Using the Eccentric Decline Squat Protocol

This post records my experience of the first two months of trying eccentric decline squats as a therapy for pat and quad tendinosis. Mid October I checked in with my physio and we talked through my problems to date and the protocol. I started on two sessions a day (first thing and last thing), using both legs (so no one-legged squats at all yet) , in sets of three and adding 3 squats each day (so 3x3x3 twice a day on day one, 4x4x4 twice a day on day two and so on). We added in a late afternoon session as well.

In parallel to the squats I was also seeing the physio for regular massage and acupuncture of specific trigger points in my quad muscles (see other post) - which proved very effective in reducing stiffness and some of the minor symptoms.

Progress was very good for the first three week. I saw a good reduction in symptoms and was building up the squats well. But then it all started to go wrong, increases in discomfort turning into a running battle by which I kept laying off the squats because of a flare-up, restarting them only to see it flare up again and so on. By Christmas I had to accept I was (apart from benefit obtained from the massage sessions) not really getting anywhere. from reading this blog and other discussions it looks likely that my rate of increase was way too high. So the plan now is to rest for a couple of days and then restart doing only one session a day and only adding one squat a day - let's see how that goes....

Possible Tendinos/Tendinopathy Treatment: Cissus Quadrangularis

I've been taking Cissus quadrangularis to see if that had any curative effect. The product I used was "Mega Cissus - 50% Ketosterone" taking 400mg tablets before breakfast and bed. Having taken it for 50 days I have noticed no effect at all. I will continue to take it for another 50 days to see what happens. So far, for me, whilst this may have some effect on muscle and connective tissue growth, it seems to have no value in tackling tendinosis. Interestingly it does seem to have made me slightly leaner and made it easier that usual to keep weight down even though I'm not training - an effect Ihave read about

End of the first 100 days

So, I'm setting out to rest for 100 days and then do 100 days of eccentric protocol....this post marks the end of 100 days of complete rest. I can categorically state that (for me) resting has achieved absolutely nothing. All the symptoms I had before, I still have and at the same level. Audible crepitus in right knee tendons. Overstretched, creaky feelinging in pat and quad tendons on both knees.If I overload it, pain on right knee pat tendon.

At least I know that I have tried rest and won't be spending all my time now thinking - "perhaps I should just be resting". I'm going to crack on with an eccentric squat protocol and see what that does for me. I've been reading this excellent blog about eccentrics squats and will have a go at it. Will also get back in touch with physio and get their guidance/supervision.

The 200 day plan....

One good thing about tendon injuries is that they teach you to slow down and have patience:)

I really think I know the extent of my problems now and can plan a way out. The two things wrong are:
(1) general crepitus and tenoditis type feeling above, below and around both knees - caused by doing too many weights too often when trying to come back after the Marathon
(2) localised tendinosis in the right patella tendon - caused by over-training before the marathon

To date any attempts to start an eccentric protocol to work on the second cause the first to flair up. So here's the plan......

First of all I need to kick the more general problems. I've read in a number of reports and journals that it takes 100 days for Type I tendon collagen to lay down and mature. So I'll do no exercise on my legs for 100 days (bar walking around and a tiny bit of swimming as a treat). I would expect this to show a marked improvement in the more general problems. Perhaps later on I will be able to add in some gentle stretching. Other things I should do in this period would be some work on ballance/proprioception (mine is rubbish now!) and some deep tissue massage as there seem to be all sorts of rough, painfull areas on innner and outer thigh muslces and nasty trigger points. It's already 6 weeks since I laid off the gym leg weights and there is already a slight improvment in the general tendon crepitus - which is promising -but the trick is to stick to my guns. If I count from when I stopped the gym weights that puts me at 50 days right now

Then.....

I've also read that any significant improvements from an eccentric protocol aimed at tendinopathy takes a min of 12 weeks (consistent with the time above taken to lay down and collagen and re-model the tendon). So the second part of the plan is a 100 day eccentric decline squat protocol (starting incredibly gently and building up slowly). Hopefully this second phase will then start to address the specific area of tendinosis. I'm also expecting to continue the eccentric work for a long time beyond this - but I'm hoping to see improvment by the end of those 100 days

Maybe I'll be able to go for a gentle bike ride at the end of the winter (forced grin)...

Heat or Ice?

I've tried both applying heat and ice and thought I'd jot down my observations. As with all this blog - consult your GP (Doctor) or physio first.

