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Squatting with Knee Pain

So, your knee is starting to give you a little trouble when you squat. Many times, people come to us having been told they need to stop squatting and rest it, or that “squatting is bad for your knees, you should never go that low.” And don’t get me started on the “knees shouldn’t go past your toes” myth… All of this couldn’t be further from the truth! If your healthcare provider is telling you otherwise, it’s time to find someone else. A big part of getting you back to 100% is volume management. This means your recent squat volume may have been a little too much for your tissues to handle and we need to take some time to calm them down and build them back up. But in the meantime, we can still find ways to get after it in the gym!

An experienced PT will not only assess your knee and design an appropriate loading program, but evaluate your squat mechanics, make future programming recommendations, and most importantly, find a way to keep you moving! Our goal with physical therapy is not about telling you what you CAN’T do, but helping you figure out what you CAN do. Rather than telling you to stop squatting, we work with each patient to figure out a squat variation that allows them to continue moving without increasing their symptoms. This could simply be moving them toward a more hip dominant squat to decrease the demand on the knees.

An easy rule of thumb is to move across the squat continuum to variations that utilize a more vertical shin. For example, if you’re having symptoms when you front squat, try a high bar back squat. When the load moves from the front rack to the upper back, the torso angle changes and the squat becomes more hip dominant vs ankle/knee dominant. Having an issue with high bar back squats? Try a low bar variation, or try box squats. This will let you really load the hips and keep your shins more vertical. From there we can keep adjusting by increasing the height of the box, decreasing range of motion to further remove the demand on the knees. There is a variation out there that will let you keep squatting, you just have to find it!

Over time, as the specific interventions for the knee continue to progress, we can gradually work back into the variation of the squat that was causing symptoms. Your rehab should be an active process, and there is no reason you can’t keep squatting!

Have questions? Send us a message at josh@vertexpt.com

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Not all ACL Injuries Require Surgery

Pictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark.  Mickey Mantle is the legendary New York Yankees outfielder who started his rookie year in 1951. In the World Series game 2 of that rookie season, he sustained a right ACL injury which was never reconstructed or repaired; however he continued to play for the Yankees receiving 3 MVP awards and a triple crown in 1956. What is the impact of these facts? It means while Mickey Mantle was a professional baseball player he was a very highly competitive, professional athlete who had no ACL. He is what we call a “Coper.”

The ACL – anterior cruciate ligament – is one of the main stabilizers of the knee joint. This ligament keeps the shin bone (tibia) from sliding forward on the thigh bone (femur). The ligament is important in general stability of the knee complex – from side to side movements to running straight. The incidence of ACL tears is fairly high in an athletic population, cited in one study as 68.6 per 100,000 people. These injuries can be contact-related, meaning someone runs into your knee or body in a way that causes the ACL to rupture, or they can be non-contact, which is typically a plant-and-turn motion or a hyper-extension moment. The majority of ACL ruptures are from non-contact injuries, reportedly as high as ¾ of all ACL tears. There is some research that suggests females are more at risk of non-contact ACL ruptures compared to their male counterparts – the reason cited in some research articles as laxity in the ligamentous complex, the hip to knee angle ratios, and hormone differences between men and women.

After an ACL-tear and within management, there is a “rule of threes” suggested. One-third of all ACL-tears can resume normal activities without limitations, one-third will require a decrease in their activity levels or modifications to improve stability, and one-third will require an ACL-reconstruction to return to normal activities. The process of determining management should take the patient’s activity level and their desired return-to-activity into effect. And ACL-reconstructions should serve to return the individual to regular activities.

So, for the general population – is an ACL reconstruction required? Maybe yes, maybe no. BUT. It depends on the activity that you’re trying to get back to. Take for instance the weekend warrior who wants to be able to return to distance running? Maybe – it would depend on what the presentation looked like. Could they weight bear without significant pain? Could they perform a single leg hop? In the very beginning, depending on the swelling, both of these activities may be significantly difficult. But over time, with decreased swelling and increased muscle activation, can they do the same things without an ACL? It’s definitely possible. Secondly, the parent who walks for exercise and just wants to be able to complete regular house or yard work activities or take their kids to the park – does this person need an ACL reconstruction? Likely not.

Research has shown that pre-habilitation is key to improving the overall outcomes of ACL-reconstruction. The pre-habilitation is focused on decreasing swelling, improving muscle activation/firing, and improving movement patterns – not to mention setting expectations for outcomes. All of these interventions are a great way to determine if an ACL-reconstruction will be required. If you can do everything you wanted to do after doing pre-habilitation, then the possibility that you’re a coper is much, much higher.

So, what can you do? When you or your child gets injured, seek a physical therapy (PT) consult first.  Your physical therapist can determine the cause of knee pain is and assist in determining the next best step in your recovery.  Physical therapists see many post-surgical patients, which means we can recommend a good orthopedic surgeon if needed.  We can also get you moving safely – being able to improve range of motion and function much, much faster.  All in all, we can get you better faster.

If you have any questions about ACL injuries, ACL reconstructions, pre-habilitation of ACL injuries, rehabilitation of ACL injuries, or surgical consults please contact Dr Tristan Faile, PT, DPT, OCS at tristan@vertexpt.com.

References:

Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. https://www.nytimes.com/2012/05/05/sports/baseball/mantle-sustained-yankees-other-famous-knee-injury.html

Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758-766

Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520-527