone else with a bad knee.

ACL News & the 3/31/14 Workout

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ACL information & Dr. Howard Luks’s excellent blog:

Got a call from Kaiser and apparently the MRI indicates I don’t have a fully torn ACL. There’s evidence of a big sprain (which is a type of tear) and some damage to the MCL. I don’t know about any damage to the minisci.

On the surface, this sounds good. I’m not certain though that a partial tear is much better than a full tear. Of course I got online and started looking up partial tears and such. I found the site of Dr. Howard J. Luks, MD of New York. His blog is incredibly informative and I got a lot of useful information on all things ACL-related. There’s this post on partial ACL tears which discusses the difference between an ACL reconstruction and an ACL augmentation:

“The difference between an ACL reconstruction and an ACL augmentation is fairly simple. During the process of an ACL reconstruction we will reconstruct or replace the entire ruptured ligament. Anatomically, the ACL is composed of two separate bundles and a complete reconstruction will compensate for both of those bundles. In an ACL augmentation, you have only sustained a partial tear. That means that a portion of your ACL remains intact and might be normal. Many high volume ACL sports medicine orthopedic surgeons are capable of reconstructing only the torn portion of the partial ACL tear. This leaves the normal portion of the ACL alone. There are many advantages to an ACL partial tear augmentation over a full ACL reconstruction. While the discomfort, and the nature of the surgery is virtually identical – – – it is far more likely that someone who undergoes an augmentation will have a much more natural feeling knee when all is said and done. The reason for that is because the normal ACL has certain nerves within it. Those nerves give the brain certain feedback as to the position of the knee joint. It turns out that those nerve fibers are quite important. If we preserve the intact portion of your ACL, then we are preserving those nerve fibers and hopefully preserving the integrity of your knee in the long run.”

Perhaps an augmentation is in my future? I’ll have to ask about that on Thursday when I meet with an orthopedist.

Another post, 4 Tips to Prepare You for ACL Surgery, included (you may have guessed) these four tips:

  1. The technique for performing an ACL reconstruction has evolved significantly.  Over the last few years nearly all high volume ACL surgeons have gone to an “anatomic” approach.  That means that during ACL surgery we put the new ligament in exactly the same position your native ligament was.  Believe it or not, that’s not how we were originally trained how to do it.  The older technique was easier… which is likely the reason why some surgeons still use it.  Take Home Message:   An “anatomic” reconstruction has become the gold standard.  It is a more technically challenging procedure, so be sure to review with your surgeon what technique they plan on using.
  2. Volume matters !  An ACL surgery is a technically challenging procedure. ACL surgery should be performed by those of us who are experienced ACL surgeons.  Take Home Message:  Be sure to find a surgeon that performs a fair number of ACL reconstructions each month… not a few each year. 

    ACL Surgery

    The Dark Side of the Moon?

  3. When we reconstruct the ACL we need to create a new ligament. We can choose to use your hamstring tendons, a piece from your patella, or a donor graft from cadaver tissue. Different grafts are better suited for different situations.  Women tend to be “quadriceps dominant” so a patella graft might better suit their needs.  A patella tendon graft might be better suited for high level contact athletes.  A hamstring graft is a strong graft well suited for most all activities.  The research shows that a cadaver graft in a young active person should probably be avoided due to a high failure rate. Take Home Message:  One graft does not suit all needs for people considering ACL surgery. Be sure to do your research and talk to your surgeon about your goals so the proper graft can be chosen.
  4. If you have suffered an ACL tear, you are at very high risk for re-tearing the ACL in the same knee — or tearing the ACL in the other knee.  Many people have a predisposition due to a “neuromuscular” impairment.  (I hate big words too) That basically means the way you jump, land, pivot, etc needs to be evaluated to correct your biomechanics to diminish your risk of  requiring another ACL surgery.  Take Home Message: Physical therapy is an absolutely critical part of the overall recovery process.  Finishing up with a formal neuromuscular evaluation may play a role in diminishing your risk of a second ACL tear.

