Hi. This might be long, so I’ll try to break it up as best I can.
Background
Male 49. August 2018 had pulmonary vein Isolation catheter ablation for paroxysmal Atrial Fibrillation. The AF had made life unbearable for the 18 months prior to surgery. Training was impossible. Gained a lot of weight. Post surgery I ran an LP. Then discovered BBM content and have run it from November 2018 until now with a focus on fat loss (mostly hypertrophy II and PBII templates) Down from 111kg to 83kg, 116cm to 91cm waist. Planning to continue to at least 33”/84cm.
Pain Issue
Bilateral knee and lateral thigh pain for several months now. I cannot pin-point exactly when it all started, but I first realised something was off around October last year when I noticed warming up for squats was very painful from the very first set, and even standing up from sitting was painful. My thighs ached constantly during stationary bike GPP. It felt “wrong” compared to any bike cardio I had done in the past, but I thought I was just “out of shape”
The pain only occurs on squatting movements (including single leg squats, lunges etc). No pain on any deadlift movements. Knee extensions, walking, unresisted leg movements are all fine. No pain at rest.
Specifically, the pain occurs along the entire outer thigh of both legs, pretty much in the area of the ITB. The pain only really exists through a small range of motion just above and below 90 degrees. Clearly worse on the right leg during unilateral movements, but I cannot differentiated during bilateral.
I haven’t yet had any formal diagnosis, since I wouldn’t expect it to change any treatment, but I guess at some point it might be helpful?
What I think has happened
I’ve devoured BBM’s content on pain, and looked further into Lorimer Moseley’s stuff. I feel I have a decent understanding of the biopsychosocial model of pain. I also realise that understanding the model does not mean I am automatically immune to the effects of negative narratives or inputs.
Overall, I suspect I had lost track of what was “normal” in regards to knee pain/mobility through my period of inactivity and obesity during AF. I’m quite sure it was a loading issue that I allowed to go unchecked too long.
My thought is that I have now become hypersensitised to squatting movements and have developed a kinesiophobia. I don’t want to squat down at all in everyday life. Standing up from a chair is unpleasant. I experience a mild apprehension before a bodyweight squat. Once I pass below the ROM where pain occurs, I experience a similar apprehension before rising back through the painful ROM.
I don’t think I have injured anything or there is any tissue “damage” but I do understand there may be tissue changes that can be treated through appropriate programming changes.
What I have done
Long before this was an issue, I was initially squatting with an SSB but swapped all squatting to a belt squat machine in April 2019 for separate reasons.
Starting from November 2019 I modified programming to add 303 or 530 tempos to all squats which perhaps helped a little but not enough. February 2020 I started the knee rehab template. I’m about to start week 9. Knee pain has basically gone, but the tight lateral thigh pain has only become a little more tolerable overall. Recently, however, the pain has been higher on the first 1-2, sometimes 3 warm up sets (RPE 5,6,7) than it was earlier in the program.
So far on the knee template, once warmed up, the thigh pain is almost gone. At the very least, my pain threshold has been significantly lifted and kinesiophobia all but gone for the rest of that workout.
What I think I should do
Given the recent increase in sensitivity, I did not feel ready to drop reps to 6 for squats (deadlifts went fine) I suspect that I’ve just pushed loading a little too much too soon.
I returned to isometric squats for my last main lifting day. On the in between days, I’ve started partial body weight squats moving just through the painful ROM for 5 sets of 45s. My thought is that I need more exposures to raise the pain threshold without too much loading. I plan to use the biofeedback test perhaps a little more strictly and restart with a week of 15s and re-evaluate from there.
Single leg has been a challenge from the start, especially once I hit phase 2. I simply didn’t have the leg strength or endurance to manage anything for 15 reps on both legs at tempo, so I settled on leg extensions. These were pain free (perhaps too much so) and more practically loaded to hit prescribed RPEs. My only concern was that even though they were pain free, they were also too different from the movement which caused issues such that they had no effect on the pain threshold. I’ve recently experimented and found band assisted pistols can work.
The one thing I have not attempted yet is to perform partials. My understanding is that the programming changes implemented to deal with pain have 2 concurrent goals – to modify the biopsychosocial inputs that help to create the pain experience, and to appropriately stress the tissues to deal with any pathological changes. My concern with partials is that avoiding the painful ROM might reinforce my kinesiophobia and thereby lower my pain threshold.
Question
Having got this far, I realise I don’t really have a specific question – mostly, I’m wondering if I’m on the right track, or if there’s anything I might have missed or not considered? Should I seek a formal diagnosis? I do understand it’s a process and I’m content with it taking a while.