T Nation

Challenge: Fix Me Up!


Hi guys and gals,

for the first time I really want to heal myself as much as I can so I need your help. Just a short timeline:

Year 2006:

  1. I tore off a piece of (long thin splinter) my lat. fem. condyle

  2. had surgery, osteosynthesis (pieced back together) with 2 screws

  3. medial menisc ruptured, sutured

  4. intensive physical therapy; almost all of ROM re-gained, except for the last 20,30 deg. flexion

  5. 2007 I can’t maintain dosiflexion, foot falls flat on ground

  6. a friend (surgeon) immediately rushes me to the MRI - L4/L5 slight protrusion, L5/S1 slight protrusion


Fast forward to 2013:

  1. in Feb I embark on “5/3/1”
  2. in about a year I make awesome strength gains and build some mass
  3. no pain in the back whatsoever; knee better on some days, a bit painful on others but mostly decent
  4. one day I just got sh*** scared and thought I should check up on the knee, save some trouble down the road

I do proper mobility drills before my workouts (DeFrancos Agile 8), I ramp up my nervous system with some Oly’s and I always warm up properly with lighter loads. Knee is fine during the deads and squats but recently it started “grinding” more than usual.

  • the noise can be described as “running your fingers lightly over the PC keyboard”, supposedly not good
  • the knee hurts more when the days get colder
  • there is cracking and popping when I flex it

During the past years I have had Xrays taken and one MRI which was a dud. A dud because the screws make certain electrical noise and make it impossible to analyse lateral part of the joint.

Xray diagnosis:
Tibiofemoral joint shows mild narrowing with a beginning “spiking” (no better word than that) of eminentia intercondilaris. Femoral-patellar joint shows mild narrowing with subchondral slcerosis of the patella.

MRI is quite long but there is a mention of “chondromalacia 1st degree” and “edge osteophytes”.

Here are some photos of what Im currently trying to fix:

  • raise right shoulder
  • bring the right hip a bit forward
  • correct kyphosis
  • correct internally rotated humeri
  • correct potential APT

Thmas test - horrible. If I lay on the table, put my thigh paralell to the floor, the shin is not nearly vertical to the floor. Quad stretching is not really an option since I cant flex that injured leg all the way

Any tips to keep me on track? Thanks a bunch!

Holy, that image is quite large :). I appologize for posting them one by one but I couldnt find a way to post more images at once


Side view

Your knees, especially the left, appear valgus which causes damage to the medial tissues of the knee (possibly how the left meniscus was injured). I would approach this from the feet and hips. Both feet are excessively turned out which usually causes a collapse of the longitudinal arch of the foot (doesn’t appear so in your side picture, however). The feet being turned out will cause the knee valgus which can lead to a tracking disorder in the knee which can damage the cartilage. Consider having gait evaluated so you can be put in an appropriate shoe or perhaps orthotic. Sorting the problem out at one end may considerably improve some of your other concerns.

The Xray and MRI readings sound to me like OA of the knee. The crepitus during knee flexion is not a good scenario. Did the doc put any contraindications on knee flexion exercises?

There are hip flexor stretches that don’t require full knee flexion so consider those. In the thomas test position have someone press down on the down leg while not allowing your flexed leg to move. Make sure you’re warmed up prior to doing this and perform contract relax in the stretching tissues.

Hammer glute med and max activation work. Can’t hurt.

Let me know if this was confusing and will be happy to clear up any concerns you have.

[quote]CroatianRage wrote:
Your knees, especially the left, appear valgus which causes damage to the medial tissues of the knee (possibly how the left meniscus was injured). I would approach this from the feet and hips. Both feet are excessively turned out which usually causes a collapse of the longitudinal arch of the foot (doesn’t appear so in your side picture, however). The feet being turned out will cause the knee valgus which can lead to a tracking disorder in the knee which can damage the cartilage. Consider having gait evaluated so you can be put in an appropriate shoe or perhaps orthotic. Sorting the problem out at one end may considerably improve some of your other concerns.

The Xray and MRI readings sound to me like OA of the knee. The crepitus during knee flexion is not a good scenario. Did the doc put any contraindications on knee flexion exercises?

There are hip flexor stretches that don’t require full knee flexion so consider those. In the thomas test position have someone press down on the down leg while not allowing your flexed leg to move. Make sure you’re warmed up prior to doing this and perform contract relax in the stretching tissues.

Hammer glute med and max activation work. Can’t hurt.

