Bill Knowles – The restoration of athletic normal following a lateral meniscus repair

“Surgery doesn’t fix the neurophysiological insult”

Bill presented on an 18-year-old NHL player who suffered a bucket handle tear on his lateral meniscus when he was walking backwards down a hill, stepped in a hole and extended his knee.

This happened in early August, when players usually start getting back on ice ready for pre-season in mid-September to get their skating time up.
Pre-season in hockey is usually 2-3 weeks long and is an important preparation period. This athlete would miss the entire pre-season.

The athletic demands on a professional ice hockey player are high. They are fast, explosive and anaerobic.
Need to prepare the athlete for the skill of skating which involves intense accelerations, decelerations and change of direction with lots of rotation at the knee.

A typical post-op program may look the this:

  • No weight bearing for 6 weeks (crutches)
  • Braced full-time for 6 weeks (sleep in brace)
  • Brace ROM limited 0-90°
  • Out of brace limit PROM 0-90° at least for 2 weeks, even in therapy
  • No pool for 9 weeks
  • No bike for 7 weeks
  • RTP 4 – 6 months

It presents a timeframe at this number of weeks you can do this and not that. Some criteria in there but pretty generic. May be written as a starting point but may not evolve past this.

Normal time frame is between 4 – 6 months

Bill targetted the 4-month mark and began building backwards from there

  • Return to competition at 4 months
  • Needs a “pre-season” on ice for 4-6 weeks
  • Return to skating by 10 weeks post op

Bill’s talk was not about the reps and sets. Instead he has a sound, solid, ethical approach of what he wanted to do and he can fill in a lot of the other things first.

Making connections to create an approach.

Use the evidence, use your experience. Make connections

Use other people’s examples to help with those connections

Experience + examples = experience-based evidence

Evidence + examples = evidence-based experience

Back in 1994 they were talking about accelerated rehabilitation processes for a meniscal tear

Accelerated rehabilitation for meniscus repairs

A typical situation for meniscal repair is 6 weeks non-weight bearing and then gradually returning to weight bearing, however there is evidence showing we can be more progressive with meniscal repairs than what is commonly done, especially with professional athletes.

Work from 2013 & 2015 shows we are fine and safe to begin more progressive loading and range of motion strategies.

Free Rehabilitation Is Safe After Isolated Meniscus Repair: A Prospective Randomized Trial Comparing Free with Restricted Rehabilitation Regimens

Weightbearing Versus Nonweightbearing After Meniscus Repair

Surgeons protocols are based on who they trained with and what their experiences have been. Part of it is based on risk and liability which they are trying to avoid.

You can look at ACL papers, it doesn’t matter as it’s a joint injury that is being dealt with.
Factors Contributing to Function of the Knee Joint After Injury or Reconstruction of the Anterior Cruciate Ligament

How do you keep increasing progressively, either the loading or intensity of a rehab or reconditioning protocol? You can’t see a healed meniscus in this case. Taking an athlete through this process and if there is the following:

  • No increase in swelling
  • No increase in heat / inflammation
  • No increase in pain
  • No loss of ROM
  • No loss in the quality and control of movement

Then it is likely you are probably maintaining good homeostatic loading that they can recover from on a regular basis which says to Bill he can keep pushing and keep advancing.

It is a brain injury. It is a neurophysiological insult that has a central consequence. It’s not just a meniscal tear, an ACL, an achilles or a shoulder injury. They have a central consequence.

Anterior Cruciate Ligament Deficiency Causes Brain Plasticity: A Functional MRI Study

Don’t worry about it as just an ACL, look at it as a joint injury.

Factors Contributing to Function of the Knee Joint After Injury or Reconstruction of the Anterior Cruciate Ligament

There are other factors that affect the reconstruction,  both arthrogenic muscle inhibition and neural plasticity.

