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Post op ACL and meniscus tear strength exercises

 
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Post op ACL and meniscus tear strength exercises - September 3, 2008 8:32:45 AM   
ballplayer10123

 

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Hi all I am new to this forum. My name is Chad and I am a former college basketball player. 3 years ago I completely tore my ACL and injured my anterior meniscus. I had patella tendon surgery to repair my ACL, and had a portion of my damaged meniscus removed. I completed approximately six months of rehabiltation at a well respected rehabilitation center. including range of motion exrecises (flexion and extension restoration), followed by balance, and finally weight training exercises. I would say that I am fully recovered. Though putting a percentage on recovery is difficult, I would say my knee is at about 85-90 percent of what it once was, not bad. I play softball twice a week, basketball twice a week, and weight train 3-4 times per week.

Here's a brief description of activity level and body type. I am 6 ft tall and weigh 190 pounds (not very much body fat, rough estimate not more than 15%). Before surgery my legs were very muscular and very strong, I went about 200 pounds
( 10% body fat or so) at that time. Once I got into the strengthening part of rehab and I was pushing my knee hard I would experience swelling, which could last for several days. Since leaving rehab I have pretty much discovered my limits as far as activity levels go. However, when first leaving rehab and getting back to playing I would overdo it, and play hoops like I used to, marathon style. My knee would swell, and I could not play again for up to 4 days. Now I will not play hoops all out two days in a row, and will not play for longer than 60-90 minutes at a time. With a couple nights of recreational softball mixed in. Seems to be working pretty well for me, swelling is generally not an issue.

However, compared to before I feel like my leg strength is lacking. When I try to weight train with my old routine I generally experience moderate to severe swelling around the cartilage area of my knee. My old workout consisted of barbell squats, reclining leg press machine (plate loaded), hack squat machine (plate loaded), leg extensions (machine w/ weight stack), leg curls (machine w/ weight stack), calf raises (standing), and once a week I include lunges (first set no weight, 2nd and 3rd set light dumbbells) and wall sits. I would do 3-4 sets of each exercise depending on energy level and swelling. I cannot do this workout, each of the squatting exercises is particularly difficult and seem to be non options. I still train my upper body fiercely. However, as far as legs go I only strengthen them through mountain biking, walking/jogging, exercise bike, and elipticals, and recreational sports. My legs are relatively strong, but not nearly as strong as I would like.

Could someone please, please help me tailor a leg workout geared toward ACL Reconstruction/meniscus tear patients, specifically avoiding exercises which tend to promote swelling around the cartilage areas of the right knee. I would assume the weights should be pretty light, and that is just fine with me. I am not looking to get tree trunk sized quads anymore, but I would like/NEED to add some lower body strength, mostly to help structural integrity of the repaired knee. P.S. I have also learned that stretching is my friend, and really enjoy it now.

Sorry for such a long post, or case study if you will. I really dont know what to do to add leg strength at this point. I figure a group of ACL patients/and or PT's etc. is the best way place to turn to for advice, so I joined the forums. I would be more than happy to keep a log of my progress from week to week in this thread for future reference.

Thank you so much for your time and assistance.
Chad 
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RE: Post op ACL and meniscus tear strength exercises - September 3, 2008 11:12:40 AM   
SJBird55

 

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How deep are you performing your squats?

(in reply to ballplayer10123)
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RE: Post op ACL and meniscus tear strength exercises - September 3, 2008 7:27:54 PM   
bonez

 

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quote:

ORIGINAL: ballplayer10123





Could someone please, please help me tailor a leg workout geared toward ACL Reconstruction/meniscus tear patients, specifically avoiding exercises which tend to promote swelling around the cartilage areas of the right knee. I would assume the weights should be pretty light, and that is just fine with me. I am not looking to get tree trunk sized quads anymore, but I would like/NEED to add some lower body strength, mostly to help structural integrity of the repaired knee. P.S. I have also learned that stretching is my friend, and really enjoy it now.

Sorry for such a long post, or case study if you will. I really dont know what to do to add leg strength at this point. I figure a group of ACL patients/and or PT's etc. is the best way place to turn to for advice, so I joined the forums. I would be more than happy to keep a log of my progress from week to week in this thread for future reference.

