Bee's Knees

3x10:
pull-ups
push-ups
sit-ups
squats

Tabata bike
SS: 1.4 mi
ED: 1.27mi

Various knee and ankle support exercises.
(Abductor R leg, Adductor L leg, step downs, both legs)

So, this is the first time going to the gym for me in quite some time. I've been recuperating the knee, and its starting to feel really good. Its about damn time too. When I was doing the warm-up squats, it was the first time in a really long time that I went down without hearing my knees creaking. This can only be a good sign. I'm still going to PT, but I'm focusing on two things right now. First, my ankle support on both legs is very poor. Whenever deadlifting or squatting, the ankles collapse to the inside. To remedy this, I've been focusing on keeping my arch when walking around the city, and doing step downs while keeping my ankle supported to strengthen the joint. My other current problem is an imbalance in the strength of the lateral muscles on my legs. This tends to push/pull my knee in odd directions, so I'm working on restoring some semblance of balance there as well.

I'm probably going to begin doing squats again next week, focusing on keeping them slow and strong, with high reps and medium weight. I'll probably include deadlifts as well. After 3-5 months I'm going to try and incorporate Oly lifts again, depending on how stressed the knee feels. Anyway, I just want to say its good to be back.

Damn Knee

Haven't done any gym work worth mentioning for awhile. My knee has been really killing me the last few weeks; anytime I drop to just above parallel there's an awful pain inside my right knee. It's been about two weeks already, and if it doesn't get better in another week I might consider getting it scanned or something. Maybe the problem is that I'm not working it though. I've signed up for some basketball tonight so we'll see if that mitigates or exacerbates my problem.

Getting back to being tossed around

Worked in surprising heat and humidity at the Dojo today. And one of the senior students who's not been around much recently was in--which was good because he is great to work with... and bad because he never tires (because he moves you effortlessly) while you get worn out.

We worked on cross hand grab evade techniques. These are interesting as you are actually using the opponents natural reaction to follow their goal target to guide them to a position where you can control the situation. (Something like moving a target mid-saccade and observing an automatic corrective saccade... or similar high level cognitive hijinks.) It was recommended that I schedule my next test again, so I need to spend some time cleaning up my bokken work and brush up on the test Aikido.

Knee is feeling mostly solid but it still occasionally feels less secure than I'd like. Rotational force is the biggest issue, but I think raw strength would make me feel better (or reduce the psychological aspects). More squats!

ACL Reconstruction

Mark arrived at my door today to announce that he wanted to join the ACL surgery club and had therefor gone and torn his ACL during a rousing game of football (that's soccer to the ignorant Americans). So, in light of this I went to look for the review articles I had read on ACL reconstruction and found that since my surgery a complete review issue was released by Clinics in Sports Medicine. I've included the important articles from that first, as it's the most recent source. But I will start by pointing out that it is clear from my reading that surgeons have their preferred methods and sometimes the conclusions drawn form the data are, by and large, opinion applied to completely inconclusive results. While I did not read any outright contradictions of the data—there was considerable wiggle room used in interpretation.

I will summarize my reading of the articles here and then group the articles by topic and relevance. I haven't read all of these articles as I couldn't find my original list and I read a bunch of them on paper hand haven't confirmed which was which.

First, Bone-Patellar-Bone autograft reconstructions are the oldest and probably the best under most valid statistical measures of knee function recovery but have the highest rate of associated long term post-surgery (anterior) knee pain. This anterior knee pain can also slow recovery as the time to full knee mobility is highly correlated with recovery time and the extra pain associated with the BPB autograft increases this time. Further, all the recent reviews I read suggested that the current generation of alternative allo and auto grafts had statistically indistinguishable results from the BPB autograft, though at least two meta-analyses showed at least one measure that was statistical better for each of the primary auto-grafts (PBP and hamstring) and the allograft comparisons appear to be the same. The primary worry cited in the allograft comparisons is the small (order ~1:400,000 chance) that you will receive an infection from the allograft and in one report I found the median surgical infection rate for this category is 0.36% suggesting that this should probably not be a primary concern (Am J Infect Control 31 (2003)). The other concern is a very small rate of rejection due to improper treatment but the rates were similarly very low (~1:100,000 if I remember correctly). There is a major advantage to the allograft as it allows for faster transition into recovery (less additional trauma) and it can be harvested to maximize match between the grafts bio-physical characteristics and that of the native ACL. A recent class of surgeries appears to be destined to be the new gold standard: the double bundle reconstruction. This actually locates two separate graft attachment points on the femur and tibia. These dual bundle reconstructions appear to be capable of both better duplicating the natural ACLs construction and reducing rotational laxity—a problem with current grafts (but least with the BPB graft).

