Knee Rehab Template

[Michael Ray]

Is Phase one supposed to be done every day? Once a day every day, or even twice a day every day?

So if I'm otherwise working out three times a week, I'd skip the upper body workout on the other four days.

At this point, I can't perform the biofeedback test. The Spanish Squat and Split Squat are killing my knees pretty good, but it generally feels better when I stop. I'm using TRX straps to help balance and get into position.

Hopefully, I can get rid of the straps at some point and then eventually move to phase two.

seriousbean Phase one can actually be skipped if you feel ready for phase 2. However, if you choose to do phase 1, then it typically is recommended 1 - 2 x / day based on your symptoms. Some people may respond well to one time per day and others may respond better to 2 x / day - it's based on your symptoms.

I'm not sure what you are asking about the upper body days. Perhaps you can clarify.

Biofeedback test - that's fine if you either need assistance or can't tolerate it right now. Isometrics - if you are finding symptoms are severely increasing during or after training then you can make modifications to the range of motion and/or sets and/or timing of holding the isometrics. Let me know what other questions you have.

[Michael Ray]

Hey Michael Ray , i sent my physiotherapist the original template, as well as some suggested modifications based on our exchanges in here, he didn't have much to say about it unfortunately, but i'm cleared to do it. So basically, i substracted two sets per exercice, and i modified RPE the following way, in order : 5,6,7,8. As you suggested i will alternate between squat days and deadlift days completed by one unilateral exercice choosen in the template. I'll also do ligth functional movements such as going up stairs on some off days, just to go trougth the motions. What do you think about that ? Any modifications to recommend ?
Thank you for your time, if my french insurance plan convered BM consults, be sure i would have taken one already.

Hey heavygrappler - I think what you've outlined is reasonable. Part of this process is finding a tolerable starting point and building from there, while realizing some alterations may need to be made along the way based on how you respond.

[Maitiú]

Depends on the exercises you select to do for your bilateral and single leg exercises but overall nothing out of the ordinary. If you have a barbell and dumbbells/kettlebells then you should be good to go.

Can I use a sissy squat as my bilateral exercise?

[Michael Ray]

Can I use a sissy squat as my bilateral exercise?

Sure. What are you goals with implementing this movement?

[Maitiú]

Hi Michael. I bought the knee rehab template this morning (although I saw last week from the forum that the Spanish squat was in the program). My gym doesn't have bands but it has one of those 'sissy squat things'. I tried it this evening, I'm not sure if I was executing the exercise properly. My toes were coming up and 'hooking' me against the round pads in front of my shins when I performed the squat. So I put some weight plates under my feet to lift me up a bit. That seemed to help. I'll wear my weightlifting shoes next time as well. I imagine it's better if my feet are flat and not ''hooking" me into place?

[Maitiú]

Hi Michael. I bought the knee rehab template this morning (although I saw last week from the forum that the Spanish squat was in the program). My gym doesn't have bands but it has one of those 'sissy squat things'. I tried it this evening, I'm not sure if I was executing the exercise properly. My toes were coming up and 'hooking' me against the round pads in front of my shins when I performed the squat. So I put some weight plates under my feet to lift me up a bit. That seemed to help. I'll wear my weightlifting shoes next time as well. I imagine it's better if my feet are flat and not ''hooking" me into place?

[mattrichards98]

Hello,

I am not sure phase 1 is necessary for me, I get quite a bit of pain in the biofeedback test however I just realized that I haven't been using a high enough decline angle (10kg plate) so will retry tomorrow. I also feel like the pain might not be as severe if I warmed up my knees beforehand.

Is there a warm-up routine you would recommend prior to the biofeedback test and/or sessions in phase 2 & 3 when I move on to those?
Would you recommend wearing SBD knee sleeves for test and/or sessions?

Thanks

[pia501]

Hi guys.

I have bought the knee template and I am planning on using it when I get back off holiday.

