Quad Atrophy and PFPS

Medical Q&A [Moderated]
1

My name is Carl. 33yo, 6’1" 208 lbs. In 2010 I had a tear in my meniscus that went untreated for some time, and as a result there was significant atrophy in my left leg. I believe about 5-7 cm. Since then there has always been some but I haven’t tracked it. I was always active but not doing any consistent programming. In the last year or two I picked up A. Thrall beginner template and started squating, benching, and DL regularly. I am now on the bridge the second time through. After starting to squat more regularly with structured programming I have noticed good squat improvements and strength improvements in both legs. I had heard your (Barbell medicine team) recommendations that the best way to even out strength imbalances was just to train as usual and the affected limb, muscle, whatever would come along. I also think that the pain I do have is pretty benign, meaning it does get inflamed from high impact activities, but doesn’t seem structural. It really seems like classic PFPS.

As far as lifting goes, lately upon looking closer at my form its frustrating that I am still lacking some balance and having trouble with my speed on the way down ( I tend to want to go slower). I can feel the tendency to want to favor the one leg although I fight it, and i know that weakness in that leg is majorly holding my numbers back. I measured again, mind you circumference, and i still have nearly an inch difference in the two legs! I am assuming this is mostly in the quad. I was surprised because I have noticed a visual difference in both and figured it was much closer. Admittedly I haven’t been tracking this so I don’t know exactly how its progressed with respect to recent history. I have been reading some studies on PFPS and I have read Jordan’s Paper on PFPS, ‘Walk a Mile Buddy I & II’. One study I read brought to my attention how common atrophy in the affected leg is witih PFPS. It also talked about how the pain can help perpetuate the issue, where as I was only thinking of it in terms of still recovering from whatever started this years ago.

“One theory is that pain causes reflex inhibition of the quadriceps, which in time induces an atrophic response within the muscle with subsequent loss of muscle size”
Young A, Hughes I, Round JM, et al. The effect of knee injury on the number of muscle fibres in the human quadriceps femoris. Clin Sci 1982;62:227–34.

In general from ‘Walk a Mile…’ it seems like the recommendation there is to just build a base of strength before doing anything high impact. It also talks about a lot of treatments and the global set of circumstances it takes to give any one person PFPS. For me I think the atrophy in the left leg is most alarming. I am past novice phase and have, I think, a decent strength base. I am squatting 375 for 3 at RPE 8. Yes i do occasionally play basketball but I have been doing that all my life. Given my circumstances is there anything more nuanced that may be recommended? Perhaps targeting the quads more? Or just continue to train?

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What are your long-term goals?

Are you squatting below parallel?

I would continue to train – and I don’t have anything against adding some direct quad work (my preference is for something like a belt squat or leg press), if it can fit reasonably within the context of your program.

3

My goals are mainly to just get generally stronger, and keep my body composition healthy to lead a better active lifestyle. One of the main reasons i was seeking out good programming in general was because I suspected my leg needed more strength training in order to feel better.

I am not squatting below parallel, and if you are wondering squatting really doesn’t inflame it much at all. Its more of a problem if its already sore going into the lift.

I guess my other option is always to stop playing basketball and doing other high impact things for a couple months and see if that helps? I think my main question that i gathered from the article i mentioned is, whether its possible that the pain and soreness prevents more improvement i would otherwise see as a result of my lifting?

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If you are capable of squatting to depth without pain in this situation, I would do so. I would also agree that a temporary reduction of the “high impact” activities you describe (like basketball) is probably wise, if you do indeed have PFPS.

5

Per your PM:

Anyway, one of the concerns the PT had was my form that I demonstrated of a squat. She seemed to think that a squat (low bar) shouldn’t have such a low back angle. Obviously you don’t know for sure if my form is correct, but in general what evidence is there for the low bar squat needing safe when done correctly? I mean starting strength as a book really doesn’t satisfy that, or is that just the best there is?

Your PT is simply unfamiliar with the exercise. I would ask them to explain their reasoning.

Additionally - what sort of evidence would you be looking for? A randomized trial of low bar vs. high bar squats looking at rates of back injury? This will never happen.

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