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  • Originally posted by physiatry111 View Post

    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
    Correct - we are discussing consistently hitting session RPE 9 - 10 may not be the best approach to training in the long run. I think the disconnect here is we are discussing athletes operating at their normative training capacity, which is different when rehabbing through an issue and accounting for symptoms. The template is likely well below the capabilities of most athletes for most of the prescribed exercises given they are completing the template for a variety of issues such as: symptomatic tendinopathies (quad and patellar) and PFPS and we are regulating other variables as mentioned above (tempo, volume, external intensity, etc). I would not recommend every session ever completed by an athlete functioning at normative capacity be at session RPE 9-10 and given what we know about how fatigue functions - this likely isn't realistic nor possible. We have also not discussed the types of load vary in the template compared to normative training. For example, phase 1 isometrics is a very different stimulus than phase 2, and the sped up pacing of phase 3.

    Recall - I also said a generalized "sweet spot" likely doesn't exist.

    Let me know what other questions you may have.
    Last edited by Michael Ray; 08-17-2019, 10:30 PM.

    Comment


    • Originally posted by Plifter View Post
      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
      Hey Plifter - thanks for providing background about your history and sorry to hear about your situation. I do not think a template would be beneficial for your situation. There are several narratives you've discussed that aren't well supported and have likely contributed to some not so great beliefs and then learned responses to exercise and activity. A consultation with us would likely be more beneficial but I do want to caveat this with - our discussion (regardless if you talk with Derek or myself) will likely be very contrasting to what you've been told thus far. We are happy to help though and nothing you've said thus far makes me think there's a reason to avoid loading of your knee. https://docs.google.com/forms/d/e/1F...ilUWA/viewform

      Comment


      • Originally posted by pia501 View Post
        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
        Gotcha pia501 - sorry to hear that. I know it may feel defeating right now but this doesn't have to be the case. We will be on the lookout for your intake questionnaire.

        Comment


        • Originally posted by Michael Ray View Post

          Correct - we are discussing consistently hitting session RPE 9 - 10 may not be the best approach to training in the long run. I think the disconnect here is we are discussing athletes operating at their normative training capacity, which is different when rehabbing through an issue and accounting for symptoms. The template is likely well below the capabilities of most athletes for most of the prescribed exercises given they are completing the template for a variety of issues such as: symptomatic tendinopathies (quad and patellar) and PFPS and we are regulating other variables as mentioned above (tempo, volume, external intensity, etc). I would not recommend every session ever completed by an athlete functioning at normative capacity be at session RPE 9-10 and given what we know about how fatigue functions - this likely isn't realistic nor possible. We have also not discussed the types of load vary in the template compared to normative training. For example, phase 1 isometrics is a very different stimulus than phase 2, and the sped up pacing of phase 3.

          Recall - I also said a generalized "sweet spot" likely doesn't exist.

          Let me know what other questions you may have.
          Thanks for your response Mike! Going to unload some questions on ya...

          1. In Gabbett's research, he calculated an acute:chronic workload for both internal and external load--internal using session RPE, and external as the number of bowls bowled (in his study on bowlers and injury). In the template, I noticed that the acute:chronic workload only calculates internal load (if I understood the excel equations right). Is there a reason you omitted calculating an acute:chronic workload ratio for the external load in the template? From Gabbett's research, he seems to have concluded that large acute doses of both internal and external loads relative to chronic loads leads to injury.

          2. You mentioned that you're a bit skeptical of Gabbett's "sweet-spot" idea. Why is that? (I'm genuinely curious if there's some sort of issue with his research that I just can't see)

          3. You mentioned that the loads vary in the template. What effect does this have as compared to keeping the same kind of load throughout? (i.e. just doing isometrics through all 3 phases)

          4. You mentioned fatigue--I'm curious what your thoughts are. One of the articles I read earlier, "Monitoring Training Load to Understand Fatigue in Athletes" (https://www.ncbi.nlm.nih.gov/pmc/art...MC4213373/#CR1), mentioned the following:

          It is the uncoupling or divergence of external and internal loads that may aid in differentiating between a fresh and a fatigued athlete.

