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On August 16th, 2010, I tore my right anterior cruciate ligament (the main ligament in the knee) at a fight training class. This is part 1 of the story of how it happened, the reconstructive surgery, the 5 months of physical therapy that followed the surgery, and my gradual return to full participation in fight training.
The Injury
The ACL (anterior cruciate ligament) is the most important of the four ligaments which stabilise your knee. It’s is a strip of connective tissue which inserts at the front of the bony plateau at the top of your tibia (in your lower leg) and crosses to the back of the distal part of the femur (in your upper leg.) Its major functions are to resist your lower leg being drawn forward and/or twisted in relation to your upper leg.
The other three ligaments in the knee are the PCL (posterior cruciate ligament) which, by contrast, inserts towards the back of the tibial plateau and runs forward to the front part of the femur. It forms a cross with the ACL, hence the name “cruciate” and the “anterior/posterior” part comes from where the ligament attaches to the \emph{tibia} (not the femur.) (The other two ligaments are the LCL, or Lateral Collateral Ligament (on the outside of the knee) and MCL or Medial Collateral Ligament (on the inside of the knee.)
The major ligaments of the knee.
ACL tears are common sports injuries, especially in sports that involve a lot of darting, landing, or changing direction, such as football (both the American and soccer varieties) and basketball. One man I met at physical therapy had torn an ACL on five separate occasions (getting it reconstructed in between, of course, he only had the two legs.) Women are more likely to tear an ACL than men, but at the time it happened to me, the only ACL tearing incident I’d heard about was that of the male English footballing legend Michael Owen, who tore his ACL in 2006 World Cup against Sweden. You can actually watch him do it here: http://www.youtube.com/watch?v=LoFimQmMrbM You’ll see that Owen isn’t touching anyone, or kicking the ball at the time. Non-contact tears like this are very common; you don’t need to be tackled or kicked to tear an ACL.
Unlike many, mine was not a non-contact tear. I was doing stand-up randori with a friend at my martial arts class. We were the only two people in the class at the time, so our instructor, Robert Miller, was watching us closely. We were outside on grass, and wearing athletic shoes. My friend is a fair bit bigger than I am, so was really putting my all into my attempts to throw him. I was feeling pretty good, because I’d just managed to get an seoinage throw to work. We were in the last few seconds of the round and I managed to line everything up for a good osotogari leg sweep with my right leg. I didn’t get it cleanly and he didn’t go down right away. So I did what you do to force it: I planted my sweeping leg, and attempted to use every atom in my body to force him back over it. He bore down to resist. I pushed hard…but instead of him going back, there was a pop from my right knee and I found myself on the ground, yelling and clutching my knee, with a very worried looking practice partner looking down at me and wondering what the hell had happened.
The intense pain didn’t last long, and within two minutes I was able to get to my feet and limp away. (We finished the class there.) The back of my calf felt tight at the top, near my knee (I now know that was because when your ACL isn’t there to resist anterior draw of the tibia relative to the femur, your gastroc muscle tries to do that job instead. The tightness was my gastroc freaking out at all the new work it was going to have to do.) But I was ok, I thought, I’d just strained my knee or my calf in some way, and a little ice and elevation would have me fixed up in a couple of days. Deep down I knew that the popping sound I’d heard was a bad sign—that people reported hearing such noises when their ACLs went—but, honestly, I thought I was ok—it just didn’t hurt that much any more. Anyway, I iced, I elevated. I walked funny. But I didn’t think I I’d done anything that wouldn’t heal itself in couple of days. More fool me.
The next night I was teaching karate at Washington University. I was demonstrating a technique, shifting forward in stance to block before grabbing and pulling someone into your punch. And as I shifted forwards there was another crack from my forward knee—this time it felt like the noise was from the femur slipping against the tibia—and I found myself back on the ground, with more yelling, this time with a few more alarmed people looking down at me. Everyone had heard the crack. And my knee had just collapsed on me.
