[ read time ~ 9 minutes ]
Owen first contacted me 11 weeks after undergoing microfracture surgery for his left knee. He was experiencing a “dull, ache” in the front of his knee, and he felt frustrated because this was “the same [pain] as before microfracture.”
Making the Decision
Owen seriously considered his options prior to undergoing microfracture surgery, a procedure to address knee cartilage injuries.
A 47 year old husband and father of two young children, he had previously run two marathons and two half marathons. In the past, he noticed his knees periodically made a clicking noise and they didn’t always feel strong. But he didn’t experience any significant problems until three years ago when he jumped and fell, landing on the front of his left knee.
A week later, he woke up with severe pain and was unable to easily straighten his knee. But he thought the pain would go away. He decreased his activities and replaced running with swimming.
Still experiencing pain a year later, Owen saw an orthopedist who diagnosed him with osteoarthritis and recommended surgery. He saw a second physician who injected his knee with hyaluronic acid and later platelet rich plasma, followed by “tons of physiotherapy.”
This approach “just wasn’t working” so he met with a third surgeon who performed microfracture surgery, a procedure that involves drilling or scraping through some of the damaged cartilage and into the bone. The procedure causes some intentional bleeding, and the bleeding helps repair the damaged cartilage by building fibrocartilage at the site of the microfracture.
Some research indicates microfracture results in people being more active with less pain up to 17 years later. But more recent research reveals that good outcomes frequently decline five years after microfracture is performed. The most promising results occur in people less than 45 years old.
Recovering from Microfracture
Owen wore an extension brace for 10 days following microfracture, and he began physiotherapy about 4 weeks after microfracture. The physiotherapy exercises included body weight squats, which increased his knee pain and caused him to limp, so he cancelled his remaining sessions.
When he contacted me, his knee was feeling pretty good when he woke up in the mornings, but worse throughout the day, especially after standing for 10 minutes, sitting for 30 to 60 minutes, or when walking-- an activity that was tough to avoid as a resident of a large city with two young children.
His knee felt better when he used crutches or avoided walking, both of which were not sustainable, long-term solutions.
A New Approach
When Owen and I began working together, his goals were to be pain free throughout the day and eventually get back to sports like cycling, hiking, swimming, and strengthening at the gym.
Owen purchased a Variable Incline Plane. This piece of equipment was necessary for two reasons: (1) to measure his Squat Load Tolerance and (2) to perform beneficial exercises, ones that were the right level of difficulty for his knee.
We first measured his Squat Load Tolerance during an online video session roughly 3 ½ months after he underwent microfracture surgery. He was able to squat pain free on his left leg using up to 16% of his body weight. If he used more weight than this, he experienced left knee pain.
This meant that every time he stood up from sitting on a chair without using his hands-- an activity that requires each knee to tolerate 50% body weight-- his left knee was receiving too much pressure. Since he could tolerate 16% of his body weight, but was using 50% body weight, he was exceeding the capacity of his left knee by 34% of his body weight. Given he weighed about 150 pounds, this overload was roughly 50 pounds each time he sat down or stood up from sitting. To avoid this overload, I advised him to press through his hands and rely on his arms as he stood up or sat down.
During Owen’s initial coaching session with me, I also walked him through the steps of measuring around each of his knees in two different places. This revealed swelling in Owen’s left knee. (To learn how to measure swelling at home, watch this video.) The swelling indicated that his knee was receiving too much pressure throughout the day, so I asked him to track the swelling. By limiting activities-- like stairs, walking long distances, sustained standing, squats and lunges-- along with measuring the girth of his knee each morning, his left knee went from being 1.3 cm greater than his right knee to only 0.1 cm larger, within 2 weeks.
I also asked Owen to perform at least 10 Quad Sets, a simple exercise that involves tightening the muscles on the front of the thigh, five times throughout the day. (To learn how to perform Quad Sets optimally, watch The Ultimate Guide to Quad Sets.) The purpose of this exercise is to improve the health of the fluid inside the knee (source). Healthy joint fluid is the consistency of egg whites, and it serves to provide cushioning and lubrication within the knee.