Icing is normally recommended (as part of RICE) soon after the injury to help reduce inflammation and bring down swelling and numb pain. Most advice says not to use ice before activity. Heat is normally recommended before exercise to warm up tight muscles or in the ongoing management of conditions where increasing the blood supply to an area can reduce stiffness and help. Never apply heat to an area with inflammation as it can make it worse

There is a brief summary of the differences here:
http://orthopedics.about.com/cs/sportsmedicine/a/iceorheat.htm

So, what might we speculate would be the affect on tendinopathy? Going with the expectation that tendinopathy is not an inflammatory problem (but one of collagen degeneration) I have tried both and found the following:

Ice: Icing (freezer gel pack with cover to prevent frost-burn) worked well to numb pain (and also my weird tingling and wet/cold feelings). It left the area feeling stiff afterwards. Despite repeated and regular use over time no obvious improvement in the condition was observed

Heat: The warmth of a heat pad helped to reduce stiffnes and felt pleasant but did not provide any relieve from pain. In addition on a few occasions, where at that time I had a particular small spot of increased crepitus and wet/cold feelings it seemed to be slightly worse afterwards.

So, on balance I guess the icing was marginally more useful and probably safer in case there is some minor inflammation (perhaps caused by the rehab protocol). Heating did not some quite as useful and I had a worry that improving blood flow could be bad thing if it worked to the benefit of abnormal capillaries growing into the damaged area. Neither seem to have any curative effect at all - but ice seems the most useful palliative

Weeks 15 - 17

Whilst on hols felt pretty good when on beach and in the (cold!) sea - but right knee got very tight and sore driving home. In a fit of frustration (sigh) attempted to start some eccentric decline squats during week 16 - but was flaring both knees up the next day - clearly not ready for that yet. By the end of this period the pain on the left quad tendon had gone (good news!) but still now got extensive crepitus, 'over-stretched', prickly feelings below and above both patella. If I walk a fair way (say a mile around shops) it goes wetter, feels less stable and a bit sore. After a few days this shifts to feeling more dry and scratchy. The palpable crepitus (all over both tendons on both legs) is constant - and there is still an audible crepitus on the right leg when going from full extension down a few degrees (but I've had that for months). The right patella tendon feels much worse than the left one (as I would expect).

RIGHT KNEE: 3/5
LEFT KNEE: 2/5

So.....think I'm going to just rest if for a couple of months (despite my intentions I've never really rested my legs completely - bar walking and driving for longer than about 4 weeks!) and get some more physio advice for an eccentric programme for when this more general tendinitis (inflamatory) attack eases off

The Medical Care I had before starting this Blog

This might be useful for other people under treatment. Loads of detail below - but here's a summary:

• GP's didn't seem to know much about these kinds of problem
  
• Expensive MRI's confirm what a (free) good understanding of the symptoms can tell you
• A good physio is a god-send - but you need to explain very clearly where it hurts and how so they have fair chance of helping you
  
• There is still a common approach to offering steroid shots - and I've read bad things about their long term effect on tendon health
• Lots of folks warned me away from surgery!
  

June 2008: Saw GP (doctor) because I was getting come crackling when bending knee and a tingling on side of right knee and bit of tingling on quad tendon. Told me to stop running but carry on swimming and cycling to keep fit, Prescribed ibuprofen. So told me nothing I didn't know and not very supportive and did not prescribe any specific exercises/stretches or refer to physio

July 2008: Got some spots of pain on the knee so (still not running) and started seeing a private chiropractor. I was not great at describing where it hurt and she went down the path of patella tracking causing rubbing and soreness (under the knee cap). Not the right diagnosis - but not really her fault. Very emotionally supportive - got me into some good stretching routines. Introduced me to the idea of trigger points. Also suggested I get sports massages. I was still cycling and swimming (which I think was probably bad) but all of this (plus, of course, the time off running) helped to reduce the quad tendinopathy. Back to running at start of October