Thank you so much for your time and assistance.
Chad 


Clearly based on your required activity level and the present limits you did not get full rehab. I would expect you to have left your rehab with this kind of program in hand.
The forums here are designed and work best for professionals to share info with other professionals to aid in client management. The material you seek is best provided one on one with attention to what makes your case unique. The best advice is to seek out someone in your area to work with you. Trying to do this kind of program over the net is frought with too many chances to get it wrong instead of right.

(in reply to ballplayer10123)
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RE: Post op ACL and meniscus tear strength exercises - September 3, 2008 9:46:40 PM   
SJBird55

 

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bonez... this guy is pretty active.  In my opinion it just seems as though he's causing issues with his workout... look how many squat activities he's doing.  There could be a very, very simple fix to his complaint of swelling.  He's not complaining of pain, buckling, feelings of instability in that knee. 

(in reply to bonez)
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RE: Post op ACL and meniscus tear strength exercises - September 3, 2008 9:52:14 PM   
ballplayer10123

 

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SJBird: I really don't squat all that low (leapfrog position?, like some of the folks at my gym). 1) Because its just not a comfortable motion for me. 2) because I knew that going to low could do further damage to the knee. I would say I go 1/2-2/3 of the way to leapfrog position.

bonez: I did get full rehabilitation. and release from my orthopedic surgeon. I finished over two and a half years ago though. Plus, I was not crazy about the routine that I was going through because my knee was swelling after almost every visit. My rehab consisted of 10-15 minute warmup on a treadmill, followed by non weighted movements such as wall sits and balancing on the half moon aerobic balls. Then weighted lifts on machines w/ stacks, exercises included: leg press, leg extension, leg curls, hip flexor, standing calf raises. They also had me do some very light squats, and step ups onto a weight bench. The program would end with ice and stim. My knee pretty much AWLAYS swelled during this routine, my rehab center made sure that the weight training was started at a logical point, not too early, my knee was ready for the program. Anyhow, I was told that swelling was a normal part of the process. Also I was told that 20% (?) of patients could expect to have swelling occur even after being fully healed.

You are probably correct, the internet is not the best place for a rehab program to be created. However, this is not really a rehab program, my rehab has been complete for some time. I don't even need a full strengthening program per se, I was just looking for a few weight training and/or exercises to perform that will be able to strengthen, but be least likely to cause swelling. I can try looking up the PT's that handled my rehab case. However, I am not sure if they are still at the same clinic. Plus I would anticipate they are very busy with new cases, and that their clinic will want some money for creating a new program (even one being performed on the patients own time and machines), which is fair, but I don't have a lot of money, or insurance at this point.       

(in reply to ballplayer10123)
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RE: Post op ACL and meniscus tear strength exercises - September 3, 2008 10:07:10 PM   
ballplayer10123

 

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Guys I am extremely active. I give myself 2 days a week away from activities that could be stressful on my knee, save for work. no softball, no basketball, at the most an upper body workout at the gym. There is absolutley no pain, or instability in my knee. It is healed, no doubt about it. I was fully released 6 months post op, and able to play basketball at a fairly competitive level 12 months post-op. Swelling from being over active was my only obstacle, but I have pretty much found out what my limit is and stick to it. I am simply trying to add lower body strength, but attempting to do so in a way that will not cause swelling (as my previous workouts have). As SJBird said, I think I am the one causing the swelling in my knee because I am doing too many exercises which put undue pressure on the surgically repaired knee. Maybe I need to only do half of my usual workout, and substitute wall sits in place of a heavy weight bearing exercise such as hacksquats?

(in reply to ballplayer10123)
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RE: Post op ACL and meniscus tear strength exercises - September 4, 2008 4:33:13 AM   
bonez

 

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quote:

ORIGINAL: ballplayer10123



Here's a brief description of activity level and body type. I am 6 ft tall and weigh 190 pounds (not very much body fat, rough estimate not more than 15%). Before surgery my legs were very muscular and very strong, I went about 200 pounds
( 10% body fat or so) at that time. Once I got into the strengthening part of rehab and I was pushing my knee hard I would experience swelling, which could last for several days. Since leaving rehab I have pretty much discovered my limits as far as activity levels go. However, when first leaving rehab and getting back to playing I would overdo it, and play hoops like I used to, marathon style. My knee would swell, and I could not play again for up to 4 days. Now I will not play hoops all out two days in a row, and will not play for longer than 60-90 minutes at a time. With a couple nights of recreational softball mixed in. Seems to be working pretty well for me, swelling is generally not an issue.