Diagnosis
That collapse was surprising and unexpected enough that I called my GP the next morning. Robert Miller came with me when I went to see her. She asked me what had happened and performed a few tests for knee stability, including one with which I am now very familiar— the Lachman test—the standard clinical test for ACL function. Then she said: “I’m not totally sure, but going from what you’ve said, the way you are holding your leg when you stand, and from manipulating it, I think you might have torn your ACL. Anyway, I’m going to send you to an orthopedist, so we can find out for sure.”
And honestly, I thought—naah. What does she know? She’s just a GP. My leg is probably fine. I’ll go and see the orthopedist and they’ll tell me it’s just a strain. (Looking back I find it easy to recognise the element of denial— a commonly reported response in the sports psychology literature—in my own process.) So I went to see the orthopedist. He repeated the Lachman test, immediately diagnosed an ACL tear and scheduled me for an MRI to try to find out what other damage I might have done. He also gave me a brace for my leg, to try to minimise any extra damage I might to the soft tissues until we figured out just how stable my leg was (at this point there was some question about whether I might have damaged the LCL at the same time as the ACL.)
One of the sad things about the injury and brace was that it took me out of FSRI's 2010 demo at the MoBot Japanese Festival. Here I am mic-ed up to present, with Chris looking sad about lacking a partner to demonstrate with.
As it turned out, I only had to wear the brace for a week, but that week was miserable. You wouldn’t think it would be such a big deal—the brace only weighs a few pounds and since I was injured anyway, it’s not as if I was walking normally before I started wearing it. So let me break down the ways in which wearing it was bad. First, it locked my leg in extension, making it impossible to bend my knee. I couldn’t ride my bike, and I couldn’t walk normally—a major disruption to my lifestyle, though since classes hadn’t yet started at the University where I teach, I didn’t need to get to work each day, and so didn’t need to ride my bike as much. But you only have to go without bending your knee for a few hours to really, really develop a serious yen to bend your knee. When I took the brace off to shower I would attempt to bend it but the hours of extension had shortened the quadriceps around it to such a degree that bending it was slow torture. The additional weight of the brace puts extra strain on your hip flexors as you walk (you end up walking as if your braced leg was a pendulum—something you have to swing forward as one piece, like a crutch) tightening them on the side with the brace. This in turn puts extra pressure on your lower back, leading to much achey-ness. I also to sleep in the brace, which is not so easy, and meant that I was getting less sleep, and with it less recovery.
I haven’t mentioned the worst part yet, which is that in the week of wearing the brace the muscle melted off my right leg like warm butter. All those years of training and building up quad and hamstring strength disappeared in a few days, leaving my right leg about half the size of the left. It was this, I think, that really brought home to me that I had to take the injury seriously. I couldn’t look at my shrivelled right leg next to the as-yet still muscular left one in the mirror and not realise that something had gone very very wrong here.
The results of the MRI came back, confirming that I had a complete ACL tear, but no other serious problems (except that I was as incapable of lying completely still for 40 minutes as a 2 year old on Red Bull. Doctors from then on would frown and shake their heads over the “movement artefact” on my MRI.) I was allowed to take the brace off, and proscribed physical therapy for a few weeks while the inflammation from the initial injury went down, and while we considered options for surgery—the topic of a future instalment of this account.
The modern understanding of “the core” and the need to properly condition it has become well known among athletic and active people, including martial artists (yes, the importance of the hips has been belabored for centuries, but the modern anatomically based concept is not necessarily the same thing). The core refers to the muscles, connective tissues and bones of the torso, yet to many it’s just the rectus abdominis (the “6-pack’). However, the core can be more accurately thought of as the support, stabilization and movement system for the spinal column. This stack of 33 vertebrae (24 moving and 9 fixed) is connected by many ligaments and muscles, which provide oppositional tension akin to the guy wires on a tall tower.
This is a follow up to Bob’s introduction to rhabdomyolysis as it relates to martial artists.