          What do you think of this statement? What are your current thoughts on fatigue and its relationship between load and injury risk reduction? Is there any good research you could point me to regarding any kinds of relationships between fatigue, loads, and injury risk reduction?

          Thanks again!

          Comment


          • Originally posted by physiatry111 View Post

            Thanks for your response Mike! Going to unload some questions on ya...

            1. In Gabbett's research, he calculated an acute:chronic workload for both internal and external load--internal using session RPE, and external as the number of bowls bowled (in his study on bowlers and injury). In the template, I noticed that the acute:chronic workload only calculates internal load (if I understood the excel equations right). Is there a reason you omitted calculating an acute:chronic workload ratio for the external load in the template? From Gabbett's research, he seems to have concluded that large acute doses of both internal and external loads relative to chronic loads leads to injury.

            2. You mentioned that you're a bit skeptical of Gabbett's "sweet-spot" idea. Why is that? (I'm genuinely curious if there's some sort of issue with his research that I just can't see)

            3. You mentioned that the loads vary in the template. What effect does this have as compared to keeping the same kind of load throughout? (i.e. just doing isometrics through all 3 phases)

            4. You mentioned fatigue--I'm curious what your thoughts are. One of the articles I read earlier, "Monitoring Training Load to Understand Fatigue in Athletes" (https://www.ncbi.nlm.nih.gov/pmc/art...MC4213373/#CR1), mentioned the following:

            It is the uncoupling or divergence of external and internal loads that may aid in differentiating between a fresh and a fatigued athlete.

            What do you think of this statement? What are your current thoughts on fatigue and its relationship between load and injury risk reduction? Is there any good research you could point me to regarding any kinds of relationships between fatigue, loads, and injury risk reduction?

            Thanks again!
            1. The majority of Gabbett's research is on field based sports and the usual metric he utilizes is Arbitrary Units = minutes of training (external) x sRPE (internal). This metric is questionable as it relates to being utilized in resistance training focused athletes, which is why I'm currently co-conducting a research study on the utilization of Gabbett's metric and our own for assessing A:C ratios efficacy for this population as it relates to incidence of injuries and performance markers through a six month prospective study. Our excel file does currently calculate AU similarly as we are extrapolating from this evidence available at this time, this may change in the future. Are you in our facebook group? We've actually had this discussion several times publicly. The knee rehab template utilizes an uncoupled A:C ratio, the prior 4 weeks of training are averaged to reach the chronic unit and then compared to the acute current session (the chronic does not include the acute, hence uncoupled). Some assert the ratio should be uncoupled; there was an editorial arguing this a year or two ago that I'd need to track down. At any rate - Gabbett appears to be claiming it doesn't matter (I've not read this yet - https://www.ncbi.nlm.nih.gov/pubmed/31291651). The template also tracks other external markers of loading (sets, reps, load, and tonnage for example). I think it pertinent to state - I've previously stated there are planned updates to this template and we do not postulate it is "perfect" rather a template (guide) to help those dealing with the aforementioned issues and wishing return to resistance training. The guide is subject to changes based on the totality of evidence on a particular topic, similar to our opinions on matters.

            2. The guy you want to look into is Franco Impellizzeri https://www.researchgate.net/publica...39;_are_flawed. He has valid arguments but I worry his apparent vendetta against Gabbett's profit off of this is clouding his critiques and will not be received well in academia. https://www.youtube.com/watch?v=mW-0C0I2mqM

            3. That likely wouldn't return someone who is a resistance training focused athlete to performing isotonic loading again. Context matters and the types of loads applied should be progressed to mimic current and future demands.

            4. This paper summarizes my current thoughts on fatigue: https://www.tandfonline.com/doi/abs/...PUyWvGssRyvgeQ. I also wrote a lengthy discussion on fatigue in the Barbell Medicine Monthly Review February edition.

