One of the most commonly injured body regions that we encounter are the knees! We get asked all the time the best stretches, mobilizations, or treatments for the knee and the truth is… the knee more often than not the VICTIM, not the cause of your pain. This means that the best treatment for the knee is to address the ACTUAL cause, whether that be the mobility of your hips or ankles, strength imbalances, or movement impairments. Sure, issues will likely occur at the knee itself, which we’ll cover in a moment, but if you ONLY address the knee, you likely won’t get the results you’re looking for!

​

Let’s start with talking about some anatomy. The knee is a simple hinge joint, much different than the hip, which is a ball and socket joint. Ball and socket joints afford much more motion than hinge joints. Think of all the ways your hip can move -  it can rotate, move forward, back, out to the side, across your body… just to name a few. Hinge joints do exactly what it sounds like, they hinge back and forth much like a door on a hinge at your house.  While hinging back and forth is the main motion of the knee, there actually is a small amount of rotation that occurs as well. When that rotation becomes excessive, it leads to pain. More specifically, we see excessive rotation into external rotation and a lack of rotation into  internal rotation. This is most often seen as the inward collapse of your knees in relation to your hips and ankles or outward pointing of your toes when going up and down stairs, standing up from a chair, or squatting. Reducing this excessive knee rotation into external rotation can significantly speed up recovery! These are our top 5 exercises to address this common issue!

​

In addition to implementing these 5 exercises above into your weekly routine, you’ll want to improve your movement patterns for long term success. Avoiding excess valgus movements is KEY. It’s this movement pattern that, when done repeatedly, leads to the most common root cause of knee pain - excessive tibial external rotation.  Check out this blog, Top 5 Reasons Knee Valgus is Bad for You to learn more about this movement pattern. 

I also want to mention that it’s okay, infact recommended, to allow your knees to translate over your toes when squatting. This is a normal motion that is needed to perform a healthy, pain free squat. BUT, you have to have the mobility and strength to do so. By addressing the impairments that cause you to move into valgus and prevent your knees from translating over your toes, you’ll be on your way to restoring health in your knee. 

Lastly, be sure to train through full ranges of motion (ie. squatting below parallel). Joints that are not trained through their full range will become stiffer, and weaker over time. Have noisy knees? The term “motion is lotion” holds true and applies here as well! Now, noisy knees aren't usually a cause for concern, check out this blog to learn more - My joints crack and pop. Is that bad? But, the more movement and deeper ranges of motion you can perform without pain, the more lubrication and nutrition you’ll diffuse into your knees. The muscles, tendons, and ligaments surrounding the knee joint will become stronger if you use them to their full potential!! 

​

Final Word
​If you’re experiencing knee pain, you’re not alone. This is a COMMON issue that CAN be addressed. (NO, bad knees are NOT genetic). Start implementing the info from above right away to get you on the right path. While this is the most common movement impairment in the knee, it’s not a one size fits all approach. If you’d like a more individualized evaluation, game plan, and customized treatment, don’t hesitate to reach out! We work with athletes just like you everyday (locally and around the country) and specialize in getting athletes back to their sport without limitations! We’d love to help!

Thanks for reading!
-Dr. Aerial

“The Doc told me I have a herniated disc! Now What??” Budging or herniated discs are consistently some of the most feared diagnoses out there, especially in athletes. They see the MD for their back pain, get an x-ray or MRI, and they’re told one of the following. “Imaging is showing disc desiccation, disc prolapse, disc protrusion, disc fissure, disc bulging, a herniated disc, degenerative disc disease, foraminal encroachment, nerve root compression (or impingement), or stenosis. At this point you’re as white as a piece of paper and picture the worst-case scenario. Medical background or not, those are some pretty terrible descriptions of a picture taken of your spine. But here’s the truth behind it: 99% of the time, you’re going to be just fine. Stick with me as I dive into what the research says about your back and a bulging disc (Hint: surgery is not typically the answer).

Let’s kick this off talking about imaging, aka x-rays, MRIs, and CT scans. Imaging is a powerful tool to show providers a glimpse of what’s going on internally within the body. MRI’s in particular can show incredible detail relating towards inflamed or degenerated tissue. Oftentimes, imaging shows us so much detail that we will have “abnormal” findings that may not even correlate to the symptoms. Therefore, without a thorough examination, just using the picture to diagnose a problem isn’t enough. We simply don’t know if the findings are related to the patients symptoms, OR, if they are just age-related changes…. like grey hair. Let me explain further. Take a look at the graphic below, which shows common findings from images of the spine in individuals with NO BACK PAIN AT ALL!

