Will that wear out my knee replacement?

Nature’s peace will flow into you as sunshine flows into trees. The winds will blow their own freshness into you, and the storms their energy, while cares will drop off like autumn leaves.           

                         -John Muir, on hiking

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Are you sure that I can do this with my knee replacement?

"J" was in his fifties. While technically a grandfather, he was no grandpa. J suffered a traumatic sports related knee injury in his twenties but continued to be active through his adult life. This caused accelerated wear and tear on his knee. A quick assessment revealed that despite having a knee replacement a few years ago, he possessed far better quality of motion than the average adult. 

Prior to surgery, J loved being active. He lifted (serious resistance exercise with free weights) consistently. He hiked and bicycled and coached and played sports with his children. He lamented that he missed these activities.

Well why aren't you doing them?

 

After completing my assessment and watching him perform a few basic functional exercises, I saw no reason why he should refrain. As J performed a set of well controlled repetitions of an exercise we call "single leg hip hinge," J mentioned how much he could deadlift in his thirties and forties.

It's likely that you could rather easily get close to that.

Sheeat no way! With a false knee?

 

There was a definite twinkle in Js eye. And it's true. Being that Js general health and quality of movement were excellent, and he had an extensive history with serious resistance training, and the numbers (deadlift weight) he mentioned were rather reasonable, there is little reason why he should not try it. I would recommend attention to detail and a slow progress slowly, of course.

But my [previous] physical therapists warned me about twisting and high impact activities.  

While deadlifts will have a relatively high load on the knee, the range of motion is limited. And you will place more impact and twisting force on your knee when you walk down a set of stairs or around a corner.

If J was a golfer I would have asked why most doctors and therapists give golfing a free pass. I often wonder why this is deemed an acceptable means of moderate impact and twisting forces on replaced knees.

 

But my orthopedist was concerned that having the knee replaced at a relatively young age may cause the knee to wear out over the years.

You have a 90 to 95% chance that your knee replacement will last 10 years, and an 80 to 90% chance that it will last for over 20 years. And since joint replacements of today are even better than those performed 10 to 25 years ago, it is widely believed that the prospects are even better.

I would take those chances. And by the years of arthritic development in my right hip, it is likely that someday I will. Because there's also the chance that something could happen, including further age, that prevents getting moneys worth out of the replaced part.

I believe that going for a hike outside, in the variable terrain of the woods, is living. I believe that a few challenging sets of dead lifts are nearly miraculous. I would risk a possible second knee surgery in exchange for even a few occasions of being actively engaged with my kids. And I believe that J feels much the same.

I'm just not sure.

 

Don't get me wrong. I'm not trying to tell you that your knee won't wear out.

It's Js call, of course. He may take every measure to protect and serve the replaced knee. He may partake of acceptable activities such as golfing and riding the recumbent bike. He may "sit this one out" when it comes times to play catch with his grandchildren.

And one day, he may go to the grave with a shiny and well preserved replaced knee. 

 

The Greatest of These Is Love

Last week I watched children between the ages of six and eight play basketball. They were of various shapes, sizes, and attention spans for organized sport. Some of them could barely run much less crossover dribble.

Some kids clomp around in heavy lead shoes.

Some try -really- -hard- to make things happen. They dart about with clenched jaw and move with the grace of C3PO.

Others run with flailed elbows or limp wrists.

But some children move with efficiency and purpose, naturally operating in the paradoxical state that all athletes aspire to. I would describe it as tranquil intensity.


It does not take a trained eye to differentiate the clompers and flailers from the athletes.

But where do those qualities come from? Every child on that court was young and moldable, and will remain so for a while. I imagine that most of them were active. Some would say that the 7 and 8 year old top performers are naturally gifted, and I would agree. But I don't think that this "gifting" is primarily physical in nature.


Nobody seems to address the psychological aspects of this "gifting" in top performers of any age. For example, the evidence contradicts what we once thought. It appears that 10,000 hours of deliberate practice are not always required and do not necessarily produce high level proficiency. 

