See below for audio interview with Jonas
If you are a strength coach or a personal trainer the chances that you have encountered an athlete recovering from some sort of ligamentous knee injury at some point in your career is pretty high. Whether it is damage to the ACL, MCL, PCL, LCL, or some combination of any of these, the incidence in the athletic and general population is alarming. Hirshman, et al estimated that 1 out of every 1000 people in the US incurs a knee ligament injury each year. The current US population is around 304,000,000 so that means according to Hirshman's figures there will be a projected 304,000 knee ligament injuries in the US in 2008. Of course our primary goal must be a pro-active one with an eye toward reducing the incidence of knee injuries. Unfortunately the mindset of the majority is to get hurt and then train or rehab rather than training with prevention in mind. Therefore it is inevitable that at some point you are going to work with a client that has suffered some sort of ligamentous knee injury.
Working in a private strength and conditioning facility, we see numerous athletes recovering from knee injuries each year. In most cases we are able to work congruently with the physical therapist. In some cases the client or athlete has completed physical therapy, and at other times we get clients that have been released prematurely from physical therapy. When it comes to these cases of premature release the athlete or client reports that their physical therapist, orthopedic surgeon, or family physician has cleared them for physical activity with little to no limitations. Sometimes if we're lucky we get documentation of their contraindications. It is not our jobs as strength coaches and personal trainers to play the role of a PT. It is, however, our job to train the athlete or client in a way that perpetuates the healing and strengthening process in order to get them back into pain free competition or daily life in a timely manner.
I am a firm believer in Gray Cook's Functional Movement Screen so this is the first step I will take with a knee injury client. Obviously the type, severity, and time frame of the injury are all going to play a factor in movement patterns and physical limitations. However, generally I find the deep squat and in-line lunge cause pain if the individual is in or around the 12 week time frame from reconstruction or from the time of injury of a partial tear.
Although I understand that Gray would advise the personal trainer or strength coach to refer out anyone experiencing pain with any movement screen tests to a medical professional, we have come to expect this result so we have developed training methods to adapt to these situations. Plyometrics (bilaterally or unilaterally on the injured leg), and running will also usually induce pain in the injured knee. Another trend that I have noticed is a lack of hip stability, particularly an inability to control the femur of the front leg in a lunging pattern and of the stance leg in a single leg straight leg deadlift (1-Leg RDL). I attribute this to compensation patterns inhibiting the glute medius and piriformis function. Very limited hip external rotation is another trend I have noticed, possibly due the individual's tendency to avoid stretching and exercising full range of motion at the hip of the injured leg which will likely result in tissue density issues.
Now that we have covered the screening process, let's talk about program design. In order to allocate credit where it is due I must say that I have been working under the tutelage of Michael Boyle for two years now so many of the exercises and techniques I will speak about are a direct reflection of what I have learned from him. The basic program outline should be very similar to a program for an uninjured person, which would include foam rolling, stretching, mobility, activation, warm-up, strength training, and conditioning.
Just as any other program it is important to implement Mike's simple rule: "If it hurts, don't do it!"
This means telling the client right from the start that this is a yes or no question and you will not accept; kind of, sort of, not really, or a little bit as an answer. It is also important to note that progression within the rehab population must always be dictated by progress, not time. To make things easier in this article I will include phases in terms of general time frame but a client that has not improved should not be pushed into the next progressions simply because the timeline says the phase is complete.
Foam Rolling
Foam rolling will always come first and will involve all of the basic muscle groups that are usually covered (hamstrings, quads, glutes, hip rotators, hip flexors, mid traps, lats, pecs, etc.). Be sure to pay special attention to any areas of significant tightness that were uncovered during the screening process. As previously mentioned this is usually the piriformis but can include glute max, glute med, TFL, and psoas. Normally 10 rolls back and forth are done for traditional foam rolling however, up to 20 rolls can be applied to these areas of significant tightness.
