Last week, Dr. Anthony Falco discussed the role of the meniscus in the knee and when you should consider getting surgery to repair a meniscus tear. This week, I will discuss some things you should implement into your training program following knee surgery and how you can further progress after you have completed working with your physical therapist following surgery. Following any knee surgery it is imperative to build back adequate muscle mass in the quadriceps, re-establish proper landing mechanics and force absorption of ground forces during high power activities and solidify sprinting mechanics.
Eccentric focused exercises are your best friends
After knee surgery it is common to experience atrophy (diminished muscle mass) of the quadriceps of the repaired leg. While your physical therapist more than likely focused on building back lost mass, it is imperative to continue this focus once you have moved on to strength and speed training.
While I have no problem with seated leg extensions early on in the rehabilitation process, I believe other alternatives should be utilized in strength training protocol. Essentially, seated leg extensions limit activity of the hamstring while the quadriceps is contracting. This never really happens in sports. So, I prefer the terminal knee extension (TKE), as a quadriceps building exercise that allows the hamstring to work in addition to the quadriceps. Basically, anchor a band and place it around your knee. Slightly flex your knee forward before pulling it back into extension and contracting your quadriceps. While many other quadriceps dominant movements can be performed to build muscle mass (lunges, split squats etc.), here are my general hypertrophy guidelines to follow:
Absorbing forces, re-conditioning tendons and ligaments and sprinting technique
While building mass back in the quadriceps you should also focus on re-introducing your tendons and ligaments to power movements such as jumping and sprinting. It is important not to jump right in to high intensity jumps and sprints as your body may not be ready to handle the demand places on the knee and surrounding areas.
Extensive plyometrics are lower intensity jumps that are essentially “hypertrophy for jumping.” Meaning, they rid of use of the stretch shortening cycle (reactive stretch reflex of the ligaments and tendons involved in maximum intensity jumping and sprinting). We accomplish this by implementing pauses or performing short rhythmic jumps. The main goal is to re-condition the tendons and ligaments and prepare them to handle higher intensities. Also, it teaches them how to behave again so performance is maximized later on. During these exercises the focus should be on sound and clean landing mechanics. Here is what you should look for:
Low Intensity Sprinting Start Types
Lastly, it is extremely important to reaffirm good sprinting technique while not exposing an athlete to sprinting variations that produce too much power. That is, low start types (push-up, mountain climber, etc.) or start types that involve excess power building via medicine ball throws.
Overall, it is important to progress through movements with a plan once an athlete has moved through a full rehabilitation program and can begin training!
The meniscus is a structure in our knee joint that provides smooth joint motion, shock absorption, joint stability, and nutrition to our knee joint. Each knee has a medial meniscus and a lateral meniscus. Together the medial and lateral menisci also enhance stability of the knee joint. They sit on top of our tibia (shin bone) and create a concave surface for the end of the femur to fit into, think of a golf ball on top of a tee - the menisci are like to lip of the tee that keep the ball in place.
As you can see below (link to image at bottom of article) the medial meniscus is larger and half circle shape and the lateral meniscus is smaller and more circular. The medial meniscus is more firmly attached to the surface of the tibia by ligaments compared to the lateral meniscus. The decreased mobility of the medial meniscus makes it more susceptible to injury.
Both menisci receive blood flow to the outer edges however further towards the center of the knee joint the blood flow becomes poor. This is an important point as any meniscal injury on the outer edge with good blood flow is more likely to heal than an injury on the inner edge with poor blood flow. The portion of the meniscus that does not receive good blood flow receives its nutrition through the lubricating fluid in the joint called synovial fluid. Movement and exercise are essential to deliver nutrition to the menisci.
There are also nerve endings that run to each meniscus. Some of these nerve endings provide sensation and others are mechanoreceptors that tell out brain how much pressure is on our knee and what position our knee is in.