There are 2 massive takeaways here. 
1) Look at the 30’s group. 50% of people in this group showed disk degeneration and 40% showed a disc bulge. 50%! These numbers are HUGE. I sure didn’t think about bulging discs in my back at 30, and most people would consider this very rare for a 30 something year old to have a pain from a bulging disc.
2) The number of “positive” findings exponentially increases in each age group. So, the older you are when you start to experience any sort of back pain, the higher the chance you would show positive findings in the event you get an MRI or CT scan. This is why face-to-face examinations are SO important – they can help to delineate whether or not your back pain is truly from a disc issue, or something totally different (joints, muscles, etc.)

So, what signs and symptoms would you have that indicate a herniated disc? Let’s discuss. First things first, because of how close the disc sits in proximity to the nerve, we are always looking out for some major red flags regarding this anatomical relationship. Two red flags that require immediate physician attention are the loss of the ability to walk, or the loss of control over your bowel and bladder. These indicate that the spinal cord itself is being compressed. No bueno. Let me repeat, if you’re having these symptoms it is an emergency and please call 911 to safely get to the Emergency Room rather than reach out to us! 

 toSo, the doc has diagnosed you with a herniated or bulging disc, and what are your next steps? Let’s start here​ with a statement from the American Academy of Neurological Surgeons: 

“The initial treatment for a herniated disc is usually conservative and nonsurgical. A doctor may advise the patient to maintain a low, painless activity level for a few days to several weeks. This helps the spinal nerve inflammation to decrease. Bedrest is not recommended.The doctor may recommend physical therapy. The therapist will perform an in-depth evaluation, which, combined with the doctor's diagnosis, dictates a treatment specifically designed for patients with herniated discs.”  

If you go by what Dr. Google has to say about exercises to do, here's what you'll find: 

So, we now know that full blown symptomatic disc herniations are actually pretty rare, that imaging will tend to show you some sort of disc related condition (even without back pain), and the first line of treatment is physical therapy. Unfortunately, not all physical therapy is the same. If you’ve seen a PT for low back pain in the past, here we do things quite a bit different. At The Charlotte Athlete, low back pain is the number one most common body region we treat, and the key to treatment in this region of the body is getting down to the root cause of why the pain occurs. Taking this approach, and addressing how you move, allows us to have excellent outcomes and even help some people who have had decades of low back issues. If this sounds like you, even if your skeptical of if we can help, take advantage of our free 20 minute phone call with one of our Doctors of Physical Therapy to see if we are good fit for you!

Thanks For Reading!!
- Dr. Mike

Remember this equation? Well, BFRT ramps up the muscle growth side, and decreases the muscle breakdown side. I may not be the best at math, but I do know that those changes to the equation will result in bigger gainz!
​
Now… here’s the disclaimer. BFRT used alone without heavy lifting is inferior to high load training alone. In the words of Mr. Olympia Ronnie Coleman “Everyone wants to be a bodybuilder, but don’t nobody wanna lift heavy a** weight.” This still holds true even with the introduction of BFRT. Don’t be discouraged though, the next section goes through who will benefit the most from BFRT (Hint: Mostly everybody!)
 
Who can benefit from BFRT if it doesn’t replace high load training?
 
1. Those who currently can't lift heavy:

• This first one is the low hanging fruit that has made BFRT a staple in the rehab world today. 
• Post-operative patients: The clients who have had surgery and are under surgical precautions that limit their ability to bear weight, limit the movements they can do, and limit the weight they can lift. In my opi required for these clients due to its ability to prevent muscular atrophy, increase muscle growth, and ability to continue to work the affected limb within the surgeon’s precautions as they work back to lifting heavy.
• Non-surgical tendinopathy patients: Tendon pain greatly reduces the muscle’s ability to contract and lift heavy weight. For example, Achilles tendinopathy may drastically limit your ability to do a calf raise, get into triple extension in an olympic lift, or run. So, how are you going to lift heavy or improve cardio fitness if pain is limiting even the movement? Enter BFRT. Low intensity and pain free stimulus, while under BFR, to get the metabolic effects of BFRT while allowing the tendon to heal. Similar to the post-operative patient, it also sets you up to come back with more normal strength after a period of being away from high load training!