Stretching
Just like foam rolling, basic muscle groups need to be addressed in the pre-workout stretching but again attention should be paid to the areas of significant tightness. Everyone has their stretch/ release preferences but we have obtained the best results from a 5 second hold at 5-10 reps on each stretch. If 5 reps of a stretch are performed for a relatively flexible muscle 8-10 reps can be used on one that is relatively tight. Depending on the ligament of injury, stretches may need to be adjusted in order to get the desired results without inducing pain in the knee. Those with collateral ligament tears tend to not like floor piriformis stretching because of the rotational force exerted on the knee. The athlete or client recovering from a knee injury also tends to dislike the ½ kneeling position so kneeling hip flexor stretches are also out. The following are four basic pre-workout stretches that I will do with my knee injury clients that will be pain free for the most part with the assistance of a stretching table and a wall.
Table 3D Hamstring
One leg is placed on a stretching table with the other foot on the floor. The toe of the stance leg is pointed straight ahead towards the table and toe of the stretching leg is pointed straight up towards the ceiling or maintaining slight internal rotation of the femur. The client is then instructed to go through internal and external rotation on a fixed femur (the stretch leg) while maintaining toe position of both legs. Make sure that it is the hips that are rotating and not just the thoracic spine.
Table Hip Rotator
One leg is folded up onto the table with flexion and external rotation at the hip so that the tibia is parallel with the edge of the table. The stance leg is positioned 2-3 feet away from the table with the toe pointing straight ahead toward the table. Start in plantar flexion on the ankle of the stance leg and slowly lower the heel into the ground to drive the stretch. If the stretch is too strong or this creates pain in the injured knee then stick a full round or half round foam roller under the knee of the stretch leg to alleviate the rotation of the femur and forces at the knee.
Table Stride Hip Flexor
One foot is placed on the edge of the table and one foot on the ground 2-3 feet from the table with both toes pointed straight ahead. The knee of the stance leg should remain as extended as possible and heel should maintain contact with the ground. The hand on the same side as the stance leg reaches for the ceiling and the hips are pushed straight forward toward the table. At the end range of the stretch the client should be instructed to contract the glute max of the stance leg as tight as possible to inhibit the hip flexor being stretched.
Wall Adductor
The client is instructed to lie on their back on the ground with the glutes pressed firmly up against the wall. The toes pointed perpendicular to the wall, and the knees in complete extension. The client is then instructed to slide the feet as far apart to the side as they can (hip abduction) while contracting the quads and pulling the pelvis down into the ground. The stretch is released by letting the pelvis pull away from the ground.
Mobility
With all of my clients and athletes we will always incorporate at least one mobility exercise each for the ankle, hip, scapulothoracic, and glenohumeral joints prior to the warm-up. Once again, knee injury clients are no different but it is important to spend a little more time looking at and addressing the mobility of the ankles and hips because of their direct relation to the knee. I am not going to waste time talking about mobility from one joint to the next because I believe that information is already prevalent. However a good ankle mobility exercise that I have been using that I got from Brijesh Patel's presentation at the MBSC 2008 Winter Seminar was the idea of incorporating ankle inversions in order to loosen up the anterior ankle followed by the traditional three directional ankle rocks.
Activation
As touched on earlier knee injury clients tend to have poor glute function. It is possible that the glutes were shut down prior to the injury, predisposing the athlete to the compromising valgus position characteristic of sports knee injuries. It is also possible that the glutes are shut down because of the inactivity the injury has caused. Either way it is very important to incorporate glute activation early in the workout to get these muscles turned on and prepped for activity. In the phase 1 program it is important to include at least two glute activation techniques that address hip extension and external rotation/abduction as well as a single leg balance exercise in each workout.
