Thoughts.

Continued from the last post:

The pain has only been debilitating once: back in December on day 2 of a hat tourney. I basically couldn’t run, strong limp when walking.

By march (Dream Cup) it was fine, basically no irritation.

But then i kind of tweaked it training for Jeju, and it got worse over the tourney weekend. I played all the way through, but was maybe 70% in our last game. That was five weeks ago, been resting since.

The pain has now subsided significantly. Normal activity is fine, I feel a slight twinge on stairs sometimes, and when I have to run (to catch the train, etc.) it will sometimes hurt a bit. But not debilitating.

I’m determined to heal it properly this time. Would much rather miss a few summer tourneys than risk further damage and chronic pain.

I’ll give the Samson stretch and the other similar one a try — pictures would be great.

Yeah, the “reprogramming” concept makes sense. Think I’ll give it at least another week or two before starting squats/lunges, but I will definitely add that to the regiment before attempting a comeback. I do have pretty skinny and relatively weak legs, and have tended to focus on upper body lifting in the past — it’s time I gave my legs more attention.

Nope, never heard of foam rolling — any resources you have on that would be appreciated.  I’m open to trying anything, as long as it’s not too much too early.

Many thanks for the help.

What about your knee history? Did you get a doc or specialist to diagnose, or did you figure it out yourself? How long did it take to recover? How does it feel now?

I‘ll send you more info, etc when I’m at home and on my computer with its links.

As for my knee, I had troubles that dated back to my sophomore year of high school–as a long/triple jumper I wound up doing a number on them, in terms of high-impact stuff and the like…this resulted in what I’m pretty sure was a strain of my achilles, and compensating for that left me with knee issues–dull, aching pain, generally, usually cropping up after workouts but slowly cropping up during runs too–during the cross-country season fall of my junior year (which would be fall of…’03?). Coach figured it was chondromalacia patella, I got a cho-pat strap (it’s the band that goes under your knee, maybe you’re familiar with it?) and persevered. I didn’t have troubles with it swimming that winter, but then when track season rolled around again it gave me a lot of trouble with my jumping on and off. As I recall I had a solid season, didn’t need to use the strap all that much, but had the occasional week or two where I needed it.

Enter college (I graduated from high school a year early). Freshman year it again bugged me on and off–generally speaking, when I was careless and didn’t warm down properly, etc it would catch up to me. Playing troubles were on and off–I got in the habit of playing with the knee strap, though sometimes it didn’t seem to make much of a difference, but almost every post-tournament/practice ride that involved my knee being still for more than 20 minutes or so would result in a dull ache. I had the occasional bout of tendinitis too, with swelling underneath the kneecap…this all continued through my sophomore year as well, though by this time I had started reading up on it and trying to train to prevent it, and, as I recall, got it under control enough that by Regionals time that year I felt great and could play at 100%, no reservations (and had one of my best/most memorable games there).

Junior year I made some real progress. Or rather, sophomore summer I made a lot of progress–I was on-campus for classes, like most of my classmates (a unique perk of the Dartmouth calendar leaves sophomores more or less in charge of the campus during the summer), but had a lax schedule and a lot of motivation, so I was hitting the gym routinely. Crossfit entered the picture, and combined with a LOT of fitness reading before and during (and after) the summer, and some good nutrition, I made some really great athletic prowess. I discovered deadlifting, started getting into squatting properly, and incorporated things like the samson stretch into my routine, as well as some other stuff specifically for my knee (and ankles, both of which I’d rolled that year, I think), including the other stretch I recommended to you and the shoulder bridges.

Junior year (’06-’07) I had a lot less trouble with the knee–I think there were a couple brief instances where I got lazy with stretching and the like and it bugged me, but I was really proactive about icing and resting at those points. I took ibu at every tourney I played in, a habit I still maintain (though I usually don’t when training anymore, as my workouts aren’t so long as to have inflammation crop up and be an issue). As I recall (and I may be mis-recalling) my real litmus test was playing in Vegas that winter, and after three days of ultimate it was doing pretty darn well as I recall (I started wearing the strap on the third day as I was starting to feel something, but it never got so bad as to make me consider not playing)…it wasn’t 100% but it generally gave me a lot less grief. The strap was still a mainstay, though more as a precaution at that point.

Senior year (’07-’08) I don’t think I ever had any trouble with my knee. Nothing leaps to mind, at least–I played a lot, and played well, and without injury. Really just a spectacular year.