Let me know if this was confusing and will be happy to clear up any concerns you have.[/quote]

Valgus deformation stresses the lateral aspect of the joint, not the medial. The medial side gets gapped, the lateral aspect of the joint gets compressed. The MCl is on stretch tho.

[quote]BHOLL wrote:

[quote]CroatianRage wrote:
Your knees, especially the left, appear valgus which causes damage to the medial tissues of the knee (possibly how the left meniscus was injured). I would approach this from the feet and hips. Both feet are excessively turned out which usually causes a collapse of the longitudinal arch of the foot (doesn’t appear so in your side picture, however). The feet being turned out will cause the knee valgus which can lead to a tracking disorder in the knee which can damage the cartilage. Consider having gait evaluated so you can be put in an appropriate shoe or perhaps orthotic. Sorting the problem out at one end may considerably improve some of your other concerns.

The Xray and MRI readings sound to me like OA of the knee. The crepitus during knee flexion is not a good scenario. Did the doc put any contraindications on knee flexion exercises?

There are hip flexor stretches that don’t require full knee flexion so consider those. In the thomas test position have someone press down on the down leg while not allowing your flexed leg to move. Make sure you’re warmed up prior to doing this and perform contract relax in the stretching tissues.

Hammer glute med and max activation work. Can’t hurt.

Let me know if this was confusing and will be happy to clear up any concerns you have.[/quote]

Valgus deformation stresses the lateral aspect of the joint, not the medial. The medial side gets gapped, the lateral aspect of the joint gets compressed. The MCl is on stretch tho. [/quote]

While standing, yes. In motion (gait, jumping, squatting, landing, sit to stand) it causes excess internal rotation of the femur on the tibia.

[quote]CroatianRage wrote:

[quote]BHOLL wrote:

[quote]CroatianRage wrote:
Your knees, especially the left, appear valgus which causes damage to the medial tissues of the knee (possibly how the left meniscus was injured). I would approach this from the feet and hips. Both feet are excessively turned out which usually causes a collapse of the longitudinal arch of the foot (doesn’t appear so in your side picture, however). The feet being turned out will cause the knee valgus which can lead to a tracking disorder in the knee which can damage the cartilage. Consider having gait evaluated so you can be put in an appropriate shoe or perhaps orthotic. Sorting the problem out at one end may considerably improve some of your other concerns.

The Xray and MRI readings sound to me like OA of the knee. The crepitus during knee flexion is not a good scenario. Did the doc put any contraindications on knee flexion exercises?

There are hip flexor stretches that don’t require full knee flexion so consider those. In the thomas test position have someone press down on the down leg while not allowing your flexed leg to move. Make sure you’re warmed up prior to doing this and perform contract relax in the stretching tissues.

Hammer glute med and max activation work. Can’t hurt.

Let me know if this was confusing and will be happy to clear up any concerns you have.[/quote]

Valgus deformation stresses the lateral aspect of the joint, not the medial. The medial side gets gapped, the lateral aspect of the joint gets compressed. The MCl is on stretch tho. [/quote]

While standing, yes. In motion (gait, jumping, squatting, landing, sit to stand) it causes excess internal rotation of the femur on the tibia.[/quote]

Im not sure what your point is unless you stated something else in your post, I only read the first sentence which is ignorant on my part.

Internal rotation has implications for ACL and meniscal injury, not sure what your point is for joint loading. It is well established that varus alignment causes excessive KAM and degenerates the medial compartement, while valgus deformity degenerates the lateral compartment.

"On the basis of measurements of joint space width in radiographs, patients with varus osteoarthritis appear to show a fourfold greater rate of progression of cartilage loss in the medial femorotibial compartment, and patients with valgus osteoarthritis a fivefold greater progression rate in the lateral femorotibial compartment.11 A recent MR imaging study has found greater cartilage volume loss in the medial femorotibial compartments of patients with moderate symptomatic osteoarthritis and varus malalignment, and a greater loss in the lateral compartment in patients with valgus malalignment.12 "

“Femorotibial and patellar cartilage loss in patients prior to total knee arthroplasty, heterogeneity, and correlation with alignment of the knee
R von Eisenhartâ??Rothe, H Graichen, M Hudelmaier, T Vogl, L Sharma, and F Eckstein
R von Eisenhartâ??Rothe, H Graichen, Department of Orthopaedics, University of Frankfurt, Frankfurt, GermanyM Hudelmaier, F Eckstein”

“Internal rotation has implications for ACL and meniscal injury”
^You said that

Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported.