The first point about the anatomical graft was news to me. I’ve read a lot on ACL repairs and that bit was new to me. I’ll definitely have to ask about it when I see the doc. On to other things…

3/31/14 Workout:

  • Deadlift:
    • 155 lbs. x 5 – 205 lbs x 5 – 225 lbs. x 5 – 245 lbs. x 5 – 265 lbs. x 5 x 2 sets
    • Used the sumo stance
    • Knee never buckled.
    • Felt good!
  • Super set 1: 4 sets
    • step-up on plyo box: no weight x 10 reps
    • pull-ups: 20 kg kettlebell x 5 reps
  • Super set 2: 4 sets
  • Ab wheel: 5 reps x 3 sets

Everything felt decent. Went up in weight on the deadlift and felt fine. I tried the sumo stance a while back and the knee wanted to cave in. Today it didn’t. Good.

The Final Victory Against My Heel Pain Part II: The Brain and Pain

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This piece about my heel pain was in the works prior to my ACL mishap. It was great to banish my heel pain! I’m still happy about it! Now I just have to overcome this latest speed bump and all will be well.

In Part I of this post I discussed my consultations with coach Mike Terborg and therapist Nick Studholme. We were trying to figure out how to resolve some very persistent heel/Achilles tendon pain that had been with me for several years. Their work was biomechanical in nature. They helped me to move better, run better and unload the sensitive tissues.

Here in Part II I want to discuss another important component to pain management, one that has less to do with biomechanics and everything to do with how we think about pain. Z-Health is where I first learned about these concepts. I drifted away from Z-Health a bit but I’ve returned to my learning about the realities of pain.

Key points

  • Pain is in the brain.
  • It’s a blend of nociceptive (danger) signals, attitudes, beliefs, past experiences, knowledge, social context, sensory cues.
  • It doesn’t equal tissue damage–particularly in chronic pain cases like mine.
  • Pain is a response to a perceived threat.
  • Reduce the threat and we reduce the pain.

Obviously there’s a lot of subconscious stuff at work when we experience pain. If we want to tie our shoes or turn the ignition key of a car, we have to consciously take action to make these things happen.  In contrast, we don’t have to think at all in order to feel pain. We feel pain without having to consciously do anything. However, research into pain reveals that we can often actually reduce our pain via cognitive processes.

One of the most powerfully fascinating aspects of pain management involves consciously considering pain and whether or not we’re actually under threat. Emerging research strongly indicates that pain management can be made more successful by educating a patient about the whole pain process. Understanding the process at work and recognizing that pain DOES NOT equal injury and that it IS NOT a threat to our health or life can be hugely powerful. For instance, there’s this analysis of research titled. Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. The conclusion is this:

 Based on this meta-analysis, patient education interventions provide additional benefits that are 20–30% as great as the effects of NSAID (non-steroidal anti-inflammatory drugs) treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60–80% as great as NSAID treatment in reduction in tender joint counts in RA.

Here, patient education offers benefits beyond that seen with drug treatment alone.

Exercise Biology explains pain:

Exercise Biology is a fantastic, very thoughtful site full of very useful information. It’s written by Anoop Balachandran. He’s gone to admirable lengths to include only evidence-based information and science. It’s not just opinion. One of the best articles on his site deals with pain science. It’s called What should fitness professionals understand about pain and injury? and it does a great job of breaking down a complex subject digestible pieces. (Todd Hargrove at Better Movement also does a great job discussing pain in a similar way.)

Very pertinent to my experience is Anoop’s discussion of how to desensitize or calm down a nervous system that is overly sensitive to a perceived threat that no longer exists. He describes the top-down vs. the bottom-up (find-it-and-fix-it) approach:

Top Down: Basically, means changing your attitude, beliefs, knowledge (neurophysiology of pain) about your pain and in turn, lowering the threat value of pain. People get hurt, they experience pain, healing follows, and they recover. But in some folks the pain lasts forever. And why is that? According to one of the most well-accepted models – the fear-avoidance belief model –  people who have heightened fear of re-injury and pain are good candidates for chronic pain. Lack of knowledge or incorrect knowledge, beliefs ( hurt always means harm, my pain will increase with any activity and so forth), provocative diagnostic language and terminologies used by medical therapists like herniated disc, trigger points, muscle imbalance, and failed treatments can further heighten this fear or threat . So education to lower the threat is THE therapy here. We now have some very good evidence to show that just pain physiology education or the top-down approach is enough to lower pain and improve function 5.

