If you are a strength coach or a personal trainer the chances that you have encountered an athlete recovering from some sort of ligamentous knee injury at some point in your career is pretty high. Whether it is damage to the ACL, MCL, PCL, LCL, or some combination of any of these, the incidence in the athletic and general population is alarming. Hirshman, et al estimated that 1 out of every 1000 people in the US incurs a knee ligament injury each year. The current US population is around 304,000,000 so that means according to Hirshman's figures there will be a projected 304,000 knee ligament injuries in the US in 2008. Of course our primary goal must be a pro-active one with an eye toward reducing the incidence of knee injuries. Unfortunately the mindset of the majority is to get hurt and then train or rehab rather than training with prevention in mind. Therefore it is inevitable that at some point you are going to work with a client that has suffered some sort of ligamentous knee injury.
Working in a private strength and conditioning facility, we see numerous athletes recovering from knee injuries each year. In most cases we are able to work congruently with the physical therapist. In some cases the client or athlete has completed physical therapy, and at other times we get clients that have been released prematurely from physical therapy. When it comes to these cases of premature release the athlete or client reports that their physical therapist, orthopedic surgeon, or family physician has cleared them for physical activity with little to no limitations. Sometimes if we're lucky we get documentation of their contraindications. It is not our jobs as strength coaches and personal trainers to play the role of a PT. It is, however, our job to train the athlete or client in a way that perpetuates the healing and strengthening process in order to get them back into pain free competition or daily life in a timely manner.
I am a firm believer in Gray Cook's Functional Movement Screen so this is the first step I will take with a knee injury client. Obviously the type, severity, and time frame of the injury are all going to play a factor in movement patterns and physical limitations. However, generally I find the deep squat and in-line lunge cause pain if the individual is in or around the 12 week time frame from reconstruction or from the time of injury of a partial tear.
Although I understand that Gray would advise the personal trainer or strength coach to refer out anyone experiencing pain with any movement screen tests to a medical professional, we have come to expect this result so we have developed training methods to adapt to these situations. Plyometrics (bilaterally or unilaterally on the injured leg), and running will also usually induce pain in the injured knee. Another trend that I have noticed is a lack of hip stability, particularly an inability to control the femur of the front leg in a lunging pattern and of the stance leg in a single leg straight leg deadlift (1-Leg RDL). I attribute this to compensation patterns inhibiting the glute medius and piriformis function. Very limited hip external rotation is another trend I have noticed, possibly due the individual's tendency to avoid stretching and exercising full range of motion at the hip of the injured leg which will likely result in tissue density issues.
Now that we have covered the screening process, let's talk about program design. In order to allocate credit where it is due I must say that I have been working under the tutelage of Michael Boyle for two years now so many of the exercises and techniques I will speak about are a direct reflection of what I have learned from him. The basic program outline should be very similar to a program for an uninjured person, which would include foam rolling, stretching, mobility, activation, warm-up, strength training, and conditioning.
Just as any other program it is important to implement Mike's simple rule: "If it hurts, don't do it!"
This means telling the client right from the start that this is a yes or no question and you will not accept; kind of, sort of, not really, or a little bit as an answer. It is also important to note that progression within the rehab population must always be dictated by progress, not time. To make things easier in this article I will include phases in terms of general time frame but a client that has not improved should not be pushed into the next progressions simply because the timeline says the phase is complete.
Foam Rolling
Foam rolling will always come first and will involve all of the basic muscle groups that are usually covered (hamstrings, quads, glutes, hip rotators, hip flexors, mid traps, lats, pecs, etc.). Be sure to pay special attention to any areas of significant tightness that were uncovered during the screening process. As previously mentioned this is usually the piriformis but can include glute max, glute med, TFL, and psoas. Normally 10 rolls back and forth are done for traditional foam rolling however, up to 20 rolls can be applied to these areas of significant tightness.
Foam rolling will always come first and will involve all of the basic muscle groups that are usually covered (hamstrings, quads, glutes, hip rotators, hip flexors, mid traps, lats, pecs, etc.). Be sure to pay special attention to any areas of significant tightness that were uncovered during the screening process. As previously mentioned this is usually the piriformis but can include glute max, glute med, TFL, and psoas. Normally 10 rolls back and forth are done for traditional foam rolling however, up to 20 rolls can be applied to these areas of significant tightness.
Stretching
Just like foam rolling, basic muscle groups need to be addressed in the pre-workout stretching but........Join StrengthCoach.com to keep reading.....
Just like foam rolling, basic muscle groups need to be addressed in the pre-workout stretching but........Join StrengthCoach.com to keep reading.....
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