The only mention of cartilage in my post was perhaps due to a tracking disorder based on the presentation of his feet.

The source you cited had to do with joint space deterioration, something I didn’t even mention other than suggesting the patient probably has OA in his knee. Stop inventing arguments. Good grief.

[quote]CroatianRage wrote:
“Internal rotation has implications for ACL and meniscal injury”
^You said that

Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported.

The only mention of cartilage in my post was perhaps due to a tracking disorder based on the presentation of his feet.

The source you cited had to do with joint space deterioration, something I didn’t even mention other than suggesting the patient probably has OA in his knee. Stop inventing arguments. Good grief.[/quote]

Don’t be so sensitive, I already stated I didn’t read the entirety of your post which is my fault.

"Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported. "

In this case yes, recent research has shown the valgus deformity as implication for lateral meniscal tear (valgus position, internal rotation, compression of lateral compartment).

I agree with your statement that OP should have his resting foot position evaluated and the rest of your advice is pretty spot on.

[quote]BHOLL wrote:

Medical professional? nope work at a desk, but I have worked in conjunction with them and am familiar with LOE.
[/quote]

[quote]BHOLL wrote:

I dont know why this guy continually accuses me of being in the medical profession, I actually work in a cubicle all day lmao, I just like to exercise and read training methodology.
[/quote]

So he admits that he neither has formal training nor does he have real-world experience.

Check out this statement he made in a post from last year.

http://tnation.T-Nation.com/hub/BHOLL#myForums/thread/5805447/

[quote]BHOLL wrote:

[quote]StevenF wrote:
I’ve posted on here before about nagging golfer’s elbow pain and I’ve seen many people also have the same problem. I started going to a chiropractor right next to my gym a couple months ago. I was going for my nagging back pain issues which are all but non-existent now. I have squatted and deadlifted more than I ever have and pain free. But I also mentioned my forearm/elbow issue and he has this laser machine that they’ve used about 3x so far.

I’ve been doing chinups and pullups and curls pain free since those treatments! I have no idea what the laser is called but for the guys who have the same problem you may want to look into something like that. I’ve done a lot of massaging and finger extensions with the rubberbands as well but this treatment was the game changer. [/quote]

yup got it in my clinic

physio
[/quote]

[quote]BHOLL wrote:

I agree with your statement that OP should have his resting foot position evaluated.

[/quote]

Wonderful news! Some cubicle slave with no formal training and no first-hand experience agrees how the OP should be evaluated.

[quote]BHOLL wrote:

[quote]CroatianRage wrote:
“Internal rotation has implications for ACL and meniscal injury”
^You said that

Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported.

The only mention of cartilage in my post was perhaps due to a tracking disorder based on the presentation of his feet.

The source you cited had to do with joint space deterioration, something I didn’t even mention other than suggesting the patient probably has OA in his knee. Stop inventing arguments. Good grief.[/quote]

Don’t be so sensitive, I already stated I didn’t read the entirety of your post.

"Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported. "

In this case yes, recent research has shown the valgus deformity as implication for lateral meniscal tear (valgus position, internal rotation, compression of lateral compartment).

I agree with your statement that OP should have his resting foot position evaluated.

[/quote]

Lol, I guess from now on I have to be VERY clear in what I’m saying. :slight_smile:

I actually like you posting research BTW. Always room to learn more.

[quote]CroatianRage wrote:

[quote]BHOLL wrote:

[quote]CroatianRage wrote:
“Internal rotation has implications for ACL and meniscal injury”
^You said that

Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported.

The only mention of cartilage in my post was perhaps due to a tracking disorder based on the presentation of his feet.

The source you cited had to do with joint space deterioration, something I didn’t even mention other than suggesting the patient probably has OA in his knee. Stop inventing arguments. Good grief.[/quote]

Don’t be so sensitive, I already stated I didn’t read the entirety of your post.

"Valgus knees during flexion cause excess internal rotation of the femur no the tibia which is a mechanism for medial meniscus tears which is what the OP reported. "

In this case yes, recent research has shown the valgus deformity as implication for lateral meniscal tear (valgus position, internal rotation, compression of lateral compartment).

I agree with your statement that OP should have his resting foot position evaluated.