Background

I was diagnosed with patellar femoral syndrome and I was told that I had signs that I had Osgood Schlatter syndrome when I was younger. I also had previously suffered a suspected torn ligament mcl when I was younger. I went foran MRI recently to see if I can get more clarification (still waiting on results)

Anyway I have struggled to do any real training this last couple of months because of it. I gave up my martial arts, as I think that was a partly causing the overuse injury, I am not planning on going back in the near future. My goal is to see if I can get myself to doing strength exercises again.

I tried to focus on using bodyweight exercises to get myself back including using skater squats and sldl. I also tried stretching as well. found my right knee was fine when I trained and I had no swelling or severe increases in pain. However when just doing everyday type activities my knee would twinge and then swell up the next day.

So I think I am fine with most of the bilateral exercises on the template, but split squat does not feel comfortable on my trail leg whatsoever. Is there a way of making this more comfortable for my trail leg or an alternative exercises? Also I have noticed my knee gets more reactive when I go into too much knee flexion ie child's pose (yoga) and kneeling, so is it okay to start with a reduced range of motion for each movement?

[physiatry111]

Hello,

I've been watching a few videos of BBM the past few weeks and I purchased the knee rehab template. From what I've gleaned (and please correct me if I'm wrong), one of the major tenants of your guys philosophy is that many power-lifting (squat, deadlift, bench) injuries result from overuse, and not necessarily from "bad" form. For instance, I remember you guys saying in one of your videos (https://www.youtube.com/watch?v=V43mSQEjZY8&t=2s) that, for example, consistently hitting RPE 10's on your workout sessions will lead to injuries.

I'm perplexed comparing this advice to what I see in the template. In phase 1 and phase 2 in the rehab template it lists hitting RPE 10 for every session (for phase 1, every set should be RPE 10; for phase 2, it's a buildup to a set of RPE 10). Doesn't this fly against the advice you guys prescribe? I tried looking at your sources, notably Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations, which I believe was the only source in the template regarding load management (however, please correct me If I'm wrong, I may have missed something). The only information I found in the paper regarding load management/programming is that, in the phase 2 of their program, they prescribed "3 to 4 sets at a load of 15RM, progressing to a load of 6RM, every second day"; this advice was taken from Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy, where they seemed to throw this number out of thin air with no clear explanation.

In any case, I'm curious to know how you guys decided what the RPE should be for this template. Overall, I feel like there is no clear guidelines based on the literature I looked at that indicate what RPE range will lead to injury, or the inverse, what RPE range one should train at.

Thanks,
Mike

[Michael Ray]

Hi Michael. I bought the knee rehab template this morning (although I saw last week from the forum that the Spanish squat was in the program). My gym doesn't have bands but it has one of those 'sissy squat things'. I tried it this evening, I'm not sure if I was executing the exercise properly. My toes were coming up and 'hooking' me against the round pads in front of my shins when I performed the squat. So I put some weight plates under my feet to lift me up a bit. That seemed to help. I'll wear my weightlifting shoes next time as well. I imagine it's better if my feet are flat and not ''hooking" me into place?

Hey Maitiú sorry for the delayed response. How have the sissy squats been going? Perhaps upload a video and I can try to help. I think it's a fine substitute for the Spanish squat.

[Maitiú]

Hi Michael. I've just seen your reply from about two months ago. I haven't checked the forum for a while. I started using a lifting strap used for lifting heavy objects on construction sites for the Spanish squats. It worked well. I've had delays in getting the program done, mainly due to having to miss sessions due to life (but I didn't skip the sessions, I just did them the next day) also, earlier on in the first couple of weeks I wasn't able to progress past the first week of the program due to pain and weakness. But I persevered and I am now on week 8, pain in my daily activities has reduced dramatically and pain during squatting is almost completely gone. I will be finishing the program fully as it is clearly working. Thank you for the offer to view a video of me doing the sissy squats, but like I said, using that "lifting strap" worked much better. I have a new question though, I have joined a new gym and it doesn't have a leg press. Leg press is included in phase 3 of the rehab program. Could you recommend an alternative exercise please? The gym doesn't have a hack squat either.

