Also, we want to continue to thank the EMI community for the massive success of Steve’s book, Overcoming Gravity: A Systematic Approach to Gymnastics and Bodyweight Strength.

If you don’t have your copy, join the hundreds of happy readers who are learning from Overcoming Gravity! At the time of this writing, the book is #2 for Gymnastics books on amazon.com, with 13 reviews averaging 5 stars. Get your copy today!

So in general there is some degree of controversy over if you should work out when sick, and if so should be be modifying your workouts depending on the degree of illness.

Basic physiological processes

What happens if we workout while sick?

So what happens when we workout is that the stress of the workouts tend to create the microtears in our muscles. These microtears from the stress are a normal process of damage and repair. The body uses inflammation to signal and start to repair the damage caused by working out. Inflammation is obviously initiated and maintained by the immune system until all tissues are repaired and strengthened against the stress that was placed on the body.

In addition, stress from activity especially sustained activity elevates cortisol levels. Cortisol helps mobilize the body’s supply of fat and glucose to provide fuel for the muscle, but it is an anti-inflammatory and immunosuppressive. For example, cortisone is a derivative of the same class of drugs, the glucocorticoids, and is used therapeutically to reduce pain and inflammation in specific areas of the body.

Our immune system is the way that our body fights infections and other pathogens that make us sick. So you can see how diverting the immune system away from fighting infections towards repairing muscles may be problematic. I have seen it many a times where someone is sick and decides to workout and they get even sicker. Similarly, you can even almost be over an illness and workout a couple of days after it has gone away and then it will come back.

This is similar to antibiotics. When doctors prescribe antibiotics they tell you to continue to take them for the whole amount of weeks and not to stop even if you feel better. Likewise, even if you do not feel sick anymore the body is still fighting the last remnants of infection within your body. So when you subject it to heavy stress from working out or trying to come too quickly to exercise it may depress the immune system such that the infection comes back. Sometimes more strongly than the first time.

Regarding the intensity of workouts while sick

The higher the intensity of the workout, the more probable it is for higher damage to the muscles.

Thus, resistance training or sprinting or high intensity interval training or circuit training in general will be poor choices to do while sick. Resistance training can be fine if there is less muscle damage such as working in lower repetition ranges for strength or working in some of the higher repetitions for endurance as long as the volume is not too high. It is the moderately-heavy weight at moderate repetitions (e.g. the bodybuilding repetitions of 6-12) that tend to do the most muscle damage.

There is the common saying that you can workout if its just a head cold, but do not workout if the infection is in the throat/chest or lower.

I find this to be true as long as intensity is kept down. Chest illnesses such as pneumonia, bronchitis,etc. tend to a bit more potent than head colds. However, the caveat is that lying down and totally resting does actually foster these illnesses a bit to an extent which is why you see a lot of nosocomial infections (illnesses you get from being in a hospital usually on bed rest).

Thus, lying around doing nothing may not actually be as beneficial when sick than at least some type of movement aside from working out. Getting up and moving around to get blood flowing and doing some deep breathing to help mobilize secretions especially if you are coughing a lot is a good idea.

I would also like to add a stipulation which is that if you have a fever you shouldn’t be working out at all. Let your body devote all of its resources to fighting the illness especially when it is most vulnerable.

Generally, if you do decide to workout then keep the workout light. Perhaps a warm-up and see how you feel or a light run may work well. If you tend to overdo it once you get started it may be better to avoid working out altogether until your sickness is over.

Any exercise that you do should leave you feeling better than you started. If you start to feel worse then it may be time to give it up for the day and rest. Remember, our muscles and bodies recover when we rest, and it is exactly the same for illnesses.

How to work yourself back into exercise

Work slowly back if you are used to high intensity exercises. For a cold, a 1-2ish week buffer between getting back to full exercise is likely good.

For more severe illnesses such as influenza or pneumonia, I would take at least 2-3 weeks after all of the symptoms have subsided to work back into things with full intensity. The problem with going back to high intensity right away is that even if all of the symptoms have gone away there is still bacteria or viral loads in your body, just not enough to make you symptomatic. So high intensity exercise can actually depress your immune system enough to make the illness come back, sometimes even stronger than ever. Thus, it is best to be conservative with this.

If you’re using a typical 3x a week type of exercise schedule, start with about 20-30% of your typical full workouts, and ramp up by 10% until after about 2-3 weeks you will reach 100%. Best to be conservative than get an illness again and be out another couple weeks if not more.

Things that may help

1. Sleep is obvious. The body can devote full attention to fighting off infection when sleeping.

2. Good nutrition. Our bodies will tend to suppress appetite when we are sick, but food is good for the calories to supply energy for our body to fight the infection. I do not know where the myth(s) came from that ginger ale or other really sugary foods are good during sick, but they are obviously not whether sick or well.

Eat healthy. Fruits and vegetables are good choices. If you have a low appetite, try to eat but don’t make yourself nauseous.

3. Vitamin D is a potent immunomodulator and increases amounts of the anti-microbial polypeptide cathlicidin, defensins 1 and 2, and T-cells which will help fight infection.

Most people are deficient, and stay indoors when sick so this is definitely a factor to look at especially since most illnesses occur during the winter when there is less sun out. Sunscreen typically blocks UVB radiation which can make people deficient even during summer.

A hospital dose you would get is 2,000 per kg of body mass over 3 days which is approximately 1,000 IU per lbs. So if you were 150 lbs that would be 150,000 IU spread over 3 days or 50,000 IU per day.

Anecdotally, I have seen that doses of 20-30k when sick tend to work well for most people. This is what I do and recommend.

4. There is some support for zinc supplementation. However, those who supplemented with Zinc also had higher incidences of side effects.

If you are deficient in zinc, which most people are like with vitamin D, then this can be a good option to pursue as well.

Things that won’t help

Vitamin C. Yes, the studies show that vitamin C does absolutely nothing for fighting colds or illnesses. However, there are still some adamant believers that it is the vitamin C that keeps them from getting sick or helps them recover from sickness earlier. More power to you if you believe this, but the skeptics should not bother. There are many reviews of which I have listed two: one, two

A quick search through pubmed shows that it may reduce symptoms very slightly at best.

So don’t bother supplementing vitamin C for colds or upper respiratory tract infections.

edit: there seems to be some evidence presented by a commenter (Ole) that very high dose vitamin C to tolerance in particular bad infections. Thus, it may help supplement your body’s natural vitamin C production to increase ability to sop up the oxidation from the immune system as it battles with the infection. Therefore, if you have a particularly bad illness it may be a decent idea to supplement which may help aid the immune system. How much I am not sure though.

Conclusion

If you work out in a gym you do not want to be infecting people around you. This is not good gym etiquette. Please stay home and let yourself rest and recover.

For sickness, getting up and moving about is good. Perhaps a light workout such as a warm up or light run is fine to get blood flowing and the lungs mobilizing secretions.

Be careful about high intensity exercise of any kind during and when recovering after an illness. It may make you sicker.

Be conservative about coming back from an illness. If you go too intense too soon you can relapse and go through the same illness again with possibly worse symptoms.

For fever, sleep and rest.

Vitamin D may be beneficial to help fight illnesses especially if you are deficient from not being outside a lot or it being the winter. A glass of milk is only 400 IU, so that would not be effective, plus dairy is an irritant in some people. A higher dose 10-30k IU that tends to work a lot better from what I’ve seen.