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Bottom Up approach: The bottom-up approach is what we see around us: surgery, postural fixing, trigger point, muscle imbalance, movement re-education, manual therapy, acupuncture and the list keeps growing. Almost all treatments out there are trying to lower the nociceptive drive without much consideration to the top-down approach. This is solely because these treatments are based on the outdated model of pain. We now suspect that positive effects of manual therapy may be due to neural mechanisms than the tissue and joint pathology explanations that is often offered. So even the bottom up approach is working via de-sensitizing the nervous system. Although not intended, there are top-down mechanisms clearly at work even in bottom up approaches( like the placebo effect, a credible explanatory model, the belief in the therapist) .

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So what we you need is a combined approach that takes into account the “entire individual” and that’s where the biopysycosocial model of pain treatments walks in. The bio psycho addresses the biology (nerves, muscle, joints), psychological ( beliefs, thoughts, fear) and social aspects (work, culture, & knowledge). 

Pain self-talk: “I’m not in danger.”

My Achilles started feeling a lot better once my running biomechanics were cleaned up (the bottom-up strategy.) I still had some sporadic discomfort though. In reading up on pain and the brain, I realized it was time to apply the top-down method. I had several internal conversations with myself. I said something like this: “I’m not under threat. My Achilles is strong. It won’t break. I’m safe and strong and I’m ready for anything that comes my way.”

I started feeling a little like Stuart Smiley as I gave myself these pep talks–but guess what!–they worked. Literally within 48 hours my residual pain was gone! This conscious thinking process seemed to influence the unconscious pain process to a very favorable result.

The pain neuromatrix

This model is known as the pain neuromatrix. and it is very powerful stuff. It may sound odd this idea that pain and injury aren’t the same, and that pain can be changed literaly through education. I haven’t made any of this up though. This is what the researchers are finding.

My ACL injury and pain

 I sustained an acute knee injury that includes a torn ACL. Did it hurt? Oh yes! It was a sudden change that my brain rapidly assessed as a significant threat. The result of the injury is instability in my knee and I can’t move as much or as well as I could prior to the injury. From an evolutionary standpoint, I’m at a disadvantage for survival. Pain is helping me avoid further damage. I will most likely undergo an ACL reconstruction (I hope to know for sure next week.) with plenty more pain to go along with it. But I’m not worried.

I went through 10 years of weird chronic pain (primarily low-back pain) that didn’t have an obvious cause. I obsessed over it and dreaded the pain constantly. I missed out on perhaps my best potential years as an athlete. I overcame it though.  (Much of my relief came from the bottom-up approach of fixing a lot of biomechanical issues–which ultimately reduced the threat level to my brain.)

Now with that perspective and my current knowledge, here’s how I see my knee injury:

  • I’m highly optimistic that I can be fixed and that I can return to all the activities I love.
  • I’m exercising as much as possible while at the same time avoiding pain. In this way I’m calming my brain and minimizing any feelings of depression, 2nd guessing, or any “woe-is-me” thinking.
  • The threat level via my knee will be high. Therefore:
    1. I must be patient and diligent with my rehab. I will!
    2. To reduce threat, my return to exercise (particularly Olympic lifting, trail running and skiing) must be gradual and non-threatening.

More resources:

Lorimer Mosely is one of the foremost pain experts on earth. Here he lectures on pain. Around the 7 minute mark he discusses his own experience with a very dangerous yet painless wound. The whole thing is fascinating but perhaps a bit long for some. If you’re in pain though I strongly suggest you watch it.

Also, here’s a link to an interview by Bret Contreras with physical therapist Jason Silvernail. Many good questions are asked and very well-informed answers given. Again, it might be long for some of you but the information is just hugely valuable.

