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jaja

Stretching techniques and anterior cruciate ligament

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Over six years ago I suffered an anterior cruciate ligament injury (right knee). I underwent a surgery to reconstruct the ligament and did the proper rehab, it all went well and my knee has been fine since then…until a few days ago. Out of nowhere my ACL started to cause me a similar pain I experienced during the rehab: I feel a sense of unease when walking long distances and a sharp sensation in front of my knee when I flex my knee to put the heel in contact with my gluteus (e.g. when I sit on my heels); nothing unbearable, but I can confidently call it "pain".

I may have caused an inflammatory state without knowing it and know I'm a bit worried. What can I do? Could ST help even in this case?

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Have you since maintained strength in the muscles around your knee? Additionally ACL injuries have been largely shown to come from poor firing patterns of the whole chain of leg muscles, starting with the glutes/external hip rotators. that is, poor biomechanics during functional activities 

Try practicing external rotation of the hip/leg etc while doing some functional activities like squatting, cutting/side stepping while running or single leg balancing with knee bent.

Look up the fifa 11+ program.

There could be many reasons why your knee has started to hurt but given the previous trauma to it, it may very well be damage secondary to ACL injury or simply something that has recently changed your biomechanics. For example, new shoes, new activity, walking on a challenging surface e.g. sand. It's very unlikely the ACL has been compromised given what you've described i.e. "came out of nowhere".

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Thank you for taking the time to answer.

I stopped most of my physical activities few months ago and only a couple of weeks ago I resumed the work with planks and the excellent Slow Flow program.

Overall my body is a mess and it will take a long time to fix my issues; among those I can list extremely tight HFs, disastrous dorsoflexion, sub-par core strength and weak back muscles. So yeah, my whole chain of leg muscles could very well be responsible for this issue and I have a feeling the root problem is lack of stability (side note: left leg longer than right one).

Questions:

  • How do I address the problem? Is it merely lack of strength or restrict ROM? I already started training legs and glutes. 
  • Should I worry about the pain when I exercise or  should I treat it like I do with uncomfortable stretching sensations?

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Update

 

From the MRI scan the ligament seems intact, but it's difficult to tell for sure because the image isn't clear: apparently the surgery left metallic traces in the area.

A physical examination revealed a laxity of my ligament, alongside a considerable lack of strength of my right quad (of which I was aware). Probably my weak leg muscle made me overuse the ligament to stabilize the knee and, at some point, a damage occurred. The prescription is to strengthen my compromised leg in order to compensate for my lax ligament and secure the knee; hopefully this will be sufficient to make me recover. My physiotherapist also told me I have an incredibly poor external rotation of my right hip and this could be linked to my knee problem.

Right now I've no pain, just a good amount of discomfort when I fully flex the knee, but I can feel there's something off when walking. Sure as hell I won't be doing open kinetic chain exercises for a while.

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Update

During the last year my knee was mostly fine, but sometimes I have strange feelings and these days I have a little bit of pain. I'm worried because I've noticed a “fiction-like” sound coming from my knee when I get up from a squat position, I fear my meniscus could be involved. An interesting thing to notice is that walking barefoot or wearing Vibram's FiveFingers seems to make the inflammation heal quicker, when the “episodes” occur.

My question is: given the apparent fragility of my right knee, what should I do in terms of stretching/strengthening in order to preserve it?

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2 hours ago, jaja said:

An interesting thing to notice is that walking barefoot or wearing Vibram's FiveFingers seems to make the inflammation heal quicker, when the “episodes” occur.

My question is: given the apparent fragility of my right knee, what should I do in terms of stretching/strengthening in order to preserve it?

Ditch your "normal" shoes entirely?

Have a quick search for posts by @CraigR regarding post-ACL reconstruction surgery rehab.  I can't remember the specifics of his journey; but I know he's been through it, wrote about it here, and is au fait with Stretch Therapy and its application to healthy movement.

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I update this thread instead of opening a new one, because I'd like to ask a question on a related topic.