For example (click for complete text):

More than 20 years ago, researchers proposed that individual differences in performance in such domains as music, sports, and games largely reflect individual differences in amount of deliberate practice, which was defined as engagement in structured activities created specifically to improve performance in a domain. This view is a frequent topic of popular-science writing—but is it supported by empirical evidence? To answer this question, we conducted a meta-analysis covering all major domains in which deliberate practice has been investigated. We found that deliberate practice explained 26% of the variance in performance for games, 21% for music, 18% for sports, 4% for education, and less than 1% for professions. We conclude that deliberate practice is important, but not as important as has been argued.

This study made me think that deliberate practice has its limits, just like every other facet of success.

A person may have the greatest work ethic on the planet...

But they could be working in a far less than optimal manner. All those push-ups and squats, pitches thrown and swings taken while under misguided coaching or poor movement patterns only serve to further ingrain poor movement patterns. Having mountains of drive and determination without proper context or know-how will leave you average or injured.

You may have the greatest environment and coaching on the planet...

But does the athlete really want it? Are they (understandably) unwilling to sacrifice some parts of life in order to achieve an optimal level in one activity? Or maybe there is a physically or emotionally traumatic experience, a serious injury, a mistake or gross oversight in the process of exposure to higher-ups. Without consistent, hard-working grit and opportunity, all the talent and resource will be missed.

And then there are "genetics."

You may have the greatest "natural" talent in the world...

But natural talent will only take you so far. At some point, you run into other talented people who have put in years of hard work. Genetics ultimately determine how far a person may develop a given ability, or the extent to which they may actually succeed despite subpar effort. While no set of genetic cards can be modified, the expression of them can. Athletes would do well to be less concerned with their genetics, and find ways to leverage every modifiable factor to their favor.

If you work terribly hard over a long period of time...And you have proper context and coaching with a supportive environment...And opportunity...

The athlete may not become Champion of the World or even make a living off the pursuit. But chances are that he or she will go very far. And I personally feel that the kind of person they become in the process is far more important than the ultimate degree of success.

But is it worth it?

Regardless of the extent of  natural talent, an athlete who has love will have no problems putting their time in. While it's likely that some of the "naturally" athletic children love basketball, I expect that all of them would show a love for physical movement.

If we could rewind the clock and observe those young athletes as compared to their less graceful peer, I imagine that we would witness a LOT more movement. For years, there were jumps to and from the couch. There was ball juggling in the basement, running and climbing, sliding and falling, leaping and tripping. While some children were given a pedometer to monitor their step count, the athletes would have destroyed theirs from getting hit, caught, and crushed.

As a young person, maybe even as a toddler, the athletes simply loved to move. Then they fell in love with a particular set of pursuits.

And that's why I say that before there was any expression of genetic potential, there was love. And all the best environmental factors are worth nothing if the athlete has not love. Without love,  the 10,000 hours of deliberate practice will never take place, and sooner or later, all the training and coaching and weekend tournaments turn into an exercise in frustration. But if there is love for the pursuit, even the losses and the failures are a win for the person.

Does the child truly love it?

The greatest of these is love.

Sorrow is better than laughter,
    because the heart is made better through trouble.
  
                                                    -Ecclesiastes 7:3

The Best Workout for Health: Be Like Amy

"Slow Ride.
    Take it easy."      -Foghat

Read part one here - an extended intro to this. While the physical freaks, the hardcore, and the professionals may have their day in the spotlight, my suspicion is that most of us may want to look to the Exercise Moderates.

Yeah - this from the guy who works in physical rehab and sports performance. Who sporadically attempts to type original content on a training related blog. The one with a hobby that includes speed and power and lifting massive masses of mass. Who enjoys reading and thinking about training and sharing the journey with others.

But what if he's wrong? Or less correct than say, someone with a different perspective? Someone who lives at the same address who doesn't put in near as much effort?
I know my wife better than anyone on the planet. I know Amy's history, her ways and inclinations. I understand her and what it means to be her - to a point. Of course we see the world differently. We don't agree on every jot and tiddle, nor do we feel the need to.

Amy is an Exercise Moderate. She values training enough to make time for it, and little more. I don't understand such creatures. It simply does not compute.
Amy never was a serious athlete. She does not love or hate sports or exercise.

