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	<title>Thoughts. &#187; injury treatment</title>
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		<title>Mobility And Injury Prevention</title>
		<link>http://www.ultimatethoughts.com/2011/03/mobility-and-injury-prevention.html</link>
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		<pubDate>Mon, 21 Mar 2011 14:10:33 +0000</pubDate>
		<dc:creator>Mackey</dc:creator>
				<category><![CDATA[Fitness]]></category>
		<category><![CDATA[injury treatment]]></category>
		<category><![CDATA[lifting]]></category>
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		<guid isPermaLink="false">http://www.ultimatethoughts.com/?p=829</guid>
		<description><![CDATA[With some broad background explanation given in the past three posts, these next posts will really drill in on specifics I&#8217;ll be using for my training. First up: mobility work. Gray Cook, noted rehab expert (check out Athletic Body in Balance, or his newest book on the functional movement screen), inspires a lot of my [...]]]></description>
			<content:encoded><![CDATA[<p>With some broad background explanation given in the <a class="vt-p" href="http://www.ultimatethoughts.com/2011/03/planning-my-next-training-phases-general-goals.html">past</a> <a class="vt-p" href="http://www.ultimatethoughts.com/2011/03/planning-my-training-gathering-tools.html">three</a> <a class="vt-p" href="http://www.ultimatethoughts.com/2011/03/starting-to-put-it-together-structuring-the-week-day.html">posts</a>, these next posts will really drill in on specifics I&#8217;ll be using for my training.  First up: mobility work.</p>
<p>Gray Cook, noted rehab expert (check out <a class="vt-p" href="http://www.amazon.com/Athletic-Body-Balance-Book-Package/dp/0736064125/">Athletic Body in Balance</a>, or his newest book on the <a class="vt-p" href="http://www.amazon.com/Movement-Functional-Assessment-Corrective-Strategies/dp/1931046727/">functional movement screen</a>), inspires a lot of my thinking here, with a strong tip of the hat to <a class="vt-p" href="http://ericcressey.com/">Eric Cressey</a>&#8216;s methods for incorporating mobility work into the warm-up and workout.</p>
<h3>My Imbalances – What I Need to Work On</h3>
<p>Here&#8217;s a list of various imbalances or mobility issues I&#8217;ve noticed over the past several months – I&#8217;ve already begun working on some of them, but I&#8217;d like to formally prioritize them going forward.<br />
<span id="more-829"></span><br />
This list is of needs large, but not complete (for instance, I&#8217;m thinking part of the gluteal imbalance is also psoas tightness/strength imbalances). The list is phrased in terms of what I need to do (e.g., my left glute fires less readily than my right, so I need to work on activating it more):</p>
<ul>
<li>L&gt;R 	Gluteal activation</li>
<li>L&gt;R Ankle 	mobility</li>
<li>L&gt;R 	Scapular mobility (R&gt;L Scapular stability)</li>
<li>R&gt;L 	Internal rotation at the shoulder joint</li>
<li>L&gt;R 	Latissimus dorsi flexibility/mobility</li>
<li>R&gt;L Hip 	adductor mobility (may be strength more than mobility)</li>
<li>Thoracic 	Spine Mobility</li>
<li>Scapular 	Retraction/Pectoralis Major/Minor Mobility</li>
</ul>
<h3>The Means to Improvement – What I Plan to Do</h3>
<p>There are a few components of the plan to even out these imbalances, and a few more components on top of that for general injury prevention I&#8217;m also adding to the mix.</p>
<p>For mobility work, step 1 is identifying appropriate drills or exercises to work all of these needs.  Pardon my preponderance of lists:</p>
<ul>
<li><strong>Glute activation:</strong> The <a class="vt-p" href="http://www.youtube.com/watch?v=bSYzFoDw6h4">Cook Hip Lift</a> is a great initial step, with progression to a	foot-elevated version from there (both non-and working-leg, starting with the non) – I&#8217;m also planning to add <a class="vt-p" href="http://www.youtube.com/watch?v=jVlQhlKf-5Q">Hip 	Thrusts</a> to my lifting routine itself to come at it from a strength as well as mobility/activation angle.  Drills for hip 	abduction also work the glutes, such as the <a class="vt-p" href="http://www.youtube.com/watch?v=9J53bAUZeT0">quadriped hip abduction</a> and <a class="vt-p" href="http://www.youtube.com/watch?v=0dOzNG6keS8">X-band walk</a>.</li>