This 10,000 IU vitamin D is the one I use. Code = LOW052 can get you $5 off your first time.

Zinc supplementation can also be potentially beneficial, but it may come with side effects.

If there are other myths / methods / tips you would like me to review and put in the in the above two sections let me know in the comments.

So I felt it was a good way to start off the year with something we all really need to hear again.

When I wrote A call for KISS, I outlined some simple points about what is effective.

Breaking down the numbers…

The four key concepts I outlined in a call for KISS are training, nutrition, sleep, and destressing.

Prioritizing what we improve first will have the biggest impacts on our training and health. Based on the “time” factor we can reprioritize everything according to its value in our daily lives.

Subsequently, a reorganized list would look like:

• 1. Sleep
• 2. Nutrition
• 3. Training
• 4. Destressing

1. Sleep

Sleep is really friggin’ important. We do it for nearly 1/3 of our lives. And lack of sleep, as well as night shifts, directly cause excessive chronic inflammation, insulin resistance, and otherwise negative effects we associate with the diseases of civilization (metabolic, neurodegenerative, auto-immune, etc. issues). WHO – the World Health Organization – has named shift work as a carcinogen. Getting on a good circadian rhythm is extremely important.

Keep it simple; get good sleep.

Guidelines and tips to get good sleep are:

1. Get at least 7-8 hours if not more in a pitch black room with no noise and cool ambient temperature.

2. Destress. Massages are great. Be disciplined in your daily life. Don’t procrastinate. Don’t let little things bother you. Again, get into a daily routine.

3. For those of us who use the computer a lot, the blue screen glow interrupts our circadian rhythm a lot leading to insomnia, anxiety, and other sleep related disorders. F.lux is a good problem to help counteract that.

~elimination of sounds
~elimination of electronic devices / outlets / plugins near body
~pitch black room
~cool, dry room (60-65 or so degrees is good if possible)

~stay away from artificial light sources (e.g. computer) at least 1 hr before sleep
~eat a meal, preferably with healthy fats and a decent amount of carbs, before sleeping (e.g. NO JUNK FOOD).

~single leg stand to exhaustion with both legs (it actually works really well)
~spine lengthening before sleep (see Esther Gokhale’s stuff)
~general exhaustion from physical activity like hiking, pickup games of stuff, lifting, etc.
~Deep breathing exercises
~Deep tissue massage

~magnesium may help (via ZMA or natural calm)
~melatonin helps some people
~phosphatidylserine (anti-cortisol)
~5-HTP (tryptophan deriv)
~L-theonine
~Vitamin D (taken during the day..)
~valerian root

Robb Wolf also wrote some more tips here

2. Nutrition

Nutrition I would rank second. We eat nearly 3 times a day for 7 days a week. Therefore, the affect of nutrition on our bodies for improvements in both health and training cannot be understated. You may have heard that “abs are made in the kitchen” and that it is 75-80% nutrition for fat loss. This is true – for the ratio of times we eat per the times we train per week is about 21:5 or about 80%.

Really though, keep it simple. There’s lots of good sayings that are generally true:

• Eat real food
• Avoid refined carbohydrates
• Avoid things that come in a package
• If your grandmother wouldn’t recognize it don’t eat it
• If it doesn’t grow from a tree or in the ground, or swim, or walk don’t eat it.

While “eating clean” and the above categories are actually fairly arbitrary, the “goal” of it all is simple.

Don’t obsess about macronutrients. Don’t even obsess about food. Eat a wide variety of plants and animals.

Enjoy your food. Don’t let it take over your life.

3. Training

While I tend to strongly encourage weights over doing cardio, getting off your butt is getting off your butt for most people. As long as you are doing something, it is better than nothing.

And, after all, everyone has their own goals. I like to try to inform people the whys of why strength training typically is more effective to get people to their goals faster. However, as long as people are getting up and moving it is good.

Movement is life.

Since I have been down and out with my training for a while, you really learn to appreciate things more. Even though I’m fairly young (mid-20s still) I have gotten a taste of very hard training and burnout already. I have had some of my fair share of injuries.

Training and exercise, while working to our different goals is fun. But sometimes, just take a few steps back and really enjoy the process. Take days off here and there to do things with your family.

I used to be the one who would skip going out with friends to play basketball (and I still hate basketball), to go train by myself and train my strength. However, strength can wait. Enjoy some time and memories with your friends.

If you’ve been thinking about learning new sports or trying new activities do it. Life can get hectic and busy, and we often get stuck in our ruts.

Learning new things can be frustrating at times, but it also engages us and challenges in a way that helps to free up accumulated stress in our bodies and minds.

Destressing

I kinda covered a bunch of the tips in the sleep section since stress and sleep quality are very intimately related. Actually, all 4 of the qualities I have talked about – sleep, nutrition, training, and stress – are all interconnected to optimal health.

Optimizing these are really 99% of the things we can do to benefit both our health and fitness.

Really, movement related destress is the best.

Massage and soft tissue work. As you may well know I am a big proponent of massage for pretty much anything and everything. Use lacrosse balls, tennis balls, foam rollers, etc to poke around your body to help loosen up. Kelly Starrett’s mobility wod is a great resource.

Females actually do have some destressing things right such as taking hot baths, enjoying hot tubs, and going to the spa. Pretty much anything goes much like soft tissue work that helps you significantly relax and enjoy yourself.

Laugh. Watch or listen to funny things. Laughter actually does beneficial things for immune system function. Funny but true.

Meditation and prayer also produce similar effects. Acupuncture may produce similar effects as well.

The real thing is just do something you enjoy or something that gets you to relax. Destress yourself. Sleep more… get rid of the chronic stress. Not only will this improve your mood and attitude but it will also improve your health and subsequently performance as well.

Supplements

Supplements are supplements.

Like I have stated in previous nutrition articles, aim to fix sleep, nutrition, and training before you even think about supplementing.

Conclusion

It’s always a good idea step back and reassess what you’re doing with your life.

It’s pretty easy to get caught up in family, work, school, even training and nutrition. Don’t be dogmatic about things.

Spare some time and invest it back into your body.

After all, health is one of the most precious gifts we have as humans.

On the heels of a fantastic AMA and the successful launch of his book, Overcoming Gravity: A Systematic Approach to Gymnastics and Bodyweight Strength, Steve has release another article on KISS, highlighting some insights into the most crucial elements of being fit for athletics, hobbies or just playing with your kids. Check out our latest article with the link below!

KISS 2.0

We urge our fans to take advantage of this access to Steven and other members of the gymnastics, parkour, and other fitness communities. Steve will also be posting up a new article on January 9 at 6 AM EST, so be sure to have your RSS readers linked to our feed for an instant update!

My question is about training for Longevity, that is a long and healthy, disease free life. Everywhere I look, people are talking about performance, improving your squat weight, DL, olympic lift numbers etc. No one in the S&C world has set out to program a training regime with the sole goal of a long life. I asked Justin Lascek this question and he said slow lineal strength gains, address imbalances (both in mobility and weaknesses, eg dont allow a strong squat if you have a weak press, work on the press) and sprints or HIIT no more then twice a week.

Do you have any thoughts on a training regime for longer life?

All I have found is the Movenat guys who seem to be heading along the right path.

Thanks.