Rhabdomyolysis is the destruction of skeletal muscle leading to the release of the muscular tissue components creatine kinease (CK) and myoglobin into the bloodstream (Huerta-Alardin, Varon & Marik, 2004). These components can pose a potential serious risk to the kidneys as they are cleared from the blood stream. Rhabdo can be caused by numerous factors, and can cause symptoms ranging in severity from mild to life threatening. Classic symtpoms include muscle pain, weakness and darkened urine (ranging from pinkto cola colored). Blood tests reveal elevated serum CK and myoglobin levels. More severe cases may present symptoms such as malaise, fever, tachycardia, nausea and vomiting (Huerta-Alardin et al., 2004). In severe cases acute renal failure can result, requiring medical attention.
Tea or Cola Colored Urine Associated with Rhabdomylosys
One of the most disturbing aspects of the martial arts is the lack of adequate sports safety training among martial arts instructors. Deference to tradition regarding training methods and expectations of performance often blinds instructors to the intrinsic dangers associated with fight training. While it is probably impossible to ameliorate all of the dangers associated with fight training responsible instructors should make every effort to be aware of the symptoms of training related injuries, and related conditions.
Rhabdomylosis is potentially fatal condition coaches and trainers of all sorts should be aware of. It can be caused by excessive exercise, and other activities that traumatize skeletal muscle tissue like katakite, tanren, or even pummeling drills. When pounding and crushing activities are combined with intense physical activity the danger is probably greatest.
Here are a couple of links to articles of rhabdomylosys that may be useful for both instructors and trainees:
Wikipedia-Rhabdomylosys
Rhabdomyolysis ( /ræbdoʊmaɪoʊlɪsɪs/ or /ræbdoʊmaɪoʊlaɪsɪs/) is a condition in which damaged skeletal muscle (Ancient Greek: rhabdomyo-) tissue breaks down rapidly (Greek: –lysis). Breakdown products of damaged muscle cells are released into the bloodstream; some of these, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure.
The practice of martial arts has come to be diverse in terms of the wide range of arts and schools available and in terms of the population that is involved. Physical fitness and talent may only be required to a small degree, or they may be paramount to success. Students may be dedicated about conditioning, or they may be “weekend-warriors” whose primary physical activity is a class. An instructor may be qualified in a technical realm but not be a good source of information in others, such as the nature of violence. The need for Evidence Based Practice (EBP) is just as high as in any other vigorous physical activity, yet appeals to tradition, history and authority and “experts” often lead students and practitioners to accept dubious information or ignore new information, which can have consequences on a number of levels. For this discussion, the practice of the various martial arts can be divided into two realms: recreational (i.e., oriented at self defense, fitness, cultural, etc.) and competitive (amateur or professional competition). Most of this discussion will focus on the recreational realm.
An extreme example of a lack of critical thinking and evidence-based practice can be found in the cult of personality that has developed around Ueshiba Morihei, founder of the Japanese art of Aikido.
You have seen them, the rows and rows of expensive cardio machines upon which so may people rack up countless hours. Most martial artists are more drawn to the kettlebells or dumbbells then they are to these behemoths. Few of the folks perched on theme look very fit anyway.
So why should you consider including them in your fitness program? There are a couple of good reasons actually. First, if used correctly they can provide a good cardio workout while reducing the pounding your joints take. Second, some machines, like ellipticals are designed to reduce the opportunities for you move in ways that can be harmful to your body.
Most martial artists have serious movement impairments at some time in their careers. Usually these stem from poor training programs that result in muscular recruitment patterns that are less than ideal.
I can’t tell you the number of martial artists I have talked to who complain about their knees popping and grinding, yet they never even consider that all of the thigh kicks they receive, all of the sumo squats they do, all of the crazy exaggerated stances they practice might contribute anything at all to their knee problems.
Once a pattern is loaded in, almost anything you do can reinforce that same pattern. If it is causing problems it takes dedicated intervention strategies to correct. Machines, like ellipticals reduce the opportunity to hyper-pronate by forcing your feet to stay on the platforms and move in a pre-established fashion. This can be helpful in reinforcing correct muscle action.
Every couple of months it is a good idea for all athletes to spend some time allowing their bodies to recover from all the abuse it has suffered. This should be a period of lighter activity, in which the joints are not subject to the same amount of pounding as they have received during the previous training cycles. As we age it is more and more important that we allow our bodies adequate recovery time.