Quadriceps Arthrogenic Muscle Inhibition: Neural Mechanisms and Treatment Perspectives

Neuroplasticity Following Anterior Cruciate Ligament Injury: A Framework for Visual-Motor Training Approaches in Rehabilitation

Ipsilateral Hip Abductor Weakness After Inversion Ankle Sprain

The role of neuromuscular inhibition in hamstring strain injury recurrence

It’s all connected, it is a brain injury as well as a local meniscal tear

An athlete will go through a cycle of moving well -> injured -> not moving well. It may be an ankle, knee, hip or shoulder, it doesn’t matter!

The injury doesn’t matter, the approach to get the person back to moving well is the same process.

Bill’s process is to restore normal movements -> restore normal athletic movements -> restore sport specific movements and do this as quickly as possible

It may seem pretty obvious but it creates a mindset as to how Bill delivers a reconditioning strategy.

A simple strategy: The restoration of athletic normal.
A state where an athlete is free to express movement competencies that have been developed over years of play and generally just being athletic through not only their current sport but other sports as well. Regardless of the situation they find themselves in, professional athletes should still be athletic in many different ways other than only in their sport”

In the rehab / reconditioning process Bill looks at restoring the athletic normal by looking at their physical literacy and by doing so, physically educating them during the entire reconditioning process while trying to restore the athletic normal.

Physical literacy should mean athletes look like they are performing movement care free and effortlessly.

Physical literacy:

Ability to reduce, stabilize and produce levels of force required in basic athletic or sporting movements.

Walk, hop, skip, run, jump, lunge, squat, push, pull, climb, twist, rotate, reach and brace.

This is what Bill will expose an athlete coming back from a meniscal tear to.

He is not restoring the quadriceps and hamstrings to stabilise the knee, he is restoring the ability to express physical movements, with precision, style and grace.

Early Phase

In the early phase the aim is to maintain joint homeostasis.

In the absence of an increase in swelling or heat or a decrease in joint range of motion or coordinated movement patterns then you are probably loading or delivering a reconditioning strategy optimally.

Don’t restrict ROM, you don’t have to. Let it happen naturally through good movements

The pool is a great place to start. There is no threat of pain or threat of injury in the water.

All the gravity is off them, they start letting actions and movements happen naturally.

You don’t even have to coach it.

That’s a lasting way to deliver a movement that then shows up on land.

Physically educate through movements you can do instead of focussing on movements they can’t you can’t do.

The more involved they are in comfortable movement strategies the more they adopt it as they are using their brain to help that process. It may help decrease the effects of the neural inhibition.

For early phase strength, you can’t load too heavy through the joint so use BFR, Compex and isometrics. They have to have good bending, extending and rotating actions without load and strengthening has to take place without a lot of load.

It’s about sequencing and timing in the early phase movements.

1.5 Weeks post-op

Bill showed a lot of videos throughout this part of the presentation that I am unable to share so I will do my best to try and explain the general theme of these where possible

Bill had the athlete work through seated knee flexion / extension movements – able to get some bouncing, which puts a bit of stretch on the tendon. Not plyometric movements but bouncy.

Hit them with EMS early and often. Hit the whole lower extremity and turn them up really high. Get uncomfortable with EMS

Uses games and play – allows reactivity and neural connection to the brain, the body and movements. Important to keep this level of action and activity taking place.

Early gait training while walking on crutches. Don’t tell them when to walk but prepare them for walking. When it happens it naturally happens and everything usually moves quite effectively throughout that process.

Delivered comfortably in a way that the athlete is in charge of. A lot of coaching takes place in the gait.

Showed videos of movement challenges early on, seated pivot step overs on gymnastics box.

Some physios and athletic trainers would say you have to do straight leg raises and hip movements, so they get them off the table and on to the floor. Move the body consistently and progressively. Get them rotating, it may not look clean but over time and in 1-2 training sessions the athlete begins to do those movements faster and faster.

Physio’s and AT with early rehab – will use hip exercises to try to keep function and activities of daily living.

Seated hurdle step over – adding weighted ball in front to counter balance

Build and add more complex tasks and say don’t think of this as traditional rehab exercise these are just training strategies- literacy – pick, move, rotate, brace and stabilise.

