REHAB PROCESS FOR THE KNEE.

Should squats be used in the rehab program of the knee? What exercise do you recommend? Do you use a specific exercise protocol?

- Mark Dimling, La Grange Park, IL

If the squat is part of your rehabilitation program, we suggest you use a Smith Machine. One-legged squats can also be performed on the Smith Machine.

Use caution in the early phases of rehab. Make sure the athlete isn't too heavy to safely perform squats with both legs simultaneously or each leg individually.

Our rehab philosophy incorporates three R's:

1. Reestablish range of motion.

2. Restrengthen the affected muscles.

3. Redevelop lost conditioning and skills used to play the game.

Note: Other basic R's to consider are Rest and Recovery from surgery.

Warning: An athlete cannot be allowed to return to competition until he can perform all of the activities in the controlled environment of rehab.

Consult a trainer or therapist during the early phases of rehab. These professionals can provide the expertise to reduce swelling, relieve pain, reestablish range of motion, and begin the restrengthening process. The trainer/therapist initiates the rehab process, but it is the coach's job to complete it.

Point: The rehab process is not complete until the athlete:

1. Returns to preinjury strength levels through a variety of lower-body exercises.

2. Develops the level of conditioning needed to compete in his athletic event.

3. Performs all game-day skills at full speed.

The key during the early phases of rehabilitation is to prevent further atrophy and begin the process of regaining lost muscle strength and size.

Atrophy is a term used to describe a loss in muscle strength and/or size. All injuries cause some atrophy. The amount of atrophy will be determined by the severity of the injury and the amount of time needed to recover. The athlete will continue losing strength and conditioning until the resumption of the preinjury activities.

Surgery immobilization (cast/splint) causes rapid losses in strength. In their Textbook of Work Physiology, Astrand and Rodahl state: "A muscle that was immobilized by a cast lost 20% of its maximal strength within a week."

Varying degrees of inactivity also promote decreases in conditioning. Brian Sharkey (Physiology of Fitness) states that with bedrest, "fitness declines as fast as 10% per week."

Coaching point: Strength and conditioning deteriorate rapidly.

Healthy athletes should document each workout to ensure progress. These preinjury records can be used to compare strength before and after an injury. A knee injury can be considered fully rehabilitated when all the muscles surrounding the knee, hip, and ankle joint have returned to preinjury strength levels. Without this information, it would be difficult to determine when the rehab is complete.

Exercises

The variety of exercises must include multi-joint and single-joint (isolation) movements.

The squat and leg press are conventional lower body multijoint movements that activate every muscle crossing the hip, knee, and ankle joint. Advantage of a multi-joint movement - many muscles contribute. Disadvantage - some of the contributing muscles perform more work than others.

Single-joint movements must be used to redevelop individual muscle groups to their full potential.

The hip flexors must be isolated with a hip-flexion exercise. The hip flexors contribute to the squat and leg press, but cannot be fully developed unless they are isolated. The same holds true for each individual muscle group.

Point: Both single-joint and multi-joint movements must be performed to regain all lost strength due to injury.

During rehabilitation, our players perform the following isolation movements: hip extensions, hip flexion, leg extensions, leg curls, adduction, manual hip abduction, bent-legged calf raises, and straight-legged calf raises.

Simultaneous vs Single

The athlete should - equipment permitting - alternate the way he performs each exercise. In one workout, he may perform each exercise with both legs simultaneously.

In the next workout, the athlete may perform each exercise one leg at a time.

In the performance of an exercise with both legs, the non-injured leg will likely do more of the work. When exercised separately, each leg is forced to do all of the work.

To complete the rehab process, the athlete should use both simultaneous and single-leg protocol. The same amount of weight should be used for each leg when exercised separately. More weight should not be used when exercising the healthy leg.

Knee rehab will vary according to the severity of the injury, the length of inactivity and the current status of the muscles involved. Early rehab workouts should be used to gather information, not develop strength. First determine which exercises can be done comfortably without pain and use those exercises as the foundation of your rehab program. Continue adding movements until all lower-body exercises are performed.

Another goal during early rehab workouts is to find safe starting weights. Be conservative. Keep accurate records and gradually increase resistance. Progressively heavier weights must be used to promote strength gains. Look for improvement from week to week, not from workout to workout.

Be patient. Communicate with the athlete. Eliminate any exercise or activity that aggravates the injured area. Irritation from an activity may not develop until the day after the activity is performed.

Pay attention to any new soreness, find the cause, and remove it. It may be possible to reinsert the activity later in the rehab process.

In the earlier phases of rehab, we train the athlete five days a week. We start with light weight to allow the athlete to recover easily from one workout to the next. The volume of work performed in each workout gradually increases as more weight is used. At some point, this will require more recovery time.

We reduce the workouts to three times a week (alternating days) when progress slows. Otherwise, the athlete will complain of unusual muscular soreness and/or fatigue. Eventually we decrease the number of workouts to two a week (Monday-Thursday or Tuesday-Friday) when the player approaches his preinjury weights.

Accurate records, feedback from the athlete, and experience will guide you through each of these phases.

The healthy athlete in some strength programs is primarily concerned with how much weight he can lift (jerk, throw, cheat, bounce), regardless of the form and technique used. Strict standards must be established in rehab to prevent further injury, and they must be adhered to in each repetition until the rehabilitation is complete.

Inconsistent repetition execution can result in injury, inaccurate records, and a possible incomplete rehabilitation.

Our healthy players use the same exercise techniques as our injured players. During rehab, the intensity of exercise is initially lower and less weight is used. As the athlete gains strength and confidence, we gradually increase the intensity of exercise and the amount of weight.

In the early phases of rehab, we increase the rep range to 20. Less weight minimizes shearing forces on the joint. As strength improves, we eventually decrease the rep range to 15, and then to 12, to complete the rehab process.

Slow reps is another technique we employ during the first few weeks of rehab. We use a stopwatch and give our players an 8-second cadence to raise the weight and then lower the weight in a smooth and controlled manner. This is a safe and effective rehab technique.

We evaluate each knee rehab with our trainers. They provide us with information on the current physical status of the rehab subject. This information will determine the way we begin our rehab protocol. The stage of recovery will determine how aggressive we are with our exercise protocol.

Conclusion

Time is the most important element of any rehab from injury. Each injury is different and will require time to heal. You can't speed up this process, nor should you delay the recovery period by doing something that will cause a physical setback.

May the Power Be With You!

REFERENCES

* P.O. Astrand & K. Rodahl: Textbook of Work Physiology. McGraw-Hill Book Co., New York, NY, 1970

* B. Sharkey: Physiology of Fitness. Human Kinetics Pub., Champaign, IL, 1979

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Dan Riley/Jason Arapoff, The Power Line c/o Washington Redskins 21300 Redskins Park Drive, Ashburn, VA 20147