Answer

Thanks for the email! This is a great question because, like you pointed out, most of the informed posts you’ll find (including here at E.M.I.) are geared more towards athletic performance or even body recomposition; however, neither of these are 100% directly related to longevity. Part of the problem right from the start is defining ‘longevity’ as different people tend to view it a bit differently.

You personally outlined it as “a long, healthy, and disease free life,” which requires us to break each of those three aspects down a bit further.

Long

The first question that needs to be addressed is one of specific quantity: using years (a common and comprehensible metric for age), what exactly is a “long” life? Average U.S. life expectancy is just under 78 years while it’s around 72 years in the Philippines. A seemingly acceptable general range for a long life would be 70-80 years old. Understanding what could stop one from reaching this age takes us to our next point: disease.

Disease Free

To hash out possible reasons someone might not reach 70-80 years old, I’ve listed the top four causes of mortality in both the U.S. and the Philippines (which is where this question came from).

Top Four Mortality Causalities in the United States

• Heart disease
• Cancer
• Stroke (cerebrovascular diseases)
• Chronic lower respiratory diseases

Top Four Mortality Causalities in the Philippines

• Lower respiratory infections
• Ischaemic Heart Disease
• Tuberculosis
• Hypertensive heart disease

The very large commonality we see here is that the root of most of these problems is essentially in the heart, lungs, and blood vessels (which we’d group as the cardiovascular / cardiopulmonary system). We’ll definitely be addressing ways to keep this system functioning well, though diet plays a major role in this.

Healthy

Beyond simply avoiding disease, we’ll assume here that “healthy” will also imply: to be as free of injuries as possible, especially those that are chronic and recurring; maintaining a level of mental health that would avoid self-destructive behavior; and competency for general daily life activities.

Injuries seem to be extremely prevalent among all sorts of people, from desk workers to construction workers to fishermen. While no one can realistically expect to be 100% injury free for life, our aim here is to live and train in a way that will help minimize these injuries as best we can.

Quite a few common chronic injuries occur in the lower body, which have been VERY thoroughly analyzed in the article Shoes, Sitting, and Lower Body Dysfunctions. The overall commonality we pick up on is that lack of flexibility, strength, and awareness in mainly the hips and ankles tends to cause a whole host of issues. In the upper body, rotator cuff issues are an extremely common problem with issues at the elbow coming in second to that. Back pain is almost a standard for anyone over the age of 40. We’ll keep all of this in mind.

Daily activity competence covers a pretty broad range of movements and physical needs seeing as everyone’s daily life will be different (and so general activities involved in his or her life will vary) and each person has his or her own preset strengths and weaknesses. Here we’ll simply base it on what seems to be daily frustrations for a lot of people.

Bending down to pick an item up tends to be a huge problem, progressively so as we age. Not only does a lack of flexibility tend to make this movement harder by nature, a lack of awareness of proper biomechanics (and properly practicing this movement accordingly) also predisposes us to injury, mainly in the spine.

Ability to grab items overhead, move items overhead, or simply reach overhead in itself tends to degrade over time as flexibility in the shoulder diminishes along with scapular stability.

All kinds of other activities tend to get harder and harder: walking up stairs gets progressively more tiring; having to move a couch is surprisingly exhausting; the dog walks YOU; and chasing the kids around feels like an olympic event. Again, specifics are hard here because demands from work, family, errands, and personal enjoyment will vary a lot from person to person.

Mental health is a crazy (no pun intended) complicated topic that would require a SERIES of articles in itself to cover exhaustively (as exhaustively as it can be based on the little we know as a whole). For simplicity’s sake, we’ll allow this to come as more of a side effect benefit from everything else: improved cardiovascular function, not having to deal with the annoyance of injuries, and feeling physically competent for day to day tasks.

The General Recommendations

• Cardiovascular/cardiopulmonary health seems to be by far the most important factor in preventing disease
• The hips and ankles need to be flexible, strong, and proprioceptive to avoid common lower body complications
• A strong, enduring back will be needed to avoid spinal shearing and consequent back pain day to day (hip flexibility plays a role here also)
• Leg and/or back intensive movements such as picking up relatively heavy items and going up stairs will benefit from the strength and flexibility work being done
• Rotator cuff issues stem from not only relatively weaker rotator cuffs, but also inflexible anterior shoulder musculature
• Overhead mobility, stability, and strength also should be addressed

The challenge here is defining a specific guideline for training based on general, potential issues. For clarity, we’ll split the cardiovascular work away from the strength & flexibility work since the two approaches are quite different.

Cardiovascular work for general health is well structured by the ACSM and isn’t complicated or all that extensive. Simply get 20-60 minutes of easy (we’ll define further in a moment), steady work for a minimum of three times a week. This type of work usually isn’t an issue to do more than three times in a week if one desires and makes great activity to do on off days from any other training that might be taking place.

“Easy” in this scenario tends to be defined by heart rate but using the standard approximation formula for maximum heart rate has a great chance of being inaccurate because of a high degree of individual variance. An easier and equally valid method is using the RPE (rating of perceived exertion) and aiming for a 3 or 4 on a scale of 1 to 10 (with 1 being the easiest and 10 being the hardest). You should be able to hold a broken conversation during this kind of activity.

Some common examples: riding a bike, going for a walk / run / hike, playing some tennis with friends, using an elliptical machine, grabbing a pick-up game of basketball, rollerblading, and so forth.

No specifics are needed outside of that and variety is a powerful tool. In fact, variety is arguably the most important factor since we have a whole lifetime here to do activity and if it gets too boring it’s likely that the individual simply won’t do it anymore. Mild intervals (alternating higher intensity with lower intensity) tend to be included with some of these activities (like picking up speed when you have the basketball to try and make it to the opponent’s end of the court during some portions of the game while other portions you may find yourself standing completely still for a few seconds) and doing these intervals intentionally offers some other benefits. Again, simplicity and variety are most important here.

Strength and flexibility work, as a bare minimum, should include two major movements (or the work needed to build up to them): a full squat and an overhead press. A full squat (as defined by the superior iliac crest coming at least as low as the patella while maintaining spinal extension) represents a standard of flexibility in the hips and ankles. Similarly, the overhead press represents a standard of flexibility in the shoulders.

If either of these movements can’t be completed, a major goal of training is to do work that will work one towards having the ability to complete these movements. Once they can be done, they are a large part of the core of the program. Variations such as the low-bar back squat versus the high-bar back squat or the dumbbell overhead press versus the barbell overhead press are acceptable and encouraged for variety’s sake.

To keep things in balance, compound pulling should be included. Cable rows, bent over barbell rows, pullups, pulldowns, deadlifts, or any other large movement that involves pulling is great. Don’t be afraid to alternate them to keep things fresh.

The major change in programming we use to separate beginners and those who are more advanced is frequency. Two days as a minimum is sufficient and would be preferred for someone who has a very physically demanding job (and so is getting a high frequency of resistance work as it is) or doesn’t care too much for doing strength work. Time restraints are a common limiting factor as well. As one advances, bumping the training up to three to four days will help further progress and a basic upper / lower split routine would typically be used, especially for a four day schedule (with the full squat and overhead press as the core of the day, respectively).

Five days of resistance training wouldn’t be necessary from a general health standpoint, but if the individual seems to take well to resistance training and truly enjoys the experience then that would be an option to cater to that individual’s preference. Again, remember that adjusting the training to what the trainee likes more will help with adherence which is critical.

