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Old 08-03-2009, 01:09 PM   #1
Nick Hunter
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Nick Hunter's New Journal of Progress

Stats as of August 03, 2009
Age: 23
Height: 5'11"
Weight: 205 lbs
Training for: Rugby Union

Best Lifts (no longer current)
Deadlift: 500 lbs
Parallel Squat: 405 lbs
Push Press: 240 lbs
Power Clean: 265 lbs
Power Snatch: 205lbs

Roadblocks Corrections
ACL Tear (July 25, 2009) Pending Surgery
Meniscus Tear (July 25, 2009) Pending Surgery
Ankle Imingement (recent) Hopefully Not Surgery

Problem Areas Corrections
Post Surgery Shoulder (Labrum/AC Joint)* Avoid Benching
Weak Abdominal Strength Planks/ Ab Rollouts
Overstretched/Weak Upper Back Band Facepulls
Extremely Poor Dorsiflexion Will See PT

I started playing rugby at age 20 in college, with no athletic development knowledge and poor posture from a high school career of video gaming. I took a beating my first semester and decided to learn how to lift weights, going from 181 to 215 lbs in 9 months, progressing to the above lifts in that time as well.

I played and trained at a reasonably high level in Metro Division 2 in Canterbury, New Zealand, where I was also reintroduced to the Olympic lifts through a former Commonwealth Games competitor. I realized I loved playing rugby but was getting hurt too much, however I found it hard to fix some things and compensated with movement patterns instead. That's landed me with a knee surgery coming up and heaps of time to rehabilitate, learn as much as I can, and come back stronger.

2 year goals:
Properly and thoroughly address biomechanics, specifically knees and ankles.
Develop safe and proper deep squat form.
Build balanced and strong body with which to re-enter competitive sport.

6 year goal:
Play at Rugby Super League level.

Lifting Goals:
HB ATG Squat: 315lbs x 15reps
Clean and Jerk: 315lbs x 1rep
Ring Chinups: BW x 20reps
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Old 08-04-2009, 04:19 PM   #2
mark williams
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Hi Nick, I feel your pain on the ACL injury - how bad is the tear and what type of surgery are you having? I had a complete tear and reconstruction which is a long road back but, fingers crossed, I'm nearly there.

It's very positive that your are taking a long term view on this - my rehab has been a miserable experience because I was counting down from day one and have pushed the limit as to what my new ACL and the patela tendon (which they cut to make a new ACL our of) could take (and probably made the whole thing even more uncomfortable than it needed to be!)

You mentioned you had some difficulties which you tried to compensate with movement pattern? What difficulties did you have and what were these movement patterns you used?

Best of luck with it mate.
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Old 08-04-2009, 05:00 PM   #3
Nick Hunter
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Quote:
Originally Posted by mark williams View Post
Hi Nick, I feel your pain on the ACL injury - how bad is the tear and what type of surgery are you having?
I asked if it was complete or partial, and my physician's assistant said it didn't matter, that for all intents and purposes it was complete and that my doctor's philosophy was that if the ACL is torn at all it doesn't function right and needs a reconstruction.

I don't know which option to choose for the surgery. As far as I know, the choices are: patellar tendon, hamstring tendon, cadaver ACL. I don't know the differences between either, but I've been told the cadaver has both the fastest recovery and the worst durability. It is the only option it seems that is a ligament already, and not a tendon, though I don't know what that means or how that works.

Quote:
Originally Posted by mark williams View Post
You mentioned you had some difficulties which you tried to compensate with movement pattern? What difficulties did you have and what were these movement patterns you used?
I have two impinged ankles that for years I just assumed was poor calf flexibility. I believe my soleus and achilles flexibility is bad, but I think now that it is because the ankles are impinged. I think this because after several intensive stretching programs I realized I got some intense pains at the front of the ankle after stretching or playing, and grew to realize that my ankle just wasn't moving, as opposed to hitting flexibility problems. I felt no stretch in my calves, but the ankle wouldn't budge, and if I pushed it, sharp pain in the front.

So since that limited my dorsiflexion in the extreme, my knees have never been able to pass my toes. I hit my max lifts like this. My heels come up very early when I walk or perform footwork during play.

The movement patterns that I exhibit (which I've read all relate) are pronation at the ankles, which is an attempt to find ROM by sending the knee inside the foot instead of straight dorsiflexion, and certain motions being performed with the heel in the air where a planted heel is preferable, like getting up from a chair or walking up stairs 100 times per day. My running sends the foot rolling off its inside, rather than front to back. This sends the knee inward which adds stress and is related to ACL injuries, so I've read. Also, I squatted with a wide stance, shifting the strength from the knees to the hips, and had difficulty with olympics lifting flexibility. Shoes helped some while lifting, but don't help while playing. Cleats don't have lift.