            The statement in question - Fatigue is complex and appears to be multifactorial in nature (see above article). I do recommend monitoring both external and internal loads to athletes, however I'm of the opinion the subjective matters FAR more than the objective. We also need to accept the processes of either training or rehab are not linear but rather emergent - unfortunately neither process operates in a vacuum.

            5. You'd likely enjoy this article: https://www.dropbox.com/s/hhmkcxcwbj...sf6roTBug8uPus

            6. If you wish to continue this discussion, please create a separate thread as it is detracting from the point of this thread at this time. With that said, perhaps you can begin with a few questions you are seeking to have answered as it relates to this discussion and why. Happy to be of assistance but time is limited and this a rather large topic to dive down the rabbit hole. I also sense an undertone you have your own thoughts, beliefs, etc on this topic and I'd be interested in hearing those in the new thread.
            Last edited by Michael Ray; 08-19-2019, 05:53 PM.

            Comment


            • Hi,

              I am currently in week 6 of the template and I have a few questions:

              1. I used to have almost no symptoms when sitting/sleeping but I seem to have developed these during the course of the template, even though I seem to be having symptom relief otherwise. i.e. my knees don't feel as painful when i stand/walk for an extended period. Would you recommend modifying loading? would this be considered increased symptoms for over 24 hours?

              2. subjectively, it feels like I have dropped my load a lot (Less than half of what I used to do for the same number of reps), Should I not be concerned about detraining and embrace the process of rehab to where I drop the load even further?

              3. If I do drop the load, would you suggest going back up in the rep range? would that depend on the symptoms also? i.e. if am able to squat just 95 for 6 reps without aggravating my knees should I just continue to do that and try to slowly increase load at 6 reps or go back up in reps to where it feels like an RPE 10?

              4. I recently had to take some days off training for a camping trip and my knees felt a lot better after a 4 day break. I have not stopped training since the onset of symptoms; I deloaded at first and started the knee rehab template 6 weeks ago, but never stopped training. I was wondering if it would be worth taking some time off training until symptoms completely abate and then get back on the rehab template or if that would be counterproductive? As an aside, I have read and understand the pain science articles and fully subscribe to the data driven scientific method of doing things so I was unsure about what to do since it apperas that HSR is the best way to rehab.

              I apologize if these have been asked before, I tried reading through a lot of posts here and searching the forums but I couldn't find a definitive answer (maybe I suck at searching )

              Thank You!

              Comment


              • Originally posted by dkarthik View Post
                Hi,

                I am currently in week 6 of the template and I have a few questions:

                1. I used to have almost no symptoms when sitting/sleeping but I seem to have developed these during the course of the template, even though I seem to be having symptom relief otherwise. i.e. my knees don't feel as painful when i stand/walk for an extended period. Would you recommend modifying loading? would this be considered increased symptoms for over 24 hours?

                2. subjectively, it feels like I have dropped my load a lot (Less than half of what I used to do for the same number of reps), Should I not be concerned about detraining and embrace the process of rehab to where I drop the load even further?

                3. If I do drop the load, would you suggest going back up in the rep range? would that depend on the symptoms also? i.e. if am able to squat just 95 for 6 reps without aggravating my knees should I just continue to do that and try to slowly increase load at 6 reps or go back up in reps to where it feels like an RPE 10?

                4. I recently had to take some days off training for a camping trip and my knees felt a lot better after a 4 day break. I have not stopped training since the onset of symptoms; I deloaded at first and started the knee rehab template 6 weeks ago, but never stopped training. I was wondering if it would be worth taking some time off training until symptoms completely abate and then get back on the rehab template or if that would be counterproductive? As an aside, I have read and understand the pain science articles and fully subscribe to the data driven scientific method of doing things so I was unsure about what to do since it apperas that HSR is the best way to rehab.

                I apologize if these have been asked before, I tried reading through a lot of posts here and searching the forums but I couldn't find a definitive answer (maybe I suck at searching )

                Thank You!
                Hey dkarthik thanks for the questions.

