Quad Muscles wont engage without resistance - why?

[truthseeker]

Hi,
Im trying to rehab my chronically dislocating right knee, Ive had ~150 dislocations/subluxes in the past 3 years. VMO was completely invisible, my OS thought it was paralysed. Finally got VMO engaging, using combination of e-stim and exercises designed to engage it.

Have good strength in quads now in terms of leg extensions with weights etc..

My question is this: I can extend my leg no problem with weights on the end and I can feel the muscles engaging and my kneecap feels stable. But if I do it with no weights I have no control at all in the last few degrees of extension and I feel as though Im about to dislocate. This causes problems walking, as every time I extend my leg I feel it trying to dislocate.

Any ideas why the muscles wont engage without resistance?
Thank you.

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[Canuck Physio]

Hi,
Im trying to rehab my chronically dislocating right knee, Ive had ~150 dislocations/subluxes in the past 3 years. VMO was completely invisible, my OS thought it was paralysed. Finally got VMO engaging, using combination of e-stim and exercises designed to engage it.

Have good strength in quads now in terms of leg extensions with weights etc..

My question is this: I can extend my leg no problem with weights on the end and I can feel the muscles engaging and my kneecap feels stable. But if I do it with no weights I have no control at all in the last few degrees of extension and I feel as though Im about to dislocate. This causes problems walking, as every time I extend my leg I feel it trying to dislocate.

Any ideas why the muscles wont engage without resistance?
Thank you.

Hello, could you please hint to the initial injury that led to such knee instability?

Additionally, although I recommend leg extensions for rehab, what is your current status, are you able to do compound exercises such as a squat or lunge? The knee extension machine does not recruit as many Motor Units as would a load bearing squat for example. The more overload you can apply the more motor units will be activated. HOwever,!!! This is only to be considered if you have local stability around that joint. You know have your VMO engaging, and you will have to begin to initiate it further with unilateral exercises such as the lunge. However, you may need significant support such as a hoist to complete these as you mentioned suvere instability.

This way you will slowly begin to recruit and activate the VMO further, while adding increased resistance will recruit further motor units, and subsequently more muscle fibres for further growth.

As well the movement should not be forceful. In order to apply a force upon the muscle throughout range this means that the release or eccentric phase of the movement should be controlled and slow, tension should remain in your muscle throughout.

Please tell more about the history of onset, and your current treatment

[Yarok]

hi
do you exercises properly another thigh / calf muscles?hams, adductors, abductors,

thanks

[truthseeker]

Thanks for the replies - its a long history - here's some details:

First dislocation age 12 (am 34 now), subsequent dislocations led to TTT, VMO advancement and LR at age 15. Knee never really felt right after surgery, I was never able to run on it again - rehab after surgery took around 2 years. Life did return to some sort of normality, then age 18 dislocations started again. Next 10 years spent seeing different OS's, no one wanted to do another surgery, periodic rounds of physio, and perhaps 3 dislocations a year. Every (public) OS would say 'if it dislocates when you run dont run, if it dislocates when you play sports dont play sports etc...', activities limited, no sports, nothing that involved running. Cycled for cardio exercise but knee would occasionally dislocate while standing on pedals. Over time dislocations became less severe but more frequent, reached a point where I would just pop the kneecap back into place and continue whatever I was doing. I was able to dance, wear high heels, and get around ok but I could never ever run and avoided anything that might cause problems such as hill walking (because of uneven ground) or anything like tennis, badminton (because of pivoting etc).

Late 20's, dislocations became more frequent, eventually had a big dislocation almost 3 years ago and immediately felt unstable afterwards, knee swelled up and I made a private OS appointment with the OS who is allegedly the 'best' in Ireland. He told me he wouldnt consider a surgery as the muscles in my leg were so badly atrophied from what he considered was years of disuse. At this stage I was on crutches as my knee was so badly swollen that I couldnt weight bear on it. Sent me off to physio and told me not to come back unless I wanted a surgery (Im not clear on how I was supposed to make that decision but thats what happened). Attended physio for a year and a half, diligently performed exercises, quads, calf muscles, glutes, lower back - all weak. After the big dislocation I was dislocating every 3 or 4 days. After a year and a half I was dislocating perhaps every 2/3 weeks but it was becoming harder and harder to walk and really there was so little improvement that I felt I was wasting my time. From the big dislocation to the next OS appointment I had perhaps 120 dislocations in a year and a half.

Tracked down original OS who had performed the surgery 19 years ago. Saw him for the first time last June (2007). He ordered MRI, did manual examination, stated all ligaments were intact but that VMO was invisible. There is a meniscus tear but he said there is no way he is fixing that until the muscles are strong as it will only introduce more muscle dysfunction. Told me to stop wasting time with the physio practice I was with(they totally ignored VMO) and sent me to new physio and told me to get an e-stim machine - which I did. New physio took one look at my leg and said that she didnt think she could help!!??!! But on OS orders began physio program using exercises designed to engage VMO supplemented with e-stim and isokinetic testing every 4 weeks. Next OS appointment in August, he told me he hadnt said before but was worried my VMO was paralysed but now could see that it was flickering the tiniest bit when I contracted VERY hard. Told me in his opinion I had a lot of hard work ahead and that I would rehab the leg in 6 months to a year. Said he didnt want to see me again unless isokinetic tests showed no change or things got worse.