[/quote]

Lol, I guess from now on I have to be VERY clear in what I’m saying. :slight_smile:

I actually like you posting research BTW. Always room to learn more.
[/quote]

In all honesty, its more of my fault of not reading the entirety of you post. Its good having someone else intelligent in this forum even if I disagree on your icing stance haha.

[quote]56x11 wrote:

[quote]BHOLL wrote:

Medical professional? nope work at a desk, but I have worked in conjunction with them and am familiar with LOE.
[/quote]

[quote]BHOLL wrote:

I dont know why this guy continually accuses me of being in the medical profession, I actually work in a cubicle all day lmao, I just like to exercise and read training methodology.
[/quote]

So he admits that he neither has formal training nor does he have real-world experience.

Check out this statement he made in a post from last year.

http://tnation.T-Nation.com/hub/BHOLL#myForums/thread/5805447/

[quote]BHOLL wrote:

[quote]StevenF wrote:
I’ve posted on here before about nagging golfer’s elbow pain and I’ve seen many people also have the same problem. I started going to a chiropractor right next to my gym a couple months ago. I was going for my nagging back pain issues which are all but non-existent now. I have squatted and deadlifted more than I ever have and pain free. But I also mentioned my forearm/elbow issue and he has this laser machine that they’ve used about 3x so far.

I’ve been doing chinups and pullups and curls pain free since those treatments! I have no idea what the laser is called but for the guys who have the same problem you may want to look into something like that. I’ve done a lot of massaging and finger extensions with the rubberbands as well but this treatment was the game changer. [/quote]

yup got it in my clinic

physio
[/quote][/quote]

cool story bro, can you tell it again

[quote]BHOLL wrote:

Medical professional? nope work at a desk, but I have worked in conjunction with them and am familiar with LOE.
[/quote]

[quote]BHOLL wrote:

I dont know why this guy continually accuses me of being in the medical profession, I actually work in a cubicle all day lmao, I just like to exercise and read training methodology.
[/quote]

So he admits that he neither has formal training nor does he have real-world experience.

Check out this statement he made in a post from last year.

http://tnation.T-Nation.com/hub/BHOLL#myForums/thread/5805447/

[quote]BHOLL wrote:

[quote]StevenF wrote:
I’ve posted on here before about nagging golfer’s elbow pain and I’ve seen many people also have the same problem. I started going to a chiropractor right next to my gym a couple months ago. I was going for my nagging back pain issues which are all but non-existent now. I have squatted and deadlifted more than I ever have and pain free. But I also mentioned my forearm/elbow issue and he has this laser machine that they’ve used about 3x so far.

I’ve been doing chinups and pullups and curls pain free since those treatments! I have no idea what the laser is called but for the guys who have the same problem you may want to look into something like that. I’ve done a lot of massaging and finger extensions with the rubberbands as well but this treatment was the game changer. [/quote]

yup got it in my clinic

physio
[/quote]

Want to hear another fun story…?

This is the one about some sad little cubicle slave who goes hunting down various studies and abstracts to regurgitate it here.

Now that, in and of itself, isn’t bad.

What is pathetic is that this cubicle slave never prefaces his posts by stating that he’s just into researching various literature. He implies most of the time that he is an actual professional in the field. Once he even flat out lied.

[quote]56x11 wrote:

[quote]BHOLL wrote:

I agree with your statement that OP should have his resting foot position evaluated.

[/quote]

Wonderful news! Some cubicle slave with no formal training and no first-hand experience agrees how the OP should be evaluated.
[/quote]

Come on dude. He could very well be an actuary, underwriter, or some other medical analyst who knows more about the subject matter than many with formal training. Research guys are as useful (although annoying, lol) as the practitioners in the field. Spamming the forum isn’t helping anyone.

I could be wrong, but in the thread where he said ‘physio’ he could be referring to working in a physio’s office that utilized cold laser.

[quote]CroatianRage wrote:

[quote]56x11 wrote:

[quote]BHOLL wrote:

I agree with your statement that OP should have his resting foot position evaluated.

[/quote]

Wonderful news! Some cubicle slave with no formal training and no first-hand experience agrees how the OP should be evaluated.
[/quote]

Come on dude. He could very well be an actuary, underwriter, or some other medical analyst who knows more about the subject matter than many with formal training. Research guys are as useful (although annoying, lol) as the practitioners in the field. Spamming the forum isn’t helping anyone.

I could be wrong, but in the thread where he said ‘physio’ he could be referring to working in a physio’s office that utilized cold laser.
[/quote]

And that’s probably the excuse he’ll use if he’s actually confronted in person with REAL LEGAL RAMIFICATIONS.