However, compared to before I feel like my leg strength is lacking. When I try to weight train with my old routine I generally experience moderate to severe swelling around the cartilage area of my knee. My old workout consisted of barbell squats, reclining leg press machine (plate loaded), hack squat machine (plate loaded), leg extensions (machine w/ weight stack), leg curls (machine w/ weight stack), calf raises (standing), and once a week I include lunges (first set no weight, 2nd and 3rd set light dumbbells) and wall sits. I would do 3-4 sets of each exercise depending on energy level and swelling. I cannot do this workout, each of the squatting exercises is particularly difficult and seem to be non options. I still train my upper body fiercely. However, as far as legs go I only strengthen them through mountain biking, walking/jogging, exercise bike, and elipticals, and recreational sports. My legs are relatively strong, but not nearly as strong as I would like.




First off SJ this cut out of the history suggrsts that this swelling is occuring more often than just with squats and or our client has unrealistic expectations for his post repair function. While it maybe particularily ego stroking to "solve" that which goes unrepaired by all others, applying advise treatment suggestions without an actual assessment especially in these kinds of cases could be medicolegal suicide.
This individual maybe trying to go at the old level but clearly if we can accept the hx a given there are potentially serious reasons for the ongoing swelling.  If he is doing all the training he claims but continues to seek more strength and ability to push the limits over and above what is doing we can be doing a great injustice to give out more exercise advice if we are already exceeding the ability of the remaining tissue.


Ballplayer: I'm sure that all signed off on your recovery but that does not mean all is right. I appreciate that the American system of health care has finanical limits but that does not excuse breaking normal protocol and giving advice without the proper steps being done.

(in reply to ballplayer10123)
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RE: Post op ACL and meniscus tear strength exercises - September 4, 2008 7:42:07 AM   
ballplayer10123

 

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bonez, I appreciate your apprehension in giving any advice, and I can respect that. But honestly my knee has not swelled on me in over six months. I am a laborer, play ball twice a week (sometimes three times, other times once, but avg. two times), and play softball twice a week. My knee does not swell. The only time it swelled was when attempting to do a full on leg workout, which I discontinued. I simply strengthen my legs via cardio and shooting jump shots. As long as I keep the cardio to about 30 minutes, or the jump shooting to an hour, then take the next day off, pain and swelling are non-issues.

In your opinion, what would realistic expectations be post-op? All I want to do is add a small amount of leg strength (along with flexibility) to help relieve stress on the joint.  

< Message edited by ballplayer10123 -- September 4, 2008 7:46:35 AM >

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RE: Post op ACL and meniscus tear strength exercises - September 4, 2008 11:31:59 AM   
SJBird55

 

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I don't know, bonez.  The guy had an ACL reconstruct 3 years ago and 6 months after PT was completed he had difficulty returning to the activity level he wanted.  He figured out how to control the swelling by adjusting his activity level and hasn't had any problems with swelling.  Now, the guy would like to return to strengthening activities and the more he tries to strengthen the more he has swelling.  Seems straight forward to me.  There isn't any insurance company in my state that would pay for him to acquire physical therapy services for his current situation.

Maybe I'm wrong, but my gut isn't indicating to me that this guy is attempting to put anyone in a medicolegal suicide position. 

The exercise advice I have is... "less is more."  I highly doubt that the resistance used in the program for strengthening is the problem, I'd be willing to bet the amount of knee flexion and the multiple redundant squat exercises are the problem.  Athletes go back to competition and strength training with no difficulties.

And ballplayer - you WILL probably have swelling issues for the rest of your life.  As long as the swelling is minimal and you can acquire full range of bending and no pain when it is swollen, don't worry about it.  That knee will never be the same as prior to surgery, but without surgery you probably wouldn't have the capability to function as well as you currently describe.