Of course there are some true believers out there in the martial arts world who think they get everything they need from their kata, kihon, and kumite. For these folks this a matter of faith, and apparently nothing will disabuse them of this craziness. More rational souls will realize that their karate will benefit substantially from a more targeted approach to addressing fitness concerns that bear on their performance and health. To these people I would like to recommend giving those funny looking machines a try once in a while.
Take a break from jumping around, lifting people, and pounding stuff for a couple of weeks every now and then. During this time these machines can help you get a sufficient cardio workout without inflicting as much pounding on your feet, knees, and back (almost sounds too good to be true to many of us old timers).
I usually impress the hell out of myself when I switch over from running on grass and pavement to running on the treadmill. The treadmill is so cushy, and it always feels like I can run twice as far. Well the truth is that running on a treadmill is easier than running on either pavement or grass. There is much less to adapt to on a treadmill, so all your effort goes into the run.
Keep in mind that you will not be doing yourself much good at all if you use your arms to hold yourself up while using ellipticals, stairclimbers or treadmills. Hypertonic lats, shoulder problems (actually these are closely related), and back pain are all ubiquitous in karate. Spending thirty minutes propped up with your elbows locked, your lats tight, pretending that you are actually using the machines the way they were intended is a sure way to make your lower back creakier, and your shoulders tighter.
If you can’t keep up without bracing yourself with your arms, turn the machine down. You will burn more calories, and feel better for it.
Now go ahead and give that treadmill a go.
Part 1 was entitled Basic Physical Training Concepts for Karate Practitioners. This installment’s differently worded title is a reflection of our broader focus on fighting arts and sports as opposed to simply karate.
Stagnation: Too Much of a Good (?) Thing
Martial arts are often marketed and practiced as if they are a finished product with set training and methods. The entrenchment of this idea varies from circle to circle, but it is quite common. It’s very appealing to both new students and long-term students alike. Predictability and stability are things that we tend to gravitate towards in our choices of recreational activities, as can be seen by the guy who goes to the gym and does the exact same workout every visit, or the karate sensei who plans each class to be a further exposition on the basic techniques that the last year’s worth of classes were based on. Stagnation of training activities can take the form of:
- repetition of specific skill-based activities: techniques or drills, especially elementary techniques
- repetition of physical conditioning exercises past the point of useful adaptation
For new students the appeal of a set training format is very strong, as it minimizes the new material that they have to learn on a given night, which reduces anxieties and confusion in front of more experienced students. A handful of things can be learned, whether that be a drill, technique or conditioning exercise, and then repeated reliably in each successive class. This is a comfortable routine, and if it is tied to claims of efficacy or magical thinking, the new student may place an inflated value on whatever he or she has done the most, regardless of ability.
For the long term student, stagnation may be appealing due to one of two factors:
In Random Training Notes 16: Heavy Bag Tips, I mentioned the importance of regular feedback from hitting bags etc. in the fighting artist’s training regimen. As important as hitting is, it cane be over done. And without stretching and conditioning, excessive bag work can lead to muscular imbalances that in turn lead to avoidable injuries and performance impairments. So what should a practitioner of a fighting art or combat sport do to stay balanced?
Stretches For Strikers
Regular stretching for the prime movers, synergists, stabilizers and antagonists involved in punching is vital, especially during periods of intense striking work on bags or pads. This is not an exhaustive list, but it covers the muscles that are most prone to interfering with punching dynamics. If you do frequent, intense bag work, consider including 1-2 week recovery periods of very light or no bag work into your training routine. Corrective exercise and self myofascial release are also recommended to provide the optimal length/tension relationships for the muscles and promote efficient recruitment patterns. Hold each stretch for 20-30 seconds, repeat x 2 times per day, especially after hitting bags/pads/makiwara. This list is loosely organized from smaller muscles to larger:
- Avoid extensive stretching immediately before engaging in heavy striking work. A light pendulum stretch can activate the rotator cuff muscles and mobilize the superior thoracic outlet and sub-acromial space, which may be tight from training/fighting in a “hunched” posture.
