Knee Rehab Template

[ceramique.soigne0l]

Hello Dr Ray,

I’m an olympic weightlifter suffering from bilateral quadriceps tendinopathy for over two years now. After many rehab modalities that were mostly unsuccessful, I’m currently slightly improving with the current protocol that I somehow put together:

- isometric single banded leg press, 3x60 sec with 2mn rest, every morning and every night where I don’t have a loading session
- tempo (3-0-0) squats with partial ROM (I try to go down to where I feel the pain, which is roughly parallel, whereas I used to really bury my squats), 3 sets of 5 reps, linear progression, 2 to 3 times a week
- tempo (3-0-0) split squats, 3 sets of 5 reps, linear progression, 2 to 3 times a week (alternating with the squats)
- RDL and snatch or clean pulls (these don’t bother my knees at all so I really do them to maintain pulling strength and power)
- no clean or snatch variation at all, although I keep jerking at those are well tolerated
- no more front squats as those really irritated my quad tendons
- GTN patches daily
- collagen+vitamin C 60mn before training (isos or loading)
- glycine+ZMA+boron+cissus before bed
- keto diet (most of the time…)
- I’ve also begun BPC-157 injections, not sure if it does anything…

After a loading session I usually have some flare up 7 to 12h after which gradually disappear after some time. I’m not sure I’m improving, it’s difficult to assess as there are variations between days, but I think there might be a slight trend for symptom reduction. Nothing exciting though.

I don’t really have a plan to return to clean and snatch for now, I want to lower my symptoms first. Eventually I guess I will start with muscle snatch, drop snatch, power variations, etc.

I’m considering buying the template, but I have some questions first if I may:

1) I think my tendinopathy is triggered by compressive loading, as the pain really only comes when I pass the parallel while squatting, and then disappear at the very bottom of the squat. Looks like it’s basically the quad tendon being smashed against the patella which get damaged and/or irritated. Would this template work for adapting to compressive loading, or would this require different principles?

2) As you can see I’m currently loading with sets of 5, almost daily, alternating everyday between split squats and squats to parallel. Would your template requires me to change this volume and scheme drastically, or should I instead adjust from what I’m currently doing?

3) You mentioned on several occasions that you were looking into releasing a template for oly lifters… is it still a project of yours? (I would obviously be highly interested!) Otherwise, would the current template somewhat be applicable, at least partly, to my objectives?

Thanks!

[Michael Ray]

Thanks for the questions. I recommend a consultation before starting the template so we can work through some of your concerns.
You can also check out this guide: https://www.barbellmedicine.com/blog...-tendinopathy/

1) Yes, the template will adjust dosage of activity to tolerance and afford options for exercise selection.
2) The template is a general guide to help manage through symptomatic movements. Folks are free to adjust at their discretion, albeit I advise following the template as written as much as possible. 5s is a rather low volume which often affords higher intensities, something we typically seek to regulate in symptomatic stages.
3) Yes, this is still in the game plan. I need to figure out if we want to release a general olympic weightlifting template for re-introducing clean and jerk and snatch movements or add-ons for each joint rehab template.

If you'd like to have a consult, please follow this link: https://www.barbellmedicine.com/shop...on-management/

[ceramique.soigne0l]

Michael,

Thanks for your answer!

1) Ok, so I guess this means tendinopathies triggered by compressive loading are not fundamentally different from those triggered by stretching, at least when it comes to treatment? (I have to admit, part of me hoped for a different answer — this might have explained why I was not making significant progress!)

2) Ok, so I understand it’s better to reset all of my routine.

3) Great news! Whatever the form it takes, I would be interested. Is there a way to be kept informed? Will you announce it in this thread?

Thanks again!

[Michael Ray]

1) Correct, the approach is the same.
3) Yes, we will make an announcement.

Of course, happy to help.

[Dolphson]

Hi,
I have just started the knee rehab program and am worried about how to integrate it with basketball. Currently I play 2 days a week and it seems to be a trigger for knee pain so think I may have to take games off. If I do decide to take games off, should I try doing 1 game per week see if it's tolerable or just go to 0. And for how long should I stop playing, is this time period just based on symptoms similar?
My main goal is to get back to basketball without pain while progressing through the squat. Recently I have realized there is a small lump (bigger on the right but still present on the left knee) my though was this was bursitis. A condition I didn't see in the template overview. Is it worth checking for bursitis (with a scan) or would this have the same treatment either way?

[Michael Ray]

Hey, thanks for the questions. We'd need a consultation to give specific advice. Generally speaking I would remove high volume and high intensity sport specific activities (e.g., basketball). Then as symptoms began resolving, slowly layer back in fundamentals of the sport (e.g., jumping, running) before transition to practice and then finally competition.

Bursitis - yes, the template would be appropriate for such a scenario.

[domitar]

Hi Dr Ray,
I had a couple of questions on phase 3 (49yo, 175# , 5’11" medial chondral lesion of the femur, advised against surgery, repeat beginner level).

First of all thank you as I saw good progress in phase 2.. tolerable level of pain now with substantial increase in stability and strength.

1. introducing HIIT. So far I’ve only done LISS RPE 6/7 and nothing dynamic. Phase 3 plans for HIIT at ‘all out’ effort (RPE 10). I’m a bit cautious on going straight to RPE 10 on either rowing or cycling…should I start with a non knee bearing workout such as swimming sprints or maybe start at rowing/cycling at RPE8?