However, the fact that every single one of his posts imply that he does indeed have formal training and/or is in the profession makes that defense very weak.

In fact, if anyone wanted to pursue this, get his IP, and pursue the matter, there is plenty of material that casts a very poor light.

All he has to do - MOVING FORWARD - is state that this is just his hobby (which it clearly is) and that these are studies that he dug up.

I do agree with you that he has a black belt in bing and google. But that’s no excuse to mislead people who genuinely need help.

Even though he cites some complex studies. It’s still his opinion that is NOT backed by anything concrete. In other words, he either:

  1. already has his mind made up and therefore hunts for studies that back his stance

OR

  1. just pulls up a few random studies and, whichever direction the abstract points, well…that’s his point of view as well

It does not take a genius to figure out that this is Russian Roulette with another person’s health.

Guys, guys… let’s keep this thread on track and useful for someone who might land here from Google in a couple of years :).

CroatianRage, I understand everything you are saying (unfortunately) because I have been reading on this subject like a maniac during the past couple of weeks. About my mack problem also (disc protrusion from 2007)

Now, I am confused about a myriad of things, since TNation guys also seem to not agree:

  1. http://www.T-Nation.com/readArticle.do?id=1444035 this article says that spine compression is bad if you have issues such as herniations, spondylolisthesis, etc. -> this would rule out all the good moves (every deadlift variant, squats, etc.)
  2. Mark Rippetoe is highly PRO squats and deadlifts on Starting Strength forum (makes sense; strengthen the musculature so it better supports the bones and connective tissue)
  3. hyperextensions are deemed as a bad move/promoted as an excellent tool
  • as I know, hypers and reverse hypers are NOT spine flexion exercises but rather a posterior chain movement! (bend at the hips, raise with the hams and glutes, which would make them excellent for strengthening the posterior chain WITHOUT compressing the spine)
  1. OA in the knee - what co I do to fix this? I guess that you cannot really fix cartilage so what am I supposed to do? I cannot not use the knee, I feel better when I exercise, it starts acting up in a couple of days if I break up my gym routine

I read and re-read Neanderthal no more and a bunch of other articles and embarked on a quest :smiley: -

GOAL
Strengthen core musculature, fix imbalances (right shoulder lower), fix posture (conscious throughout the day)

METHOD
Do the “Neanderthal program” as outlined in the article for a couple of weeks, see if it fixes me up

(I am worried about the step-ups, front squats and other knee moves from that program)

1.) You can’t really avoid spinal compression but can do your best to avoid shear and rotational stresses which are worse for the spinal tissues. The majority of spinal compression doesn’t come from the weight on your back, it comes from the contraction of the back musculature. Movements that would reduce shear and rotation would be front squats instead of squats and trap bar deadlifts instead of mixed grip deads.

2.) Rippetoe style squats are the reason I hurt my back 3 years ago, lol. I basically moved my feet in and put the bar at a moderate height to maintain a more upright back to modify the movement. I haven’t done a regular squat since I began lifting again and my back has felt great (currently only do front squats and maybe pause squats for my back off work).

3.) Hyperextension exercises put huge amounts of compression on the spine. I don’t have the exact numbers but I believe more than squats and deadlifts. The low back isn’t a prime mover, it is a stabilizer.

4.) You can’t fix OA, but you can stall its progress. OA is degenerative which means your joint space will narrow and you will get those bone spurs (osteophytes) that were seen on your Xray and MRI. Stalling OA is a “move it or lose it” proposition–get the knee functioning correctly and do smart exercises that stress the knee, but not too much. i.e. jogging is a bad idea.

Your feet during stance are something you should seriously consider getting looked at. My initial post summarized the mechanism a bit.

As for the shoulder, I think this would also improve by getting the feet evaluated. If you look at your back picture your left knee is more valgus than the right causing your right hip to sit higher. Your body will level itself out so your eye level is parallel to the ground so its compensation is to lower the right shoulder.

Fix feet --> Better knee function --> Hips level out --> Shoulders level out

Use trial and error to find knee flexion movements that don’t cause the grinding sensation in the knee and stick with those. Stop at any sign of pain.

Other than that keep up with the remedial core training and thoracic and shoulder mobility work. McGill curl ups, bird dogs, and side bridges are the “go to” for core training. Remain very strict with them, however, and don’t progress without fully mastering the level you’re at.