She is usually able to overcome the anti-exercise inertia that we all experience. But she gets it done. She knows and believes in what's good for her, the prevention of osteoporosis, the maintaining of strength and balance, and the blood flow to the brain. She has experienced how it makes her feel.

Three to four days per week, Amy runs for approximately thirty minutes and then lifts weights. The resistance exercise is a basic total body battle against free weights and gravity; a few circuits of movements such as squat, push-up, row, deadlift, and lunge variations. With minimal equipment and no travel time, the ceremony is finished within 40 to 50 minutes.

If she's feeling a bit soft, she'll reign in her diet a little. She does it all without drama or fanfare.

This truly may be the absolute best way to go for health. We are finally pinning this down, and it makes sense. A number of studies have suggested that moderate exercise appears best for longevity, and while exercise is critical, the "more is better" mindset needs to go.

Although joggers as a group appear to live longer than sedentary nonjoggers, moderate joggers have lower mortality rates than sedentary nonjoggers.

However, strenuous joggers - people who ran faster than 7 mph for more than four hours a week; or who ran faster than 7 mph for more than 2.5 hours a week with a frequency of more than three times a week - have a mortality rate that is not statistically different from that of the sedentary group.


The dose of running that was most favorable for reducing mortality was jogging 1 to 1.4 hours per week, with no more than three running days per week, at a slow or average pace," the authors wrote.

In truth, the problem may be that the Exercise Moderates are not the ones who feel compelled to work in fitness, study exercise through research and experience, or write health/fitness blogs. They have received the numerous benefits of their efforts. And they have moved on.

Somebody has to take care of the couch potatoes and fitness fanatics.

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This is Amy




She doesn't feel the need to compete at anything.


Amy overcomes many legitimate barriers and the internal inertia that resists movement.


She doesn't need a training partner or app. She does, however, need some music.


Amy can perform one unassisted chin-up but could care less.


She doesn't make a big deal about personal records or set-backs.


Amy doesn't complicate and obsess regarding her diet.




Amy is smart.

Be like Amy!

The Best Exercise for Good Health (Part 1)

Is training your serious past-time or hobby? Do you exercise in order to crush the competition? Do you love to test your limits and feel the burn? If not, this one IS for you.

Have you ever watched someone pull off a jaw dropping physical feat? You may have thought or said "Nope - could not do that even if I tried for the rest of my life." Well, you would be surprised at how far targeted training and extreme commitment would take you. But you're probably right - the featured guy or gal probably possesses the combination of hard work over time and a pure gift.

But don't feel bad for being relatively normal. Being an outlier in athletics usually comes at a price. It comes at a price to your personal life and other professional interests and especially to your body. The years of mechanical pounding take their toll.  And the very God-given qualities that define a super athlete often come with at least some degree of long term consequences.

What's best for freakish superhuman physical performance is not always what's best for health. There are many example, but here are a few.

-Throwing with high velocity is awesome. But arm speed is also the greatest factor of stress to the elbow and shoulder, causing a literal twisting of the structure and position of the upper arm bone. We still don't know exactly how much this preserves or hinders the integrity of the shoulder joint as we continue to throw and then age.

-Advanced and even casual endurance athletes, especially females, often suffer osteoporosis in middle age. You could easily claim that fall related fractures and the associated downhill spiral are more of a problem than cardiovascular disease.

-You thought that repetitively heaving a barbell overhead while in a state of mental and physical exhaustion was not going to have paybacks? There are many ways for the average Joe to work hard. Just be careful with how far you Crossfit yourself.

-An outlandish degree of trunk and leg flexibility allows gymnasts to effortlessly perform cartoon-like maneuvers. Top power athletes such as sprinters and team sports have much anterior pelvic tilt with stiff arched lower backs. Both are known to cause lumbar spine and hip arthritis.

Who is to say if the fifteen minutes in the spotlight is worth the consequence, or how many problems such gifted individuals would suffer without all their training. But the questions remains - where is the line for health - the optimal middle ground for normal people that exists somewhere between couch potatoe and fitness freak?


What kind of coaching and rehabilitation should you seek when you do not aspire to win a national or even a street championship, but want to look good, feel good, and function well outside of the gym, for the long haul?

In all of the fitness and sports performance world, is there any room for moderation?
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Foot Pain - First Things First

I try to give a straightforward response to the person with a chronic foot problem...