Phase 1
Supine External Rotation/Abduction with Mini-Band below Patella 20x 0:02sec. (no video)
Bilateral Bridge with Isometric Adduction 10x0:03s
Single Leg Balance on Airex with Resistance into Adduction/Internal Rotation 2x0:30s each leg
(No video)
Phase 2
Standing External Rotation/Abduction with Mini-Band below Patella 20x0:02s
Cook Hip Lift (Hands Free) 10x0:03s
Single Leg Balance (Eyes Closed) on Airex with Resistance into Adduction/Internal Rotation 2x0:30s each leg
Dynamic Warm-Up
Knee injuries around 10-12 weeks post injury/reconstruction should be kept to a warm-up linear in nature. Lateral and multi-directional movement generally should not be incorporated until at least 16 weeks if not longer depending on the progress of the individual. I will also always inform the client to start out easy on the injured leg and to be attentive to anything that feels uncomfortable on that side. Instability is ok and is to be expected, pain is not. I will generally just select a few exercises from the linear warm-up toolbox that will tend to not induce pain. These will include:
Phase 1 (weeks 10-12)
high knee walk (pulling from posterior thigh on injured leg)
cradle (figure 4)walk (pulling from posterior thigh on injured leg)
heel to butt
heel to butt with forward lean
backwards straight leg walk with forward reach
5 minute bike warm-up
Phase 2 (weeks 13-15)
high knee walk
cradle (figure 4)walk
heel to butt
heel to butt with forward lean
backwards straight leg walk with forward reach
high knee skip (light)
high knee run (light)
heel up (light)
5 minute bike warm-up
Phase 3 (weeks 16-18)
high knee walk cradle (figure 4)walk
heel to butt
heel to butt with forward lean
backwards straight leg walk with forward reach
backwards lunge walk high knee skip high knee run heel up 5 minute bike warm-up
Plyometrics
This topic will apply more to the athletic population as opposed to the general population. Although it is important to incorporate power training with the general population, when continuing a rehabilitation program there are other and more useful ways to allocate your time. When it comes to the athletic population it is important to maintain the ability to produce power with the uninjured limb, therefore a program should incorporate single leg plyometrics for the uninjured limb. I will use a power circuit that includes a power exercise for the uninjured leg with more balance/activation work for the injured leg along with modified medicine ball throwing exercises to maintain core power.
Phase 1 (weeks 10-12)
MVP Shuttle Hop -- Uninjured Leg 3x5
MVP Shuttle Press (light load) -- Injured Leg 3x5
Seated Overhead Shoulder Stability Throws 3x10
Seated Chest Throw 3x10
Phase 2 (weeks 13-15)
Single Leg Box Hop -- Uninjured Leg 3x5
MVP Shuttle Hop (light load) -- Injured Leg 3x5
Standing Overhead Throw 3x10
Standing Chest Throw 3x10
Side Twist Throw (Facing Wall) 3x8ea
Phase 3 (weeks 16-18)
Single Leg Hurdle Hop -- Uninjured Leg 3x5
Single Leg Line Hop -- Injured Leg 3x5
Overhead Throw with Forward Step -- 3x10
Chest Throw with Forward Step -- 3x10
Side Twist Throw (Facing 90° to Wall) 3x8ea
Lateral Movement
As previously mentioned lateral and multidirectional movement warm-ups and drills should not be attempted before the 16 week period post reconstruction with ACL injuries. The risk of rupturing the graft is simply too high before the 16 week mark. These same guidelines should be taken for collateral ligament injuries but since there is rarely surgery involved with these injuries with the absence of meniscus involvement the 16 week period should be measured from the time of injury. Again these exercises pertain more to the athletic population then the general population. Introduction to lateral movement should be slow and of very low intensity. We will start with some simple slow ladder drills and 1-2 stick drills. Once the athlete gets comfortable with these low intensity drills with no pain the next step is to simply increase the speed of the drill. After a few weeks of lateral introduction the athlete should also be capable of performing some light slideboard intervals at a time of 20 seconds on, 40 seconds off.