Different repetition ranges should be targeted while the others are maintained. Training with a 1-5RM will heavily improve neural strength factors and have a high effect on bone density, though it can be very mentally stressful and rough on the joints. Training with a 5-8RM will give a good mix of strength and muscular growth but is still pretty heavy to work in as far as connective tissues go. Moving into 8-12RM will lighten up the loads on the joints and start to work muscular endurance and offer overall growth, while moving into 12-15RM will be moving more deeply into muscular endurance which is arguably equally important as strength for life tasks.

For general health, there’s not much of a need to go beyond sets of 15-20RM (which are useful for technique practice and retention and as a break from all the heavier stuff, given the intensity is low). A reasonable exception might be to simply test common markers that the general public tends to have set in its mind (at least here in America), e.g., sit-ups in a minute, push-ups until failure, air squats, or miscellaneous bodyweight circuits. To reiterate, these would simply be used as tests or for the fun of trying something a little different rather than be used consistently as an effective training stressor.

Using all of these ranges in some fashion or another is recommended since variety is helpful to fight staleness and each offers different yet important benefits. Understand that there is crossover between the ranges and they lie on a continuum, not in distinct, separate groups; using a 8RM will confer some benefits of the 5RM and some benefits of the 10RM. The further away the ranges lie on the continuum (say 3RM vs. 11RM), the less the crossover.

Amount of rest time in between sets can affect performance during those sets and consequent improvements. Strength work (1-8RM) should have higher rest such as 2-5 minutes between sets while endurance work (12RM+) should keep rest lower such as 30-120 seconds.

As a good general guideline, one to three sets per exercise is plenty. The higher the repetition range being used, the lower the sets can be. This also allows for changes in mood and overall tenacity during the workout. Some days will just simply suck and cutting back the sets helps reduce the overall load and time needed to complete the workout. Don’t forget about the big picture here.

Continually increasing the load of these stressors is important, too. With 1-8RM, focus on really increasing the weight being used. With 12RM+, aim to increase overall volume and / or decrease the rest time between sets. That weird middle range of 8-12RM can go either way, so volume and weight increases will help but so will decreases in rest time. The trainee should pick whichever he or she tends to gravitate toward naturally.

For programming, one could use simple undulating periodization where one day of the week a certain range is used and another day a different range is used. Alternatively, one week could be focused solely towards one range and the following week is focused on another. It’s important to note that one range shouldn’t be ignored too long and done at least at maintenance even when other ranges are the focus. In a similar vein, once a satisfactory level of fitness is achieved, everything could be switched to maintenance to allow time for other pursuits in life.

To train at maintenance, one can cut back to both 1/3 of the volume and 1/3 of the frequency as long as the intensity remains as high. For instance, let’s say a bench press was trained 3 times a week for 3 sets of 10 which brought the trainee’s usable weight in that range to 180 lbs. If the trainee now chose to simply maintain this, the setup could use 1 set of 10 once a week but the weight must remain equally heavy at 180 lbs. As a general rule to fall back on, one specific range as defined above shouldn’t be completely left out for longer than a month.

And that pretty much covers what needs to be covered. We’ll finish off with a recap of the major needed points and a sample program modeled after someone who only wants to cover his or her bases with the bare minimum.

Guiding Factors

• Cardiovascular work should be done at least three times a week for a solid 20-60 minutes straight. Aim for an average intensity of a 3 or 4 on the RPE scale of 1-10. Variety, variety, variety!
• Strength and flexibility work should be modeled towards the full squat and overhead press. Some form of pulling like rowing or pullups should be included for push / pull balance. Variations of these movements are completely fine and helpful to adjust for equipment limitations and boredom.
• Repetition ranges are typically categorized as the following: 1-5RM which offers heavy neural strength and bone density improvement but is harder on the joints; 5-8RM which offers a very good fall-back range for strength and growth; 8-12RM which eases stress from the connective tissue and begins to enter muscular endurance while providing good overall growth; 12-15RM moves more into muscular endurance; 15-20RM is good for backing off of any significant weight while allowing practice of movements and even further muscular endurance; 20RM+ is reserved for testing things for fun
• Rest time between sets of 1-8 should be high (2-5 minutes) whereas sets of 12+ should have short rest times (30-120 seconds)
• Progressive overload is very important. The 1-8 range should rely on increases in weight used while the 12+ range should increase overall volume or decrease rest time. Sets of 8-12 can progress well through either.
• Working all of the different ranges is important to keep training helpful for the goal here: general health and fitness. Alternating the focus on different ranges is encouraged and allows for a lot of variety in the program.
• When a range isn’t being focused on, it should at least be maintained. Don’t ignore a range for longer than a month.

Bare Minimum Sample Program

Monday: Recreational hockey game with the old buddies. Takes about an hour, give or take 10 minutes.

Tuesday: Weights day. Low-bar back squat done for 3 sets of 5. Barbell strict overhead press done for 3 sets of 7. Weighted pullups done for 3 sets of 6.

Wednesday: Full rest day.

Thursday: Morning run for twenty minutes. Lots of hills here so no choice but to do intervals. Gym workout at night. Goblet squats done for 2 sets of 15 (dumbbell weight doesn’t go high enough for working in the heavier ranges anyway). Dumbbell overhead press done for 2 sets of 15 (might as well keep the theme). Pulldowns usually feel good here so 3 sets of 12.

Friday: Full rest day + social life.

Saturday: No obligations midday on Saturday so it makes a great day to ride the bike outside. If the weather’s not so hot or time does happen to be shorter, all out for 20 minutes. Relaxed days could go up to two hours though ( since the scenery is nice and fresh air tastes good).

Sunday: Either full rest or bowling.

For further information on setting up a workout, be sure to delve into Fundamental Exercise Concepts Part 1 and Part 2

We are pleased to report that the book is now available online through Amazon.com!

If you want to discuss the book, or review its table of contents, follow through to the post on the book’s forum to learn more.

One is the physical aspect of rehabilitation, and the other is the psychological aspect of healing. The latter for most people depends on the extent of the injury, if it impairs them from activities or sports they enjoy, and how long the injury has been present.

We will talk about these two aspects especially in dealing with the concept of pain and how it should be cared for in rehabilitation.

This is a semi-excerpt from the upcoming bodyweight strength training book.

The physical aspect of rehabilitation

There are two prevailing popular methods of thought out there in regards to common injuries. The first I am sure that everyone know is “no pain no gain.” While this applies great to aspects of training such as metabolic conditioning, it does not scale well with injuries. The other line of thought is rest, rest, and more rest. While rest is good it depends on what kind of rest is implemented. Often the truth is somewhere between each of these two lines of thought.

Let’s take a step back and look at movement in general. Why is it so good for us?

I think the most underused example is the use of mobility in the context of how good it is for our joints. Take for instance the fact that hip replacement is becoming extremely common in the United States. Joint replacements occur because our joints become “unhealthy” in that they start to develop arthritis and other painful maladies.

The main occupational thing that has become prevalent with people working jobs in the US is desk work. That is to say that people are sitting down 8+ hours per day and not moving their hips at all. When you compare this to Asian cultures such as the Japanese who eat on low tables and have to constantly get up off of the floor to use their hip joints you see a remarkable contrast in the amount of hip replacements between the ethinicities.