                1. This happens in these scenarios, often with a particular sustained amount of time staying in the same position. If in clinic someone reported this to me, it's unlikely to alter my plan. Instead, I advise finding the threshold for tolerance in a particular position and then for now preemptively change the position. This should de-sensitize with time and works well with sitting issues. Sleep is a different story because often you won't pay it attention until you wake with symptoms. Hopefully once you are up and moving around the symptoms decrease. You can also do easy exercises like an isometric hold upon awakening that people anecdotally report helps knock symptoms down a bit.

                2. I wouldn't get too concerned with this. That's actually the point of the template - keep you training at a tolerable level rather than have a complete loss of baseline fitness by being inactive.

                3. No easy answer here. Instead try it and see how you respond. I'd probably stick at 6 reps and if you don't respond well then make rep range alterations.

                4. That's actually really common with tendinopathies - take time off, feel better, go back to activity and have increased symptoms because tendons like and need to be loaded. We do not recommend rest for tendinopathy situations as this would indeed be counterproductive to improving the area's tolerance to loading.

                No worries about the questions. If you continue to struggle with finding tolerable loading, I recommend a consult with us to help guide this path a bit more individually.

                Comment


                • Originally posted by Michael Ray View Post

                  Hey dkarthik thanks for the questions.

                  1. This happens in these scenarios, often with a particular sustained amount of time staying in the same position. If in clinic someone reported this to me, it's unlikely to alter my plan. Instead, I advise finding the threshold for tolerance in a particular position and then for now preemptively change the position. This should de-sensitize with time and works well with sitting issues. Sleep is a different story because often you won't pay it attention until you wake with symptoms. Hopefully once you are up and moving around the symptoms decrease. You can also do easy exercises like an isometric hold upon awakening that people anecdotally report helps knock symptoms down a bit.

                  2. I wouldn't get too concerned with this. That's actually the point of the template - keep you training at a tolerable level rather than have a complete loss of baseline fitness by being inactive.

                  3. No easy answer here. Instead try it and see how you respond. I'd probably stick at 6 reps and if you don't respond well then make rep range alterations.

                  4. That's actually really common with tendinopathies - take time off, feel better, go back to activity and have increased symptoms because tendons like and need to be loaded. We do not recommend rest for tendinopathy situations as this would indeed be counterproductive to improving the area's tolerance to loading.

                  No worries about the questions. If you continue to struggle with finding tolerable loading, I recommend a consult with us to help guide this path a bit more individually.
                  Thank you for the detailed and considered reply! I will indeed consult with you if I need more help.

                  Comment


                • Hi Mike,

                  I'm at the start of week 10 of the template for quad tendonitis and for the past 3-4 weeks I've been experiencing a sharp pain in my right knee (around the top of the fibula) when applying resistance roughly at or below parallel. The pain will usually go away after "warming up" but return when "cold". This has caused me to consciously and subconsciously use my left leg more in day to day movement and I feel the symptoms in that knee have begun to increase more that usual. Do you have any recommendations for how to deal with this?

                  Thanks,

                  David

                  Comment


                  • Originally posted by Swarles View Post
                    Hi Mike,

                    I'm at the start of week 10 of the template for quad tendonitis and for the past 3-4 weeks I've been experiencing a sharp pain in my right knee (around the top of the fibula) when applying resistance roughly at or below parallel. The pain will usually go away after "warming up" but return when "cold". This has caused me to consciously and subconsciously use my left leg more in day to day movement and I feel the symptoms in that knee have begun to increase more that usual. Do you have any recommendations for how to deal with this?

                    Thanks,

                    David
                    Hey Swarles sorry to hear about the recent spike in symptoms. If you are finding symptoms are increasing during activities of daily living then I'd likely make adjustments to programming. If you are noticing symptoms increase at a specific range of motion then perhaps try and stay above that range for a week or two and then slowly increase the range of motion. I'm assuming this is with squatting so for example if you notice increased symptoms at or below parallel then implement a depth cue via a box squat and stay just above that symptomatic range and then slowly increase range in the subsequent weeks. Make sense?

