Getting bored with the hip: “Because like in a lot of things in the in this type of space, we thought things were really complicated and they are, ⁓ but we were making them way more complicated than they need to be. And when it turns out with a hip is you pretty much just need to find the comfortable position and then just start loading them up.”
Hips: “We know that labral tears are extremely common, just like meniscal tears. And so just because they have it doesn’t mean that it’s a problem and it could be totally normal and their pain presentation may actually have nothing to do with it, or it could be triggered by it.”
“The hip being a ball and socket joint, there’s not a lot of complexity to it. You put a load into it, it’ll self center and away it goes. And there are definitely people who disagree with me, but they’re wrong and that’s okay.”
Hips: “Figure out why they can’t squat, sort that out and then squat. That’s pretty much the answer to hip. And so that, that makes it really difficult to do a full weekend course.”
In-Season Tendon Management: “If you can’t shut them down, then you can’t control their load. And so if they’re playing, they’re playing and you don’t want to control load in the middle of a season.. The instantaneous loads are often what’s kind of setting it off. And so what you could do is pain management. And there are some strategies around that, but you’re not going to sort it out until you can really shut this person down for a period of time to get it under control and get the process going.”
“Unfortunately, with a lot of these high level athletes, what they do is, they get to the end of the season and the team even has the best intentions, but the player goes off for the off season. And because they’re not loading it [the tendon], it feels fine. And they think it’s sorted. And then when they come back at beginning of season, it blows up again.”
Instantaneous loads and tendons: “In order to change momentum, you need a certain amount of impulse produced. So if you look at a force-time curve, impulse is the area under the curve. The problem is the peak load typically, not the impulse. And so they’ll make the change of direction, but what they’ll do is extend the ground contact time to lower that peak load. And of course a slower ground contact time is not the best from a performance perspective. So the other option is to try to change the load profile so that the request from that joint and therefore that tendon is reduced.”
“The ACL is really fascinating because it all comes down to can the quad produce force and the amount of time required to produce that force. So in order to slow down and change direction, that kind of thing, you have a certain impulse requirement from the quadriceps… there’s no way around this thing… you don’t want to use other strategies than the quadricep unless you’re really skilled at those other strategies, which is something that’s kind of a separate question.”
ACL rehab: “What’s fascinating is why is this quad not coming back? And there’s a lot of complexity around it, and I do see a lot of parallels with an Achilles repair where you don’t realize how much is a normal amount of force production from this region.”
“You have people that think they have that strength and they just don’t and this is where people go back too early and it’s not that it’s too early from a timeline perspective is that it’s too early that the quad is not back yet and it’s not back in that window as far as producing a that peak force in a very small window that’s the thing that’s super super important because when somebody is a hard change of direction, they only have like a quarter of a second to generate the force they need before they’re going to the other foot.”
“You see somebody like 75 % coming out of that quad, it’s like, all right, well, if you go at like 50 % speed, you’re probably gonna be fine because you have enough capacity to do that. But you know, you can’t go full speed. Well, you can, you just can’t slow down. you know, because deceleration is really the big factor with those folks.”
“What’s fascinating is, why is the quad kind of stuck like this?… You also had a major disruption to that knee joint and you have things like bone bruising and cartilage injuries that take a long, long time to heal if ever. This is a great way for the body to protect the knee is by shutting the quad down. So it’s going to be as simple as just a nervous system loop saying quadricep, I’m not going to let you go any higher than X amount until I’m sorted out. And this is where we often see it’ll take over a year for this person to get totally sorted out and then you see that quad restore.”
“The quad is your indicator that the knee is healthy. So if you whack your knee and test the quadricep right afterward, you’re gonna see a decreased force output in the quadricep. It didn’t get weak. The solution isn’t making the quad strong, the muscle itself didn’t change, but the situation did, and the nervous system reacts to that. and this is where people get a misunderstanding.”
“They think that their strengthening program, because it made them better, it’s because the muscle got stronger, but the reality is, there’s a lot of things that you’re working on when you’re working on ‘strengthening a muscle’. There’s a lot of things that are attached to that, you know, both physically and mentally and emotionally that go through all of this that has to get sorted out.”
“If it’s not back yet, you could be doing everything perfectly well. And that quad is just going to sit there and just flip you the middle finger.”
“You could put 1cc of fluid in the knee joint and you’ll see quad inhibition happen right there. So just a little bit of swelling in there and immediately the quads like, well, what’s up? I don’t know if I should be loading this and a great way to unload a leg is to make the quad not be able to engage.”