Jan 2009: Through the Autumn and winter I trained hard and ran a half marathon. Was still getting some quad tendon niggles but managed them with stretching. But then after a long run (14M) a few weeks after flu, in the cold I got the first taste (of what I now know to be) patella tendon problems -sharp pain just under the kneecap and also a flare up of the quad tendon as well. Went to see a private knee specialist because I wanted to know what was wrong. Had an MRI and he was able to diagnose the quad tendinopathy but thought the lower knee pain was wear under the knee cap (no MRI evidence of this though). Offered a intra-articular steroid shot for this which I took (probably a bad call given that it was really my tendon that was the problem - but where the pain referred made it hard to describe at that time). I've uploaded one image he gave me. The paler parts on the quad tendon he said where the tendinopathy. I'm no radiographer.....but isn't there one of those a but further down below the patella as well? Anyway the jab worked like a dream (hmmmm..perhaps I was more inflammatory than tendinopathic at that point - otherwise I would not have thought the steroid would have done much). So this was expensive only partially correct, but I was back to running and now knew about tendinopathy. Started seeing a physio at this point as well. She was fab - got me strengthening my hips, more stretches, regular sports massage and strength exercises for VMO, buttocks. She also explained about eccentric exercise - but I did not do much of them (she gave me lunges which I hate!). Good emotional support and encouragement as well

March 2009: Through Jan, Feb and March I gradually eased back in and got up to 16 miles as my longest run - before a short but fast run caused the patella tendon pain to reoccur. Resting did nothing, tried to run anyway (felt really stressed as I'd raised 3K for Oxfam for the marathon in 7 weeks time!) the pain got really bad (in fact it has never been anything like as bad as it was at the end of March when I could barely walk). Saw the GP (different one) who had got the private MRI results - he agreed with the consultant and offered another steroid shot intra-arcticualr. I had a niggle this was a bad plan but just wanted it to work so I could finish my marathon training - so took it). Did not work this time - so I'm now guessing I now had tendinopathy rather then '-itis' type inflammation. The pain was now so diffuse that it felt like the whole knee - so the physio still never got to a diagnosis of patella tendinopathy - but I was rubbish at explaining exactly where it hurt.

April 2009: Rested, swam legs only and did leg strengtehning. Was getting patella tendon pain throughout. Just before the marathon the pain went (for walking - but would come back from running) and I could feel my right MPFL was tight. Pressed on and did the marathon - wow! what a fab day - but painfull ;-)

Week 13-14

Pretty much straight after I started to get pain on LEFT knee quad tendon (up and down stairs) I knocked off the weights and went for resting (with wretched knee supports back on again...grrrr). Despite resting I got gradual build up of palpable crepitus symptoms in patella and quad tendons of both knees along with that pain on the left quad tendon attachment. This big surge in problems above and below both knees is a real blow! Looks like the gym weights have been overloading the tendons (despite trying to focus on eccentric phase) but it took a while to build up and become obvious

RIGHT KNEE: On the plus the pain on the right patella tendon seems to have disappeared. Still feels wet, squashy (often) and very scratchy and crepitus and still with a tight MPFL. 3/5

LEFT KNEE: 3/5

Full List Of Symptoms

Thought I'd just jot down a list of all the various symptoms I've had. I get problems in both legs but generally the right is much worse

LL = Left Leg. RL = Right Leg

Patellar Tendon

• Diffuse and very nasty pain all across the face of the patella - spreading up from the lower focal pain spot (RL)
  
• Sharp pain just where it joins the patella - felt quite deep inside (RL)
• Occasionally unstable and gives way (RL)
• Audible crackling noise wen going from a straight locked leg to a small amount of bend whilst the tendon stays tensed (RL)
• Squashy feeling (RL)
• Does not look (when fully relaxed) quite as substantial as the left one and has a slight concave. No visible difference between legs when patella tendon tensed
  
• Palpable (but not really audible) creaking when the tendon is tensed a bit and then gently touched (LL and RL)
  
• As if my trouser knee fabric were wet and cold even when the skin in warm and dry - really weird feeling (perhaps neurological?) (LL and RL)
• Prickly burning feeling
  

Quadriceps Tendon

• Palpable (but not really audible) creaking when the tendon tensed a bit and then gently touched
• Warm (but not to the touch)
• Prickly, mild burning feeling
• Tingling (neurological? - in fact this was the very first symptom I ever had - imagine if I'd taken a few weeks out then...sigh....)
• Wasted VMO caused by limping and avoiding that leg

Also a very tight band going from my medial patella - I think this is MPF Ligament (might have aways been tight but I just noticed because I now spend so much time fiddling with my knees :)

Weeks 6 -12

So, from the start of this period I've put away the neoprene knee supports (which make me feel a lot more normal!) and been in the gym doing leg weights. Having read a bit about tendinopathy I've been trying to focus on the eccentric phase over the concentric phase.
At the start there was visible wasting of the right VMO (I guess caused by all the limping) and a dramatic strength imbalance. After gradually building up the weight over 6 weeks the legs were the same strength and VMO had plumped up on right leg. Gained a lot of strength back and was feeling very mentally positive. Did try a bit of cycling but that flared up the pain on the patella tendon.

