Knee Rehab Template

[Michael_Ray]

@sooghs

Good evening Dr. Ray,

Thank you and the rest of the Barbell Medicine team for your incredible work in synthesizing this beautiful template. I am eager to learn the from the rehabilitation principles and methods you all used in designing it.

My question is, would such a template be suitable for someone recovering from a partial knee fracture?

The person of interest is a 60 year-old woman who strength trains recreationally while more keenly pursuing other activities, such as hiking, biking, etc. She is currently out of her cast (no surgery) and pursuing the road back previous levels of strength, pain, and function.

Many, many thanks!

Hey, what fracture occurred and how? Is the person scheduled to attend rehab at a facility? What information has she received from her current provider regarding return to activity? Potentially the template would be helpful but I’ll need the above information and potentially a consult to speak more confidently about the matter.

[Marouane]

Hi Michael Ray, I just bought yesterday the knee rehab template, and I have a few questions.

I was diagnosed with patellar tendinopathy in both of my knees which I got about a year ago from running starting strength LP and not paying attention to my fatigue levels (with hindsight, I went from squatting once per week to 3 times per week, my knees weren’t able to adjust).

Before buying the template, I was already doing a modified version of the Hsr protocol (https://onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0838.2009.00949.x) plus one session per week with a PT. I only did 2 sessions per week and on only squats (high bar) because I didn’t want it to add up to too much because of the PT session (he makes me do ketbell squats, lunges, small jumps stuff like that) .

My question : last session I thought about squatting normally (without a tempo and below parallel) to see how it felt, and it felt good. I had no pain in my knees (while I had some with a HSR style squat) and I still have no extra pain 2 days afterwards.

1. Can I run the knee template phase 2 program with a regular squat (since it doesn’t cause me pain) and the other exercises or do I have to do the Hsr one?

Does a HSR style squat promote faster healing ?

Thank you for your time and attention.
​

[Jungle_Dave]

@Michael_Ray

Hey Jungle Dave,

Thanks for purchasing the template and glad you like it.

Exercise selection was programmed for the needs of strength-based athletes and what we typically see in the literature for HSR for the knee. Squatting and Deadlifting are a part of the templates but we’ve also included single leg exercises because that’s how we see it in the research typically. Anecdotally the thought here is to ensure we are driving adaptation to the symptomatic extremity with single leg exercises.

Sorry to hear about missing out on the sale. Email: support@barbellmedicine.com and perhaps they can help you out.

All sorted. Thanks again. Template is excellent- been enthusing about it to my 74 year old Dad who has been lacking knee cartilage since he was 19, I’ll let you know if I have any luck getting him running again…

[Michael_Ray]

@Marouane

Hi Michael Ray, I just bought yesterday the knee rehab template, and I have a few questions.

I was diagnosed with patellar tendinopathy in both of my knees which I got about a year ago from running starting strength LP and not paying attention to my fatigue levels (with hindsight, I went from squatting once per week to 3 times per week, my knees weren’t able to adjust).

Before buying the template, I was already doing a modified version of the Hsr protocol (https://onlinelibrary.wiley.com/doi/…8.2009.00949.x) plus one session per week with a PT. I only did 2 sessions per week and on only squats (high bar) because I didn’t want it to add up to too much because of the PT session (he makes me do ketbell squats, lunges, small jumps stuff like that) .

My question : last session I thought about squatting normally (without a tempo and below parallel) to see how it felt, and it felt good. I had no pain in my knees (while I had some with a HSR style squat) and I still have no extra pain 2 days afterwards.

1. Can I run the knee template phase 2 program with a regular squat (since it doesn’t cause me pain) and the other exercises or do I have to do the Hsr one?

Does a HSR style squat promote faster healing ?

Thank you for your time and attention.
​

Yeah, this is a really good question and I’m not sure I have a great answer right now. There are several factors that seem important to mention when discussing tendinopathy interventions:

1. Symptoms are a part of the process - meaning if HSR does cause you discomfort then that is ok but we wouldn’t want baseline symptoms severely increasing and leaving you feeling debilitated.
2. I tend to like HSR because it allows for regulation of loading by performing a tempo pace which typically mitigates trying to increase external intensity (load being lifted) quickly but allows for internal intensity (RPE) to stay higher and leave the person feeling as though they are training.

Now for the tricky points…

3. Can you continue the template on without using tempo work? Maybe, I don’t think supportive evidence exists that says you can’t or shouldn’t. With that said, my concern here is the premise will be concerning oneself with load being lifted rather than embracing the process.

4. We can likely get symptom mitigation with a multitude of muscle contraction types (isometric, concentric and eccentric, and eccentric only) but whether this provides long term positive outcomes is likely a different discussion.