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RE: Post op ACL and meniscus tear strength exercises - September 4, 2008 6:53:56 PM   
Tom Reeves DPT ATC

 

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keep your knees behind your toes when you squat, maintain neutral Lumbar spine during the squat, think defense in basketball.  If your knees are going in front of your toes you are beating up your patello femoral joint and overloading your 1/3 smaller patellar tendon.  no open chain knee extensions.

that said, patellar fractures do occur with patella tendon reconstructions so if these things don't work, get an xray.

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RE: Post op ACL and meniscus tear strength exercises - September 4, 2008 9:50:02 PM   
ballplayer10123

 

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I want to thank everyone for taking an interest in this thread so far. I've decided that I will resume a leg strengthening regimen, but with more humble expectations. I am simply going to try to add a small amount of strength (especially concentrating on my hamstrings) and continue with my stretching warmup (usually takes me about 20 minutes to stretch). My routine will consist of leg press (reclining plate loaded), leg extension (machine w/stack), leg curls (machine w/ stack), bench step ups, and wall sits. I don't know that I will necessarily be using the 70 or 80% of 1RM for my workout. My 1 RM are still pretty strong, and when doing 70-80% of that it may put more stress on my knee than I am looking for. So I will start off slowly, and if necessary go more for reps/muscle endurance than bulk and 1RM strength. I may look into adding some plyometric exercises either in addition to this routine or in place of some exercises, but we'll see how it goes at first. If anyone sees a problem or adjustment that could/should be made to my routine please do not hesitiate to say something.

I want to reiterate I ALONE am responsible for making decisions in how to go about adding leg strength/endurance. I hold no one responsible for the educated advice they are including in this thread. I am an adult and know my body pretty well, just was looking for some suggestions about how to avoid exercises which promote swelling given my circumstances. Thank you for your time and consideration.  

(in reply to Tom Reeves DPT ATC)
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RE: Post op ACL and meniscus tear strength exercises - September 5, 2008 1:22:05 PM   
Tom Reeves DPT ATC

 

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Ballplayer, skip the knee extensions with the stack.  It will make you more sore.  stick to squats and lunges.

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RE: Post op ACL and meniscus tear strength exercises - September 5, 2008 1:44:51 PM   
SJBird55

 

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Hold on, Tom... Is "more sore" a bad thing?  Qualify "sore."  If you follow some of the work by George Davies (I think)... athletes require a combination of strengthening venues.

I have used Daily Adjusted Progressive Resisted Exercise (DAPRE) on quite a few athletes post ACL reconstruction.  As long as there is no patellar pain, no joint pain and no to mild edema, there are no problems.  Definitely, that type of strengthening makes the muscles sore... but there are pretty good strength gains.  Muscle soreness is expected and is a reasonable complaint with strengthening - I expect soreness and actually desire some degree of muscle soreness.  It shouldn't last more than an hour, but strengthening at the right intensity isn't completely pleasurable.  Squats and lunges just don't cut it in providing the full realm of strength throughout the available range of motion.  For some reason, I think Davies did work on this too.  Someone can correct me if I'm getting the Georges mixed up.

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RE: Post op ACL and meniscus tear strength exercises - September 6, 2008 8:41:59 PM   
Tom Reeves DPT ATC

 

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SJ,
I think you are thinking of the right George.  I am not talking about muscle soreness, no problems with that.  I am talking about excessive training forces on the patellar tendon and the patello-femoral joint.  open chain terminal knee extensions place HUGE forces on the PF joint over a smaller surface area.  the reason this is different than the squats I advocate is that the entire move is an isolated quad contraction with a horrible mechanical advantage, in the ROM where the contact surface between the patella and the femur is the smallest, thus maximizing compression forces.  Further, in order to generate 10 N of extension force you have to create something like 70 N of tension on the patellar tendon.  (forgive my estimation, I remember that it was a big number)  Remember that the patellar tendon is approximately 2/3 the mass that it once was (or at least it was right after the surgery after the harvest of the bone-tendon-bone graft) and therefore has 2/3 the tensile capacity.  that makes it prone to developing inflammation. 