Remember, learning about pain can help you overcome pain! Reading and listening to those who understand pain can be hugely beneficial to anyone who suffers. Below are more resources.

Informative sites:
www.somasimple.com (excellent forum)
www.bodyinmind.org
www.forwardthinkingpt.com
www.bboyscience.com
www.saveyourself.ca
www.bettermovement.org
www.thebodymechanic.ca

Excellent books:
Beginner Level

  • Explain Pain by David Butler & Lorimer Moseley (This is a must read)
  • Painful Yarns by Lorimer Moseley

Intermediate Level

  • Pain by Patrick Wall
  • The Challenge of Pain by Ronald Melzack
  • Sensitive Nervous System by David Butler
  • The Back Pain Revolution by Gordon Waddell
  • Topical Issues in Pain by Louis Gifford
  • Therapeutic Neuroscience Education: Teaching patents about pain by Adriaan Louw ( a book on how to do the top down approach)
  • Pain by Lorimer Moseley (DVD)

3/23/14 Workout

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I had another good workout today. My mobility continues to increase while my discomfort is on the decline. Here’s what I did:

    • Exercise bike: 5 minutes for about 1 mile at a 1 resistance.
      • Difficult to get started but feels better as I pedal.
      • Going to do this tomorrow morning for more time/distance.
    • Warm-up super set:
        • body weight squats to about 90 degrees x 10 reps x 2 sets
        • anti-rotation cable press (aka Pallof Press): 10 lbs x 10 reps w/5 sec hold x 2 sets

      • The Pallof press is my first attempt at challenging my transverse plane abilities since I tore my ACL. My ability to resist rotational forces is severely compromised without an ACL. Glad to see I could do this successfully.
    • Super set 1
      • Barbell press
        • Worked up to a 1RM of 135 lbs.
        • Did 95% (about 125) x 2 reps x 5 sets in a super set with
      • Split squats with the right leg fwd: 10 reps x 5 sets and pistol squats to a bench for the left leg x 6 reps x 5 sets
    • Super set 2
      • Deadlift: (My favorite exercise!) 95 x 5 – 105 x 5 – 135 x 5
        • Really happy to pull!
        • Tried a sumo deadlift with an unweighted bar and the knee wanted to collapse in. Won’t be doing sumos for a long while I’m guessing.
      • Bent Row: 95 x 10 – 105 x 10 – 135 x 6
    • Super set 3
      • Kettlebell 1-arm press: 16 kg x 10 reps x 2 sets
      • 1-leg RDL – right leg: no weight x 10 reps x 2 sets: Here’s a look at the 1-leg RDL:

I believe all this work I’m doing is helping me a lot. Psychologically I feel much better than I would if I were sitting around with this thing. Much of what I’m reading discusses the benefits of continuing to move and maintaining any and all strength and mobility. That’s what I’m doing.

Major Detour On All Fronts

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The good news is I have a radically brand new challenge in front of me. This new wrinkle is going to help me learn new discipline and it will push me to learn all sorts of new things. I’ll be able to relate to a large population of people in a way that I’ve never been able to relate before.

Wonderful! 

The bad news is I don’t want anything at all to do with this new “wonderful” opportunity. See, on Saturday I tore my right ACL while skiing.   (At the very least I’ve torn the ACL. That’s according to the ER evaluation.) New skis, steep terrain, poor visibility all combined to pinwheel my down the slope and jackhammer my knee into some degree of twisted gristle. (I’ll also admit with some degree of dumb pride that I resumed skiing and made it to the bottom on my own. Probably not a great idea but I’m looking for all the silver to the lining of this cloud.) I’ve been feeling fantastic lately. I’ve been strong in the gym and I’ve been running a lot. Whatever the opposite of that is, this is it.

So all my high falutin’ lofty running goals are going to take a back seat to 1) surgery and 2) a very gradual return to normal human movement. Running, biking, hiking, lifting weights and all that fun stuff is way out there on the horizon. That said, I have every intention to resume all my favorite activities. No way in hell do I intend to give up the active outdoor lifestyle that I love so much.