Hip replacement rates // Photo from this study: http://ard.bmj.com/content/62/3/222/suppl/DC1

Anyone can tell you that what happens when you break a bone and you are put in a cast that your muscles start to atrophy, joints start to become stiff, and your connective tissues become weaker. The same thing occurs with self imposed semi-restrictions such as with padded shoes (akin to soft casts), and restrictions just imposed by working such as sitting. This is why I have much on this topic.

Movement in general is good for our joints, connective tissues, and muscles. We always want to be moving our injuries – albeit non-painfully – because that helps to start to loosen up tight muscles, get the blood flowing to the area, etc.

When you stub your toe or hurt your finger the first thing you do is move and take it to its full range of motion as possible. As long as it doesn’t hurt more the movement and other rubbing that we do helps to tell our nervous systems that everything is relatively fine, and it does not need to impose any restrictions on movement or dial up our pain sensations to prohibit us from potentially damaging the tissues more.

However, we are taught that we generally should not be moving other injuries and it is definitely detrimental to our overall health. Do not get me wrong there is some times where movement restriction is necessary such as after surgery or where the pain is made worse by movement and a doctor should be checking you out but these are more rare cases and you will tend to know when these cases present themselves because you will probably be going to the emergency room.

Regardless, if I were to put a number on it I would say that movement and/or exercise in general should be used in healing about 90-95% of injuries. Ice, heat, anti-inflammatories, ultrasound, e-stim, etc. are all well and good, but most of the time they are not needed (or can be used in the context of helping speeding healing in some cases).

I don’t think I have to elaborate on why pushing through pain is a bad idea. Our bodies have pain to tell us when we are damaging things. If you want to make an injury worse the best thing to do is push through pain. There are some exceptions, but generally they should only be done under a qualified medical professional or physical therapist during rehabilitation.

Gate control theory

If you are having issues is pain soft tissue work and non-painful mobility work is extremely important. One of the major factors in eliminating pain is the gate control theory of pain. The gate control theory of pain shows us how to help dull down the pain so the body can heal itself better.

Gate control theory of pain. Photo from health.howstuffworks.com

All of the fibers under ‘gate control’ are sensory afferents from the skin, muscles, ligaments, and joints. The large fibers specifically are the ones that travel fastest – alpha and beta fibers (Ia and II, and Ib respectively) – in humans these are golgi tendon organs and muscle spindles. The small fibers tend to be smaller afferents responsible for nociceptive (pain) input including Adelta and C fibers.

The theory goes that stimulation of the large alpha and beta fibers can interfere and help dull the body’s sense of pain from the smaller delta and C fibers. What stimulates alpha and beta fibers? That’s right: soft tissue work and movement.

Many people have probably experienced this phenomena but did not know it. Have you ever injured yourself during exercise? For instance, possibly a skinned shin during a deadlift or clean and jerk? Or you were running and hit a limb or toe on something but it didn’t hurt? Or been so hyped up for something that you did not feel the pain such as in a fight or flight situation?

Since there is so much feedback from the faster fibers from movement and/or exercise or total body sympathetic response it literally drowns out the pain fiber sensations that are sent to the brain. And you don’t feel any pain.

Edit: Thanks to Anoop for referring to Neuromatrix theory of pain which expounds upon Gate control theory while integrating more sensory, processing, and output modalities. See the above PDF for a bit more details if you are interested.

Like with programming you don’t need to understand a more complex model if it is not applicable to your specific case(s) so understanding the simple model is fine in some instances.

How much is too much?

Generally, movement is good as long as the pain, inflammation, swelling, are improving or at least staying neutral. Most of the time if you are focused on movement or mobilizing a joint you should end up feeling better than when you started.

This is important for any stretching, mobility, or prehabilitation work as well.

Acute injuries are a difficult topic to discuss directly which is why you should always talk to your physical therapist about rehabilitation progression and planning.

It is important not to progress too fast as it clear that injured tissues are vulnerable to reinjury more than healthy tissues. However, it is important not to baby injuries such that they lead to functional impairments or compensations that interfere with normal activities or sports.

Any questions during the rehabilitative phase should be addressed to the appropriate health care professional. If they cannot answer your questions then you may want to search for a new one. Although “it depends” may not be the answer you’re looking for which is often the case, but most health professionals if they are good should be able to give you a decent time frame or progressive plan or alternatives if you ask.

The psychological aspect of rehabilitation

Chronic pain also presents an interesting case. After about 3-4+ months most of the damage from injuries are healed. While there may be some restrictions in movement via things such as scar tissue, if there is chronic pain present without damage to the soft tissues why is it still there?

The answer lies in our nervous systems. Our brains can interpret stimuli any way it wants and there are a lot of disorders such as aphasias where our brains incorrectly process what we hear and how we understand and speak out our response. The same is true of chronic pain after injuries.

When it all comes down to it and we have chronic pain after 6 months and it continues we can almost always know that our brains are interpreting almost any sensation or movement that gives feedback to the nervous system as pain.

There are many keys to rehabbing chronic pain, but I think the best approach is the graded response which can be approached from two directions. First, the ‘fear” response (or phobia) psychology where people are gradually introduced to things they fear such as spiders and is continually progressed such that they eventually see that they really have nothing to fear of that. This can be introduced with proper gradation in movements starting from simple movements building up to more complex or greater movements.

The second approach is through somatosensory experience. If we take people through a variety of sensory experiences even near painful and demonstrate that on normal tissues the same near pain or pain response is not normal we can start to get the brain to realize that it is incorrectly interpreting these responses. After all, if someone thinks that even placing a hand on a painful area is going to hurt are they not going to tense up all their muscles and have a fear avoidance reaction of trying to move out of the way at all costs? The key is to introduce the sensory experiences gradually just like with exercise such that we limit the fear/pain/sympathetic responses and help restore proper activity within the nervous system.

I think that both of these techniques (and there are probably others that I do not have time to cover) are very useful in understanding that our bodies are not just based on musculoskeletal factors. We need to understand that movements and developing mobility is actually a combination of neuromuscular and musculoskeletal factors including even some primary neurological factors as well.

After all we know that some people even with hours of stretching can never get any flexibility. Why?

Muscle spindles (gamma motor neurons) govern a muscle’s length. The nervous system controls these fibers. When they are “tightly wound” the muscle does not respond very well to length increases and stays tight.

This can happen for a variety of reasons but the most elucidating is when you have spinal cord injury or stroke. When upper cerebral control is cut off from the spinal cord, the inhibition that the cerebral cortex puts on these gamma motor neurons is lost. Thus, they become overactive and the muscles tend to get extremely tight and hypertonic. You can this in the synergistic patterns where the a lot of the flexors tighten up and the arms, legs, and body start to move into the fetal position as they all start to contract.

I made this point just to say that flexibility and mobility are not just about lengthening the muscles and connective tissues. We have to take into account how the nervous system responds to these exercises.

What to do?

Tough question.

Gate control theory tends to be variable at this point. Sometimes the feedback from the muscle movement activates pain sensations when it should not with chronic pain. Sometimes it helps. If movement HAS pain, but does not increase it then it is generally best to move even if there is pain. It will get better as the body relearns how to sort out the sensations coming from its fibers.