[Michael Ray]

Hello,

I am not sure phase 1 is necessary for me, I get quite a bit of pain in the biofeedback test however I just realized that I haven't been using a high enough decline angle (10kg plate) so will retry tomorrow. I also feel like the pain might not be as severe if I warmed up my knees beforehand.

Is there a warm-up routine you would recommend prior to the biofeedback test and/or sessions in phase 2 & 3 when I move on to those?
Would you recommend wearing SBD knee sleeves for test and/or sessions?

Thanks

Hey mattrichards98 - How'd the test go when you changed elevation of your heel? There is usually a "warming-up" period with tendinopaties where the area may be initially symptomatic with a particular movement but then as the area adapts to the movement demands/load the symptoms regress - this is we advocate for the biofeedback test to be performed twice if the initial test has increased symptoms above tolerance level. I don't typically recommend knee sleeves in these scenarios since we are gauging symptoms in the biofeeback test to help dictate loading for the day.

[Michael Ray]

Hi guys.

I have bought the knee template and I am planning on using it when I get back off holiday.

Background

I was diagnosed with patellar femoral syndrome and I was told that I had signs that I had Osgood Schlatter syndrome when I was younger. I also had previously suffered a suspected torn ligament mcl when I was younger. I went foran MRI recently to see if I can get more clarification (still waiting on results)

Anyway I have struggled to do any real training this last couple of months because of it. I gave up my martial arts, as I think that was a partly causing the overuse injury, I am not planning on going back in the near future. My goal is to see if I can get myself to doing strength exercises again.

I tried to focus on using bodyweight exercises to get myself back including using skater squats and sldl. I also tried stretching as well. found my right knee was fine when I trained and I had no swelling or severe increases in pain. However when just doing everyday type activities my knee would twinge and then swell up the next day.

So I think I am fine with most of the bilateral exercises on the template, but split squat does not feel comfortable on my trail leg whatsoever. Is there a way of making this more comfortable for my trail leg or an alternative exercises? Also I have noticed my knee gets more reactive when I go into too much knee flexion ie child's pose (yoga) and kneeling, so is it okay to start with a reduced range of motion for each movement?

pia501 - did you get the results of the recent MRI and if so, what's the gameplan for management based on the findings?
You may benefit from a consult with us so we can adapt the template to your needs and address some narratives surrounding pain. https://docs.google.com/forms/d/e/1F...ilUWA/viewform

If you are on phase 1, you can select leg extension instead of split squats and see if that is better for you.

Child's pose and kneeling - yes, if you are having symptoms dramatically increase with these movements then I'm fine with you easing yourself into those ranges of motion. I'm not so sure this will reflect how resistance exercises such as squats will go though given Child's pose tends to demand max knee flexion for the position. What are your current goals?

Happy to help.

[Michael Ray]

Hello,

I've been watching a few videos of BBM the past few weeks and I purchased the knee rehab template. From what I've gleaned (and please correct me if I'm wrong), one of the major tenants of your guys philosophy is that many power-lifting (squat, deadlift, bench) injuries result from overuse, and not necessarily from "bad" form. For instance, I remember you guys saying in one of your videos (https://www.youtube.com/watch?v=V43mSQEjZY8&t=2s) that, for example, consistently hitting RPE 10's on your workout sessions will lead to injuries.

I'm perplexed comparing this advice to what I see in the template. In phase 1 and phase 2 in the rehab template it lists hitting RPE 10 for every session (for phase 1, every set should be RPE 10; for phase 2, it's a buildup to a set of RPE 10). Doesn't this fly against the advice you guys prescribe? I tried looking at your sources, notably Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations, which I believe was the only source in the template regarding load management (however, please correct me If I'm wrong, I may have missed something). The only information I found in the paper regarding load management/programming is that, in the phase 2 of their program, they prescribed "3 to 4 sets at a load of 15RM, progressing to a load of 6RM, every second day"; this advice was taken from Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy, where they seemed to throw this number out of thin air with no clear explanation.

In any case, I'm curious to know how you guys decided what the RPE should be for this template. Overall, I feel like there is no clear guidelines based on the literature I looked at that indicate what RPE range will lead to injury, or the inverse, what RPE range one should train at.

