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A Plea For Your Knee

In our physical therapy clinics, we treat patients with knee pain on a daily basis.  It has become more common to train younger clients with a history of knee injury and ongoing knee pain.  Jane Brody’s recent *article in the New York Times has some excellent advice on the care and management of knee pain problems.  I have some further suggestions and clarifications.

Less Mass

The mass portion of the Force = Mass x Acceleration formula needs to be at an appropriate level for your knees to stay healthy.  Carrying extra body fat creates an environment that invites knee wear and tear.  The common knee pulverizing mistake is to perform high impact exercise activities in an effort to lose fat.  If you are twenty pounds overweight, do not run, stadium step, soccer, tennis, or pickleball.  Start with strength training and low impact cardio.  Lose the fat first, and even then, the lower impact activity will be healthier for your knees.  From the overweight client limping into the clinic I get the “I need to move around to lose weight” protest.  I am sorry, but fat loss is primarily a function of dietary alteration.  Exercise has very little impact on body fat levels if you do not eat properly.

Train the Way You Wish to Play

A properly planned fitness program makes your knees more durable (fewer injuries) when you participate in your favorite recreational activity.  The training must be tailored to your activity goals.  If your goal is to play tennis, then you must perform three dimensional deceleration / acceleration activities as part of your training program.  Yoga will not prepare your knees for tennis.  If you want to water ski, then you must perform strength training for your back, hips, and knees.  Distance running will not prepare your knees for water skiing.  If hockey is your recreational past time, you need to be strong, well conditioned and competent in all planes of motion.  Long duration recliner intervals will not prepare your knees for hockey.

Look Above

If your hips do not move well, your knees will pay the price.  In this age of all day sitting and minimal physical activity, hip function is at an all time low.  Physical therapy patients with knee pain nearly always present with glaring restrictions in hip range of motion and strength.  If your knees hurt, dedicate some training time to restoring hip rotation and hip extension movement.  Learn how to perform some remedial gluteal activation drills.  Learn a proper hip hinge, squat and a pain free lunge pattern.

Think First

Participation in a single inappropriate activity can produce a lifetime of knee trouble.  That box jump workout of the day- maybe not.  The warrior, electric shock, mud hole, death run–bad idea.  Trampoline with the grandchildren–what were you thinking!

Be Proactive and Seek Treatment For Knee Pain

“Training through the pain” can take a graceful athlete and turn them into a lifelong speed limper.  The presence of pain changes the way your brain controls movement.  Left untreated, it can permanently alter neural signals and produce movement patterns that linger long after the pain has resolved.  Live with enough cycles of inefficient movement and you develop early breakdown in the knee.

Michael O’Hara, PT, OCS, CSCS

*What I Wished I’d Known About My Knees, Jane Brody, New York Times. July 3, 2017

Read the NY Times article here: https://www.nytimes.com/2017/07/03/well/live/what-i-wish-id-known-about-my-knees.html?_r=0

PDFIn this issue, Mike O’Hara, PT gives ten reasons to love lunges.  Video of lunge exercises/progressions are included.  In Going Grizzly, Mike presents the exercise combination of Crawls and Sandbag Carries; a combination that helps you train more efficiently and move better.  Watch the video for instruction on these exercises.

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Three Gifts I Would Give And Three I Would Take Away

Santa Gives You Gluteal Activation
You need a responsive and strong set of butt muscles to function at optimal levels. Many gym goers have gluteal muscles that are neurologically disconnected.  The term physical therapists and strength coaches use is “gluteal amnesia.”  Our sedentary lifestyle involves very little of the glute recruiting sprinting, deep squatting, and climbing that activates the butt muscles.  We mistreat our gluteal muscles with hours of compressive sitting and little in the way of full range hip movement.  Most fitness clients are in need of some intensive gluteal training.  The hip lift is a simple exercise activity that produces a superior response.  See the attached video for a demonstration.

Scrooge the Lumbar Spine Flexion
Drop the sit ups, stop doing crunches, ditch the glute ham developer sit ups, and forgo the toes to bar competitions.  Father time, gravity, and the stress of prolonged sitting are already bending our lumbar spines forward all day long.  The last thing you need to do is accelerate degenerative breakdown of the lumbar segments with more repetitions of spine flexion.  Please forget about isolating abdominal muscles.  Instead learn how to control the team of muscles that hold the lumbar spine stable.  It is a neural event that is worthy of all your efforts.

Santa Gives You Medicine Ball Throws
medballLife is an up tempo game.  What you do in the gym is reflected in how well you can move during activities of daily living.  If you continually exercise at slow tempos you will get better at moving slowly.  The capacity to decelerate a fall requires fast reactions.  Gracefully traveling up the stairs and getting out of the car are only improved with exercise that enhances power and speed of movement.  Medicine ball throws are the easiest way to improve power.  Medicine ball throws can be scaled to all fitness levels and are safe as long as you use a properly sized and weighted ball.  The large, soft Dynamax balls are a good choice for beginners.  They rebound well off of the block walls in the gym and are easy to catch.  Do not overload your medicine ball throws, a two to eight pound ball is best for most gym goers.  Get with one of the trainers for instruction on adding medicine ball throws to your training program.