<li><strong>Ankle Mobility:</strong> <a class="vt-p" href="http://www.youtube.com/watch?v=ieJBm7X_PMQ">Rocking ankle mobilization</a> or the <a class="vt-p" href="http://www.youtube.com/watch?v=qaaU4EZpmE8">wall ankle mobility drill</a> are good 	means here, as well as an emphasis on foam rolling the calves/ball rolling the feet.</li>
<li><strong>Scapular Mobility:</strong> The scapula moves in a couple planes, so there are a variety of ways 	to mobilize it – I&#8217;m thinking primarily of <a class="vt-p" href="http://www.youtube.com/watch?v=iY9Vuo27pCs">scapular push-ups</a> to 	work on scapular retraction in the transverse plane, and scap wall 	slides to work the same in the coronal.  <a class="vt-p" href="http://www.youtube.com/watch?v=8O5UbsYQjbY">Reach, roll, and lift</a> is 	another drill that does a good job of mobilizing the scapula by 	activating the lower trapezius, an oft-overlooked muscle group.</li>
<li><strong>Shoulder Internal Rotation: </strong>This is one I really haven&#8217;t 	focused on in the past.  The <a class="vt-p" href="http://www.youtube.com/watch?v=cH-1ni5k4ls">sleeper stretch</a> is a good start (likely just for my right arm &#8211; the left has fine ROM in internal rotation)&#8230;otherwise I think I just need to focus on getting my R scapula working more consistently in retraction (which is perhaps a strength imbalance more than a mobility issue).</li>
<li><strong>L. Dorsi Mobility: </strong>This 	is one where I need to pay more attention to stretching – not only 	in the gym, but in the day-to-day as well, as basic flexibility is definitely an issue.  I&#8217;m also looking at doing  <a class="vt-p" href="http://www.youtube.com/watch?v=ysAnAYSH_jM">side-lying extension-rotation</a>s, as well as adding an overhead reach 	component to drills like the <a class="vt-p" href="http://www.youtube.com/watch?v=uCmcNSmvHMM">squat-to-stand</a> or <a class="vt-p" href="http://www.youtube.com/watch?v=1ar0g-ztdVg">spiderman</a>, to 	reinforce the use of that range of motion.</li>
<li><strong>Hip Adductor Mobility: </strong>Another 	area I haven&#8217;t been focusing enough attention on. This will probably 	be as simple as adding <a class="vt-p" href="http://www.youtube.com/watch?v=CRwZCe1LMaM">rocking adductor mobilizations</a> to the warm-up, doing more <a class="vt-p" href="http://www.youtube.com/watch?v=qpPVNlW_2q0">lateral squats</a>/lunges, etc.</li>
<li><strong>T-Spine Mobility: </strong>I&#8217;ve 	already been adding <a class="vt-p" href="http://www.youtube.com/watch?v=cq1MCjihXq0">t-spine mobilization</a> to my foam rolling routine, 	but I&#8217;m looking to expand and work things from the cervical spine 	(neck) side as well to really minimize the presence of the 	ubiquitous hunched/forward head posture we all have from sitting in front of 	a computer as you are right now; <a class="vt-p" href="http://www.youtube.com/watch?v=Pkd26tLVop0">quadriped chin tucks</a> are a means to 	restore some range of motion there, as are various <a class="vt-p" href="http://www.youtube.com/watch?v=Q4FkZLe5pnQ">neck stretches</a>.</li>
<li><strong>Scapular Retraction: </strong>This 	gets hit already in some of the above drills for scapular mobilitiy.</li>
<li><strong>Pec Major/Minor Mobility: </strong>Tightness in these muscles 	(particularly the pec minor, which inserts on the coracoid process 	of the scapula) is another factor contributing to scapular/shoulder 	dysfunction and the aforementioned forward head posture.  <a class="vt-p" href="http://www.youtube.com/watch?v=HddLMhubEN8">Rolling</a> and <a class="vt-p" href="http://www.youtube.com/watch?v=xzR9trLRD0c">stretching</a> are both means to loosen up the muscles; I&#8217;ve also 	become fond of the broomstick pec mobilization drill to work on 	mobility there.</li>
</ul>
<h3>Putting it Into Practice</h3>
<p>So how do I put this all together into something coherent and useable?  Given I have some time demands in my life and can&#8217;t spend 20-30 minutes on mobility at every workout, I&#8217;ll be breaking things up in to two warm-up routines and alternating/mixing and matching as I see fit – on recovery days when I&#8217;m motivated to hit the gym, I&#8217;ll take the time to do more of an extended routine.</p>
<p>The other way I&#8217;ll work these in is to pair them with lifting sets – instead of idling for a few minutes between deadlift sets, I&#8217;ll pull, then stretch the pecs (which has the added bonus of facilitating scapular retraction and better posture for the pull).  I&#8217;ll pair bench presses with ankle mobility.  Etc.</p>