So I’d say a few months of dedicated, hard work got me to the point where I was playing competitively without too much worry about relapse, and another year on top of that put me in the clear. Lately though I’ve been really lazy with my fitness, and I’m starting to see some of the old symptoms crop back up–it’s mostly a flexibility issue for me, with my quads being too tight, though I think my hamstrings are also too weak/tight now too. Planning to keep foam rolling / stretching and bring back some lifting to help with all that–really need to get my ass back in gear, both for playing these last months here and hopefully for latching on with a halfway decent club team when I get back to the states in August.

And my follow-up, later:

Sorry for the delay getting back to you.

You might give this blog a look for information on foam rolling. There’s a crapton of information there (and linked from it–the links can give you some good in-depth stuff): The short is to get a foam roller and start using it on your quads, hips, and hamstrings and calves, focusing on kneading out knotted-up issues and, if you’re up to the task, applying extended pressure to the tight spots until the muscles loosen up a bit.

Regular foam rolling will do wonders for your muscle health and flexibility.

For pictures of the Samson stretch, a quick google image search gives you a good idea there (keep in mind you don’t need to go out THAT far, especially when you’re just starting), but a better idea can be had in this PDF. I <3 Crossfit. The other stretch I mentioned to you is a little more intense; it basically involves using SOMETHING to put your foot up on–whether that’s a bench, or back against a wall, etc–to force your leg into flexion: this emphasizes a different part of your quadriceps when you stretch, and it’s one that tends to be chronically tight in most (it was and, now again, is in me). You might find this helpful for assessing the state of your hips–everything is connected. If you’re going to take the stress off the knees, it needs to be taken in somewhere else–the hips are that place.

Lastly, you might be especially interested in this bit on bulletproof knees.

I think that article might describe the stretch I mentioned above–I’d check it right now, but I’m still at work and the site is full of bodybuilder pics. Can’t start a rumor like THAT.

There’s plenty to sift through there; feel free to hit me with impressions and I can try and give my experience in some more detail.

Hope that’s all helpful! There’s a bit on the “mobility” topic in the bulletproof knees article, but I owe you a better resource than that–unfortunately, a lot of what I’ve learned about that has been in-person, or with DVD’s I’ve bought, so your luck is probably as good as mine trying to dig that info up.

Any readers have good recommendations for resources on mobility work? I know there are bits and pieces scattered about the internets, but anybody know some nice compiled (free) resources? I’m talking mobility drills and the like, not foam rolling.

I thought I’d post up the e-mail transcript of an exchange between myself and a reader–as a former JET, we got talking about ultimate and life in Japan, and eventually about his knee troubles, a topic I’ve a done a lot of reading, experimenting, and self-diagnosis/treatment in. (UPDATE: Part 2, with links to some resources, is here).

Hopefully it proves useful/instructive for those of you out there with knee pain or similar trouble. Without further ado:

…It all started on a long jog back in December. Next day there was a little discomfort above the right kneecap. Tried to play through it at a hat tourney in Vietnam–bad idea. Rested for two months, pain/discomfort basically went away just in time for DC in March. Whew.

But the pain returned a month ago at a tourney in Jeju (Korea). Same process: niggle at first, then progressively gets worse. I’ve rested since, and it’s better, but this time the pain is more diffuse: sometimes above the kneecap, sometimes medial, sometimes… everywhere.

X-ray and MRI say no structural damage; two docs say just rest. One mumbled something about jumper’s knee, but I doubt it because the pain is mildest below the kneecap. Symptoms are soreness in the morning, and dull to acute pain when standing from a sitting position, or sometimes going up/down stairs. I also experienced sudden bouts of severe pain when sitting for long periods on a recent flight to Atlanta. Strange, and scary.

I can accept resting for as long as it takes to heal properly. But I’m 31, and can’t help but worry that this is serious and might not just go away. I’m looking for a knee specialist around Tokyo, but no luck so far. Not really knowing is the worse part, know what I mean?

That bites. Ultimate’s a terrible sport for that sort of thing too, with all the high impact combined with the weekend-long duration…I assume you already use it, but ibuprofen is mandatory when you play–from the sound of it, if you don’t have any structural damage you’re likely feeling the pain from inflammation and swelling. The aching when you fly has to do with the pressure differences, as well as just the lack of movement from the tight confines; I’ve gotten that sometimes too, with ankles (rolled both at one point or another) and the knee (a few years ago when it was still an issue)…though not the “sharp pain” you describe. Weird indeed. They’ve definitively ruled out meniscal tears?

It certainly sounds like there’s some tendinitis/tendonosis, even if it’s not jumper’s knee. How are you flexibility/strength wise? I always had knee issues when my legs were so tight that it affected my footstrike and kept my hips from taking the brunt of the impact. I’d wager you’ve got tight hips and (perhaps) quads, tight/weak hamstrings, and perhaps tight calves too (the latter is more of a personal thing for me rather than what I’ve read/seen, but it might apply to you). Especially if you’re sitting all day and don’t do a lot of training with mobility in mind (ie, if you run lots but don’t do much in the way of squatting or lunging or the like).