We shall get to know each other very well.

We shall get to know each other very well.

In less than 24 hrs I’ve learned some useful things about ACL reconstruction. First, there are two basic types of ACL reconstructions. The autograft uses my own tissue either from the patellar tendon or hamstring tendon. The allograft uses a cadaver tendon. There are advantages and disadvantages to all these different strategies. I’ll probably discuss them further in the future.

I hope to get an MRI and further evaluation as soon as possible. I’ll call the doc tomorrow to see when I can get in. I want to get on this thing aggressively and soon. I may learn that there’s more damage than simply a torn ACL. There are other tendons and minisci that could also be damaged.

The full recovery progression on this condition seems to be about a full year, and that’s full-on aggressive multi-dimensional movement. More good news here is that ACL reconstruction has been around for a long while. Lots of high-end powerful athletes go through this process and come back to perform at very high levels. From my understanding, the results can be excellent.

 

 

 

 

The Final Victory Against My Heel Pain Part I: Addressing the Biomechanics

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I’m really thrilled to be writing this post because it seems I’ve finally truly gotten rid of a chronic heel/Achilles/plantar fasciitis issue that has been with me for a long time. (I’ve said this before and I’ve been wrong, but for the record I’ve been running a lot and my heel hasn’t felt this good for this long in years.)

This thing has been with me for maybe three years. It’s never been enough to really knock me out. It didn’t derail me from my first marathon and subsequent 10-milers and half-marathons. However, several weeks ago I did a long trail run and it felt like a nail had been driven into my heel. I figured it was time to sort this out. The solution has been a mix of biomechanical and running technique adjustments, and a deeper understanding of pain science.

Before I met with anyone I put a green Superfeet insert into my shoes. I’m a minimalist shoe advocate.  I don’t want to rely on a crutch but I’m also very much willing to do whatever is appropriate to solve a problem. A lot of what I’ve read for addressing heel and Achilles problems suggests putting some sort of insert into a shoe. The idea here was to unload some of the muscles and structures that hold up the foot, including the Achilles. I’m still using the inserts on a lot of my runs but I rarely wear them at work and I do some of my runs with without the insert.

I next met with a couple of guys with a lot of great knowledge and experience. Mike Terborg and Nick Studholme were both very instrumental in my progress.  Mike is a performance and injury recovery specialist in Boulder and Nick runs Studholme Chiropractic. Mike is heavily influenced through John Hardy and the principles of FASTER Global which teaches a process of biomechanical reasoning. Nick studied under the innovative physical therapist Gary Gray. Both guys speak much the same language when it comes to movement and movement analysis.

They both have tremendous ability to explain what they see and communicate the changes they thought I should make. They both used a fantastic and powerful video program called Spark Motion which was created by Nick and a group of other guys. This was just an amazing way to record and analyze movement. Spark is a great tool that I need to look into.

The visit with Mike Terborg: Running adjustments

I first visited with Mike in Boulder a few weeks ago. We spent a couple of hours looking at how I moved. The major issue we found was prolonged eversion of my left foot. The foot stayed in contact with the ground for what seemed a long time. Mike explains his observations and thought process:

“Adhering to the Biopsychosocial or BPS model of pain (vs the Postural-Structural-Biomechanical model), we couldn’t say for sure what was causing the pain other than it could be a combination of things including but not limited to biomechanics. You had chronic pain of the plantar fascia, like to run, and wanted to be able to run more without aggravating this injury so we needed to look at your physiological skills and tendencies relative to gait. We cannot say for sure that eversion and dorsiflexion of the subtalar joint caused the injury (because these are natural motions of subtalar joint and thus normal motions for the PF to decelerate), but we can deduce that less loading of the plantar fascia (less dorsi/eversion) might be helpful in reducing the amount of stress on the PF during running. Our hope was that less stress/load during gait may allow you to run pain free for longer. In sum, we can say for sure that we crossed some type of stress threshold (bio, psycho and or social), so we wanted to ask your body what happened if we backed off on the biomechanical load to the pissed off tissue. 