<p>The key with all of this is to <strong>favor the side that&#8217;s lacking mobility</strong> in cases where I have L-R imbalances; Cook suggests a 3 or 4:1 ratio until the imbalance is corrected for his corrective work, and that&#8217;s a pretty good rule of thumb here: so, for my ankles, I&#8217;ll wind up doing 20 wall ankle mobilizations for the left side, but only 5 on the right.</p>
<h3>The Routine</h3>
<p>This is of course subject to re-edits as I go, but the plan for now is:</p>
<p><strong>Warm-Up A</strong></p>
<ul>
<li>Foam Roll</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=QxiIEWpnvDA">Warrior Lunge 	Stretch</a></li>
<li>Cook Hip 	Lift/FE Hip Lift (Focus on L)</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=TMtP7k1RcTY">Figure 4 	Stretch</a></li>
<li>Rocking 	Adductor Mobilization (Focus on R)</li>
<li>Quadriped Hip 	Abduction (L)</li>
<li>Rocking Ankle 	Mobilization (L)</li>
<li>Sleeper Stretch (R)</li>
<li>Reach, Roll &amp; 	Lift (L)</li>
<li>Scap Push-Ups (L)</li>
<li>Squat-to-stand 	w/ OH reach</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=2lBxS_9XCZs">OH reaching 	lunge walk</a></li>
</ul>
<p><strong>Warm-up B</strong></p>
<ul>
<li>Foam Roll</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=5RC06DF3FKE">Wall Hip 	Mobilization</a></li>
<li>Cook Hip 	Lift/FE Hip Lift (L)</li>
<li>Figure 4 	Stretch</li>
<li>X-Band Walk 	(L)</li>
<li>Wall Ankle 	Mobilization (L)</li>
<li>Sleeper Stretch (R)</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=4k2kqyzz3Ug">Scapular Wall 	Slides</a></li>
<li>Lateral 	Squats (R)</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=zGvJ0dmjRDQ">Broomstick 	Pec Mobilization</a></li>
<li>Spiderman w/ 	OH Reach</li>
<li><a class="vt-p" href="http://www.youtube.com/watch?v=fTVgTivG5Ps">Reverse 	Lunges w/ Rotation</a> (unweighted unlike the video)</li>
</ul>
<p>I realize I didn&#8217;t mention all of these drills in my self-assessment above. I&#8217;ve previously been focusing a lot on hip mobility and it continues to be of primary importance in my warm-up; almost every drill not mentioned falls into that category you can follow the relevant link for video.</p>
<p>In terms of structure, I have a few guidelines:</p>
<ul>
<li>Foam Roll First</li>
<li>Stretch before mobilizing (if stretching)</li>
<li>Start with the hips/lower body</li>
<li>Then progress to the torso/upper body</li>
<li>End with more dynamic/integrative hip mobility</li>
</ul>
<h3>Do it Yourself!</h3>
<p>I&#8217;ll touch more on some of the other injury-prevention work I&#8217;m doing – incorporating <a class="vt-p" href="http://www.youtube.com/watch?v=0vhJza-2xiI">TGUs</a> and single-leg work – in a later post. For now, take a look at the above and PLEASE consider adapting a similar mobility routine for your warm-up in lieu of jogging for 5 minutes or, heaven forbid, nothing.</p>
<p>A great place to start would be to take a couple days and just run through a bunch of mobility work.  Really take the time and foam roll, do the drills properly, learn the movements, and then look to incorporate more into your routine, especially in areas you&#8217;re lacking (hip mobility is a great place to start!).</p>
<p>Not only do these exercises do great things for injury prevention, they also prepare your body to perform more efficiently and effectively for a given workout. Don&#8217;t you want to optimize your gains?</p>


<p><strong>Related posts:<strong></p><ol><li><a href='http://www.ultimatethoughts.com/2009/09/why-mobility-is-king-for-fitness.html' rel='bookmark' title='Permanent Link: Why Mobility is King for Fitness'>Why Mobility is King for Fitness</a></li>
<li><a href='http://www.ultimatethoughts.com/2011/03/starting-to-put-it-together-structuring-the-week-day.html' rel='bookmark' title='Permanent Link: Starting to Put it Together: Structuring the Week/Day'>Starting to Put it Together: Structuring the Week/Day</a></li>
<li><a href='http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-2.html' rel='bookmark' title='Permanent Link: Treating Chronic Knee Issues: An E-Mail Case Study (Part 2)'>Treating Chronic Knee Issues: An E-Mail Case Study (Part 2)</a></li>
</ol></p>]]></content:encoded>
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		<title>Treating Chronic Knee Issues: An E-Mail Case Study (Part 2)</title>
		<link>http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-2.html</link>