Thanks,
Mike

physiatry111 thanks for purchasing the template and for your questions.

Podcast and injuries - this is a complex topic and defining injury in of itself has demonstrated to be quite difficult. The reference you are discussing from the podcast is likely related to session RPE. There are different types and scales of RPE.

The template allows for increased internal intensity (RPE) because external intensity is being heavily regulated with tempo work in both concentric and eccentric phases and the set repetitions are higher than most powerlifting programs typically run further regulating top end external intensity. You are correct regarding selected rep ranges (15s - 12s - 10s - 8s - 6s), there isn't solid evidence validating these as the therapeutic dose of exercise for all tendinopathies. Rather the typical premise is linearly progression from a higher volume and lower external intensity to a lower volume and higher external intensity (the premise for most powerlifters). Reflecting on the creation of the template and anecdotally what I personally do in clinic - some cases can handle set RPE 10 and some may not but the general premise does appear to be reaching max effort for that particular training session so the expectation of RPE 10 helps with that. Some cases may be better suited for a different RPE and some may better be suited with higher or low beginning rep ranges, however, when designing a generalized template we went with broad parameters with autoregulation via RPE. We do have planned updates for the template and some of this will likely be addressed in the future.

To the question of a particular RPE and injury - I don't believe this exists generally speaking and is far too dependent on confounding variables such as prior training history, stress coping mechanisms of the individual, prior injury, etc. RPE is more of a guideline to follow that does have evidence of support based on a subjective rating system needing to be monitored to reduce the risk of injury (see Eckard et al). There are also multiple types of RPE scales that typically don't get mentioned but overall what matters is we are taking the human performing exercise into account rather than just saying "add fahve" each week. Are you familiar with the Acute:Chronic workload ratio - I'm not a fan of Tim Gabbett's generalized "sweet spot" idea via concrete numbers but I think as a heurestic for programming and reducing injury risks - it's a good approach. See: https://bjsm.bmj.com/content/50/5/273

Happy to discuss more.

[Plifter]

Michael Ray

Hello Dr Ray,

Just now seeing the new knee template and am wondering if this could help me. Been struggling with a knee issue for almost 3 years now since initial issues started.

Very long story as short as possible ...

I have had quite the long journey these past couple years with a knee issue. Was at the peak of fitness as a crazy Crossfitter early 2017 (was 47 then, now 49), best shape of my life. 5'8", 180 lb, 6% bodyfat. Ripped, putting up major weights, incredible WOD times, keeping up with the 25 yr olds :-) ... Good times

But alas, it wasn't meant to last. I guess that's what happens when you have a 25 year old mentality in a 47 yr old body :-(

Seemingly out of nowhere (no previous indication of any imbalance or issue), one day my knee was swollen and tight (April 2017). Never ever had knee issues in my life. Ortho thought it was meniscus tears (and confirmed via MRI), so had menisectomy (medial and lateral) January 2018. I have had constant issues ever since. In hindsight, I do not believe the source of my issue was EVER meniscus, but instead major patellar tracking issues, leading to what I suspect is/was chondromalacia patella. And of course this happened due to imbalance (quad, glutes, hip, etc.), likely related to major overtraining. I went to another ortho again in March 2018 ... He confirmed chondromalacia patella due to poor tracking and told me to stop running, no more squats, no more weights, ever. Of course this crushed me. Then I go to multiple PTs and they all tell me I will be fine, it will heal, just need to strengthen the surrounding muscles and correct the imbalance/tracking.

Fast forward to today, 180 lbs, 25% bodyfat, weak, I am a mess ... A shadow of what I once was, all due to my knee, which has never been the same. Have tried PT with multiple providers as mentioned above, it never gets better. I have periods of time where it does feel better, I start pushing it a bit (albeit carefully), and it blows up. Swelling, tightness, etc. I have repeated this same cycle over and over again for past year or so.