But it's gone a bit wrong at the end of this period....Started to get pain on the quad attachment of the left knee. Carried on despite for a few sessions and then common sense kicked in (I've learned something after all!). Just going to rest for a few weeks and see what happens.

RIGHT KNEE: The weights do seem to have helped the pain and wet feeling in the right patella tendon - but still got plenty of stiffness, twinges and wet feeling there. So would still say this was 3/5 for right knee

LEFT KNEE: Pain at quad tendon attachment on ascending, descending, lowering and rising from sitting - but not to sharp. 3/5

Weeks 2-5

At the end of these 5 weeks my symptoms were:

• RIGHT KNEE: No pain across face of knee (big improvement!). Medial patella pain point gone but feels like a very tight band going from medial patella to underneath VMO I think this is my MPFL. Still focal point of pain just under right knee slightly to medial - intermittent (whereas was constant before the marathon whenever moving). Also the right patella tendon feels kind of wet and squashy. I can tense the patella tendon without pain now but can feel crepitus (and hear it at maximum extension). Lets call that 3/5 for future reference
• LEFT KNEE: No problems. So lets call that 0/5 for future reference
  

Originally I was thinking I'd got PFPS (Patello femoral pain syndrome) but now I reckon the pain across the face of the knee was just diffuse pain from the patella tendon and really its nasty case of patella tendinopathy - which is consistent with problems from the prev year. I had audible crepitus before the marathon and thought it was coming from under the knee cap -but it's clear now that it's coming from where the patella tendon attaches to the lower patella pole

Week 1

Here's how my knees felt this week

• RIGHT KNEE: awful pain all over the knee. Specific focus (palpable spots) of pain just below patella on the medial side and on the medial edge of the patella. Could not bear to bend it, move it or even really touch it. So lets call that 5/5 for future reference!
• LEFT KNEE: had a nasty bit of ITBS on the outside of the knee and a corresponding medial patella niggle. Lets call that 4/5 for future reference.
  

Getting up and downstairs with two knees out of action was tough.

The story so far...

January 2008 - I decided to run the London Marathon in the following Spring. The next 15 months were a roller-coaster ride of injury! Increases in my fitness were interspersed with long lay-offs. Basically I trained too hard and did too much road running causing all sorts of problems with tendinopathy of my quad tendons in both left and right knees and pain right on my right knee. The start of 2009 was pretty good but one hard, fast run in the dark, in the cold, in the rain, in mid March saw it all flare up. I struggled on and still ran the marathon, firstly because it was a goal I was desperate to achieve and secondly because I had gathered pledges and donations worth nearly £3000 for Oxfam. In an attempt to clear the injury I had never run further than 16 miles and had not run at all in the 6 weeks before the Marathon. It nearly worked and, by the big day, I could walk, ascend, and descend stairs without pain – but running still hurt.

So here's the thing – it was still one of the most amazing days of my life! Yes my knee hurt. Yes I wasn't fit enough. Yes it was a real struggle to get round. But I still got a time I was pleased with and the sounds, colours and crazy things I saw will stay with me forever. The relief of stoping after 4 hrs 16 mins and 3 secs of running was enormous and the sense of achievement is huge. Perhaps having to dig that deep (I never walked despite how tired and sore I was) has changed me a bit inside as well?

Of course afterwards, and the next day (in fact week) my legs (and feet and arms, and stomach and lungs!) were sore – but it was worth it and I'd make the same choice again any time. Before the Marathon I knew that I was letting myself in for a huge relapse with my right knee and, sure enough, it was extremely painful the day after and only marginally less painful now, a few days later.

Going into the marathon my plan was to achieve that goal and then take the time out from exercise to really sort out my knee. To rest, rest, rest until pain free and then work back in incredibly carefully. I am guessing this will take something like three months – but I don't really know. I am expecting it to be a bumpy road with slow progress and lots of disappointment. I am hoping that keeping a blog will give me an outlet for that frustration but also, hopefully, let me look back and see the progress I am making. I'll try and collate hints, tips, links etc. - I've a fair few already from the last year believe me! Perhaps this blog will also be useful to other people with knee problems.....