Conditioning or graded response will also work. You have to take these things slowly and introduce the movement back. Preferably as stated before the small amounts of movements and mobility work will only have lower levels of pain or stiffness. However, as the body begins to learn again how to differentiate between them you can increase the movement.

It has been shown in studies that “chronic pain” is less in countries where there is no such thing as time off work or workers compensation. The mindset of the person is very critical to overcoming any type of chronic pain, so you really have to believe that you can do it along with the other protocols.

For a more in depth discussion of some of these concepts see Anoop’s article on pain here. I honestly do not see this as a revolution (in his words) at least in the injuries world, but information is not as widespread as other types of treatment and application for acute injuries.

Also, here is an interesting article from Todd Hargrove on how taping can help with pain and/or injuries. Theory behind it is similar to gate control on the effects of movement.

This article is not going to be an end all article on how to solve knee pain and injury. Rather there are categories of knee injuries that all need different attention depending on what has been injured. From there we can determine what the best course of action that needs to be taken for each individual because everyone is a bit different.

This article is going to be relatively brief on each because there are many topics I will have to cover. I expect that if you have any questions they should be addressed to your orthopedic doctor or physical therapist. Searching the Internet or asking people on the web for more information is at your own risk.

Disclaimer: Any information contained herein is not professional medical or physical therapy advice. Always consult your doctor or physical therapist before using such information.

Where the pain is occurring during movement is generally a good indicator of what may be wrong, and differential signs and symptoms can be used to further delineate what is wrong in most cases.

Image courtesy of Adam Inc. (though extremely modified)

Despite the generalized locations of what you think is injured compared to the chart sometimes the physiological issue or pain bleeds off into other areas. Also, there may be multiple pathologies in a certain area since there are a lot of different muscles, ligaments, tendons, etc. running through the area(s). I cannot say for sure (again, this is the Internet after all) that if you have a pain in a specific area that it corresponds to the conditions. Thus, for a sure diagnosis you should definitely see an orthopedic doctor or physical therapist on these issues.

Additionally, the pathology of knee injuries is very important. Often times for many of the types of non-impact knee injuries there are also mobility or flexibility issues at the ankles and hips. The knee sits smack dab in the middle of the two longest bones in the body, the femur and tibia. Given this alignment any issues in the ankles and hips that create any odd forces are distributed along the kinetic chain into the knees. Since the bones are so long any of the torques (Torque = Force * Distance) at the adjacent joints are magnified significantly which means that something as small as a bit of tightness in the ankles or hips can lead to a significant change in torques at the knee which may exacerbate or even create a pathology.

The knee is between the longest bones in the body // Photo from http://kitssportschiro.com

If there is a loss of range of motion at some joints, the other joints or tissues will have to take up the slack. This leads to many types of overuse or compensation injuries.

This means that in addition to any potential rehabilitation there needs to be an assessment of the whole lower body up to the back to ensure that things are moving correctly especially with recurring knee injuries. If you know you are tight or have a lack of mobility in certain planes this may also be your wake up call to eliminate tight areas. You may be surprised how much improving areas like the feet, ankles, hips, and back will improve your knee problems.

Notes:
1. If the pain is on the back of the knee then see the back of the knee section.
2. If the pain is over a particular muscle and not a tendon/ligament/connective tissue or deeper structure then see the muscle strains section.
3. If you suspect your injury does not fall into any of these categories then see the other pathologies section.

Given that you now know this head over to your particular section to see if we can possibly figure out what is going on with your particular pain and dysfunction.

Table of Contents
I. Introduction
II. Categories of knee injuries
III. Quadriceps tendonitis
IV. Patellar issues
V. Patellar tendonitis
VI. Tibial tuberosity issues
VII. Knee capsule / plica / medial collateral ligament
VIII. Pes anserinus issues
IX. Fibular head / biceps femoris / Lateral collateral ligament
X. Iliotibial Band issues
XI. ACL issues
XII. Meniscus issues (lateral and medial)
XIII. Muscle strains
XIV. The back of the knee
XV. Other pathologies
XVI. Conclusions

If you suspect you have an injury that does not fall into any of the categories above see a medical professional immediately. Also, if you have an injury which presents debilitating pain or presents possible insidious neurological symptoms such as sensory or motor deficits see a medical professional immediately. Motor deficits are critical enough that you may want to go to the ER ASAP.

Image from http://orthoinfo.aaos.org

If you are quad dominant from sitting a lot with marginal activity (feel quads burning a lot while running, lifting, etc.) then this could be an issue that needs to be dealt with. Strengthening and activation work for the posterior chain and learning how to squat correctly will help a lot in the correction of this.

This is exacerbated more in women because they have a greater Q-angle which puts more torque on the knee. If you would like to read more about this you can see Shoes, Sitting, and Lower Body Dysfunctions which talks about this issue more in depth.

Photo from http://www.doctorkolstad.com/

Treatment

Thankfully, we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photo from http://www.kneeguru.co.uk/

Around the patellar there are a myriad of structures. If the pain is around the quadriceps tendon insertion and patellar tendon origin then it may be related to those two overuse injuries respectively.

If the pain is slightly under the apex (bottom of the patella) that may be an issue with the infrapatellar fat pad.

If the pain is over the patella that may indicate overuse to one of the bursas in the area such as the pre-patellar bursa seen in the picture above, or just below the kneecap with a bursa such as the infrapatellar bursa (commonly referred to as clergyman’s knee).

Patellofemoral syndrome and/or chondromalacia patella is the other common cause of pain localized around the patella. These two often go together because they are somewhat coupled in the pathological etiology.

The knee is a delicate balance between forces that pull the patella laterally and medially, and it is just so happens that the muscles that pull it laterally tend to get more emphasized by poor biomechanics (e.g. inward collapsing knees during running, squatting, etc.) and are larger from the start. Vastus lateralis is bigger than the vastus medialis/vastue medial obliquus.

Now, what happens is that when the patella is start pulled more laterally is it starts rubbing on the lateral articular surface of the femur more and starts wearing down the cartilage both on the patalla and femur. This process starts softening and breaking down the cartilage (chondro = cartilage & malacia = softening) and will eventually cause a lot of pain and inflammation.

The reason why it does appear right away when this occurs is because cartilage has no sensory/pain fibers located within it. So only when it gets to a higher level of damage by wearing through a lot of cartilage and inflammation does your body start to feel the effects. This also means that there must be significant time taken to correct biomechanics because usually these are ingrained pretty well before the pain starts occurring so good care must be taken to teach proper technique especially with females who experience this issue.

Treatment

Typically, bursitis and fat pad irritation can be treated with typical RICE protocol, massage, and anti-inflammatories if necessary.

For the fat pad irritation if it is making the knee unstable taping can be an effective protocol to ensure that any mobility or exercise does not aggravate it any further.

Generally, for any impact injury to this area it should definitely be checked out by a doctor to make sure there is not any issues with the patella itself though.

With patellofemoral syndrome/chondromalacia patella there are multiple things we need to focus on. First, bringing down the pain and inflammation is paramount. Like the bursitis this can be done with the typical RICE protocol, massage, and anti-inflammatories if necessary.

Secondly, there must be loosening/strengthening of particular muscle groups. We want to strengthen the vastus medialis, vastus medialis obliquus, hamstrings, and glutes. We want to massage, trigger point, foam roll, tennis ball, etc. to loosen the vastus lateralis, rectus femoris, IT band, calves, hip flexors, etc.