 
2. Fully healthy CrossFit, Olympic Weightlifter, bodybuilder, ball/stick sport, and endurance athletes:

• Both the CrossFitter and Oly lifter have very demanding workout regimens. Oftentimes , to be competitive, this requires multiple skill/weight training workouts within the same day. With this schedule, it’s very difficult to add any heavy load/volume workouts without leading down a path of overtraining. BFRT becomes an excellent adjunct to work on those weak areas without adding significant volume, and limiting the amount of muscular breakdown and soreness from extra work!
• Bodybuilders: The whole purpose behind bodybuilding is muscle hypertrophy. While we can’t replace heavy lifting, BFRT is an excellent addition as a finisher at the end of the workout. Depending on the workout split, using BFRT to target specific muscle groups will not only help achieve the desired pump, but the metabolic cascade that goes along with it – which can be very beneficial to maintaining muscle size! 
• Ball/Stick Sport Athletes: The biggest benefit for these athletes is in-season use with little turnaround time between games. Sports such as baseball/softball, basketball, and hockey play so many games on a frequent basis it would limit performance to continually lift heavy within season. By adding BFRT training it allows them to continue to build strength without the deleterious effects on performance associated with the 24-48 hours after high load training (aka muscle soreness). In the offseason, while they are performing traditional high load/intensity training, BFRT becomes an effective recovery tool to increase the metabolic response to assist with the repair and building of muscles. 
• Endurance Athlete: BFRT works great to maintain strength when ramping up endurance training for a race. Using lower intensity strength training with less muscular breakdown allows for maintenance from a previous strength phase without taking away from the training stimulus of the increased time spent focused on running/cycling/swimming. It is also useful as a recovery tool to help increase VO2 Max without excess stress on the bones or muscles!

 
The previous section highlights the most common uses of BFRT, but certainly isn’t fully comprehensive.

Here’s a quick recap of important points to remember: 

• BFRT is a safe and effective way to promote muscle hypertrophy and strength in just about any athlete. 
• While it cannot replace high load training, it can provide a low training load with a high metabolic effect to promote increased recovery and improved strength on weak spots while still allowing for a rigorous training schedule. 
• It’s especially effective in reducing the deleterious effects of immobilization and surgical precautions. It may even be the missing key behind the loss of strength following surgeries such as ACL reconstructions where there is significant loss of Quad size and strength even up to 1 year after surgery.

The other half of the population, which typically includes the majority of the younger and more athletic people, have a very flat thoracic spine. A flat thoracic spine results in a loss of normal kyphotic curvature. To connect the dots back to posture… while sitting with a naturally flat thoracic spine, when you actively sit up straighter and pull your shoulder blades back you are taking your spine further away from a normal resting curvature! ​

Videoing all of my progressions on my phone was a HUGE help to myself! With some of these movements, it became difficult to watch and make sure everything was functioning the way it needed to, so being able to watch it back directly after helped tremendously!

At about 1.5 months postpartum, I tried some small butterfly pull ups which actually looked (from a coning perspective) and felt really good. It took about 2 months for me to feel comfortable/confident enough to try out bar muscle ups. But once I did, they ended up being successful. My kip felt awful from not doing them for months, but each time I did them, they felt better and better. ​

​While there is no one specific cause of GIRD, there are 3 reasons linked to this shift in total arc of motion. First, there are capsular changes. The capsule is a soft tissue surrounding the entire shoulder (largely ligamentous), and is asked to dissipate extremely high forces on the posterior, or back, side of the shoulder while throwing. As we throw, the capsule tends to take on similar stresses as the muscle resulting in significant stiffness that changes how the shoulder rotates in the socket.

​Pathologic GIRD is now seen in the graphic below. There is a loss of internal rotation which ALSO results in a loss of the total arc of motion from 180 degrees. If there is pain present during throwing it is very important for your physical therapist to determine the appropriate course of action here. In this instance, we work to reduce the stiffness of the capsule and muscles of the rotator cuff/scapula as these are the two causes noted above that are able to be affected through treatment.

​Now that we know what GIRD is and what it is not, let me hop up on my soapbox for a minute. Pathologic GIRD is actually very UNCOMMON. In three years of working regularly with all levels of throwers from the adolescent, high school, college, and professional levels I have seen ONE case of true GIRD. In my practice it has become a term that I try to avoid even using because it is always negative. To treat it, my job is to increase mobility into internal rotation. If that is not the true cause of pain and symptoms (and usually isn’t!) I am creating MORE instability and WORSE muscular control. This then results in more stress to the shoulder or elbow, more pain, decreased velocity, and decreased control of throwing.

​Remember the harmful effects of GIRD? Yeah, me too. In reality, most throwers display a limited total arc of motion with less IR than the non-throwing arm. However, it is not a loss of IR that results in this change in the arc, but a loss of ER! Unfortunately, I’ve had way too many athletes receive treatment for shoulder issues that only get more painful, reduce their ability to perform, and ultimately take longer to resolve. I will leave you with one final thought: the throwing motion is developed throughout the lifespan. There is no way to predict whose shoulder will adapt into the most humeral retroversion nor is there a way to speed up that
process. If you’re having pain with throwing at the shoulder OR elbow, that is not normal and unfortunately will not just go away.

​These sounds could be due to a number of things such as muscle tendons moving over each other or moving over bones, air building up in our joint spaces, or crepitus (grinding and clicking). In many cases, the noises that our bodies make end up being more of an annoyance than being problematic, especially if there are no other symptoms associated with these sounds. But if you do have associated pain, limited range of motion, limited strength, or have experienced some traumatic event that caused these sounds, then it may in fact be problematic...more on this to come.