“I keep loading the quad and I say I’m requesting the quad and I keep poking at it, but I’m waiting for it to say, OK, I’m ready.”
“Once the quad starts producing some serious force again, all of a sudden you might start seeing some patellar tendon or patellofemoral type symptoms start up because you have these tissues that have been unloaded for six months because the quad can’t put load into those things. And ⁓ now you’re starting to get some symptoms from those areas. And so then the quad stalls again, because now you have to get those areas to become conditioned to load. And so you get a lot of kind of back and forth with that.”
“It’s force production because that’s the thing we measure. We just measure force production and people label it strength… But when people hear strength, they think weak muscle. And it’s like, no, it’s just the force production isn’t there. And there’s lots of reasons why that could be when the muscle is perfectly strong.”
ACL grafts: “So patellar tendon and then especially quad tendon, these are slow rehabs because they’re really angry after that surgery. The hamstring tendon actually feels pretty good after the surgery… They still have the same quad deficit because of the knee disruption. Again, no disruption to the extensor mechanism, but the knee itself creates that quad inhibition in a hamstring graft.”
“With the bone-patellar tendon-bone and especially the quad tendon, they’re really irritable for quite a while. And so they just don’t feel comfortable trying to get back. And so they kind of hold themselves out for longer.”
Quad weakness? “I say knee extensor mechanism because it could be the patellofemoral joint. It could be the quad tendon, it could be the patella tendon, it could be the quad muscle itself. It could just be fear of putting load in that area. And that’s why you have a decreased force output.”
“So what’s the purpose of pain? Pain is there to protect us. Think of an alarm system. So there’s alarm going off saying, danger, you’re gonna damage this tissue if you push any harder through it. And so I think in tendinopathy, in a lot of situations, that’s overreactive. It’s being too sensitive. So you imagine you have a motion sensor out in front of your house for security reasons that sets off an alarm when motion goes by it. But for the love of God, it’s going off when a fly goes by. Okay, well, that’s not appropriate. That’s going off way too early. And so we need to calibrate that thing. Cause we don’t want to just turn the system off. Pain is useful. We want to have that for real danger, but we don’t need it going off when a fly goes by. And so to me, what’s happening is, ⁓ you know, going back to that analogy with the, with the alarm system is, well, we need to start calibrating it. So we need to start exposing it to flies and saying, okay, fly is not a problem. So let’s calibrate this to be less sensitive than that. And then you keep bringing it up, bringing it up to larger and larger things you don’t want it to worry about.”
Isometrics for pain: “It’s pain you can sit with. And this is where I like the 45 second hold. So a really long, easy hold when I’m treating ‘pain’. I just say, sit there for 45 seconds. And to me, the alarm system’s going danger, danger. You’re going to tear. What are you doing? Danger. What the hell is happening? Nothing’s getting torn here. And so the alarm system starts going, okay, maybe I’m overreacting here. So then you give it a break and then you go to the next one and all of a sudden you’re able to push a little harder.”
Isometrics: “What we find is by the third rep, typically the nervous system’s like, hell man, I don’t know. I don’t know. Just do whatever. And then you’re allowed to kind of go to what your actual capability is.”
“Sometimes the sensation of pain is what the limiting factor is. It’s fear. So we’re treating fear the way we would treat any other type of fear, which is with exposure therapy. And so all of a sudden this is not a ‘strengthening program’. It’s an exposure therapy. And just like with any other exposure therapy, you don’t go with some weird abstract thing. You go right to the thing they’re fearful of, which is load to the anterior knee. And you go directly to that and you go, we’re just going to sit with that and get used to not being afraid of this anymore.”
“We’ve had some high level athletes that, you know, they have just a nasty chondral legion on their patellofemoral joint. And no matter what kind of conditioning and training we do over the off season, there’s just so much they can tolerate. And then after that, there’s just no more. We actually work on teaching them some strategies to unload that knee because that’s all we got.”
“The amount of load that the patellar tendon or the patellofemoral joint or the quadricep needs to produce is related to the amount of torque that’s being requested from it.”
“Your more sissy squat is gonna create more load to the anterior knee because it’s creating a longer moment arm. But if you did an RDL, which would be the kind of the opposite, your moment arm stays at zero essentially. So there’s like no load to the anterior knee when you do an RDL. And so this is also where somebody has raging anterior knee issues, whether it’s tendinopathy, patellofemoral joint, whatever, we’re gonna start with RDLs right off the bat, just get them loading heavy and feeling like they’re not gonna break, because it’s not gonna overload their knee and they’re gonna feel usually really comfortable and really strong all of a sudden where they’ve been feeling like, man, the slightest load, I feel pain in my knees. It’s like, all right, let’s go to an RDL and just do that. And then we can start progressing from the RDL to a deadlift, regular bent knee deadlift and then going all the way to what we would call like a sissy squat.”