“Your ranges and sequencing in the breakout evaluation all looked good, so we went straight to your running technique. Using Spark Motion for gait analysis, we deduced that it was possible for you to run in a way that reduced the stress to your PF and apparently that helped. The drills were all part of a progression to not only teach your body the skills and sequence of a more rapid gait but to train your ability to sustain that gait for longer periods of time (strength endurance of a skill). Nothing fancy, just following biomechanical reasoning to look for clues and strategies.” 

I really like Mike’s explanation of the process. He puts his explanation in a very honest way. In saying that we don’t know for certain why the pain is there, nor do we understand exactly how or why it might go away, he reflects the current cutting edge of pain science which reveals that pain is in many ways a baffling mystery.

He directed me to several exercise progressions of which here are three:


We changed my running gait along these lines:

  • Put less pressure through the heel into the ground. Let the heel touch the ground but only lightly.
  • Quicken the stride so the foot stays in contact with the ground for less time.
  • Swing the right leg through faster to facilitate less time on the ground of the left foot.
  • Run with a metronome set somewhere between 170-190 bpm.  This quickens the stride rate. Experiment.

The resulting new gait felt like I was some sort of prancing fool–La la la la laaaa!!!–dancing through the daisies.  Fortunately the video Mike shot of me indicated that in fact I just looked like I was running with a quicker step. (I could in fact go running in public this way.) Finally, Mike also suggested I visit with Nick so I did.

Analysis from Nick Studholme & fine tuning the lower leg

Nick put me through a muscle testing process and winnowed out some weak and unstable muscles in my lower leg. Specifically, big toe muscles known as flexor hallucis longus, and flexor hallucis brevis weren’t working up to par. The fibularis muscles (aka peroneals) were also a bit off line.

Taken together, when these muscles work they create and control plantar flexion and inversion of the foot as in the push-off of running or walking, and they create/control dorsiflexion and eversion of the foot as when the foot hits the ground.

Of great importance is the ability to anchor the big toe to the ground while the body passes over the foot. I was missing the mark. Nick taped my foot in a way to help facilitate this anchoring and he showed me several exercises to help me feel, create and control better big toe function while running. These exercises were similar in nature to what Mike showed me.

It’s several weeks later and what are the results? The heel and Achilles quickly started feeling better. I did a series of short interval type runs. The quicker pace (around 175-180 bpm) was challenging at first. I didn’t want to become exhausted while running and lose the technique, thus I only ran 1 or 2 minutes at a time. and walked in between. (Running with my dog tends to be a good way to break up the running with walking.)

Some discomfort remained for a couple of weeks in a stubborn way. It wasn’t terrible but it was hanging around like it was ready to pounce. I was worried that there was something we might be missing. This last bit of hanging-around heel trouble would be gone within 48 hrs after I reviewed the current ideas on pain and the brain. I’ll discuss that in the next post.

 

 

Athleticism Part II: Get More & Make it Better

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In the last post I discussed the big, powerful idea of athleticism and what it looks and smells like. Here are what I believe to be the essential pillars of athleticism and a few ideas on how to expand your own athletic base. In no way have I covered every angle of this vast concept, but I hope I’ve touched on a few useful ideas.

  • Full, pain-free range in the joints:
    • Full movement of our joints is a prerequisite for overall healthy movement. Improperly rehabbed injuries–an old ankle sprain for instance–can contribute to diminished athleticism. Our modern lifestyle (hunched sitting) is also an enemy of athleticism. Our time in cars, at desks and in front of TVs helps destroy hip mobility, thoracic spine mobility, shoulder mobility and the like.
  • Mobility in 3 planes of motion (sagittal, frontal, transverse):
    • This is related to the point above but it goes beyond single-joint movement. This pertains to large movement patterns like squatting, lunging and reaching which are conducted through several joints.
    • A lot of us are very good at moving in the sagittal (forward/backward) plane. Many of our gym exercises (especially machine-based exercises) are sagittal plane dominant.  Endurance athletes are particular specialists in moving  forward only. Start looking for competence in the frontal (side-to-side) plane and transverse (twisting) plane and you’ll often see problems. Ankles, hips and thoracic spine are frequently limited in the frontal and transverse planes.
  • Stability in 3 planes of motion (same 3 planes as above):
    • Mobility and stability are two sides of the same coin. Too much or not enough of either is a problem. Focusing your efforts on improving only one of them will lead to problems. A lack of mobility is a detriment to stability. Here are a few ways to check your tri-plane stability.
    • Watch the video below on half-kneeling and see if you can follow along. (Can you get into the position?  If not, there’s something worth working on.) What do you notice? Are you stable or not? Half-kneeling is a very useful window into 3-plane stability.