Meniscal tears are a common injury. They can be traumatic - like twisting a knee during a sport. They can also be non-traumatic or degenerative meaning that over time the meniscus starts to get worn out. Clinical examination including a detailed history and physical exam by a physician or physical therapist can be very accurate at identifying a meniscus problem. Sometimes an MRI may be done to visualize a tear and identify the size, type, and location of the tear.
When a diagnosis of a meniscus tear is made there are options for treatment. Two common options are arthroscopic surgery or conservative management. Over the past 20 years the use of arthroscopic surgery to treat meniscal tears has expanded significantly. Specifically in the case of adults with degenerative (non-traumatic tears) the rates of surgery have gone through the roof. Unfortunately many studies have identified little to no advantage to this type of surgery for treating these types of meniscus tears. Conservative management, including exercise, is much less expensive and invasive and has no negative side effects has been shown to be better or equally as effective as surgery in some studies!
Here at Performance Physical Therapy & Sports Conditioning we specialize in treating pain, identifying problem areas to address, and designing an individualized treatment plan to address those problem areas. In the case of a meniscus tear, strength, flexibility, balance, joint mobility, and function are all thoroughly assessed. A combination of mobility exercises, strengthening exercises, and manual therapy can be customized to treat a meniscus tear effectively and efficiently.
If you are having knee pain or have been diagnosed with a meniscus tear, give us a call! Don’t rush out and have an arthroscopic meniscectomy if you have not seen us first. Based on the latest science conservative management with manual therapy and exercise should be the first line treatment for meniscal tears and surgery should be the last resort.
Next week Coach Gerry will discuss his approach to starting a strength training program with a client who has been discharged from physical therapy following a knee injury or surgery.
Dr. Anthony Falco
Fox AJ, Bedi A, Rodeo SA. The basic science of human knee menisci: structure,
composition, and function. Sports Health. 2012 Jul;4(4):340-51.
Muheim LLS, Senn O, Früh M, Reich O, Rosemann T, Neuner-Jehle SM.
Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease.
Acta Orthop. 2017 Oct;88(5):550-555.
Azam M, Shenoy R. The Role of Arthroscopic Partial Meniscectomy in the
Management of Degenerative Meniscus Tears: A Review of the Recent Literature.
Open Orthop J. 2016 Dec 30;10:797-804.
Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise
therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear
in middle aged patients: randomised controlled trial with two year follow-up.
BMJ. 2016 Jul 20;354:i3740. doi: 10.1136/bmj.i3740. PubMed PMID: 27440192
Swart NM, van Oudenaarde K, Reijnierse M, Nelissen RG, Verhaar JA,
Bierma-Zeinstra SM, Luijsterburg PA. Effectiveness of exercise therapy for
meniscal lesions in adults: A systematic review and meta-analysis. J Sci Med
Sport. 2016 Dec;19(12):990-998. doi: 10.1016/j.jsams.2016.04.003. Epub 2016 Apr
20. Review. PubMed PMID: 27129638.
Knee Image: http://www.vangsnessmd.com/wp-content/uploads/2015/02/proc_img_meniscal01.jpg
Last week, Dr. Anthony Falco discussed the basics of heart rate training and how to properly calculate your resting heart rate and maximum heart rate. Once you determine these numbers you can properly utilize heart rate monitors to enhance your training. In athletes, this can be tremendously useful, as it will allow them to better determine if their aerobic training is focused on recovery, maintenance, or aerobic improvement. For the sake of this article, we will be focusing on aerobic improvement. To improve an athlete’s aerobic capacity you must understand the percentage of maximum heart rate needed to reach the improvement threshold and also how to use exercises which best work towards achieving that same goal.