Ladder Drills Weeks 16-18
In-In-Out-Out - Forward/Backward/Left/Right
Shuffle w/ Stick -- Forward/Backward
Crossover -- Forward/Backward
Weeks 18-20
Shuffle Quick & Stick - Forward/Backward
Cross-over -- Forward/Backward (Faster)
Cross-behind -- Forward/Backward
Scissors
Movement Drills Weeks 16-18
1-2 Stick 3x4 each direction
Weeks 18-20
1-2 Cut & Return 3x4 each direction
Slideboard Introduction 0:20s on, 0:40s off x 6 +1 each week
Strength Training
Strength training on a knee injury is often the point where most trainers get in trouble. They will either do too much, aggravating the injury, or not enough, inadequately strengthening the supporting musculature. Just as it is important to categorize movements and systematically develop your strength program for the uninjured population, it is equally important with the knee injury population. Another responsibility that differentiates the personal trainer and strength coach from a physical therapist is that we must still train all of the regular strength movements in addition to the knee rehab exercises. So our workouts will still be full body but now with the knee rehab exercises sprinkled in. One thing that you will notice is that the lower body exercises incorporated here are similar to those of a regular program. The only difference is the load, intensity, and variation is altered. I will incorporate four lower body strength movements within a 2 day program:
Day 1
Bilateral Knee Dominant
Supine Hip Dominant
Day 2
Unilateral Knee Dominant
Standing Hip Dominant
Day 1
Bilateral Knee Dominant
Going back to the movement screen, the deep squat in the screening process will determine the load and variation of the bilateral knee dominant movement. If the deep squat in the screen produces knee pain then we know that a bodyweight squat will be a heavier load than the client can handle. In order to keep the program functional it is important to keep the individual on their feet and off of the leg press. Therefore I will incorporate Gray Cook's deep squat corrective progressions starting with an assisted deep squat with a mini-band around the knees to get some extra activity out of the glutes.
The assisted squat requires the client to hold onto a bar overhead that is pulling them away from the ground. I will test the waters using heavy assistance and will progressively reduce the assistance as long as pain free range of motion is maintained. This exercise is performed best on a Keiser Functional Trainer with the use of a Cook Bar where the assistance can be adjusted in small increments. If need be it can also be performed on a Free Motion cable unit or with exercise tubing tethered overhead to a power rack. It is important to be vigilant of weight shifts to the uninjured leg. If I witness this I will use a superband to pull the individual into the compensation (Gray Cook's RNT) in order to force them to counteract the compensation. Once the client has progressed to the point where they can comfortably perform three sets of twelve on an unassisted deep squat, I will feel comfortable moving to a loaded deadlift pattern in order to really start strengthening the posterior chain.
Supine Hip Dominant
The first exercise in this progression is yet another exercise that I learned in my on-going mentorship with Mike Boyle. For most, the Cook hip lift will be more of an activation tool than an exercise used in the strength portion of the workout. However, if you put a Bosu Ball under the shoulders of the client you will create a significant element of instability that will force the client to use their trunk stabilizers increasing the difficulty of the exercise. For this exercise I will start with eight reps with a two second hold and progress up to twelve reps.
The next progression will be a slideboard leg curl with the use of an ultraslide board or a Valslide. I will start with six to eight reps and progress up to twelve. If the glutes are too weak (signified by an inability to maintain full hip extension during concentric portion of the exercise) or there is too much torque on the knee then I will modify the exercise to only involve only the eccentric portion of the exercise, dropping the hips during subsequent knee flexion.
If the client progresses to twelve reps on the modified version of the slideboard leg curl they should be able to perform six reps on a traditional slideboard leg curl. This, however, is not always the case and in such a situation I will once again modify the movement by elevating the shoulders using a 6-12in box. So now the client is in a supine position with the shoulders resting on a box which slightly reduces the resistance on the hip extensors during this movement. The client will still go through the repetition progression until they can perform twelve flawless reps of the traditional slideboard leg curl. The exercise can be further progressed by adding resistance in the form of a weight plate on the sliding mechanism or exercise tubing tethered around the feet.
Day 2
Unilateral Knee Dominant
If the In-Line Lunge produced pain in the Functional Movement Screen then once again it is necessary to use a functional exercise with a load that is less then bodyweight. Therefore I will use an assisted split squat where the client will again be holding onto a bar overhead with tension pulling them upward in order to reduce their bodyweight. This will allow them to perform the exercise in proper form without pain. This is an area where glute medius issues will present themselves in the form of the front femur collapsing into adduction and internal rotation. It is important to recognize and correct this with the same RNT techniques described with the deep squat by pulling the knee into the dysfunction and telling the client to counteract the resistance. When it comes to unilateral knee dominant exercise with knee injuries it is important avoid holding back the uninjured leg from getting stronger. For the uninjured leg I will have the client perform an actual single leg squat so there is no potential for the injured leg to reduce the strength gains of the uninjured leg.