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Originally Posted by mark williams View Post
Best of luck with it mate.
Thanks, man. I hope I fair okay.
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Old 08-05-2009, 11:13 AM   #4
mark williams
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In terms of the options for reconstruction I did a lot of reading up before having my surgery and discussed it at length with the surgeon so below is a crash-course in what I discovered.

Cadaver
-The cadaver donation does allow for the quickest recovery time because there is minimal trauma to the surrounding soft tissue and the ligament is "ready-made", but you are correct in that it tends not to be the best choice for a return to contact sport and was ruled out immediately by my surgeon as "not worth doing for our purposes" for this very reason. Plus, it doesn't always "take".

Auto-Graft
Both the hamstring tendon and patellar tendon grafts are basically a case of cutting a strip out of the harvest site (in the case of the hamstring, a very long strip then folding it over a few times), and replacing the old ligament with tendon tissue which, over time, adopts the characteristics of the original ligament.

Auto-Graft: Hamstring
The hamstring option is a good balance of recovery time versus success in that it will stand up to most stresses once it is in place and has taken root, is your own tissue so won't be rejected, and isn't as traumatic or uncomfortable, therefore making rehab easier.

Auto-Graft: Patellar tendon
The patellar tendon (which I had) was recommended by my surgeon because I specifically wanted to go back to contact sports and it is considered the sturdiest replacement. It is a lot tougher than the hamstring tendon by nature and has the added benefit of how it is attached once inside the knee (this bit I found really interesting)....
They cut the middle third of the tendon over the knee-cap but also take a piece of the insertion points at each end of the tendon - ie; a small bit of bone that it is already attached to. What you then have is a strip of nice, strong tendon with a small blob of bone on each end. They then go into the knee and drill a small hole where the original insertions of the ACL were and then put the small bits of bone into those holes. The bone that has been drilled has undergone trauma so starts to rebuild around the freshly inserted bone, so it's attachment is just as strong as the original ligament (the body is amazing!).
The downside is that rehab is longer and more painful. This is because the process of harvesting the patellar tendon is, in itself, pretty traumatic and there will be a fair amount of pain as a result of that which will slow down the rate at which you can build up the supporting muscles, simply because it hurts to do and you can't put much force through the damaged tendon for a while.

In a nutshell
So, in conclusion: cadaver is fine if you just want to be able to walk up and down stairs without your knee popping, or go on the odd run and recover quickly from the surgery; hamstring is fine if you are probably going to do non-contact or semi-contact sport (although it can and does stand up to full contact - it used to be the preferred method) and while you'll have to put the effort in on the rehab, you will recover reasonably quickly; the patellar tendon is the current choice of sportsmen because it is sturdier, but the flip-side is you will hurt during rehab... 8 months on and I still feel pain in the tendon itself when I push it (happily, this is diminishing ).

As a matter of interest - there is a process, pioneered over here I believe, which is becoming more popular with sportsmen called contralateral patellar harvesting whereby if you've busted your left ACL, they take a strip of the right patellar tendon and put it in. This cuts recovery almost in half because you can start hammering away at rehabbing the right leg almost immediately, and then rehab the left leg when the new ACL has had a chance to bed-in. Otherwise, you have to wait for all the swelling, discomfort etc to pass inside the knee (plus wait for the new ACL to have taken root) before you can start rehabbing the donor site, by which time you are a few months of atrophy down the road.

After Surgery
Whichever you choose (hamstring or patellar), the basic process after surgery is that the tendon that is now pretending to be an ACL essentially dies over the course of a month or so. So for the first month it is pretty strong (it's a tendon after all), then up to 3 months it is pretty worthless (at this point, a slip on an icy pavement can snap it and thisd period is the most hazardous time in your rehab)... from 3-6 months it starts to rejuvenate and becomes pretty much a fully-fledged ACL and from 6 months+ goes from strength to strength (my last MRI showed it to be thicker than my original ACL).

I'd suggest patellar graft reconstruction seeings how you want to get back to rugby, but be prepared to pay the price in discomfort and slow progress in the short term. Of course, I am not a professional, just an interested party with an opinion! I hope the above helps
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Old 08-05-2009, 02:50 PM   #5
Nick Hunter
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Quote:
Originally Posted by mark williams View Post
All that stuff above...
Wow. Great information!

1. For the contralateral surgery, are you basically in a wheelchair for a month being that both legs are healing connective tissue?

2. Assuming I had a high level of leg strength (not your usual soccer player who just runs and doesn't lift) will this muscle-memory help accelerate the rehabilitation? Everyone talks about how muscle can get as strong as it once was much quicker than it took to originally get there. My interest is not the knee I lost. I want a stronger one.