- Subscapularis: Shoulder internal rotator. There are also ways of performing this using a stick or towel for assistance, but starting out in the lying position makes it easier to monitor the head of the humerus (upper arm) to ensure that it is not rotating forward.
- Teres Minor and Infraspinatus. Shoulder external rotators. Notice that she is not forcing her arm down. If the head of the humerus wants to bulge forward and the shoulder up off of the table, don’t push it past this point.
- Rhomboids: Retract and elevate scapula. These may lengthened and inhibited from the forward shoulder “hunched” posture common to fighting and training.-Pectorals : Flex, internally rotate and adduct shoulder arm at shoulder, pec minor specifically pulls the scapula forward and down. Do one at a time, avoid the double arm “hanging” doorway stretch.
- Levator Scapulae: Scapular elevator and medial rotator, neck rotator and lateral flexor. This muscle attaches the cervical vertebrae to the upper medial aspect of the scapula. The upwardly rotated, “hunched” position that many fighters adopt during bag work and fighting can shorten and tighten this muscle.
- Triceps: Extends forearm. This muscle is heavily used in straight-arm punches and strikes.
- Biceps: Flexes and supinates forearm. Used heavily in hooks and uppercuts, as well on the return to guard from a strike.
- Upper Trapezius: Assist in elevation and retraction of scapulae. This region of the trapezius may be tight from forward shoulder “hunched” posture common to fighting and training.
- Latissimus: connects the humerus to the thoracic spine, adducts, extends and internally rotates arm at shoulder. These are often tight in people who kick a lot or engage in excessive “air punching.” Hint: if you can’t do a squat with the arms stretched overhead and keep the hands in line with your ears, or can’t help but fold at the waist as opposed to the hips, the lats need serious stretching attention.
Relevant surface muscles of the back and chest
- Deeper muscle layers, rotator cuff muscles and tendons
All throwing techniques, including trips and tackles, involve movement in the transverse plane. Initiation may involve sagittal or frontal plane movements, but the follow through and landing will occur around the thrower’s longitudinal axis to a greater or lesser degree.
For the person being thrown, this means that:
- Landings will involve rotational forces and increased risk of damaging the ankles, knees, shoulders and neck. Pursue isometric strength conditioning as well as concentric conditioning, especially for the neck.
- Falling skills should be thoroughly practiced in all three planes of motion, as well as from kneeling, standing and moving positions.
- Failed throws wherein a foot remains planted will pose a high risk for knee injury, particularly ACL damage. Agility training can help a student to recognize these conditions and react quickly to move an endangered leg.
- For students and fighters whose activity is throwing and takedown-intensive (Judo, wrestling), specific programming for muscle hypertrophy should also be included to protect bony surfaces and joints and to help diffuse impact forces.
Rotating around my longitudinal axis as I land
For the person throwing, this means that:
- A throw will involve torsion on all joints involved in the technique. Specific strength and stability conditioning involving transverse plane movements can help to increase joint stability and ensure proper muscular activation around the ankles, knees, hips and core.
- Depending on the other person’s weight and velocity, a successful throw will involve accelerating and potentially decelerating several times more than one’s own weight and mass. Strength conditioning programs typically emphasize movements in the sagittal plane, while the frontal and transverse planes are less emphasized or neglected.
- Progressive balance and stability conditioning, comprehensive core conditioning, and agility/reactive training in all three planes are strategies that can reduce the chance of avoidable injury while improving a student or fighter’s performance.
- If a throw begins to fail at any phase, your body will be required to decelerate and stabilize the load while in non-optimal conditions, and several times your own weight and mass will pose a threat to your knees in particular. Condition the knees in all planes of motion, emphasize single leg balance and stability skills.
- Throwing and takedowns occur predominantly in the transverse plane. Most athletic injuries occur in the transverse plane. Do not neglect conditioning in the transverse plane (do I sound like a broken record yet?) .
Gill travels around Chopper's longitudinal axis
- Here, John’s knee is involved in stabilizing and producing force in the transverse plane
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