“We do a wall slide on toes… So one foot pound of torque per pound of body weight, which is equal to three newton meters per kilogram, which is the standard amount of load that the anterior knee should take.”
“Just because you can do a double leg wall slide and feel comfortable with it, you’re about halfway there. I know it feels like a lot of load, but you’re about halfway there. You need to take a body weight worth of load. And then of course, a lot of our high level athletes, know, soccer players in particular, you’ll see, you know, three new meters per kilogram is easy for them. They’re actually closer to like six. And so you’re not going to get that on a body weight load activity like that, because a body weight is just not enough.”
Addressing pain: “I see the nervous system calibration being that first thing. Let’s get the nervous system in reality to line up, especially with regards to pain and force. And so that’s the first thing. And then the next thing is we got to get their peak load restored… It needs to get back to a body weight roughly of peak load. So we’re not worried about how quick they’re producing it. Just can they produce it given all the time in the world? And that can take months or if their problem is strictly nervous system, it’ll happen in a session.”
“This can take, in an ACL, you know, it’s easily six to nine months before we get that peak to come back to what it needs to be. You can be working on all sorts of other stuff in the meantime, mostly for the athlete sanity. But I don’t know that it really matters. I joke about an ACL rehab can be nothing more than just sitting on a leg extension machine and working on getting that peak back up.”
“Unless you have a baseline, you’re going to assume it’s 90 % of the other side. That’s probably kind of getting into your safe zone.”
“That third phase is going to be now I got to restore it [peak force] in the window required… So it’s great that they can produce a body weight worth of torque. The problem is they don’t produce it until two seconds into the push. All right. We got to get that to happen in the first quarter of a second. So now we got to work on rate based type things.”
“And then the final one, the fourth one is return to sport. You know, this is where I do my ‘functional exercise’. Of course, what’s the most functional exercise an athlete can do? The damn sport. So this is where I wanted to be functional. Like okay, just go do the activity. Okay. Everything else is building up the capacity to do the activity. And if you’re finding that they don’t have the capacity to do the activity, you got to get the capacity back before you’re working on that functional transfer.”
“I think that the other argument for BFR is it tends to select your fast Twitch fibers a little bit more. So again, you’re really doing good CPR, so to speak, on that muscle. But to me, it’s not sorting out the actual problem, which is the tendon won’t take load. So I need to condition that tendon to take load, and I don’t see BFR as doing that.”
Stereo Effect: “I can’t put load through that tendon because of that 4 out of 10 pain. And then we do a bunch of BFR, which gives me like a 10/10 or a 9/10, a very high sensation. And then I take that away. I now may score my tendon pain as a 2 out of 10 at the same load. So I’ve kind of tricked the nervous system to allow that to now take more load. Cause again, it may not be the tissue that was the initial limiting factor. It may be the, you know, the nervous system itself.”
“I like it better to do isometrics directly without BFR or NMES or any of that… to let the nervous system just sit with this is actual load going to the tendon and I’m going to reckon with it and decide whether this is safe or not and give it that true unadulterated pure version of that.
“You think of that 80-20 rule, the old Pareto principle, the 20% of work that’s gonna get you the 80% of the results. To me, isometrics are probably over there on that side, the 20% that’s gonna give you your 80% of results. And then all the other stuff is in the 80 % that’s gonna give you 20 % of your results.”
The hurt paw analogy: “So when a dog hurts its paw, it doesn’t go to rehab to figure out how to use its paw again. It just it unloads it because of the pain. It hurts so it unloads it, but it has to kind of use it. And so it puts it down and over time, it’s kind of testing itself and it kind of does its own rehab, so to speak.”
“I’ll see these older NBA athletes come and see me and they’re like 10 years into the league. And they’re like, yeah, I’m just starting to have problems. You’re like, OK, well, let’s look at your injury history and you go through their injury history and they like four or five things. And the first thing I do is I just test force production of those four or five things. And nine times out of 10, they have not restored their actual capacity to any of those areas. And again, whether that’s tissue or nervous system, doesn’t really matter. The problem is force production. And so the first thing we do is we just restore that. And so we go through just in an isolated way, let’s just restore those things. And then I throw them back on the court and just go, okay, now how you feel? And they’re like, my God, like, I feel great now. It’s like, yeah, we don’t need to retrain anything. We don’t need to re coach anything. It’s just you were building a house of cards and then it fell because each injury started to limit what you could do.”