I will use the same rep progressions on the injured leg as mentioned previously with the deep squat. The assistance on the assisted split squat will be continually reduced until the individual is performing pain free, technically correct bodyweight split squats. Once they can perform three sets of twelve reps comfortably I will move them to what we call a rear-foot elevated split squat (Bulgarian Split Squat). Again, once they can perform 3x12 they are then progressed to a single leg squat on the injured leg.
Standing Hip Dominant
The hip dominant exercise used on the second day of the week will be a single leg straight leg deadlift. This exercise is important to incorporate because it will teach the client how to properly recruit the glute to extend the hip in a single leg stance position. It also allows us to work on the stabilizing hip musculature supporting the femur. It is important to watch the knee of the injured leg when performing this exercise because glute medius dysfunction will again present itself in the form of adduction/internal rotation in this exercise. How do we fix it? You guessed it, gently pull that knee into adduction/internal rotation and tell the client to push it back out.
I will follow the same 1-Leg SLDL progressions that we use in our facility with the general athletic population. We'll start with an anterior reach with a medball to reinforce good extension through the spine (reaching to create a straight line from the heel to the wrists). Once the individual is comfortable and stable with this exercise we'll move to holding a dumbbell in the hand in opposition to the stance leg (standing on the right leg and holding the dumbbell in left hand) and increase the weight until it is too heavy to hold in one hand. We will then divide the load into two dumbbells and progress the weight in small increments from there. The beauty of this exercise in a knee injury population is that we are able to put a significant on the posterior chain with limited involvement at the injured knee.
Core Training
At this point you might be wondering "What does this longwinded derelict have to say about core training and what does it have to do with knee injuries?" As I mentioned before, I don't like to alter the program much from the general template that I use for training any other population so I will include the traditional bridging exercises for core stability. It gets tricky when we start talking about rotary stability training. As you can probably tell I consider myself a "Gray Cook guy," so I like to include his bar chopping and lifting progressions. However his progressions start in the half kneeling position and as we discussed earlier, knee injuries tend to not like the half kneeling position particularly before sixteen weeks.
My solution is to try to replicate the half kneeling position as close as possible without putting weight on the injured knee. I will do this by putting the individual into what I call the half seated position. I will have them place the hip of the forward (uninjured leg) on a box and let the femur of the downside (injured leg) hang off the side of the box lightly resting on an Airex pad. The femur length of the client will dictate the box height. The goal of this position is to let the injured knee get to as close to the ground as possible without allowing any load to be placed on the knee. I will still cue them to extend the hip and contract the glute of the downside leg as strongly as possible and to get as tall and as tight as possible. The rest of the cues of the bar chop and lift remain the same. The half kneeling position with the uninjured knee down will be unchanged.
Conditioning
I will do nothing but bike with a knee injury until after the sixteen week mark. This will exercise the knee through limited flexion and extension and increase the blood flow to perpetuate the healing process. Do not make the mistake of running a client with a knee ligament injury too early. The general rule in our facility is if you can't perform a set of pain-free single leg squats you are not ready to run. Once the client is able to perform a flawless set of single leg squats it should be ok to start doing some light interval jogging on the treadmill with close attention being paid to running mechanics and gait.
Conclusion
It is always our number one goal to reduce the incidence of injury in the general and athletic population. Unfortunately, despite our efforts there will always be a high prevalence of knee injuries in the untrained population. This article is the product of my success with knee injuries and hopefully it will provide you with a strong base from which you can build your own programs. I am a "how does it all fit together," kind of guy so I have included a sample first phase program that I use with most of my knee injury clients and athletes that depicts methods of the inclusion of knee rehab exercises in a full body program.
Listen to an interview with Jonas about the article:
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Cook, G. Functional Movement Screen Seminar. Perform Better Seminar Series. Boston, MA: October, 2007.
Hirshman H. P., Daniel D. M., Miyasaka K. The fate of unoperated knee ligament injuries. Knee ligaments: structure, function, injury, and repair. New York: Raven Press, 1990: 481-504