I respectfully disagree with your statement that squats and lunges don't cut it in providing the full realm of strength  . . .   In my opinion and through clinical observation the LE muscles are strengthened through the entire functional ROM with the added benefit of training the proprioceptive system at the same time, thus training the muscles WHEN to contract, which is arguably more important.  the analogy would be with the upper extremity.  bench press is taught and used by many many coaches, PTs trainers etc . . . but performance in the bench press does not translate to throwing a baseball faster AND if you do bench press and allow the elbow to move behind the mid frontal plane of the body you create anterior shoulder laxity, leading to instability and rotator cuff problems.

So, the long (very long) and short of it is, strengthening for strengthening's sake does not make it better.  The target activities should be mimicked (sp) if possible to train the movement pattern as well as strengthen the muscles.


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RE: Post op ACL and meniscus tear strength exercises - September 6, 2008 10:05:21 PM   
bonez

 

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quote:

ORIGINAL: Tom Reeves DPT ATC

SJ,
I think you are thinking of the right George.  I am not talking about muscle soreness, no problems with that.  I am talking about excessive training forces on the patellar tendon and the patello-femoral joint.  open chain terminal knee extensions place HUGE forces on the PF joint over a smaller surface area.  the reason this is different than the squats I advocate is that the entire move is an isolated quad contraction with a horrible mechanical advantage, in the ROM where the contact surface between the patella and the femur is the smallest, thus maximizing compression forces.  Further, in order to generate 10 N of extension force you have to create something like 70 N of tension on the patellar tendon.  (forgive my estimation, I remember that it was a big number)  Remember that the patellar tendon is approximately 2/3 the mass that it once was (or at least it was right after the surgery after the harvest of the bone-tendon-bone graft) and therefore has 2/3 the tensile capacity.  that makes it prone to developing inflammation. 

I respectfully disagree with your statement that squats and lunges don't cut it in providing the full realm of strength  . . .   In my opinion and through clinical observation the LE muscles are strengthened through the entire functional ROM with the added benefit of training the proprioceptive system at the same time, thus training the muscles WHEN to contract, which is arguably more important.  the analogy would be with the upper extremity.  bench press is taught and used by many many coaches, PTs trainers etc . . . but performance in the bench press does not translate to throwing a baseball faster AND if you do bench press and allow the elbow to move behind the mid frontal plane of the body you create anterior shoulder laxity, leading to instability and rotator cuff problems.

So, the long (very long) and short of it is, strengthening for strengthening's sake does not make it better.  The target activities should be mimicked (sp) if possible to train the movement pattern as well as strengthen the muscles.




I couldn't say it better!

(in reply to Tom Reeves DPT ATC)
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RE: Post op ACL and meniscus tear strength exercises - September 7, 2008 1:14:41 PM   
SJBird55

 

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Someone who is 3 years post op shouldn't have to necessarily worry about the patellar tendon.
100 N = 22.5 pounds

I tend to think of things in daily living... think of stairs.  There is a lot of torque occuring with descending stairs:  http://www.ejbjs.org/cgi/reprint/62/5/749

Since you seem to be concerned about the patellofemoral joint reaction forces this article nicely supports that with stair ascent and descent the reaction forces are more than 3 times body weight and with squatting activities can be 7-8 times body weight. 
http://rheumatology.oxfordjournals.org/cgi/content/full/kem114v1#B26

I can't find the work by George Davies that supports both squatting type activities and knee extension type activities.  I think it was this year that I listened to him present at either the CSM or annual.  With muscle testing/evaluation of strength, the strength gains aren't as large with just squatting type activities/sport specific type activities.  Athletes need both.  If I happen to come across his work, I'll share.  Maybe it is still work in progress?  He's always got something going on with research.

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RE: Post op ACL and meniscus tear strength exercises - September 7, 2008 5:10:20 PM   
Tom Reeves DPT ATC

 

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i just typed a long and pretty good post and tried to insert an image and poof, the whole thing was gone.  I will try again.

SJ, stair ascent and descent are not the same things as your first link suggests.  The difference is the location of the knee relative to the foot and the hip flexion angle.  Same thing that I am trying to describe when I teach my patients to do squats with their knees behind their toes.  Stand up and do a squat with your trunk upright and feel your hamstrings, quads, and butt.  The work is almost all in the quads (which translates to PF compression) Now stick your butt out behind you like you teach your patients to sit without plopping, like playing defense in basketball.  Feel those muscles again.  All are active.  Same amount of work being done both ways, but in the second way the work is distributed through more muscle groups and therefore the PFJ is relatively spared. 