You're going to consider months of medication, injections, various diagnostic tests (MRI, CT Scan, etc) and surgery, without trying much simpler things first?

What about the basics?

What about a solid and consistent short-term effort of (relative) rest of the foot, working on movement related issues like inflexibility or weakness, and getting into the most appropriate shoe for your situation?

The basics are not rocket science. The basics are somewhat inconvenient. The basics, while not a miracle cure, will often take you a long way. And they are a necessary foundation. Even if you do ultimately need surgery or other more invasive treatments, the basics will need to be in place in order for the "non basic" to be effective over the long term.

I understand that the various treatment options and guidance can be confusing and seem complex. But here I lay out a path for you. Though you probably will not fit perfectly into this as a protocol, it should serve well as a general guide for you to know what pieces of the puzzle may need to be addressed.

Get (relatively) off your feet for a while. 

There is absolutely no substitute for a period of rest from the offending activity. And when you have a sensitive foot, even one step of supporting your body weight can flare things up. Two or four weeks in a walking boot may be in order. It will be at least that long should you elect for surgery.

I realize that taking some time off work or fitness and athletic activities can cause various hardship. But if your feet remain painful despite various treatments, and you're running out of options, do not neglect this step in the process!

Treat the symptoms.

While you're off your feet, you can still use modalities like ultrasound and electric-stim, massage, and other passive treatments to help restore normal soft tissue tone and sensory input to the foot. Many people try new shoes, new orthotics, exercises, and other modification before they first (including pain medications) simply manage the symptoms. Most of the time, you can successfully implement these strategies while you're on rest from the offending activity (see step one above).

Stretch and strengthen.

The time of relative rest is also a great opportunity to work on select stretching and strengthening exercises. This is a critical step in the process, but by no means the only step. If you don't address movement related problems to the best of your ability, steps one and two above are likely to help you feel better only until you attempt to resume your normal activities. For example, people with a neuroma or metatarsal (ball of foot) pain can usually stretch their toes and hips to help avoid twisting off the ball of the foot when they walk.

The therapeutic exercises may feel uncomfortable but they should not hurt. If they cause the same symptoms, you are doing something wrong and need further guidance. For example, people with plantar fasciitis can and should stretch their calves, and when done properly, this does not irritate the symptoms.

Put time and money into the best shoe for you.

There is no "best shoe for plantar fasciitis." The best shoe for you may be different than for someone else with the same diagnosis, and depends on your foot structure, walking or running style, and activity level.

Expect to pay more for a well constructed shoe. For example, the Asics that you buy on sale for $40 at Kohls are absolutely not the same as the Asics that you buy for $100 in a shoe store.

As compared to the shoe store, you can probably find the same quality shoe for $10 less on-line. But then you miss out on the expertise of shoe service staff, and the ability to try multiple shoes on at once. When the size 9 fits good in length but not width, you can immediately try the 9.5, the 9-wide, and a comparable shoe that possibly suits your needs better. Try doing that on-line.

Consider an appropriate off-the-shelf or custom orthotic (inserts).

Soft gel insoles rarely fix the problem. If all of your problems are solved with a $15 gel inlay from the grocery store, then truly good for you! But most people with chronic foot problems need something that provides contoured support to the arches of the foot and facilitates a change in the mechanics of the foot/ground interface.

Do not expect a custom orthotic to magically address all factors above. They always...ALWAYS work much better when you have given your foot relative rest, have managed the symptoms, and have addressed biomechanical issues with the lower extremity.

If you do obtain a rigid or semi-rigid device, be prepared to gradually taper into full time use of them. Be prepared to have them revised to fine-tune the fit and function as needed.

S L O  W   L    Y  return to full activity.

In my experience, this is where many clients miss the boat, whether or not they successfully completed any of the above or even had a favorable response to injections and medications.

The person who works 10-hour days standing on cement, returns to 10-hour days standing on cement. That's simply a case of too much, too soon, and most of the population without foot problems would struggle with that.

Also, the person who loves to walk or run, simply returns to their former exercise routine, when they should have undergone low impact weight bearing strengthening exercises with a very light start to their walking/running progression (adding less than 10% distance or duration per week).