Are you familiar with the Samson stretch? (I can probably get you a .pdf with more details if you want). Great for loosening up the hips/quads, good for daily stretching and highly recommended for pre- and post-workout/play. If you don’t do squats or lunges or the like I’d definitely recommend getting into them–I can get you LOTS more information to that end. Docs in the states might tell you to avoid squatting but with the right technique (going to the right depth, and engaging the right muscles), it’s far more protective than destructive.

Here’s the rehab menu from the last doc:

1. Sit with legs dangling, massage quad vigorously (like meading).

2. Sit with legs stretched out in front and knee slightly bent, massage calf.

3. Sit with legs stretched out in front and small pillow directly under knee, engage quad by pushing down on pillow. Hold quad, especially inner quad muscles tight for 3 secs, slowly release.

4. Sit with legs stretched out in front and gently massage kneecap forward (towards toes). He says my kneecap is likely being pulled up (towards head) by tight quad and calf muscles, and this off-centering is causing irritation.

5. A new exercise is lying down face-up and with knees bent, and lifting butt off the ground until the body is straight (knees still bent). Focusing on core, butt and hamstring muscles.

I’ve been following this regimen pretty consistently over the last month, and there is improvement. But something is def still off. The last few days, for example, I’ve been feeling pain in the inner knee area. But other times its medial, or above. Strange, and frustrating.

Not sure if I’m ready for the Samson stretch — seems like a fairly intense exercise, want to make sure I don’t aggravate the knee. But will give it a try. Any other advice for low-impact strengthening exercises for the quads and hammies?

How bad is the pain?  Is it debilitating?

I’d imagine you could step up the vigor a bit if this stuff isn’t pushing you too hard. For instance, on that last one you do (I know them as “shoulder bridges”), you could try doing them on a single leg with the other extended straight–I’d also recommend keeping your hands on your butt cheeks while you do it, and really focus on contracting those muscles (the extra tactile sense from the touch can help you body figure out what muscles to activate). 

Based on the other stuff, it sounds like you’ve probably got chronic tightness and weakness in the quads…the Samson stretch might sound intense, but you can definitely ease into it and I think it’d do you a lot of good. A similar stretch that’d probably hit the areas you need to stretch really well is pretty similar–the same lunge position, but you put the foot of your back leg up on a bench or other raised surface such that the back leg is bent–this will focus the stretch on a deeper part of the quad, that I think tends to contribute a bit more to the knee pain.  I can dig up pictures or the like if you need a better explanation than that.

In terms of strengthening, my knee troubles coincided with an inner quad strength/mobility deficit–specifically, my right Vastus Medialis (VMO–the “teardrop” shape) was a lot smaller and activated (contracted) a lot less easily than my left, and I had right knee troubles.  Again, doing some stuff single-leg can likely help with this (holding the top position on single-leg shoulder bridges, for instance).  If you’re able to find a trainer and able to bear some weight/range of motion, getting somebody knowledgeable to coach you in doing lunges or Bulgarian squats or other single-leg types of exercises can help a lot.

The one issue I’d raise with all the rehab stuff you’re doing–all of which makes sense and is reasonable to prescribe–is that, while it addresses the muscular deficits (strength and flexibility), it’s not doing much to reinforce good movement habits–in other words, it might fix the symptom, but your body is at this point probably so used to, for instance, running whilst compensating for the deficiencies that without some kind of re-programming you’re probably going to continually struggle.

That’s why I think it’d be a good idea to incorporate good lunges and perhaps some squatting or even deadlifting into the mix eventually.  Doing those exercises with decent form and the right sort of flexibility/strength will help reinforce good habits, and if, for instance, you do mobility drills (again, something I can send you more info on) as part of your warm-ups, it’ll help continue to reinforce good habits.

One last thing–are you familiar with foam rolling at all?  This email is long enough, but it’d probably go a LONG way towards helping you improve your mobility if you haven’t been doing it yet.

Yeah.  So, let me know if you want me to dig up some resources for that stuff.  I’m not surprised if your rehab specialists haven’t been aware of this sort of stuff, as thinking in terms of mobility, foam rolling, and the like is still more…hm, cutting-edge, and has only recently started getting enough data and support that it’s becoming popular, accepted, and therefore, taught to aspiring therapy professionals.

More to come in a later post, including some resource references.  Anyone out there have advice or insight to offer that I’m missing?  Especially if you think I’m talking out of my ass at any point I’d love to be corrected–I’m basing this largely off my own history, along with some advising of teammates, so I’m hardly a professional.