You probably wouldn't have your patients train by repetitively running down stairs because that is too tough on the joint to do purposely over and over.  Certainly you would do it some but not as a foundational exercise.

The way I teach my patients to do squats is different than a lot of people teach them.  Frankly, I think most PTs and ergonomics advocates don't get it.  The words that are taught are " keep your back straight and use your legs."  I agree with those words but what usually is demonstrated is keeping your back vertical and doing a deep squat.  If you squat that way, it is IMPOSSIBLE to pick up something from the floor and maintain a neutral spine.  Plus your knees are infront of your toes, plus your balance sucks.  The way it should be done IMO is to actually keep your back in neutral by bending at the hip and getting your trunk more horizontal (but maintaining a slight lordosis, i.e. neutral)  keeeping the knees behind the toes, with feet wide.

Think about how one year-olds lift, your great grandma, Olympic weight lifters.  They all keep their knees behind their toes and bend at the hip.  The reason? they all routine approach the limits of how much they can lift.  If they don't do it the most efficient way possible, they can't accomplish their functional goal, whether it be picking up a tootsie roll, their teeth, or #500.

My point is, The second article you referenced regarding the PF compression comparison between stairs and squatting does not reference HOW they did the squats.  I suspect that they did it like a catcher giving signs to the pitcher, not like an Olympic weight lifter.  I would expect the deep squat with a vertical trunk to be the bigger of the forces.  That is probably how Ballplayer was taught to do his squats.  I propose that if he sticks his butt out and pretends he is standing and sitting from the toilet his PF joint will hurt less.

My first try was much better. I won't try the image thing again.

(in reply to SJBird55)
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RE: Post op ACL and meniscus tear strength exercises - September 7, 2008 9:19:16 PM   
SJBird55

 

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Tom, I'm not sure we're on the same page here.  I'm really confused.  Initially, I interpreted your September 6 post to mean squatting and lunges are good strengthening exercises and reduce the compressional forces and tendinous tensile forces of the patella and patellar tendon respectively.

My argument has been that even the activities you suggest DO have compressive and tensile forces, maybe even greater than performing knee extension activities.  Of course stair ascent and stair descent are not the same - but there are ground reaction forces with both activities that create flexion moments that need to be counteracted and when those flexion moments are counteracted, there will be compressional and tensile forces imposed on the patella and patellar tendon respectively.

You are now mentioning how a squat is performed.  Biomechanically the activity would be assessed via hip, knee and ankle joint angles and forces.  In the second article, you'd have to go to the reference article to see how the forces were measured and at what angles.  No matter how you look at it, there will still be ground reaction forces generating a flexion moment. 

The most simple philosophy is that no matter the choice for strengthening - there shouldn't be any patellar pain.  Simple.  For the best, well-rounded benefit, there should be knee extension exercises performed and there should be squatting type activities performed.  None of the activities performed should increase patellar pain though because if they do, there is a pretty good likelihood that the tissues aren't handling the compressive or tensile forces.

(in reply to Tom Reeves DPT ATC)
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RE: Post op ACL and meniscus tear strength exercises - September 7, 2008 10:24:33 PM   
Tom Reeves DPT ATC

 

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No arguement on the last half of your last post.  As for the first part, let me try to clarify.  I recognize that there are ground reaction forces, and depending upon how the squat or lunge is performed the forces can be either greater or less than climbing stairs.  I posit that if they are done incorrectly (by my definition) they more resemble descending stairs (undesirable) and when they are done correctly (again, by my definition) they more closely resemble ascending stairs (desirable).  When  done correctly, they serve multiple purposes in the rehab world.  They train proprioceptors, they reinforce proper biomechanics, and they distribute those ground reaction forces over a larger cross-section of muscle mass and therefore reduce the likelihood of overuse -itises. 

Of course you have compressive and tensile forces, Ballplayer is just exercising and causing pain and swelling.  I just wanted to have him try and change his technique and see if it helped.  In my clinical experience, and consistent with known biomechanical models, the squat technique I described is easier on the knee and demands more of the hip. 

(in reply to SJBird55)
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