    • One leg balance is extremely important. Whether you consider yourself an athlete or not, you spend a lot of time on one leg (walking, running, stair climbing, getting out of a car).
    • Try standing on one leg. Can you do it? If so, for how long? How about a squat?  What happens when you try a one-leg squat? Can you perform a controlled squat or do things start to collapse?
  • Ability to manage forces through the core:
    • The core is everything from your skull to your pelvis.  Your arms and legs attach to your core through your shoulders and your hips. The core is analogous to the foundation of a house. If it’s strong then you’ve got great potential to operate from that foundation. If it’s weak, then everything you try and do from that base will be compromised.
    • If the core doesn’t function correctly then your spine is unstable–and that’s a bad thing.  Spinal stability is critical for both your health and your performance. If you can’t stabilize the spine against external forces (a suitcase, a bag over your shoulder, a shovel full of snow, a lawn mower, heavy door, an opponent and gravity at all times) then you will have many ongoing problems. By expanding your core stability skills in three planes then you’ll be much safer in general.  You’ll be stronger and potentially more powerful.  (BTW, don’t bother with crunches.  They do little and less for core strength.)
    • Dr. Stuart McGill’s work is a good place to start for core competency. His “Big 3” exercises address core stability in three planes.  Here’s a video

 

  • Adequate strength for the task:
    • I compare strength to money in that rarely do we find ourselves having too much. A lot of people come to the gym but they never get stronger. Endurance athletes are classic examples. These good people often spend their time lifting very light weights for very high reps.
    • Many of us would benefit from training in the 1-5 rep range, using weight that is actually difficult to lift. Heavy lifting enables runners to put more force into the ground, helps cyclists put more force into the pedals and helps everyone perform their daily tasks in a safer, more effective fashion. Beyond making stronger muscles, heavy lifting enables us to recruit more muscle fiber plus makes the bones and connective tissue stronger.
    • Now, clearly the power lifter has different strength requirements than a triathlete. So beyond a certain point, training for more strength doesn’t yield more athleticism. For the endurance athlete, there is a point where very heavy lifting may impede endurance training. No need to go there! Just recognize that most of us will benefit from getting stronger.
  • Speed:
    • Lots of grown-ups left speed behind a long time ago.  We quit sprinting and jumping. We started plodding. Go to the “cardio” section of any gym today and you’ll see a zombie-like scenario in which the walking dead sort of lope and limp yet never go anywhere. This is the opposite of speed.
    • But why did anyone ever run in the first place?   To go fast of course!  Humans have had a need and a desire to move across the earth rapidly. We needed to evade predators like the evil older sibling and we needed to chase down prey like the annoying younger sibling. It’s in us and it needs to be done!
    • Many endurance enthusiasts believe they don’t need speed. Nonsense! All good endurance athletes work on speed. The vast majority of athletic endeavors are based on getting somewhere faster than an opponent, so speed is valuable to very nearly every athlete.
    • “But I’m not an athlete,”  you say. So? Ever have to catch a subway or bus or plane and you’re running late? Suddenly there’s no substitute for speed is there? How about in an emergency situation? Can you get yourself out of trouble quickly? How about getting a child out of trouble? Your being able to move fast could help save a life!
    • Speed work can do wonders for the physique. Moving a top speed can be a superb and possibly superior way to remove fat. You can sprint on your feet, on a bike (stationary or real) or a rower.
    • Research (here and here) suggests that high-intensity sprint-type work can is superior for improving the health of cardiovascular patients and it protects against cardiovascular disease.
    • HUGE MAJOR POINT: NEVER LET YOUR QUEST FOR SPEED OVERRIDE YOUR TECHNIQUE! Move perfectly first, then speed up. Don’t get sloppy or at some point you’ll probably get hurt.
  • Coordination/dexterity:
    • This piece is closely tied to the stability and mobility in three planes. Can you change directions quickly? Can you turn and run? Can you jump and land without destroying yourself? Can you catch and throw an object? Can you run, throw, catch, jump and land all in one fell swoop?
    • If you haven’t done this type of thing in a while it can be a lot of fun and can certainly provide a mental break from the same old routine.
    • This isn’t just for “athletes” by the way. Let’s say you’re stepping off a curb and–Whoa! Here comes a cyclist/bus/skateboarder/escaped zoo animal–you need to hop back on to the side walk. Can you get the job done? How about navigating an icy parking lot? Or nabbing your pet before it escapes out the front door? Better dexterity and an ability to move in unpredictable situations is a safety issue for sure.
    • How about getting down on to and up off of the ground? If you fall, can you get up? That’s a highly coordinated activity that demands core strength, mobility and stability. Again, as adults, we spend a lot of time avoiding the ground. It might be a good idea to get down there and so some stuff.
    • Appropriate exercises include: speed ladder drills, three dimensional hopping on one or two legs, throwing medicine balls, juggling kettlebells, battling ropes, shuttle runs, rolling, crawling, the Turkish get-up and tree or rock climbing.
    • Here’s a great video of several speed ladder drills.  Play around with some of them.