Proper Heart Rate Percentage For Aerobic Improvement
In the past I discussed using the aerobic capacity system to help aide in recovery for athletes. For recovery, it is best to work in a 60-75% range of the athlete’s max heart rate. However, the range for aerobic improvement goes as high as 85-90% of the max heart rate. Basically, apply Dr. Falco’s formula for your maximum heart to these percentages and you can find the best threshold for an athlete to work in to improve aerobic capacity. For example:
How To Construct A Proper Movement Pattern Aerobic Program
As I previously mentioned, the movement patterns are great to use for aerobic improvement for a number of reasons. In addition to helping improve an athlete’s working capacity, you can also use this as extra time to drill home proper form with the main movements. However, it is extremely important to note that an athlete must show proficiency in these movements prior to using them, as it is never ideal to learn a new skill or movement in a fatigued state. For example, an athlete who cannot perform a proper bodyweight squat should not be allowed to use this movement in an aerobic circuit as they will be susceptible to not only injury, but can further program their nervous system to perform the movement incorrectly.
The most important thing to remember here is that you can find success with a multitude of different methods. Once you have determined your proper heart rate the main goal is simply stay in that zone and maximize your aerobic capacity. Movement pattern circuits are simply a great alternative to use because they can further solidify the proper form and technique of the most important qualities and movements for an athlete.
The start of a new year is often a time when people will start a new fitness or health goal. One important factor that aids in meeting goals is having a way to measure progress. Heart rate can be a simple metric to help measure progress of a fitness program and can serve as an indicator of cardiovascular health.
Tracking heart rate can be as simple as finding your pulse in your neck (carotid artery) or wrist (the radial artery) and using a stopwatch. Count the number of beats for one full minute or count the number of beats in 10 seconds and multiply by 6 for an estimate. The old fashioned way works great but today fitness trackers, fitbits, heart rate monitors, even apps on our phones can help measure our heart rate.
Here are 3 ways that heart rate can be utilized to keep you on track for your fitness goals:
1 - Measure heart rate recovery 1, 2
-Heart rate recovery is defined as how long it takes your heart rate to return to baseline following a bout of exercise. This is a measure of how well your nervous system regulates your heart.
-Perform a baseline workout - walk for 20 minutes, run 2 miles, take a spin class. Pick something that can be repeated after a few months of training.
-Following exercise rest quietly for 1 minute and then take your heart rate and take it again each minute until it returns to your resting heart rate.
-At one minute heart rate should decrease by 12 beats per minute or greater.
2 - Calculate your target training zone.
Here is a link with a calculator for target heart rate:
As an example:
A 40 year old with a resting heart rate of 70 beats per minute wants to train between 70 and 80% of his max heart rate.
220-40 = 180 (max HR)
180 (max HR) - 70 (resting HR)= 110
110 x .7 = 77 + 70 = 147
110 x .8 = 88 + 70 = 158
Target training zone using = 147 to 158 beats per minute.
This calculation is based on age and resting heart rate to determine an appropriate training zone to improve aerobic capacity. This method known as the “Karvonen Formula” is a simple estimate that is correlated to VO2 max which is considered the gold standard measurement of aerobic capacity.
The American Heart Association makes recommendations for amount of exercise. For moderate intensity 50-70% of max heart rate and vigorous intensity 70-85%. Keep track of the amount of time you spend exercising in the target zone!
If you have any previous heart conditions or issues consult with your doctor or physical therapist before starting any new exercise program. If you have questions or want to learn more about how to start a new exercise program we can help with that too! If we can help you conquer any barriers that prevent you from reaching your fitness and health goals come see us!
Check in next week and Gerry from Challenger Strength will share is insight on how he helps his athletes and clients improve their cardiovascular fitness.
1 - Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate recovery
immediately after exercise as a predictor of mortality. N Engl J Med. 1999 Oct
2 - Jolly MA, Brennan DM, Cho L. Impact of exercise on heart rate recovery.
Circulation. 2011 Oct 4;124(14):1520-6. doi: 10.1161/CIRCULATIONAHA.110.005009.
Epub 2011 Sep 26.
Dr. Anthony Falco
Gerry DeFilippo: ISSA CPT- CPPS, AAPS. Founder/Owner: Challenger Strength.