		<comments>http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-2.html#comments</comments>
		<pubDate>Mon, 01 Jun 2009 04:00:00 +0000</pubDate>
		<dc:creator>Mackey</dc:creator>
				<category><![CDATA[Fitness]]></category>
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		<category><![CDATA[lifting]]></category>
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		<description><![CDATA[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&#8217;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 [...]]]></description>
			<content:encoded><![CDATA[<p>Continued from <a href="http://mmackey.blogspot.com/2009/05/treating-chronic-knee-issues-e-mail.html" title="Part 1">the last post</a>:<br /><span id="fullpost"><br />
<blockquote><span style="font-size: large;">T</span>he pain has only been debilitating once: back in December on day 2 of a hat tourney. I basically couldn&#8217;t run, strong limp when walking.</p>
<p>By march (Dream Cup) it was fine, basically no irritation.</p>
<p>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.</p>
<p>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.</p>
<p>I&#8217;m determined to heal it properly this time. Would much rather miss a few summer tourneys than risk further damage and chronic pain.</p>
<p>I&#8217;ll give the Samson stretch and the other similar one a try &#8212; pictures would be great.</p>
<p>Yeah, the &#8220;reprogramming&#8221; concept makes sense. Think I&#8217;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 &#8212; it&#8217;s time I gave my legs more attention.</p>
<p>Nope, never heard of foam rolling &#8212; any resources you have on that would be appreciated.&nbsp; I&#8217;m open to trying anything, as long as it&#8217;s not too much too early.</p>
<p>Many thanks for the help.</p>
<p>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?</p></blockquote>
<p>
<blockquote><span style="font-size: large;">I</span>&#8216;ll send you more info, etc when I&#8217;m at home and on my computer with its links.</p>
<p>As for my knee, I had troubles that dated back to my sophomore year of high school&#8211;as a long/triple jumper I wound up doing a number on them, in terms of high-impact stuff and the like&#8230;this resulted in what I&#8217;m pretty sure was a strain of my achilles, and compensating for that left me with knee issues&#8211;dull, aching pain, generally, usually cropping up after workouts but slowly cropping up during runs too&#8211;during the cross-country season fall of my junior year (which would be fall of&#8230;&#8217;03?). Coach figured it was <a href="http://en.wikipedia.org/wiki/Chondromalacia_patella" title="Wikipedia on CMP">chondromalacia patella</a>, I got a <a href="http://www.supportsusa.com/knee/cho-pat/chopat1.htm" Title="SupportsUSA with a picture and a purchase link for the cho-pat strap">cho-pat strap</a> (it&#8217;s the band that goes under your knee, maybe you&#8217;re familiar with it?) and persevered.  I didn&#8217;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&#8217;t need to use the strap all that much, but had the occasional week or two where I needed it.</p>
<p>Enter college (I graduated from high school a year early). Freshman year it again bugged me on and off&#8211;generally speaking, when I was careless and didn&#8217;t warm down properly, etc it would catch up to me. Playing troubles were on and off&#8211;I got in the habit of playing with the knee strap, though sometimes it didn&#8217;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&#8230;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).</p>
<p>Junior year I made some real progress. Or rather, sophomore summer I made a lot of progress&#8211;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&#8217;d rolled that year, I think), including the other stretch I recommended to you and the shoulder bridges.</p>
<p>Junior year (&#8217;06-&#8217;07) I had a lot less trouble with the knee&#8211;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&#8217;t when training anymore, as my workouts aren&#8217;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)&#8230;it wasn&#8217;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.</p>
<p>Senior year (&#8217;07-&#8217;08) I don&#8217;t think I ever had any trouble with my knee. Nothing leaps to mind, at least&#8211;I played a lot, and played well, and without injury.  Really just a spectacular year.</p>