Not long after we started working together, Owen had a follow up appointment with the surgeon who performed the microfracture. His surgeon had an additional recommendation-- more surgery, specifically ACI or Autologous Chondrocyte Implantation. ACI involves harvesting cartilage from an uninjured area, creating a patch of cartilage, and securing it over the injured area. Owen declined this procedure.
A bit discouraged by the recommendation for additional surgery, Owen said, “I wish that I had read Doug’s book and come to you before the [microfracture] surgery.”
Owen’s joint conditioning exercises now included easy squats. Lying on the Variable Incline Plane at an angle that only required him to use 22% of his bodyweight, he used both legs to slowly squat for five minutes. And he did so six times throughout the day.
In addition to daily Quad Sets and joint conditioning (which included Sitting Sliders and easy squats on the Variable Incline Plane), he performed a separate set of exercises three times per week. One particular exercise involved standing on his left leg while moving his right leg to challenge his balance and encourage his left hip muscles to work. (I call this exercise the Jack Knife.) And to focus on increasing the strength and resiliency of the cartilage inside his knee, Owen performed Eccentric Single Leg Squats using 22% bodyweight with his left leg on the Variable Incline Plane.
Owen’s knee was still hurting every day because his knee was not yet strong enough to withstand his daily activities. However, his tolerance for squatting had more than doubled during the first month that we worked together. He was able to squat pain free with his left leg using 34% of his body weight. And because he couldn’t limit his walking enough to avoid swelling, he was intermittently using crutches to decrease pressure on his left knee.
When we met via online video two weeks after this, Owen told me that he felt slightly stronger, but he thought his left knee should be less painful at this point. (It had almost been five months since his microfracture surgery.) He and his wife were planning to move their family back to Ireland, but he was unsure if his knee would hold up for an international move.
Despite his concerns, his knee was another 5% stronger than when we measured it 2 weeks previously. (His left Squat Load Tolerance was up to 39% of his body weight.) I recommended some advancements in his exercises, and he committed to staying the course.
The next time we met, after another two weeks had elapsed, Owen was happy to report he was experiencing “way less pain” and less frequent “clicking.” His left Squat Load Tolerance had improved to 45% of his body weight.
However during his next session, another two weeks later, Owen was again experiencing swelling in his left knee. Having periodic increases in symptoms while strengthening and recovering is typical for most clients. Progress is rarely linear and some setbacks will likely occur; this is a part of the process.
In response to Owen’s swelling, I recommended a Recovery Cycle. This is a period of time in which more challenging exercises and activities are suspended, and the focus is on protecting the knee while also performing Quad Sets and gentle knee motion.
Two weeks later, his left Squat Load Tolerance measured 51% of his body weight. As a result of this improvement, Owen began a more difficult exercise, Assisted Eccentric Chair Squats. This exercise is an excellent way to move from squatting on the Variable Incline Plane to squatting upright without overloading the knee joint. And it only requires a standard chair and a Gray Cook Band, which was particularly helpful because Owen was going to be without his Variable Incline Plane for several days during his family’s international move.
One month after Owen’s return to Ireland, I received this email from him:
“My knee is actually doing great! It’s practically pain free and that aching that bothered me is completely gone… I have been going for really long walks here and have had no problem with that so I am absolutely thrilled! It’s been a long time since I could do that.”
I heard from Owen again 6 months after his move:
“My knee is improving slowly, but still improving all the same… If I haven’t done any exercises for a while it will ache, but it seems as soon as I start exercising again then it starts improving... Walking is fine so this has been great getting out most days with the kids. If I kneel down it feels tender so I avoid that still… So overall it is still on the mend but is improving all the time.
It’s almost a year since the surgery and I really wish I didn’t go through with it. But I will keep going with the strengthening.”
A procedure to address injured cartilage, microfracture surgery by itself rarely prevents future knee pain. However, when microfracture is followed by the approach that Owen observed, strengthening occurs inside the knee, making it possible to return to an active life without knee pain and swelling.
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