We know we are making adaptations to the area with higher magnitude loads and over longer periods of time (>12 weeks) - whether these adaptations mean morphological, mechanical, or otherwise and to what extent it matters - we can have a very long nuanced debate over and I’m not sure it would be clinically meaningful for the patient (decreased symptoms and return to function/play). Here’s an article I like that we discussed on a previous podcast with Jason Eure:

Podcast: http://www.clinicalathlete.com/clini…for-the-donuts

Bohm et al: Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults - PMC

As an aside - I will look into this more and see if I can provide a better answer.

[Marouane]

Thank you Michael Ray for taking the time to answer my questions.

​​​​​​I like this particular point of yours: “With that said, my concern here is the premise will be concerning oneself with load being lifted rather than embracing the process.”

I will keep it in mind while going through the process and not try increasing the weight just for the sake of increasing it.

I will also try another session this evening (I liive in France and it is morning right now) with a regular squat and I will keep you posted.

[PanosP]

Hello!

I’m going to start the knee rehab template next week (I’ve diagnosed with patellar tendionpathy a few months ago). I have 2 questions.

1. Can I change the 2 bilateral movements in the middle of Phase 2? For example first 6 weeks with HB Squat and Conventional Dl and the rest 6 with LB Squat and Sumo DL? I’m in the off season (next meet I’ll compete will be on May, so I want to include some different variations every few weeks.
2. Can I add some more lower body exercises (like in the format of your 7 wk hypertrophy program) like SLDL,GM with minimal knee flexion or RDL? I also want to add some kg on my BW and I’ll be on a slight surplus so I’d like to add some more stimulus!

Thanks in advance!

[Michael_Ray]

@PanosP

Hello!

I’m going to start the knee rehab template next week (I’ve diagnosed with patellar tendionpathy a few months ago). I have 2 questions.

1. Can I change the 2 bilateral movements in the middle of Phase 2? For example first 6 weeks with HB Squat and Conventional Dl and the rest 6 with LB Squat and Sumo DL? I’m in the off season (next meet I’ll compete will be on May, so I want to include some different variations every few weeks.
2. Can I add some more lower body exercises (like in the format of your 7 wk hypertrophy program) like SLDL,GM with minimal knee flexion or RDL? I also want to add some kg on my BW and I’ll be on a slight surplus so I’d like to add some more stimulus!

Thanks in advance!

Hey! Thanks for purchasing the template.

1. Yes, this is fine but you may notice alterations in the loads you’ve been lifting when you make changes to exercise selection. Just something to be cognizant of.
2. Yes, you can add exercises but I’d be cautious as tendinopathies are load based issues (volume and/or intensity). Adding exercises will increase loading to the area, not a bad thing necessarily - again just something to be cognizant of. Regarding specific exercises - can you type out the name of the exercises you abbreviated (to ensure we are discussing the same things).

[Marouane]

Hi Michael, I just did yesterday the third session of week 2. But I think there might be a confusion with people who start the program. It certainly happened to me.

Let me explain:

In the instructions, it says that the frequency is 3 times per week. So I went to the gym 3 times per week this past week ( 2 days with ISOINERTIAL exercises and in between a day with isometric exercises), thinking that I finished one week of phase 2.

Only today I realized that the isometrics don’t count in the frequency, so I am still missing one day of ISOINERTIALs.

So in my opinion, it should say in the instructions that the frequency is 5 times per week (which is a lot, I am not sure I can find time to go 5 times to the gym per week)

Can we skip the isometric days, or do them at home (wall sits for instance), so we only go 3 times per week to the gym?

[Michael_Ray]

@Marouane

Hi Michael, I just did yesterday the third session of week 2. But I think there might be a confusion with people who start the program. It certainly happened to me.

Let me explain:

In the instructions, it says that the frequency is 3 times per week. So I went to the gym 3 times per week this past week ( 2 days with ISOINERTIAL exercises and in between a day with isometric exercises), thinking that I finished one week of phase 2.

Only today I realized that the isometrics don’t count in the frequency, so I am still missing one day of ISOINERTIALs.

So in my opinion, it should say in the instructions that the frequency is 5 times per week (which is a lot, I am not sure I can find time to go 5 times to the gym per week)

Can we skip the isometric days, or do them at home (wall sits for instance), so we only go 3 times per week to the gym?

Hey, thanks for the questions and the feedback. For phase 2, the isoinertial days are what matter; days 2 and 4 can be skipped and are NOT necessary. They are programmed in as a means to load the area for analgesic purposes if the person has an increase in baseline symptoms that remain 24 hours after training.

[jaylikessandwiches]

A friend of mine had his ACL surgically repaired two years ago and went through three or four months of pt after . He has not had any problems or pain since but is reluctant to return to strength training as he is unsure of how to get back into it . Would this be a good template for him. thanks

[Michael_Ray]

@jaylikessandwiches

A friend of mine had his ACL surgically repaired two years ago and went through three or four months of pt after . He has not had any problems or pain since but is reluctant to return to strength training as he is unsure of how to get back into it . Would this be a good template for him. thanks

This would likely help him return to lower body training in a controlled manner. He may benefit from a consult with us to help him implement the template and address any concerns he may have.
Contact Us | Barbell Medicine.