Helpful...help for foot problems-

I would strongly suggest that you find a health care professional with the appropriate clinical expertise who will also be an advocate for you, and help you find context and perspective.

-Did the professional examine your foot flexibility and strength in both weight bearing and non weight bearing positions?

-Did the professional examine your general movement patterns - how you walk or run, squat down, balance, etc?

-Did they comment on the status of your current footwear, athletic and casual shoes?

-Did they offer means to manage the symptoms?

-Did they offer means to restore proper function prior to resuming your typical activity level? Did they offer guidance on a reasonable plan for getting back to what you want to do?

-If they construct orthotics, did they offer a compatible shoe suggestion, activity modification, and easy follow-up for making revisions as needed?

If you get the feeling that a professional is attempting to push you into their own "mold" of treatment; only injections, or surgery, or shoes, or orthotics, or exercise, and it's not working...move on.

Plyos on Christmas

My neighbors see us jumping in the yard and sprinting down the road, as usual on Friday afternoons. But this is Christmas.

Do they think we're crazy? In a certain sense we are. But who is not, in some way? Why is three or nine hours watching sports or movies that we have already viewed a more acceptable thing to do on Christmas?

I was thankful to have a handful of like-minded friends join me for the afternoon 12/25 session. Each of us have busy lives but try to find time to train.

Not because I can't take a day off. Every week I take 4 of 7 days "off."

Not because I need to burn off holiday calories. Well, that may be the case as my diet has been less than stellar. But I'm honestly not training to atone for Christmas cookies.

Not because I hate or love my own body.

There is time to train on Christmas afternoon because this is what I enjoy. The challenge. The process. The dealing with and overcoming barriers. The experience of controlled discomfort. The need to run around outside and sweat and breathe fresh air.

I truly don't understand why or how this happens - someone becomes the kind of person who wants to take an hour to train on Christmas.  But I would guess that becoming the type of person who enjoys the fitness journey would be a good thing to consider for 2016.

I also read this today:

"Intensity is for amateurs. Consistency is for pros."

It's absolutely true. You do not need to go crazy with your exercise program, in any sense of the word.

Most beginners and casual gym goers do need to learn how to work with intensity. It's true that twenty minutes on the elliptical (machine) followed by 3 sets of 10 on various strength training gadgets is FAR better than nothing. This is not intensity. Beginners need to learn how to be mentally comfortable with being physically uncomfortable. But only to a point.

The amateur makes the mistake of thinking that if a little gut-busting is good, then a lot must be better. That's why you have hordes of people regularly taking part in death marches like The Filthy Fifty. I understand this is necessary for Crossfit (and other high level) competitors. But if not, regular white-hot intensity is not necessary and can be counterproductive.

I will readily admit that I've been guilty of this and slowly learning how being more selective with high intensity work is more productive than pushing the limit on every occasion. I'm trying not to be the amateur, chasing a feeling for the day, rather than sticking with a reasonable and disciplined long-term goal.

Athletes who lift weights in order to improve in their chosen sport (outside the weight room) should especially heed this advice.

Pros identify a specific goal and enter into a process with razor focus. Pros do not worry about achieving more than one thing at once. Sometimes they feel like doing more, other times like less, but they follow the big picture plan despite their feeling. They put in consistent days of hard work, applying the high intensity techniques few and far between. Pros are highly selective with elements of their life that will cut into their recovery.

And remember that you should not pound your body in the gym for "calorie control" or to make up for what you should be achieving through your diet. That's a ticket to overtraining and spinning your wheels as an athlete.

Every remarkable thing that I've achieved in training has come from following a systematic plan that keeps me on task toward one thing and refraining from pushing the limit at each and every workout.
You don't need a lot of special programs, equipment, or variety. I firmly believe that this applies to what we eat. Eating mostly well, most of the time trumps the extreme diets, gimmicks and quick fixes.

On all fronts, the real magic is in consistency. Focus on quality movement rather than slogging through brutal rep after brutal rep. Whether you walk, run, kick box, lift, etc, do it well before you do a lot of it. Find a good mentor, refine your goals, and following the plan despite what you feel like doing on any given day.

Learn to love the process.