3. I'm trying to figure out which position to return to. Forward pack would mean more resisted effort with heavier contact, but less stepping and changing direction. It would also have a diminishing rate of return as I play higher level rugby and do not grow taller with the other forwards... back line would be far less contact and more un-touched running, but more changing directions, stepping, and agility stuff.



Chinups
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Old 08-05-2009, 03:42 PM   #6
mark williams
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Glad you found it useful mate.


1. Not sure on exact timescales, but seeings how the donor site is soft tissue and no mucking about with drilling bones and moving stuff around, I would imagine you would be on crutches for a couple weeks - wheelchairs are avoided as far as I'm aware.

2. You're absolutely right - a stronger muscle will come back quicker because of muscle memory etc. I pre-habbed my leg as much as possible - you'll have a stronger tendon to take a donation from and you'll get your strength back quicker.
Just be prepared to lose a lot of strength quickly though. The effect is twofold - apart from having a lot of inactivity and lack of regular muscle activation causing atrophy over a few weeks, your CNS kicks in to protect the traumatised donor site and won't let your quads fire very hard for a while.
In terms of having a stronger knee, I'd say you can... sort of. I'm not sure if the ACL itself is ever quite the same (although mine shows as thicker on MRI), but where your knee is stronger/better is that a lot of your rehab will focus on proprioception (balance through feedback from muscles/tendons/ligaments etc) which is something most people don't bother with. This in itself will help safeguard from injuries because you will have better co-ordination. The potential strength in your muscle will be entirely unaffected long term.

3. You could view this as a positive - a chance to totally re-invent yourself. As you pointed out in my log, at 5 foot and a fart, I'm not your typical centre but ended up there previously because of a great scrum half being at the club I played at, but my having enough pace and strength for crash ball... scrum half could be the way forward for me though.
For yourself, don't let the injury dictate your position. At 5'11" and 205lbs you have the frame to play anywhere but the front 5. I'd go with your natural strengths - if you are genuinely pacy try back-line, if not then 6,7 or 8 awaits.

The modern game means as a back you'll be required to clear out rucks, and as a forward you'll need to be able to hit space and beat defenders so just focus on getting the knee 100% and play to your strengths.

Great book to read for rugby specific ACL stuff is Richard Hill's autobiography - one of the few English players I genuinely admired.
Although he blew his ACL out again straight after returning from a reconstruction (replays showed that it was a freak accident and nobodies ACL could have taken it) the fact he came back and played for the British Lions and that the effects of his retirement are still being felt in the English pack speaks volumes for the ability to bounce back.
More recently, Wales's Mike Philips also came back from an ACL reconstruction... when he hurt himself he was a fringe player for the Welsh side... when he returned he went to be first choice for Wales almost immediately and then onto being one of the standout players of the recent Lions tour to South Africa. He plays a particularly physical style of scrum-half which means he's forever being twisted and turned and he's holding out well.

My advice is, when you get a surgery date, sit down and plan the comeback. Set milestones and small targets to break up the 9months+ it's going to take.
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Old 08-06-2009, 12:38 AM   #7
Steven Low
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Quote:
Originally Posted by Nick Hunter View Post
I have two impinged ankles that for years I just assumed was poor calf flexibility. I believe my soleus and achilles flexibility is bad, but I think now that it is because the ankles are impinged. I think this because after several intensive stretching programs I realized I got some intense pains at the front of the ankle after stretching or playing, and grew to realize that my ankle just wasn't moving, as opposed to hitting flexibility problems. I felt no stretch in my calves, but the ankle wouldn't budge, and if I pushed it, sharp pain in the front.

So since that limited my dorsiflexion in the extreme, my knees have never been able to pass my toes. I hit my max lifts like this. My heels come up very early when I walk or perform footwork during play.

The movement patterns that I exhibit (which I've read all relate) are pronation at the ankles, which is an attempt to find ROM by sending the knee inside the foot instead of straight dorsiflexion, and certain motions being performed with the heel in the air where a planted heel is preferable, like getting up from a chair or walking up stairs 100 times per day. My running sends the foot rolling off its inside, rather than front to back. This sends the knee inward which adds stress and is related to ACL injuries, so I've read. Also, I squatted with a wide stance, shifting the strength from the knees to the hips, and had difficulty with olympics lifting flexibility. Shoes helped some while lifting, but don't help while playing. Cleats don't have lift.
Excellent analysis there.

Like you are doing you need to focus on reseting your movement patterns. Making sure your knee tracks correctly is a big part of the solution, and this is solved by focusing on spreading the floor with the feet (hence bringing the knees back in line over the toes) in any of the heavy lifts.

Do you have any other problems with collapsing arches or plantar fasciitis? Tight calves, femoral anteversion, and other such problems are VERY common (and potentially lead to ACL and achilles tendon tears) of which I believe contributed to your problems.