Thirdly, we need to make sure there is enough range of motion at the ankles and hips. We want to especially gain more dorsiflexion in the ankles with calf stretches, and we would like to gain more hip extension by stretching the hip flexors as well as mobilizing hip internal and external rotation.

Many of the specific stretching/strengthening exercises can be found here.

Lastly, we need to teach proper biomechanics by deemphasizing the anterior chain by sitting back more in squats, teaching proper running technique, etc.

In addition, the knees must NOT be allowed to collapse in during any exercise that is taught. This is paramount. One of the best ways to do this is to cue to spread the floor with the feet during squatting, lunging, etc. if the knees want to collapse inwards. If this is ineffective, a band can be placed to pull the knees inwards to force the the person to think about forcing the knees outwards during the movement.

Since the glutes are one of the potent external rotators of the hip they should be evaluated for weakness/inactivation especially if there is a lot of sitting during the day. Once you get them active not only will it help correct the technique, but it will make you significantly stronger as well.

Photo from http://www.arthealthcare.com/

If you are quad dominant from sitting a lot with marginal activity (feel quads burning a lot while running, lifting, etc.) then this could be an issue that needs to be dealt with. Strengthening and activation work for the posterior chain and learning how to squat correctly will help a lot in the correction of this.

This is exacerbated more in women because they have a greater Q-angle which puts more torque on the knee. If you would like to read more about this you can see Shoes, Sitting, and Lower Body Dysfunctions which talks about this issue more in depth.

Photo from http://www.doctorkolstad.com/

Treatment

Thankfully, we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photos from http://www.boostphysio.com/ and http://4.bp.blogspot.com/

As can be seen above this can be easily diagnosed by X-ray, and it will physically manifest as bumps on the shins that will be sore to the touch.

Treatment

Typical doctor recommended treatment is the RICE protocol. Activity should be limited to non-painful activities lest it be aggravated.

Like said in the above sections on tendonitis it is important to do soft tissue work to help loosen up the quads to exert less stress through to the tibial tuberosity. In this respect, foam rolling, massage, and light stretching should help significantly with the RICE protocol.

Posterior chain and proper biomechanics during running, squatting, lifting, etc. activities should also be examined to make sure that more stress is not being put on that area. However, generally this type of injury is more self limiting than the tendonitis issues.

Photos from http://www.ortho.com.sg/ and http://www.floridaortho.com/

The knee capsule and plica band can be easily aggravated given improper biomechanics or scar tissue around the area from surgery. This is why the pictures above are of plica and not the TCL/MCL because most type of pain here is likely not going to be of the ligament but rather the capsule and plica especially if there is a lot of cutting/torquing movements and bigger Q-angle.

Treatment

So if the injury is suspecting MCL see an orthopedic doctor.

Since the knee capsule and plica are more connective tissue typical modalities are aimed at reducing the aggravating inflammation. Thus, RICE, NSAIDs, and non-painful mobility and mobilization of the muscles around the area are generally prescribed. Also, other modalities to decrease inflammation such as iontophoresis or phonophoresis can be used, and as a last resort there is surgery.

Photos from http://www.jointventurespt.com/ and http://kneespecialistsurgeon.com

To check to see if there is an issue with tendonitis or the pes anserine bursa this area can be palpated for pain, soreness, and sensitivity.

To check if it is the right area it should be approximately below the MCL and band of plica that sit directly medially along the knee joint. Additionally, if you are sitting and push your heel into the ground and feel for the semitendinosus tendon along the inside of the leg and follow it then it should and insert on the tibia in the position seen above.

Pes anserine tendonitis or bursitis can exist for a variety of reasons. From what I have seen it tends to occur there is improper biomechanical patterns and general overuse.

The most common pathologies I have seen this occur in is if there are the issue of collapsing knees (knees collapsing inwards) during movements such as squatting and running. Likewise, if there is hip internal rotation immobility or a foot pathology such as flat feet where the feet start to “toe out” or duck walk this may start to cause issues with the pes anserine (as well as many other pathologies in this article).

Treatment

Like the rest of the bursitis and tendonitis issues the typical treatment lies with RICE protocol, massage, and anti-inflammatories if necessary. Stretching, heat, and massage may be used on the muscles that make up the tendons to help loosen them up to take pressure off of the bursas and/or tendons to help improve healing.

If it is tendonitis we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photo from http://www.anytimehealth.com/

Like the MCL, the LCL is often rarely injured without a significant impact or twisting injury so if you suspect as such you should see a doctor. If you are sitting you can check it’s integrity by sitting in cross leg position. Then feel underneath the knee for the bump that protrudes on the femur and the fibular head which should be below it. The ropey connective tissue that bridges between them is the LCL.

The fibular head should move in 3 planes when you flex and extend your ankle. If it does not move well then there may be an issue there if there is any type of pain in that area. When you dorsiflex the fibular head should move up, forward, and rotate outwards. The opposite should occur when you plantar flex.

To check the biceps femoris tendon you should put your knee at a 90 degree angle and locate the fibular head on the outside of the leg. If you dig your heel into the ground you should feel the biceps femoris tendon become taught and you can palpate if the area is painful, tender, or swollen.

In regards to the biceps femoris tendon like the pes anserine tendons it can also suffer from bursitis and tendonitis so if the issues are along that tendon as it runs into the fibular head then you probably know what it is.

Treatment

If the issue deals with the LCL or the fibular head not moving correctly then see an orthopedic doctor or physical therapist. Usually if the fibular head is not articular correctly it is a multijoint issue dealing with the foot, ankle, knee, and possibly the hip/SI joint/low back as well. When one thing gets gummed up so to speak other joints/connective tissues/muscles have to take up the slack. Thus, get it looked at by a professional.

If it is tendonitis we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photo from http://www.itendonitis.com/

It’s etiology is very similar to that of patellofemoral syndrome where improper biomechanics, muscle imbalances, or anatomical issues can lead to its development. The various muscles that connect into the IT band do various things. The tensor facsiae latae assists in hip flexion, internal rotation, and abduction; the gluteus maximus is a prime mover of hip extension, abduction, and internal rotation.

Also, what is less known is that a majority of the vastus lateralis sits directly under the IT band itself as it extends fairly far up the lateral side of the leg. That means if the fascia between the IT band and vastus lateralis is tight for whatever reason being it overuse or immobility then that can also affect correct function of the IT band.

If these muscles get tight, overused, build up with scar tissue, etc. it can put a lot of tension on the rest of the IT band. In addition, the improper biomechanics like collapsing knees will also force a lot of stress onto the IT band because it is one of the only forces that prevents the knees from collapsing inwards besides the vastus lateralis and the LCL. Now you can see why patellofemoral syndrome (via vastus lateralis overdevelopment) is a similar issue to IT band issues especially with poor biomechanics.

Treatment

The treatment is very similar to the patellofemoral issues since connective tissue and articular cartilage have low blood supplies they need many things to help correct these issues.

First, bringing down the pain and inflammation is paramount. This can be done with the typical RICE protocol, massage, and anti-inflammatories if necessary.

Secondly, there must be loosening/strengthening of particular muscle groups. We want to strengthen the vastus medialis, vastus medialis obliquus, hamstrings, and glutes. We want to massage, trigger point, foam roll, tennis ball, etc. to loosen the vastus lateralis, rectus femoris, IT band, calves, hip flexors, etc.