  • And here’s a helluva multi-directional jump matrix.  Think I’ll try this soon.

  • Here’s some more athleticism in the form of the Turkish Get-Up. This is a very good breakdown of an exercise that combines strength, mobility and stability in what may be the most complete exercise you can find:

  • Adequate endurance for the task:
    • Greetings very-strong people. Can you walk up a flight of stairs without turning purple? Can you go on a short hike without buzzards circling overhead the whole time? Can you walk 18 holes of golf? Can you go skiing and not spend 10 minutes at the end of every run getting your breath back?
    • A lot of us are endurance specialists but some of us are far from it. Various activities can be a lot more enjoyable if we have the heart and lung capacity to get through them. Being a tourist in Washington, DC during the summer is definitely an endurance activity. Any significant amount of gardening probably requires some endurance as does any sort of house work.
    • I remember in my scuba certification we were required to swim like 2-4 laps across a pool. This was by no means a full-length swim workout. One lady had to stop about halfway through. She was exhausted. She couldn’t complete the swim and she couldn’t muster any energy to complete the class. Her young daughter was OK to keep going. So in her case, a potential fun family activity was curtailed by a conspicuous lack of endurance.
    • Strong, skillful athletic teams are often limited by endurance. If an athlete doesn’t have the stamina to last an entire contest, then they will very likely be beaten by an opponent who can continue to execute their game plan to the end of the game.
  • AWARENESS!
    • None of the above are possible without it! Do you know if your pelvis is tilted? Do you know where your shoulder blades are? Is your neck protruding?
    • Do you have any idea how well you balance or how coordinated you are? When was the last time you tried to move fast? Are you conscious of how you lift heavy things off of the ground?
    • In other words, are you aware of any weaknesses or where along the athletic spectrum you may be lacking? Do you make an effort to try new things in your workout or have you been doing the same thing forever?
    • I often tell clients, “We’re going to find what you’re bad at and then do a lot of it!” We often discover something (or several somethings) that is particularly challenging–not painful–but difficult. (By using exercise, we expose a weakness.) Then we want to find a way to bring up this capacity whatever it may be. But first we must become aware of this weakness.
    • Sit and think for a moment. What do you NOT do? What’s always been difficult? What have you NOT done in a long time? In contrast, what do you do a lot of? What’s easy for you? See if you can turn this paradigm inside out. Can you think of a way to expand your athletic base?