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2. ’Id like introduce ‘return to sport’ (recreational tennis) in phase 3 [shuffles, cariocas, ladder drills etc starting at RPE 5/6 and going up over 5/6 weeks to cooperative hitting]. Any suggestion on how to titrate return to sport vs HIIT /LISS.? By starting at low intensity/ dosage should I just add on to a LISS workout? Once drills become meatier I could use them at my actual cardio, Or would you recommend a more cautious approach ?

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3. Unilateral vs Bilateral movements in phase 3l. Based on single leg press/leg extension at RPE 8, my injured leg strength is approximately at 85/90% of the other . However on more complex movements (box squats 12/14”) I can still see a decent difference in stability/ fluidity of the movement. Would you keep one of the squat movements in phase III as unilateral, or is it something that will solve by itself over time?

Thank you in advance!

[Michael Ray]

Thanks for the questions. Glad to hear the template has been helpful.

1) I think it's fine to layer in the activity you want to train via HIIT, but starting at a lower RPE is reasonable.
2) I usually follow a return to sport approach of fundamentals -> practice -> competition. Introduce components of the sport (fundamentals) first then practicing the sport and finally competition. A consultation would help us work through this a bit more.
3) I'm fine with keeping a unilateral movement in the mix for phase 3.

No problem!

[domitar]

Thanks !

Consult is a good ideas .As I need some input on programming trying to balance strength training, cardio improvement, return to sport (and then actual play) and maintenance from old injuries all on a protein restricted diet that’s not helping my recovery.


do you still have an intake form as my (medical) history is pretty messy.

[Michael Ray]

Yes, happy to help. Please follow this link: https://docs.google.com/forms/d/12hL...6n3IBidgw/edit

[kampingal]

Dr. Michael,

I am a S&C coach and KB instructor but I have been mostly in the office for the past 2 years due to low back. Since I learned of BBM I have been able to slowly get back to lifting more than light weight. Making great progress for the first time in many years. Thank you all for all the content you put out!!!

Wondering if the knee template will give me options to keep working on increasing my deadlift strength significantly? The deadlift does not seem to bother my knee. I'm assuming that a knee rehab program would not have anything that would be contraindicated for my low back.

Background: Knee is a long time issue. Had a scope on it aout 8 years ago to drain swelling and "clean" it up. No official diagnosis. "Avoid squatting and running and this should last you about 5 years." That's all I got from surgeon. My knee did do quite well for many years. I competed in PL and had a max squat of around 200 and DL around 270 (49 yr old female, 5'5"150 lbs) but I had some serious setbacks with low back about 5 years ago and never fully came back from repeated bouts of trying to rehab it. My last workout I lifted 105# for sets of 10 sumo DL. Still modest but such a huge accomplishment for me. When I used bulgarian squats last month, no knee issues at all. When I added bilateral and just a day of very little interval running my knee started screaming, mostly at night when trying to sleep. It's a deep aching sort of pain, sometimes sharp pain in the kneecap going up or downhill. I tried nixing the run but it still hurts after squatting.

Thanks! Kathy

[Michael Ray]

Hey Kathy! Thanks for the questions. I think a consultation would likely be more beneficial in this scenario. If you are interested, please complete our intake paperwork here: https://docs.google.com/forms/d/e/1F...ilUWA/viewform

[kampingal]

Hi Michael, I completed the consult form. Please let me know when you get a chance to review. Thanks!

[Jungle Dave]

Hi, I've been treating a tendonosis in the Pes Anserine area for... well, more than a couple of years.

Been using the knee rehab template for most of this time.

I've squatted, deadlifted, and for unilateral movement, leg extension.

It's taken me this much time to get to phase three.

I recently found if I did leg curls, I recruited the area in question far more than the above movements. And yes, it's painful.

Would it be advisable to apply the protocol to this movement in order to desensitise and strengthen the problematic area, would this be a more effective choice of exercise than say, the leg extension or the squat, which gives me no pain during the actual movement? (these patterns can still hurt afterwards especially if RPE 8 or more- and I've been pretty inefficient at this process by anyone's standards, feels like I'm missing something obvious)

[Michael Ray]

Hey, thanks for the questions. It is difficult to give detailed insight without talking with you further in a consultation. However, based on the information here, I'd be fine with implementing leg curls to tolerance, especially if you are noticing a strength deficit side to side.

[Jungle Dave]

Hello Michael, thanks for your prompt response.

I will certainly invest in a consultation at some point, especially should I end up having to return to phase 2, I'll be 50 in a couple of years and I really need to get that squat and deadlift into a more sensible place.

I'd have weighed in for a consult before now but been self employed, covid, yadda yadda yadda...

Nice and gentle curls it is then.

[Jungle Dave]

By the way, I've had other injuries that I've treated with barbell medicine protocol, and had really speedy results. Especially after tweaks.

Thanks for all the resources you lot have offered up over the years.

[Kharris996]

Hello Doctors,

I am an avid cyclist that trains in powerlifting and weightlifting.

I was diagnosed with patellar tendiniopathy and it’s been really hard to get back to cycling. Anyway you guys can help with that? I know the knee template is not designed to get you back to endurance.

or should I do a consult?

[Spam man]

Hi Michael
Hope you are well.

I am most likely going to book in a consultation with the team, but thought I'd ask here too. I recently dislocated my patella in one knee, and was diagnosed with a shallow and dysplastic trochlear from an MRI scan.

I was essentially wondering whether this template is suitable for a 'mechanical' issue such as this - according to the scan all of my connective tissues and ligaments appear intact apart from minor injury to the patellar tendon which is apparently normal following a dislocation.

Thanks very much in advance for any insights you can provide!