                    Comment


                    • I have just purchased the template and have done the first two days! Definitely cursing you throughout the sets of 15, but I am excited to be pain free and to have better supported knees

                      A potentially very basic question - typically for RPE 10 (or RPE 8+) squats and deadlifts, I would be using a belt. Should I be going beltless for these workouts in order to make sure that my lower body is working as much as possible (as the belt normally makes things feel easier), or is it okay to continue using a belt, especially because it helps me keep my trunk engaged?

                      Comment


                      • Hi, I’m a 22 y/o 6’4 230lbs male.

                        Since I had a partial meniscectomy on my ‘left’ knee, i get some quad tendon issues on my ‘right’ knee. I’ve dealing with this on my own for about 2yrs now. But the symptoms get better or worse time to time. It never goes away. I can low bar squat for 315lbs for 3 reps now but after I squat around my 1rm, I can feel sharp pain right above my knee cap on very next day. But weird thing is I feel ZERO pain when squatting, runnning, playing basket ball. I only feel pain when I do movements like lunge(single leg movement) . So, the pain usually comes when I go up and down the stairs.(single leg movement in life) And plus, pain get worse when knee travels forward to the toes(such as heel elvated squat). So I feel more pain when going up the stairs than squatting. This is hard to understand for me. I can deadlift for 400lbs, squat for 315lbs with no pain at all. But just going up stairs with no weights feels like stabbing a knife in my tendon.


                        So, My question is 1) Is there any chance my pain goes a way within 16 weeks? I’m seriously worried because my injury has gone for a long period of time(2yrs) and now it became a chronic pain. And I need to get it done in 16 weeks because I have to join military in january. South Korea has a lot of mountains. Army should be able to climb mountains with heavy gears and rifle. No one climbs mountains with double-leg movement right? It is natural for humans to climb mountains with single leg movement which is painful for me. So is it possible? Can I make my tendon tolerable to these climbing things in 16 weeks? Are there any cases like me?

                        Thank you for reading this. Hope you reply me.
                        Thanks.
                        Last edited by Republic of Korea Army; 10-15-2019, 12:11 PM.

                        Comment


                        • Michael Ray
                          Michael Ray commented
                          Editing a comment
                          Apologies for the delayed response. I missed seeing your post when previously responding.

                          1) I can't answer this as it's dependent on innumerable variables and case context. I rarely tell patients specific timelines such as that and try to give general guidelines and expectations about pain but usually say something to the effect of "This is like looking into a magic 8 ball". My larger concern is helping instill self-efficacy in the individual to self-manage if pain re-occurs (since it is a part of life). Usually we can get people progressing towards their goals during such a timeframe though. Hope that helps.

                          I understand the time constraints you are placed under and I'd be willing to say it's likely we can help you cope with your symptoms, get some symptom regression when we manage loading of the area, and try and progress you towards activity goals - whether that's in time to meet the military's demands, I do not know. I suggest getting a consult with us to help guide this path. Happy to help.

                      • Hey Michael,

                        I really only get knee pain when squatting or leg pressing. Is it recommended that I follow the template exactly and only dead lift when instructed in the later phase?

                        Comment


                        • Hello,

                          If at week 12 i have an increase of symptons should i transition to phase 3 ? Or maybe redo a week of 6's ? Or go back to 10's ?

                          Thanks for your response.

                          Comment


                          • Originally posted by 18conhea View Post
                            I have just purchased the template and have done the first two days! Definitely cursing you throughout the sets of 15, but I am excited to be pain free and to have better supported knees

                            A potentially very basic question - typically for RPE 10 (or RPE 8+) squats and deadlifts, I would be using a belt. Should I be going beltless for these workouts in order to make sure that my lower body is working as much as possible (as the belt normally makes things feel easier), or is it okay to continue using a belt, especially because it helps me keep my trunk engaged?
                            Thanks for purchasing the template. Using a belt is fine.

                            Comment

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