Trying to do a writeup on this right now but I gotta get my applications out first.

---------------------------------------------------------


Mark: Nice analysis on ACL.

I tend to "prefer" allograft b/c I am not particularly keen on basically "weakening" the patellar or hamstring area, but they do have better durability than the allograft. All in all it's a tough choice.

The contralateral patellar seems interesting though... that might become my recommendation from now on. I'll check it out more.

---------------------------------------------------------


As for pre-ACL surgery recovery...

1. Prehab the crap out of it. Do as much strength work as possible.. strong and bigger your muscles are the faster you will bounce back with strength.

2. Also, make sure your flexiblity is adequate with full extension (straight leg) especially in flexion. You don't want to be one of those people who has to start with 90 degrees of flexion and work your way back up to 120-130 degrees with very painful stretching when you can do it relatively "easier" pre-surgery.


Post-ACL (couple things to add on top of what Mark said)

1. I would say get your feet/toes, etc. wiggling as much as possible post surgery. Any neurological stimulation, especially to the lower limbs, will help prevent muscle atrophy in the upper leg.

This is why squeezing objects with your hands when you're in a cast for upper arm/shoulder/etc. helps to stave off atrophy and recover quicker.

2. Keep up strength in the opposing leg if possible... cross-education helps prevent atrophy.

3. I'm not quite sure, but you MAY be able to start isometric work such as quad sets relatively soon after surgery. Basically get those muscles firing.. prevent the atrophy like the stuff above.

Probably not stuff like single leg balance yet... BUT you can be practicing it on your other leg... work your way up to eyes closed + eyes closed standing on the ball of your foot. Getting your body used to balancing with one leg will help when you have to do it with your other leg.. although it will be frustrating.

4. Compression stockings... wear them. The edema/swelling you'll see in your knee from the surgery will prolong recovery so let your body eliminate it as soon as possible by limiting excessive inflammation.

5. Massage... pull the swelling from the knee up towards your heart. Like compression stocks will help.

6. After any significant movement like just going to work or whatever... ICE. It really helps. A lot. You should be icing 3-5x a day for 10-15 minutes at least.

7. Diet... hopefully you eat clean as this will help speed up your recovery as well.

8. Natural anti-inflams will help too such as fish oil. Try to stay away from the pain meds and NSAIDs as systemic inflammation limiting will hinder the natural healing process that the ACL will be undergoing.


Essentially, the more strength you have after the ~4-5 month period when the ACL is getting stronger again the faster your recovery will be. You've seen people in the NFL get back to playing within a year... Same for some guys in the clinic I'm at (although not elite athletes). People have gotten 90% power back within 8-9 months is pretty good.

On the other hand, I've seen some recovery take >12-16 months in some cases just because there's so much atrophy and gaining proprioception back is poor in some cases.

---------------------------------------------------------


Whew. Hoped that helped you guys some.
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Last edited by Steven Low : 08-06-2009 at 12:41 AM.
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Old 08-06-2009, 03:50 PM   #8
mark williams
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Nice post Steven, I could have done with that when I was starting out on my rehab! I'd say my biggest issue now is that my tendon isn't back to 100% - this is as much mental as physical I'm sure, I need to work more on quad flexibility and continue the self-massage to loosen the bugger up.

Regarding the contralateral protocol, below are a couple of links (WFS) - the bottom one just mentions the guy who pioneered it (although there are a few surgeons listed as "pioneering" it...) apparently active rehabilitation is around 3 months on this.

http://www.thekneedoc.co.uk/content....D=1&section=36

http://www.privatehealth.co.uk/news/...?vAction=fntUp

Steven, perhaps you can offer some specific advice for me? I had my second rugby practice this evening, again no real contact, and while on Tuesday I was just grateful to have made it through without problem, tonight I was frustrated at my sluggishness. For instance, while I was focusing on catching a high ball, I was pre-occupied with my foot placement and balance which made it hard to move quickly.. it's like I have to conciously plan my movements. I always used to be so co-ordinated and now I really struggle. Anything specific you can suggest to address this or is it just a case of gritting my teeth and waiting it out?

Also, I am struggling getting real drive down through my operated side when sprinting from a standing start, even though the strength is returning I don't seem to be able to put that power down... it is as if something is stopping me? I'm taking this to be a self-preservation act by my CNS... how do I over-ride it??!!

I hope I'm not hijacking your thread, Nick, with these questions but hopefully Stevens answers/suggestions will be of use to you later on in your rehab!
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Old 08-07-2009, 12:19 AM   #9
Steven Low
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What exactly have you been doing in your rehab to regain power? What about proprioceptive work?

I realize you might be out of rehab as well so if that's the case what have you been doing since then and what was the last things you did then?
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