[handsomewizard]

Just purchased the template and I’m really impressed with the overall layout structure etc.

I have a question on exercise selection. I read that you suggested one bilateral movement be a squat and one a deadlift. Is there any issue with having two squat movements ie highbar + belt squat? I should note I compete in bodybuilding and not any strength sports- if that matters.

Also I’m familiar with every exercise in the lists there except for “Lift offs” I don’t see a video for it in the template either.

Finally, must the biofeedback test be a single leg pistol squat? I don’t think I could do that to 90 degrees in heeled shoes even when I was pain free haha. Is a bilateral bodyweight squat in olympic lifting shoes at tempo sufficient for this?

[Michael_Ray]

@handsomewizard

Just purchased the template and I’m really impressed with the overall layout structure etc.

I have a question on exercise selection. I read that you suggested one bilateral movement be a squat and one a deadlift. Is there any issue with having two squat movements ie highbar + belt squat? I should note I compete in bodybuilding and not any strength sports- if that matters.

Also I’m familiar with every exercise in the lists there except for “Lift offs” I don’t see a video for it in the template either.

Finally, must the biofeedback test be a single leg pistol squat? I don’t think I could do that to 90 degrees in heeled shoes even when I was pain free haha. Is a bilateral bodyweight squat in olympic lifting shoes at tempo sufficient for this?

Hey, thanks for purchasing the template.

There shouldn’t be an issue (especially if you are used to that many squatting type movements in a single session - although it could likely be argued perhaps not, but I don’t know your background).
Lift-offs likely depends on which sport you affiliate with. The term will mean something different in weight lifting. For our purposes think of these as rack pulls (which reflecting back on this - we likely should change the terminology). These can be done either in a cage rack and pulling from an elevated height or from blocks. The purpose- if you are struggling to get into the setup to pull from the ground and/or lower to the ground.

[handsomewizard]

@Michael_Ray

Hey, thanks for purchasing the template.

There shouldn’t be an issue (especially if you are used to that many squatting type movements in a single session - although it could likely be argued perhaps not, but I don’t know your background).
Lift-offs likely depends on which sport you affiliate with. The term will mean something different in weight lifting. For our purposes think of these as rack pulls (which reflecting back on this - we likely should change the terminology). These can be done either in a cage rack and pulling from an elevated height or from blocks. The purpose- if you are struggling to get into the setup to pull from the ground and/or lower to the ground.

Thank you for the reply

What about the biofeedback test ? Can I hold on to something or should I just keep going to whatever ROM I can achieve and hope that it builds over time?

[Michael_Ray]

@handsomewizard

Thank you for the reply

What about the biofeedback test ? Can I hold on to something or should I just keep going to whatever ROM I can achieve and hope that it builds over time?

Ooops, apologies for missing that question. Are you using a decline board or placing a plate under your heel?

[handsomewizard]

@Michael_Ray

Ooops, apologies for missing that question. Are you using a decline board or placing a plate under your heel?

Plate under the heels thus far (Or just in 3/4 inch oly shoes). I don’t have a decline board at either of the gyms I frequent unfortunately.

[Michael_Ray]

@handsomewizard

Plate under the heels thus far (Or just in 3/4 inch oly shoes). I don’t have a decline board at either of the gyms I frequent unfortunately.

Make sure you are using a high enough plate (likely a 35# or 45# bumper) to angle the heel well above the toes. This will counterbalance you and allow the ability to more easily get into the recommended range of motion. Ideally, try and go as low as you can while maintaining balance. It’s just a load tolerance test for biofeedback to see if you need to adjust loading or not. Lifting shoes alone is not likely sufficient enough of a heel lift.

[AndyDublin]

Hi Michael,

You linked to this article on lack of evidence for arthroscopy for meniscal tears a few months back (Loading...). Would this knee template be suitable for someone with a meniscal tear? Meniscal tears aren’t listed as one of the indications for using the template.

Thanks

[Michael_Ray]

@AndyDublin

Hi Michael,

You linked to this article on lack of evidence for arthroscopy for meniscal tears a few months back (Loading...). Would this knee template be suitable for someone with a meniscal tear? Meniscal tears aren’t listed as one of the indications for using the template.

Thanks

If someone presented to my clinic with the diagnosis of “meniscus” related knee pain/dysfunction - there are few cases I can think of that I wouldn’t apply a very similar approach to with this knee template. I’d likely need a consult to give more individualistic advice on this topic. Contact Us | Barbell Medicine.

[bluesboy5]

If someone has torn their ACL and has chosen not to have surgery, would the knee rehab template be a good choice for them.