Below I am grouping and categorizing the reviews. I would remember that the graft comparison reviews (especially the conclusion/discussions) appear to be slightly biased towards the particular surgeons favorite technique.

Clinics in Sports Medicine Review Issue

• Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction
• Allograft safety in anterior cruciate ligament reconstruction
• Soft tissue allograft and double-bundle reconstruction
• Primary anterior cruciate ligament reconstruction using contralateral patellar tendon autograft
• Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction
• Biology of autograft and allograft healing in anterior cruciate ligament reconstruction

Allo vs Auto Graft

• Allografts in the treatment of anterior cruciate ligament injuries
• Should allografts be used for routine anterior cruciate ligament reconstructions?
• Anterior cruciate ligament reconstruction: allograft versus autograft

Additional ACL Surgery Procedures

• Cryotherapy after ACL reconstruction: a meta-analysis
• Bracing after ACL reconstruction: a systematic review

ACL Graft Comparisions

(Orrin Sherman's review first)

• Anterior cruciate ligament reconstruction: which graft is best?
• A comparison of autogenous patellar tendon and hamstring tendon grafts for anterior cruciate ligament reconstruction
• Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis
• Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery
• ACL reconstruction: a meta-analysis of functional scores
• Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft
• Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Structure, Double Strand and Partial Tear

• Partial rupture of the anterior cruciate ligament
• Review article: anatomic double bundle anterior cruciate ligament reconstruction
• Anterior cruciate ligament anatomy and function relating to anatomical reconstruction

One Nasty Complication of BPB Grafts

• Indirect patella fractures following ACL reconstruction: a review

Injury Fate and Recovery Rates

• Fate of the anterior cruciate ligament-injured knee
• Return to play after anterior cruciate ligament reconstruction
• A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments

Stretching and Kneading

PT today was, again, really good for the hip-flexor and IT band. The IT band has what feel almost like 'knots' in places it definitely stretches and feels more mobile after the work. The hip-flexor stretch is just really good.

10min elliptical
Calf stretches and raises
Step downs 3x10
Karaoke 4x20m
Laterals 4x20m
Squat jumps 3x20
One leg hops (left) 3x10
Adductor 3x10 @ 90#
Contra kicks four ways, balance pad, 3x10 @ 10#
Left leg lunge (bozu)
Left leg wall ball supported squat

Hip feels more flexible and the patella is gliding better. Been told to lay off the leg work for a couple of days, so I guess it's upper body and core for a bit.

Crazy PT

I switched to one of the other PTs who I've been working with. She is a professional body builder and has the strength to really stretch my hip flexor and get into my IT band.

10min elliptical
adductor 3x10 @ 140#

left leg isolated work, 3x10:
leg raise @ 40
leg press @ 130
leg curl @ 2x45#,1x40#

3x10 step down
calf stretches
left leg lunge (bozu)
one leg wall ball supported squats
contra kicks 4 ways, 3x10 @ 10#

karaoke 4x20m
laterals 4x20m

squat jumps 3x20 for speed
one leg hops 3x10

foam roller for IT band 2min

The PT really got into my IT band and smoothed it out. It felt like getting rid of knots in a tight muscle. Then she really opened up the hip flexor! It was like having a new leg (or at least hip join) afterwards! Felt good. But the whole thing was tiring...

PoTential

Simple but good PT today.

5min forward elliptical/5min reverse
IT band rolling + PT work on patella mobility, IT band and hip flexor
3x10 one leg hopping
3x10 step-downs
3x20 squat jumps
3x10 one leg leg press @ #90
3x10 lunge (Bosu)
3x10 one leg wall-supported squat
3x10 (four ways) opposition kicks

Knee felt better today, which I attribute to the stretching in yoga and by the PT. Now that I'm allowed, time to really build muscle--but only if I can keep up the stretching. My hip flexors and IT band are still super tight.

Knee Recovery Review

I had a followup appointment today with the surgeon (actually a Fellow who was his assistant) and he declared the knee tight and the reconstructed ACL strong. The left quad is still less than 80% of the right quad and that is one of the markers that can keep me from full activity (specifically long runs, cutting and twisting--so no serious Aikido yet). But, I should be able to close that gap in the next month or two at the most. I can do everything else now and should work on quad, hamstring and calf strength... so more squatting is definitely in the cards. Also, yoga is a definite go. The PT road may be coming to an end soon.