Scrooge Sitting Down in the Gym
Movement happens in an upright, standing position.  “Seated exercise” is an oxymoron.  If you want to improve how your body functions, you must stand up and defy gravity. Every athletic endeavor is performed in a standing position. Seated exercise reinforces poor postural habits and diminishes your capacity to move.  I call it the “illusion of exercise” and it will always be highly visible in commercial gyms because it is easy to sell.

Santa Gives You Four-Point Training
Crawling is the neurological training tool an infant uses to develop the capacity to stand and walk.  It is the pathway to better motor control and less pain.  Nearly every physical therapy patient and most fitness clients benefit from a healthy dose of four-point position exercise.  In your fitness program, reinforce the patterns of spinal stability and reboot the postural reflexes with some horse stance horizontal, crawling, and Jacobs Ladder training.   Four-point training can be scaled to any fitness level.  Watch the attached video for some examples.

Scrooge Elliptical Training
I know you love the elliptical.  It is the no impact, cardio darling of the gym but it should be used as a fitness dessert and not a main course.  Elliptical training has multiple drawbacks.  Ergonomically, it is a one size for everyone apparatus that does not work well for taller or shorter people.  When you walk or run, you improve the important skill of stabilizing your body over one leg.  An elliptical keeps both feet stapled to the machine and deadens any neural enhancement of balance or single leg stability.  Hip extension keeps our back healthy and our body athletic.  Maintaining or improving hip extension should be part of every training session.  There is no hip extension produced when you train on an elliptical.  Many people maintain a flexed spine when they use an elliptical.  Sitting produces the flexed forward spine we all need to work against in our fitness programs.  The repetitive use of the shoulder girdle is a frequent generator of referrals to physical therapy for head and neck pain.  Metabolic adaptation to elliptical training happens fairly quickly.  In January, a 30 minute session burns 330 calories, but by June, your body becomes more efficient and that same routine creates only a 240 calorie deficit.  The low impact, reduced weight bearing nature of an elliptical makes it a poor choice in your fight against osteoporosis.

I am happy when people are more active.  Patients and fitness clients love the elliptical and they believe it helps.  Use that belief to keep you motivated and training.  I just want everyone to manage the drawbacks of this type of training.  Injured people always say “Why didn’t someone tell me?”  Before you jump on the elliptical, take ten minutes and improve your core stability and hip function with some four-point exercises and hip lifts.  Learn how to throw a medicine ball and stay standing through the rest of your training program.  Next Christmas you will thank me.

Merry Christmas and a Humbug to you.

See video of Mike in the gym demonstrating these exercises here: https://youtu.be/H0my94BPHNQ

Michael S. O’Hara, PT, OCS, CSCS

PDFIn this month’s issue, Mike O’Hara, PT provides information on Achilles tendinopathy with exercises that will help prevent this painful condition. Watch the video for the exercises by following the link in the article “Achilles Recovery”. Mike also demonstrates and describes the combination of turkish get ups and waiters walks–paired exercises that can help you train efficiently. Video for this article can also be seen on our youtube channel; just follow the links in the article.

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WORKOUTFitness training for those of us past 40 years of age is more complicated. Physical performance and recovery capacity are dramatically different. If you need proof, look for the forty year olds in the NBA or NFL. The good news is that with proper planning, consistent performance, and the wisdom that comes with age, we can stay fit and active for a lifetime. I have compiled a collection of tips for the forty plus fitness client.

Punch the Clock
I am a big fan of what strength coach Dan John calls “punch the clock workouts.” Go to the gym with a plan and complete a quality training session that leaves you feeling good and not gassed. Eat well, sleep soundly, and repeat.

Keep it simple and well within your capacity to recover.
High intensity training routines are currently all the rage. The Tap Out, Insanity, Ripped in 30, P90x home fitness videos all operate at fairly high levels of exertion. It is difficult for anyone of average capacities to sustain that level of training on a consistent basis.

Competitive exercise protocols that involve performing “as many reps as possible” in a defined period of time are omnipresent on the internet. Competition creates a training environment that impedes good judgment. “Men will die for points” is a common quote that I hear in certain training circles.
As a physical therapist who treats exercise related injuries, I can state that pushing the exercise envelope and forty years plus is a dangerous combination. You may have another injury in you, but you may no longer have the capacity to fully recover from that injury.

In the long run, the guy or gal with the fewest “dings and dents” is the one who is able to remain in the fitness race. I like the idea of “user friendly” fitness activities. Training does not have to be complicated or overly intense. Get better at moving a weight or your body through three sets of eight, four sets of six, or two sets of twelve. Perform five or six exercises with your chosen set/repetition range. Take a long walk every day of the week. Consistency is King– eat, sleep, rest, and then repeat.

-Michael S. O’Hara, P.T., OCS, CSCS

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