<p>So I&#8217;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&#8217;ve been really lazy with my fitness, and I&#8217;m starting to see some of the old symptoms crop back up&#8211;it&#8217;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&#8211;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.</p></blockquote>
<p>And my follow-up, later:<br />
<blockquote><span style="font-size: large;">S</span>orry for the delay getting back to you.</p>
<p>You might give <a href="http://ultitraining.wordpress.com/2009/03/12/self-myofascial-release-oh-the-pain/" title="Ultitraining on foam rolling, plus links to more reading">this blog</a> a look for information on foam rolling.  There&#8217;s a crapton of information there (and linked from it&#8211;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&#8217;re up to the task, applying extended pressure to the tight spots until the muscles loosen up a bit.</p>
<p>Regular foam rolling will do wonders for your muscle health and flexibility.</p>
<p>For pictures of the Samson stretch, a quick <a href="http://images.google.com/images?q=samson+stretch" title="JFGI">google image search</a> gives you a good idea there (keep in mind you don&#8217;t need to go out THAT far, especially when you&#8217;re just starting), but a better idea can be had in this <a href="http://library.crossfit.com/free/pdf/08_03_Better_warmup.pdf" title="free Crossfit Journal Article: 'A Better Warmup'">PDF</a>.  I &lt;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&#8211;whether that&#8217;s a bench, or back against a wall, etc&#8211;to force your leg into flexion: this emphasizes a different part of your quadriceps when you stretch, and it&#8217;s one that tends to be chronically tight in most (it was and, now again, is in me).  You might find <a href="http://www.biancolo.com/articles/diagnosing-and-fixing-common-hip-issues" title="Lean and Hungry Fitness--er, Jim's blog, with links to hip issue diagnosis/treatment">this</a> helpful for assessing the state of your hips&#8211;everything is connected.  If you&#8217;re going to take the stress off the knees, it needs to be taken in somewhere else&#8211;the hips are that place.</p>
<p>Lastly, you might be especially interested in this bit on <a href="http://www.tmuscle.com/free_online_article/sports_body_training_performance_repair/18_tips_for_bulletproof_knees" title="T-Nation: 18 Tips for Bulletproof Knees">bulletproof knees</a>.</p>
<p>I think that article might describe the stretch I mentioned above&#8211;I&#8217;d check it right now, but I&#8217;m still at work and the site is full of bodybuilder pics. Can&#8217;t start a rumor like THAT.</p>
<p>There&#8217;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.</p>
<p>Hope that&#8217;s all helpful! There&#8217;s a bit on the &#8220;mobility&#8221; topic in the bulletproof knees article, but I owe you a better resource than that&#8211;unfortunately, a lot of what I&#8217;ve learned about that has been in-person, or with DVD&#8217;s I&#8217;ve bought, so your luck is probably as good as mine trying to dig that info up.</p></blockquote>
<p></span><br />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&#8217;m talking mobility drills and the like, not foam rolling.</p>


<p><strong>Related posts:<strong></p><ol><li><a href='http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-1.html' rel='bookmark' title='Permanent Link: Treating Chronic Knee Issues: An E-Mail Case Study (Part 1)'>Treating Chronic Knee Issues: An E-Mail Case Study (Part 1)</a></li>
<li><a href='http://www.ultimatethoughts.com/2008/07/post-150-719-20-ow-my-knee-or-hey-just-so-you-know-were-really-good-at-ultimate.html' rel='bookmark' title='Permanent Link: Post #150! 7/19-20: Ow My Knee, or: &quot;Hey. Just so you know. We&#8217;re really good at ultimate.&quot;'>Post #150! 7/19-20: Ow My Knee, or: &quot;Hey. Just so you know. We&#8217;re really good at ultimate.&quot;</a></li>
<li><a href='http://www.ultimatethoughts.com/2009/04/spring-training.html' rel='bookmark' title='Permanent Link: Spring Training'>Spring Training</a></li>
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		<title>Treating Chronic Knee Issues: An E-Mail Case Study (Part 1)</title>
		<link>http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-1.html</link>
		<comments>http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-1.html#comments</comments>