A Little Hopping PT

10min treadmill 7@4.5mph, 3@6mph
Squat Jumps 3x20
Karaoke 6x3m
Laterals 6x3m
One Leg Hopping 3x10
Step Excercise (Speed/Agility Training) 3x1min
Step Jumps 3x1min
Step Downs
1 Leg Calf Raise @ #120
Abductor 2x10 #180, 1x10 #120
Lunge (Bosu) 3x10
One Leg Squat (Wall Ball Supported) 3x10
Two Leg Squat (Wall Ball Supported, Bosu) 3x10
Contra-Kicks (Ballance Foam) on Cable System #7.5 3x10 all four directions
IT Band Rolling

Bending the Knee in PT

So I told my PT that I had done 400m of walking lunges and did she keep me from doing lunges? No! But, she did allow me to skip the crazy jumping--which would probably have been bad.

10min fast walk on the treadmill with 3 min jogging
5min rolling the IT band
2x10 calf raises
3x10 back lunges
4x10m sideways run
3x10 Tensor Fascia (with green Theraband), both sides
3x10 one-leg wall-squat
3x10 gel balancing with leg extension

I was told that I really need to focus on technique when I do exercises to keep the pelvis aligned and even engagement of the leg muscles. (Mostly to reduce the tightening of the IT band and hip flexor as well as engaging the glutes more.) She did a lot of stretching work on the lateral fascia today--attempting to allow the patella to float more freely. All in all another vote the get back to yoga.

Blasted post vacation with PT

10min treadmill at 4.7mph with a brief jog

wall supported squats on the DOSU 3x10

Balancing on gel with Straigt-leg pull 3x10 four ways

Backward Lunges 3x10

Jogging and jumping on trampoline 2x30s each

Jump as high and hard as you can for 20s x3

Calf raises

I was out of shape or the jumping was more brutal that I remember. I just was hitting muscle exhaustion at the end of each set and she was yelling 'keep going!' Lots of stretching and lifting to do this week to catch up.

Jumping for PT

Today they had me really working my use of stabilizers and working deceleration with the knee.

10min treadmill @ 3.6mph
5min foam rolling for IT band
3x60s jogging on the mini trampoline
3x60s jumping on the mini trampoline
3x10 front sliding lunges (uses a cool PT torture foot-slider thing... really made you work)
3x10 back sliding lunges (using cool PT torture foot-slider)
3x10 heel step-down (basically stand on a platform with one foot and slowly lower the other heel to the ground keeping body straight... this also really showed my knee weakness off)

3x10s high jump-fast as possible
4x30m sideways walking

Amazing how different the heel step-downs were. Oh, and my hip-flexor was super tight today.

Burpees! (ok, not really... but Jumping PT!)

So, I'm on my own for weights now. And were now at the point where I can consider Bikram Yoga!

10min treadmill @ 3.2mph (a fast walk, almost jog)

Fast as possible high jumps!! 3x10s
Cross leg sidewalking (4x~30m)
Wall supported squats on BOSU ball 3x10
Back lunge 3x10
Standing leg extensions on gel with balance pushes (theraband) 3x10, four ways

They did some mobilization and my patella is better as is my IT band, but they suggested that I should really just get a foam roller to constantly work on it. Given that Kenway clearly will be regularly needing it for his lower back, perhaps I'll get on for the lab... And I was jumping. Felt odd. Actually they wanted me to do fast-as-possible for 20s but I was to hesitant about landing on the knee. Lots of protective instincts have been built up. Felt good throughout though, so a milestone non the less.

So, boys, when do you want to do a Bikram Class? It's been hot and humid enough out that you should be physically prepared... and I'll ask about doing light weight thrusters/pushpress for next week if this weeks jumping is ok. Seems like those shouldn't load the kneed any more.

And now for something completely different: PT

10min stationary bike @ L9, 90RPM

IT band stretch using foam roller

Leg extensions 3x10 45#
Leg press 3x10 130#
Leg adductor 3x10 80#
Leg abductor 3x10 80#
Knee raise 3x10 80#
Hamstring curl 3x10 50#

Wall/ball supported squats 3x10 with elastic between knees standing on BOSU
Backward lunges 3x10
Gel balancing with straight leg raises (theroband)

Lots of mobility work today and stretching again. I have noticeably greater flexion than a few weeks ago, but the improvement is slowing (as you'd expect). The last few degrees are going to take a while. Doing the squats on the BOSU was interesting. This is all about getting me to use my stabilizers and improve balance. They have told me I'll be starting things like jogging on the treadmill next week...