Pool work began 9 days post op. Aqua running in deep water and pool walking, using a floatation cuff on the ankle to help achieve knee lift. This helps lift the knee a few degrees more, then when they go back to pool running they get a bit more knee lift in the running cycle in a period of only 3 minutes.

Uses a series of primal like movements to get the quad, hip and torso to brace simultaneously to produce coordinated movement strategies that are brain driven, brain connected, complex and dynamic.

Some of these movements included a single-leg push ups, pike rolls using the good leg to push off, single leg crab turns with the injured leg off the floor.

Spatially these exercises make a difference for the athletes Bill works with as they have stopped moving as aggressively because they have had the injury.

Bending is important for coming back from these injuries. Squatting in water. Sequencing the ankle, knee and hip simultaneously working together preparing for loading strategies and loaded movements.

The crutches were removed around 2.5 – 3 weeks

4 Weeks post-op

2 sessions / day. 1.5 – 2.5 hours / session

Starts getting the athlete to squat to a bench. The traditional protocol was non-weight bearing for 6 weeks. The surgeon understood they were advancing the protocol, they kept him updated and sent him videos.

Bouncy pulses on tramp – drive neural input, making a connection in space.

Maintaining homeostasis

Proprioceptive work – hula hooping

Train the athlete not just the knee. Work around it as often as you can.

Create the ability to let the leg be a part of the movement, not the focus of the movement. Legs are part of the strategy. E.g. single arm bench press with shoulders on a Swiss ball.

Mid Phase

  • Load because you have prepared the athlete for loading
  • Bodyweight with coordinated movements
  • Keep using pool. Off load and keeping moving
  • Sequencing middle phase movements, timing & rhythm. Bodyweight speed increases
  • Continue Compex, BFR & isometrics
  • Add increased loading with resistance cords and DB’s

5 weeks post op:

  • Cycling
  • Partial burpees with box
  • Pike roll back
  • Single leg crab turns – knowing where the body is during motion
  • Feet elevated wall plank shoulder taps

More bending and loading. Rolling backwards – Teaching squat and squat to stand pattern

  • Backward fall to crash mat – return to feet.
  • Backward fall to crash mat – to single leg stand – like standing from a SL pistol squat
  • Backward fall to sloped crash mat – and stand – lands in a squat position
  • Obstacle course – forward roll on mat, straddle jump, to backward fall on sloped mat

In the pool training good quality ankle, knee and hip movements – deep skate positions

  • 5 weeks post op healthy gait
  • Coordination, neurally driven exercises hula hoop with ball taps

Late Phase

  • Load because you have prepared the athlete to load – sport specific movement patterns
  • Use the pool
  • Sequencing and timing
  • BW speed increases – eccentric exposure
  • Careful with plyometrics

8.5 – 10 weeks post op

  • Goal to be back skating at 10 weeks
  • Good range on the bed
  • Conditioning in the pool
  • BW Bulgarian split squat / lateral squat, making sure bending well at ankle, knee and hip with good control
  • Start adding resistance – Hip thrust, SL RDL
  • Maintain movement quality but look to increase movement challenges – squat under hurdle to knee drive
  • SL bosu ball hula hoops on each arm (1 forward, 1 backward)
  • Keep training coordination and drive neural response to muscle.
  • Linking and sequencing is starting to come to special movements. Diagonal bounds, dribbles on sprung floor – has bounce and forgiveness in it.
  • Trampoline jumps – opportunity to develop stiffness and co-contractions in the lower extremity.
  • Start loading movements but still only 10 weeks post op so not trying to maximally load yet. Just adding load while sequencing movements.
  • Timing, tempo and rhythm important in exercises.
  • Speed of movement becomes faster – pulse squats – better eccentric loading opportunity.
  • Multi planar type movements, preparing the athlete to resist forces with lateral hops.

Returned to team environment at this point

6 weeks of on ice prep

6 weeks continued strength development

Being biologically healed does not mean you are athletically prepared.

If you are going to do a 4-month post op return to play you have to prepare the athlete while protecting the injury, you can’t do it the opposite way around and protect an injury for 8-10 weeks then turn them loose or ramp them up quickly

Physically educate them from week 1!


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