		<pubDate>Thu, 28 May 2009 04:00:00 +0000</pubDate>
		<dc:creator>Mackey</dc:creator>
				<category><![CDATA[Fitness]]></category>
		<category><![CDATA[injury treatment]]></category>
		<category><![CDATA[lifting]]></category>
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		<description><![CDATA[I thought I&#8217;d post up the e-mail transcript of an exchange between myself and a reader&#8211;as a former JET, we got talking about ultimate and life in Japan, and eventually about his knee troubles, a topic I&#8217;ve a done a lot of reading, experimenting, and self-diagnosis/treatment in. (UPDATE: Part 2, with links to some resources, [...]]]></description>
			<content:encoded><![CDATA[<p>I thought I&#8217;d post up the e-mail transcript of an exchange between myself and a reader&#8211;as a former <abbr title="Japan Exchange Teaching Program member--what I'm doing right now">JET</abbr>, we got talking about ultimate and life in Japan, and eventually about his knee troubles, a topic I&#8217;ve a done a lot of reading, experimenting, and self-diagnosis/treatment in. (UPDATE: Part 2, with links to some resources, is <a href="http://mmackey.blogspot.com/2009/06/treating-chronic-knee-issues-e-mail.html">here</a>).</p>
<p>Hopefully it proves useful/instructive for those of you out there with knee pain or similar trouble. Without further ado:<span id="fullpost"><br />
<blockquote>&#8230;<span style="font-size: large;">I</span>t 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&#8211;bad idea.  Rested for two months, pain/discomfort basically went away just in time for DC in March.  Whew.</p>
<p>But the pain returned a month ago at a tourney in Jeju (Korea).  Same process: niggle at first, then progressively gets worse.  I&#8217;ve rested since, and it&#8217;s better, but this time the pain is more diffuse: sometimes above the kneecap, sometimes medial, sometimes&#8230; everywhere.</p>
<p>X-ray and MRI say no structural damage; two docs say just rest.  One mumbled something about <a href="http://en.wikipedia.org/wiki/Jumper%27s_knee" title="Wikipedia on Jumper's Knee">jumper&#8217;s knee</a>, 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.</p>
<p>I can accept resting for as long as it takes to heal properly.  But I&#8217;m 31, and can&#8217;t help but worry that this is serious and might not just go away. I&#8217;m looking for a knee specialist around Tokyo, but no luck so far.  Not really knowing is the worse part, know what I mean?</p></blockquote>
<blockquote><p><span style="font-size: large;">T</span>hat bites.  Ultimate&#8217;s a terrible sport for that sort of thing too, with all the high impact combined with the weekend-long duration&#8230;I assume you already use it, but ibuprofen is mandatory when you play&#8211;from the sound of it, if you don&#8217;t have any structural damage you&#8217;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&#8217;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)&#8230;though not the &#8220;sharp pain&#8221; you describe.  Weird indeed.  They&#8217;ve definitively ruled out meniscal tears? </p>
<p>It certainly sounds like there&#8217;s some tendinitis/<a href="http://en.wikipedia.org/wiki/Tendonosis" title="Wikipedia on tendonosis--link to tendinitis in the intro blurb">tendonosis</a>, even if it&#8217;s not jumper&#8217;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&#8217;d wager you&#8217;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&#8217;ve read/seen, but it might apply to you). Especially if you&#8217;re sitting all day and don&#8217;t do a lot of training with mobility in mind (ie, if you run lots but don&#8217;t do much in the way of squatting or lunging or the like).</p>
<p>Are you familiar with the <a href="http://www.crossfit.com/cf-info/faq.html#Exercises9" title="Crossfit FAQ: 'What is the Samson stretch?'">Samson stretch</a>? (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&#8217;t do squats or lunges or the like I&#8217;d definitely recommend getting into them&#8211;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&#8217;s far more protective than destructive.</p></blockquote>
<p>
<blockquote><span style="font-size: large;">H</span>ere&#8217;s the rehab menu from the last doc:</p>
<p>1. Sit with legs dangling, massage quad vigorously (like meading).</p>