Oh, Whee PT!

10min stationary bike @ L9, 90RPM

IT band stretch using foam roller

Leg extensions 3x10 45#
Leg press 3x10 130#
Leg adductor 3x10 80#
Leg abductor 3x10 80#
Knee raise 3x10 80#
Hamstring curl 3x10 50#

Wall/ball supported squats 3x10 with elastic between knees
Backward lunges 3x10
Gel balancing with straight leg extensions (theraband)

Lying straight leg raise (4 ways) 3x10 5#

The straight leg raises (while lying down) really get harder with an extra pound. Felt better all around today, but the balancing is more difficult now (they are making me take my shoes off).

PT When Slow

10min stationary bike @ L9, 90RPM

IT band stretch using foam roller

Leg extensions 3x10 45#
Leg press 3x10 120#
Leg adductor 3x10 70#
Leg abductor 3x10 70#
Knee raise 3x10 70#
Hamstring curl 3x10 50#

Wall/ball supported squats 3x10 with elastic between knees
Backward lunges 3x10
Balancing on gel will doing straight leg extensions (with theroband)

Definitely felt being ill today. More stretching, especially working on maintaining lateral movement of the patella. They are worried about asymmetrical tension on the knee and especially the patella creating problems down the road.

PT My Knee

10min stationary bike @ L9, 90RPM

IT band stretch using foam roller

Leg extensions 3x10 45#
Leg press 3x10 90#
Leg adductor 3x10 70#
Leg abductor 3x10 70#
Knee raise 3x10 70#
Hamstring curl 3x10 60,50,50#

Wall/ball supported squats 3x10 with elastic between knees
Backward lunges 3x10

Lying straight leg raise (4 ways) 3x10 4#

Basic stuff today. I was a bit sick so the bike felt harder than it should have. They spent a bunch of time working on my patella and stretching my hip flexor and it band.

Bend it like...

10min cycle with resistance (level 9)
3x10 leg lifts (all directions = X 4) with 2#
3x10 shallow assisted squats
2x10 'stork' leg balance
3x10 weighted (PT) leg raise (45°)
3x10 weighted knee raise 3#
3x10 hamstring pulls
2x10 resistance (PT) leg press
3x10 calf raises

Pretty good all around today. Flexion was at ~120 still (assisted) and there was no pain and good movement. The 2# really make a difference when you're doing leg lifts. Generally, I'm getting consistant pain-free movement walking and my gait is normalizing. Going down stairs is still not possible and I'm assisting slightly going up.

As the Knee Bends

10min cycle with resistance (level 7)
3x10 leg lifts (all directions = X 4)
3x10 hamstring knee bends
3x10 quad knee bends
3x10 quad press
3x10 shallow assisted squats
3x10 'stork' leg balance
3x10 weighted (1#) leg raise (45°)
3x10 knee raise
3x10 hamstring pulls
2x10 resistance (PT) leg press

My knee bend is up to 115° active and 120° passive (assisted). Feels good. I'm getting some strength back but the leg still is noticeably weak. After my first full day of crutchless walking yesterday, my knee and quads were stiff and a touch sore. I still cannot walk actively down stairs (even with a light assists) as passing through about 50° with weight is too painful.

The PT Plan

3x10 leg lifts (all directions = X 4)
2x10 hamstring knee bends
2x10 quad knee bends
2x10 quad press
3x10 shallow assisted squats
2x10 'stork' leg balance
3x10 weighted (~4#) leg raise (45°)
10min cycle (forward till pain, then reverse till pain)
2x10 resistance (PT) leg press

Last time I made it through the cycles and managed to do 3 min of full rotations. Today I was tighter. I was able to do the whole rest of the sets without too much trouble, but the hamstring bends are hard. I measured my thighs this evening. My left is over 1" smaller in diameter!! it's got noticeably lest muscle. This is from ~12 days of reduced use! The lesson: don't skip workouts. I'm now allowed to bend my knee freely and bare full weight, however, so things should start improving quickly. I was actually able to use my left leg to lift my body up a few stairs on the way home. Still a lot of scar tissue to work through especially under the patella at ~45°. Active knee bend at 90° and passive knee bend at 97°.

Prepare for my return (slowly!)...