“If you aggravate something, pain is going to be the number one thing limiting your force production. So if you just let it calm down. That might be all you need to do.”
“With ACL, I think if you just give them enough time and don’t let them start messing with weird strategies, I think the quad will restore itself naturally. I mean, this is, we see this three newton meters per kilogram kind of everywhere. Well, what if I do a bunch of training on my quad? Won’t that make that number go up? You’ll also gain some mass because of the muscle mass you gain. And you’ll find that you don’t really creep it much higher than whatever it is, whatever normal is for you based on your genetics.”
“Now, a deadlift, for example, you’re going to see huge gains in that because that’s a compound movement that’s using multiple single joints working in concert to produce maximum, you know, ⁓ function, so to speak. Whereas an isolated single joint is it’s pretty much alimetric. So the bigger you are, the more force you produce, the smaller you are, the less force you produce. And that’s kind of genetically wired into the person.”
“You’ll take somebody that’s totally untrained and you put them on a leg extension torque meter and they’re going to hit three new meters per kilogram. And you’ll take a high level athlete that may have a higher number by a little bit, but usually it’s going to be around that three new meters per kilogram. What makes them good is how skilled they are in the application of that.”
Post ACL strategy: “It’s because they’re constrained into it, because if they were to bend that knee, the quad would fail because they don’t have force output from the quadriceps… So we do 5-5 testing… it’s 5 meters to align 180 degree change of direction. And then you come back five meters… And so if you’re turning towards the left, you’re actually using your left foot to decelerate planting with the right foot to put to pivot and then to accelerate out of that coming off of that right foot… When you take somebody with a quad deficit coming off ACL and you ask them to do a 5-5, what you’ll see is when they plant and pivot with their surgical side, they look perfectly fine. When they plant and pivot with their non-surgical side, they show all the stiff knee valgus, knee abduction, all those things that we talk about being being risk factors… And the reason is, is because their surgical side could not decelerate them because that’s that’s the leg that should have decelerated them. So if they’re turning to the right and it’s the right knee that had the surgery, what you’ll find is that right knee didn’t decelerate for crap… And so what happens is if they were to bend that knee, it would immediately overload even a normal healthy quad. And so they have to keep that knee stiff and then they have to get some sort of excursion somewhere. And so they get a little valgus, a little abduction, and you can see their center of mass is still going the wrong direction. It hasn’t been decelerated yet. So their center of mass is still going. So that’s where they get the abduction. And you look at this hot mess on the contralateral side.”
“The soleus in particular can work as a knee extender by controlling the tibia by basically pulling the tibia back… So you can imagine the soleus holding that knee from going any farther forward by being there. And so when you, when we talked about this with moment arms before, if you add moment arm, you add how much load goes to that joint. If you reduce moment arm, you take it away. Now with a strong enough soleus, even with a short moment arm, it can still produce, when you look at torque to body weight on a soleus, we’re looking like 18 Newtons per kilogram when we talk about force to body weight… That soleus is just like the quad, just like the adductor, super big, strong muscle group and glute would be one of those as well. So it can work as a knee extensor just fine.”
“This could be where I have somebody who has a chronic issue with their extensor mechanism that they just have enough damage that this is just as much as it’s gonna take… So it’s not going to adapt anymore. Let’s have the strongest soleus as possible because that’s a way that we can help control that knee and still allow it to go forward and allow it to bend. We can also work on a lot of ⁓ hip and hamstring strength as well to help support that. My thing is always that’s adding a lot more complexity. Again, it doesn’t hurt to add that strength, ⁓ but their true problem is that knee extensor mechanism.”
“I’ll do a weekend course. And my main citation is Newton’s Principles. So we’re going to use Newton’s three laws of motion. And with that, we can understand impulse. We can understand acceleration. We can understand how mass and acceleration affects force. And we just add in torque and go from there. And so what I find is where we tend to make things way more complicated than they need to be. Like I just said, you know, this person’s nine months out from an ACL reconstruction. We’re really worried about whether their cognitive capabilities and their fear and all this other stuff. And then and then their their neuromuscular control and all this. And then when you test their quad, they don’t have the force production from the quadricep. And so everything you’re seeing and ‘treating’ is an adaptation to this constraint that they’re being presented with. And so you just fix the constraint.”
“I don’t know if I’m just dumbing things down a whole lot or just trying to keep it simple and not overwhelm either the athlete or the therapist or the trainer. ⁓ But I think in a lot of these professions, I don’t know if we get an inferiority complex or something like that. And we like, it can’t be the simple. It has to be very, very complicated and all that.”
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