Resistance training helped my knee a lot and I'm the strongest I've ever been. However, lately my right knee started to randomly ache again. Nothing serious, but it's still something I should monitor, since I deadlift and squat heavy. The discomfort is truly random: usually I feel nothing while exercising and right now I'm fine, but there're days when my knee is constantly in my awareness. Sensations spread in my calf too, to the extend I think there's some mild inflammation going on. Sadly the mobility of my right ankle is limited, so I cannot get a decent stretch in the area.

Now the question. I have no way to know exactly the state of my ACL, but since the day opened this thread I feel there's something not quite right. My right knee feels weaker and I don't think it has something to do with muscles — my legs are decently strong. I remembered @Kit_L saying that someone he knows managed to heal a damage (not ruptured) ACL through training. Mine may or may not be damaged, but I think more strength in my ligaments would help me anyway. So…what's the more effective way to strengthen them? I know it's a really slow process, I don't mind.

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Single leg training is THE way to go for any of these kinds of problems. The reason is that SL training (compared to two-leg training) requires a much higher proportion of stabilisation, coordination, and balance—and all train the stabilisers to do their jobs properly. The may be nothing wrong with that ACL, either—just that one leg will be being favoured when you squat and deadlift. Just what will need to adapt will not be clear, and likely cannot be known.

My dear friend Craig (whom @pogo69mentioned above) has posted here, and has enjoyed a 100% recovery from a full knee reconstruction—and SLS was the key.

So, ditch the squats for a while (and the DLs, too, if you want) and learn how to single-leg squat. Only do what you can do for the weaker leg (on the stronger/better side) and this way and differences will reduce quite quickly.

I will be making a video on my "seiza SLSs" shortly; I have to get over a hand injury first.

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17 hours ago, Kit_L said:

So, ditch the squats for a while (and the DLs, too, if you want) and learn how to single-leg squat. Only do what you can do for the weaker leg (on the stronger/better side) and this way and differences will reduce quite quickly.

I've just measured my thighs: the left one is 2cm bigger than the right one. Not surprised: the difference can be seen with naked eyes.

My ankles are notoriously stiff, my right one (the one on the weaker leg) even more so. I'm gonna need to put my heel on a 1kg plate in order to perform them, hope it's not a problem.

What about single leg deadlifts with kettlebells?

18 hours ago, Kit_L said:

My dear friend Craig (whom @pogo69mentioned above) has posted here, and has enjoyed a 100% recovery from a full knee reconstruction—and SLS was the key.

I searched for that thread, but couldn't find it. Maybe @CraigR could throw me a link…

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10 minutes ago, jaja said:

Thanks @Nathan! I searched among Craig's threads, but it was actually a comment! My bad.

No problem!

And I'm not Kit, but...

2 hours ago, jaja said:

I'm gonna need to put my heel on a 1kg plate in order to perform them, hope it's not a problem.

Not a problem at all. Simply lower the support over time, as possible.

2 hours ago, jaja said:

What about single leg deadlifts with kettlebells?

Sure, but start with no weight and impeccable form. Make sure you can do a reasonable volume unweighted, perfectly, before adding weight. Throw away the ego. The point is not to lift more weight, but to (re)build patterns/muscles that have atrophied/fallen behind.

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9 hours ago, jaja said:

I'm gonna need to put my heel on a 1kg plate in order to perform them, hope it's not a problem.

What about single leg deadlifts with kettlebells?

Whatever heel lift you need, use it. All Olympic lifters use boots with a minimum of a 1" (2.5cm) solid heel.

You will find that the higher the heels get, the more the quads do the work, but for your problem, this is actually a blessing. And @Nathan's advice re. the SL DLs is spot on: bodyweight first! As he said, we will be building new patterns; and you can't build new patterns if there any perception of difficulty, because in that case, the body immediately reverts to what it can already do.