Thirdly, we need to make sure there is enough range of motion at the ankles and hips. We want to especially gain more dorsiflexion in the ankles with calf stretches, and we would like to gain more hip extension by stretching the hip flexors as well as mobilizing hip internal and external rotation. In addition, in the case of IT band we need to stretch out the glutes and TFL.

Many of the specific stretching/strengthening exercises can be found here.

Lastly, we need to teach proper biomechanics by deemphasizing the anterior chain by sitting back more in squats, teaching proper running technique, etc.

In addition, the knees must NOT be allowed to collapse in during any exercise that is taught. This is paramount. One of the best ways to do this is to cue to spread the floor with the feet during squatting, lunging, etc. if the knees want to collapse inwards. If this is ineffective, a band can be placed to pull the knees inwards to force the the person to think about forcing the knees outwards during the movement.

Since the glutes are one of the potent external rotators of the hip they should be evaluated for weakness/inactivation especially if there is a lot of sitting during the day. Once you get them active not only will it help correct the technique, but it will make you significantly stronger as well.

Photo from http://www.youcanbefit.com/

First, if you suspect that you have an ACL tear you should see your orthopedic doctor to get tested. There are some tests that can be used such as Lachman’s, pivot shift, or anterior drawer tests, but these should be performed by a profession who knows what they are looking for.

Generally, if you have an ACL tear there will be some unmistakable symptoms:

1. Pain within the joint. Usually sharp from an impact or contact injury.
2. Many times a pop can be heard when the injury occurs
3. Usually the knee will swell fairly significantly
4. Instability when walking or running. The knee will feel like it will suddenly give out on you.

Directly after an injury it may be hard to confirm a diagnosis since if there is pain and swelling and general tightness of the muscles it may lead to some false positives.

However, diagnostic imaging is used in almost all circumstances to confirm before surgery is scheduled.

Finally, I must note that meniscus injuries sometimes present like ACL injuries and often happen concurrently with ACL injuries which means it is imperative that you seek proper medical attention instead of trying to self diagnose yourself. You will not be able to treat them yourself anyway which is why you should see an orthopedic doctor especially if your activities of daily life or athletic performance are hindered.

Treatment

If you have an ACL tear and want to get back to athletics you should get the surgery. Talk to your orthopedic surgeon and physical therapist.

You can live a perfectly normal life without an ACL as long as the surrounding musculature of the knee is strengthened properly. A repair is not needed in these cases. In some instances, athletes have been able to play on a torn or partially torn ACL for years without knowing they did drastic damage to their knee because they are strong and the muscles were able to stabilize the knee correctly.

If you have any questions about this type of injury talk to your physical therapist or doctor. Listen to your PT for rehabilitation options.

Photo from http://www.riversideonline.com

However, there are some similarities and a couple differences you can look for that may point towards a meniscus injury as opposed to an ACL.

1. Pain within the joint. Usually sharp from an impact or contact injury.
2. Many times a pop can be heard when the injury occurs
3. Usually the knee will swell fairly significantly. For a meniscus injury this may or may not occur.
4. Instability when walking or running. For a meniscus injury this may or may not occur.

Additionally, the meniscal injuries may also present:

5. Occasionally or often the knee will “lock” often when trying to straighten or bend the knee during any type of movement
6. The pain is usually localized towards one of the diagonal directions of the knee. The pain will be inside the joint but it will usually be localized towards the front or back and off to one side or the other. This is because the anterior and posterior horns of both meniscus are the easiest to damage during an impact and/or with a twisting action that messes with the proper articulation of the bone.

If you suspect a meniscus injury please see your orthopedic doctor to get a confirmation and your options depending on the extent of the injury.

Treatment

There are a fairly large amount of different types of meniscus tears and a significant degree in the extent of injuries. Sometimes they can be repaired; sometimes the menisci will have to be removed.

Photo from http://www.foundrysportsmedicine.com/

There are some instances where you may not need arthroscopic surgery and the meniscus can heal itself although they are more rare. Injuries in the “white zone” tend to have no vascularization which means the body cannot repair the injury itself. However, if the injury is in the “red zone” that means the body has some limited degree of blood supply there where it may possibly heal the injury (depending on the extent of the damage).

However, even if the injury is in the red zone if the tear breaks through the rim of the meniscus that may cause significant destabilization of the knee so there may be problems with non-surgical options even if the tear can heal itself.

Again, your best bet is to see an orthopedic doctor and get assessed. They will likely do some tests such as McMurray’s and Appley’s compression test as well as confirm it with medical imaging such as MRI like they would with an ACL.

If you have any questions about this type of injury talk to your physical therapist or doctor. Listen to your PT for rehabilitation options.

If the pain is located in the quadriceps or hamstrings themselves they it is likely you have some form of strain or at least tight muscles/scar tissue/adhesions in the muscle(s).

In the case of muscles strains or pulls unless it is extremely bad where your tissues are turning black and blue and you absolutely need pain killers, you probably do not need to a see a doctor. This is because you will most likely just get a prescription for pain killers and be told to rest.

However, if you are that worried about your injury then do not hesitate to see a doctor or physical therapist. Better safe than sorry.

Treatment

I have already written extensively on muscle strains which will help you get started on the road to recovery.

Photos from http://www.fpnotebook.com and http://www.5skaggs.com

As you can see from the above image there is mostly only ligaments crisscrossing the knee joint, and then muscles running around doing various actions on the knee. The plantaris tends to be inconsequential but the hamstrings, popliteus, and both heads of the gastrocnemius all play multiple roles in the proper function of the knee joint.

Hyperextension injuries are the most common cause of pain on the back of the knee, and if they are severe enough the injury is likely to be the ACL which helps to prevent anterior translation of the tibia on the femur.

Thus, the other most common type of injury is strains of the aforementioned muscles. But if you have any doubts about the diagnosis, see a doctor or physical therapist.

Treatment

If you suspect ligamental damage, again see an orthopedic doctor or physical therapist.

If you suspect a strain I have already written extensively on muscle strains which will help you get started on the road to recovery.

Obviously, for everything I have not covered it is important to get checked out by a qualified professional.

Treatment

Other problem(s) may show up even if you have a diagnosed pathology, so it is important to be under the plan of care of a orthopedic doctor or physical therapist who you can trust to talk about your injuries and any concerns you have about your rehabilitation.

Remember, there are good and bad doctors and good and bad physical therapists. If you don’t have a good one who can answer your questions and provide you with a good rehabilitation program or options then you can always find another.

If you are an athlete specifically you may want to look for doctors and physical therapists who work with sports teams.

I hope this article was helpful in determining any potential knee injuries and what some of the options are about treating such dysfunctions.

Remember however that this is the Internet and even though this article may be right 90% of the time in correctly figuring out a pathology it should not be used as a definitive guide for injury diagnosis and treatment.

You should always talk to your orthopedic doctor or physical therapist for a confirmation on diagnosis and treatment especially if you have any questions regarding a certain pathology and subsequent rehabilitation process.

If you suspect you have an injury that does not fall into any of the categories above see a medical professional immediately. Also, if you have an injury which presents debilitating pain or presents possible insidious neurological symptoms such as sensory or motor deficits see a medical professional immediately. Motor deficits are critical enough that you may want to go to the ER ASAP.