Finally just within the last week I have found what appears to be an excellent PT. He confirmed that indeed it appears I have chondromalacia patella, and the reason I have been repeating the above cycle is my knee inflammation is never coming down enough for things to heal. Not to mention my quad is one giant knot (especially rectus femoris) and basically it is totally shut-down. SO no matter how much I work it, it will not get stronger and only my knee joint continues to get slammed. So, he started dry needling with e-stim and it has been a game changer! Finally my quad is starting to feel like it is part of my body again! Waking up and starting to function. Swelling is down significantly. PT has told me I need to back off on the lower body stuff for a while until they can get my quad (and glute) back to some level of normal function via passive therapy (basically, no significant extension or flexion of the joint...minimal movement is ok though).

So, I am not sure if I could start to get any benefit from the template now, or if I should rather wait until my quad/glute is more functional, and my inflammation down further?

Thoughts?

...Mike

[pia501]

Michael Ray

Hi Mike
Got my results back and it does not look good. The doctor said I have a medial menicus tear and I have ruptured the medial collateral ligament, he has referred me for surgery. I will fill in your form now.

Thanks

Phil

[physiatry111]

physiatry111 thanks for purchasing the template and for your questions.

Podcast and injuries - this is a complex topic and defining injury in of itself has demonstrated to be quite difficult. The reference you are discussing from the podcast is likely related to session RPE. There are different types and scales of RPE.

The template allows for increased internal intensity (RPE) because external intensity is being heavily regulated with tempo work in both concentric and eccentric phases and the set repetitions are higher than most powerlifting programs typically run further regulating top end external intensity. You are correct regarding selected rep ranges (15s - 12s - 10s - 8s - 6s), there isn't solid evidence validating these as the therapeutic dose of exercise for all tendinopathies. Rather the typical premise is linearly progression from a higher volume and lower external intensity to a lower volume and higher external intensity (the premise for most powerlifters). Reflecting on the creation of the template and anecdotally what I personally do in clinic - some cases can handle set RPE 10 and some may not but the general premise does appear to be reaching max effort for that particular training session so the expectation of RPE 10 helps with that. Some cases may be better suited for a different RPE and some may better be suited with higher or low beginning rep ranges, however, when designing a generalized template we went with broad parameters with autoregulation via RPE. We do have planned updates for the template and some of this will likely be addressed in the future.

To the question of a particular RPE and injury - I don't believe this exists generally speaking and is far too dependent on confounding variables such as prior training history, stress coping mechanisms of the individual, prior injury, etc. RPE is more of a guideline to follow that does have evidence of support based on a subjective rating system needing to be monitored to reduce the risk of injury (see Eckard et al). There are also multiple types of RPE scales that typically don't get mentioned but overall what matters is we are taking the human performing exercise into account rather than just saying "add fahve" each week. Are you familiar with the Acute:Chronic workload ratio - I'm not a fan of Tim Gabbett's generalized "sweet spot" idea via concrete numbers but I think as a heurestic for programming and reducing injury risks - it's a good approach. See: https://bjsm.bmj.com/content/50/5/273

Happy to discuss more.

Hey Mike, thanks for your response.

I was not aware that training load could be differentiated into internal and external load, nor of Gabbett's acute:chronic workload ratio, so thank you for that--it led me down an interesting rabbit hole. I think part of the confusion, to me at least, is that some of the scientific papers I've looked at throw around training load without a clear indicator if they are looking at internal/external load (or subjective/objective load or absolute/relative load, which Eckard notes in his paper are different measures of training load).

You noted in your response to me that the general premise is to reach a max effort for the training sessions--isn't this essentially saying to hit a session RPE of 10, which is what you guys say not to do in that podcast? See timestamp 35:00 in the video I linked above for the statement I have in mind. Wouldn't consistently hitting session RPE's of 10's lead to going outside this "sweet-spot" and contribute to long-term fatigue, which will increase injury risk? In my opinion, the template will yield consistent session RPE's of 10, since it is prescribed that each exercise should hit a RPE of 10 for the final set (at least for phase 1 and phase 2).

Let me know if anything is not clear, still trying to wrap my head around this stuff