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3 hours ago, Kit_L said:

Whatever heel lift you need, use it. All Olympic lifters use boots with a minimum of a 1" (2.5cm) solid heel.

You will find that the higher the heels get, the more the quads do the work, but for your problem, this is actually a blessing. And @Nathan's advice re. the SL DLs is spot on: bodyweight first! As he said, we will be building new patterns; and you can't build new patterns if there any perception of difficulty, because in that case, the body immediately reverts to what it can already do.

Something that Roman Pallesits (a very good physio from Austria, Emmet knows him and Ido used to visit him as well) says the following: first you do 10000 reps. After that, training starts. I think his point was that when you are not intimately familiar with the motion, there is a very important learning component that will make your results vary more.

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Tried single leg squats, 2x5, only with my right leg. I used a rail to aid my balance and had to elevate the heel with a kettlebell's handle (and it was barely enough). Movement was shaky, foot arch definitely prone to collapsing.

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@jaja, fantastic.

I'll just add a couple more thoughts to what I wrote in the comment linked to above. Thanks @Nathan for digging it up.

I mostly focused on a combination of two main variations with the SLS. Using a weight held out in front as a counter balance, and using a heel lift. The weight I used was the absolute minimum required to provide enough counter balance to overcome any ankle restriction, from memory the max I used was 5kg.

I continuously changed it up, using a heavier weight with no heel lift, no weight but a higher heel lift, or a lighter weight and a small heel lift.

Bodyweight only full depth SLS without a heel lift was the goal, but most importantly to me, no pain.

I feel the SLS works so well because of the challenge it presents to the knee, ankle and hip joint. Ankle and intrinsic foot muscles are working hard. Focusing on keeping hips level during each rep ensures the hip stabilisers are engaged, and ultimately controlling the accessory movement at the knee. This is probably why simple knee circles helped so much, it was a gentle and safe way of reintroducing and stabilising the accessory knee movement.

I also chose to start and finish with a set on my reconstructed knee, so my stronger side was doing 1 less set every single time I trained.

Good luck.

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On 12/20/2018 at 10:22 PM, Kit_L said:

you can't build new patterns if there any perception of difficulty, because in that case, the body immediately reverts to what it can already do.

So true! That is why the Pilates tradition blocks effort and struggle (Likewise, Alexander Lowen writes about "the neurotic attitude of trying.") Yet so many people make effort their target.

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We are addicted to the "More Machine" model: if some is good, more must be better, right?

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On 12/21/2018 at 8:41 PM, Rik said:

first you do 10000 reps.

This is the now-famous 'Mastery' idea (I forget the book name that popularised this idea, but it's relatively recent). The number's not hugely critical, but the fundamental idea of the necessity of repetition (and attention) to master anything is. If I had a dollar for everyone who has been stretching for a while who asked me, "how long will it take to get front splits?", I could retire. I could reply (in keeping with this thread) "how many stretching sessions have you done?" When you get to 10,000, give me a call!

In fact, 10,000 hamstring stretches is many year's work and you probably don't need to do 10,000 to have loose hamstrings. But the basic point is so sound. And let's be honest: we all want it, and want it now.

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On 12/25/2018 at 8:33 AM, Kit_L said:

I forget the book name that popularised this idea

It was probably Malcom Gladwell’s book, Outliers.

I feel it should go without saying on this forum, since it's such a core part of Stretch Therapy, but deliberate practice and not simply repetitions is what's important.

"Unfortunately, Ericsson says Gladwell misinterpreted his research and that 10,000 hours of merely repeating the same activity over and over again is not sufficient to catapult someone to the top of their field."

https://www.businessinsider.com.au/anders-ericsson-how-to-become-an-expert-at-anything-2016-6

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17 hours ago, Rik said:

I'm sure Malcolm Gladwell is not the source of Roman's assertion. He was talking about reps, not hours.

Thank-you Rik, and I'm sure you are correct re Roman.

I was simply referring to Kit's comment about the book that popularised the idea with respect to attaining mastery.

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