<p>2. Sit with legs stretched out in front and knee slightly bent, massage calf.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>I&#8217;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&#8217;ve been feeling pain in the inner knee area. But other times its medial, or above. Strange, and frustrating.</p>
<p>Not sure if I&#8217;m ready for the Samson stretch &#8212; seems like a fairly intense exercise, want to make sure I don&#8217;t aggravate the knee. But will give it a try. Any other advice for low-impact strengthening exercises for the quads and hammies?</p></blockquote>
<p>
<blockquote><span style="font-size: large;">H</span>ow bad is the pain?&nbsp; Is it debilitating?</p>
<p>I&#8217;d imagine you could step up the vigor a bit if this stuff isn&#8217;t pushing you too hard. For instance, on that last one you do (I know them as &#8220;shoulder bridges&#8221;), you could try doing them on a single leg with the other extended straight&#8211;I&#8217;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).&nbsp; </p>
<p>Based on the other stuff, it sounds like you&#8217;ve probably got chronic tightness and weakness in the quads&#8230;the Samson stretch might sound intense, but you can definitely ease into it and I think it&#8217;d do you a lot of good. A similar stretch that&#8217;d probably hit the areas you need to stretch really well is pretty similar&#8211;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&#8211;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.&nbsp; I can dig up pictures or the like if you need a better explanation than that.</p>
<p>In terms of strengthening, my knee troubles coincided with an inner quad strength/mobility deficit&#8211;specifically, my right Vastus Medialis (VMO&#8211;the &#8220;teardrop&#8221; shape) was a lot smaller and activated (contracted) a lot less easily than my left, and I had right knee troubles.&nbsp; Again, doing some stuff single-leg can likely help with this (holding the top position on single-leg shoulder bridges, for instance).&nbsp; If you&#8217;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.</p>
<p>The one issue I&#8217;d raise with all the rehab stuff you&#8217;re doing&#8211;all of which makes sense and is reasonable to prescribe&#8211;is that, while it addresses the muscular deficits (strength and flexibility), it&#8217;s not doing much to reinforce good movement habits&#8211;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&#8217;re probably going to continually struggle.</p>
<p>That&#8217;s why I think it&#8217;d be a good idea to incorporate good lunges and perhaps some <a href="http://mmackey.blogspot.com/2008/10/lifting-squat-and-some-words-on.html" title="Me, on squatting">squatting</a> or even <a href="http://mmackey.blogspot.com/2008/10/lifting-deadlift.html" title="More me, on deadlifting. Please do deadlifts!">deadlifting</a> into the mix eventually.&nbsp; 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&#8217;ll help continue to reinforce good habits.</p>
<p>One last thing&#8211;are you familiar with foam rolling at all?&nbsp; This email is long enough, but it&#8217;d probably go a LONG way towards helping you improve your mobility if you haven&#8217;t been doing it yet.</p>
<p>Yeah.&nbsp; So, let me know if you want me to dig up some resources for that stuff.&nbsp; I&#8217;m not surprised if your rehab specialists haven&#8217;t been aware of this sort of stuff, as thinking in terms of mobility, foam rolling, and the like is still more&#8230;hm, cutting-edge, and has only recently started getting enough data and support that it&#8217;s becoming popular, accepted, and therefore, taught to aspiring therapy professionals.</p></blockquote>
<p>More to come in <a href="http://mmackey.blogspot.com/2009/06/treating-chronic-knee-issues-e-mail.html">a later post</a>, including some resource references.&nbsp; Anyone out there have advice or insight to offer that I&#8217;m missing?&nbsp; Especially if you think I&#8217;m talking out of my ass at any point I&#8217;d love to be corrected&#8211;I&#8217;m basing this largely off my own history, along with some advising of teammates, so I&#8217;m hardly a professional.</span></p>


<p><strong>Related posts:<strong></p><ol><li><a href='http://www.ultimatethoughts.com/2009/05/treating-chronic-knee-issues-an-e-mail-case-study-part-2.html' rel='bookmark' title='Permanent Link: Treating Chronic Knee Issues: An E-Mail Case Study (Part 2)'>Treating Chronic Knee Issues: An E-Mail Case Study (Part 2)</a></li>
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