In late September I woke up one day with shooting pains in VMO - have been able to engage it ever since. It went from nothing in June to perhaps half the size of good side now.

Physio is despairing of me now. Isokinetic tests do show slow improvement in quad strength but I cannot shake the 'feeling' that my kneecap is trying to dislocate when I walk. I can extend my leg without feeling unstable when it is loaded with weights but when its weightless it feels loose and unstable. As a consequence I have not been able to walk properly for almost 3 years now and unless I break this hurdle Im not going to progress. As you can imagine Im in a lot of pain and feel very frustrated frequently.

The exercises Im now doing are as follows - all exercises are performed using 30 lb weight (except where stated), 15 reps, 3 times a day:

• Squats against a gym ball
• 1 leg squats against gym ball
• Sit on gym ball and use bad leg to roll back and forth
• Calf stretches/Quad stretches
• Lunges
• Step downs
• SLRs - foot straight (25lb)
• SLRs - foot turned out 10 degrees to engage vmo (25lb)
• Partial leg extensions (not extending to absolutely straight to avoid stress on joint)
• 2 different sets of hip exercises -
  dont know the names, lying on stomach raising leg behind me, and lying on side raising leg up like scissors) - both 15lb weight

I also do 30 mins on treadmill (but it is just 30 mins of torture feeling like Im going to dislocate) and two 20 minutes sessions of e-stim each day.

I dedicate over 2 hours of time every day trying to rehab this leg but I just feel Im going nowhere as long as I cant get those muscles to engage without resistance.

Isokinetic test in June showed I could exert 29 pounds per square inch force with right leg, last test was early Dec showed I could exert 46 pounds per square inch - so my quads are definitely getting stronger.

Have not had a dislocation in 15 weeks now - but any and all walking has been very torturous.

Sorry for such a long post - wanted to provide a detailed history.

Thanks all!

[Canuck Physio]

Hello, thanks for the detail.

I am going to be brutally honest here. The fact that you have been able to re-engage the VMO is excellent, however the exercises appear to be too easy for you now that you have made improvements.

"IF" you are able to do lunges, you will need to progressively overload the legs with more weight, overload builds muscle, while intensity i.e. a low rep range recruits the most muscle fibres to build that muscle.

If you have no pain, and you are able to do the exercise safely, while getting basal levels of activity in the VMO I would strongly suggest combining the Compound Barbell Squat exercise with the Barbell Lunge Exercise. These are the most significant Muscle Building exercises. The problem is that the squat has a tendency to build up the Vastus Lateralis, whereas the VMO is hardly stimulated. This is where Heavy Lunges come in. They 'tug' on the Patella from the medial side, and are heavily targetted during lunges.

Additionally, It is very important to have good hamstring strength and length. By this I mean you need to incorporate Romanian Deadlifts, or Stiff Leg Deadlifts in a way that you are balancing heavily through the VMO. Ie. Engage the VMO during these movements while keeping the knee 'Slightly' flexed. This is absolutely necessary for engaging the Hamstrings for maximum muscle growth. Strong hamstrings prevent the typical hyper-extended knee position commonly seen in individuals with weak quads. Additionally some lower leg, calves, exercises should be included.

All of this should be done with supervision of course, but to me based on what you have said it appears like you can make significant progress by doing fewer reps, and providing more overload. The Neuromuscular system is designed to recruit more MOtor Units when more overload or weight is applied to the active muscle group. The recruitment of more VMO fibres will lead to greater growth.

I also believe that maintaining this muscle growth is highly dependent upon proper post rehab nutrition. As a personal fitness instructor I know the importance of having whey protein after a workout, with a sugary juice.

This technique is research proven to build the most muscle in the shortest amount of time.

The following I present you evidence behind my above recommendations:

Journal of Strength and Conditioning Research, 2005
Eur Journal of Applied Physiol 89; 578-586, 2004.
The Journal of Strength and Conditioning Research 17 (1): 109–114, 2003.
- Research is beginning to show indisputably that low reps 1-6 reps with heavy weight is required to induce maximal muscle growth and muscle fibre recruitment.
- Additionally, the ACSM guidelines are confused as terms such as hypertrophy are not considered analogous to strength, their recommendations further compound this confusion in that they suggest 8-12 reps for hypertrophy, yet 6-8 for strength!

Cribb PJ , A.D. Williams, A. Hayes. The effects of supplement-timing during resistance training. Med Sci Sports Exerc 37(5) A2188, 2005.
- Supplements Whey protein, with some sugar, and creatine are found to be most beneficial in inducing muscle strength gains when taken after an exercise program.

Please consider very carefully the above information, and consult with your physiotherapist before making changes to your program. Based on what you have said so far, you need to really build a lot of muscle around your knee joint. In fact research suggest that Weighttraining aids to prevent degenrative changes seen in arthritis for example: Arthritis Care Research 55;690-699, 2006.

Years of high impact activity followed by prolonged periods of inactivity and disuse are the usual culprits of joint degeneration and arthritis. Weight training is a low impact activity that does not cause trauma to joints, it increases nutrient circulation to joint tissue and promotes structural integrity.

You require significant joint stability to prevent further meniscal damage, that is why careful emphasis must be placed on form. You need to control your movements making sure there is no Pain. If a movement can not be done pain free then it must be modified.

Please respond with your thoughts.
Regards

[Canuck Physio]

I also do 30 mins on treadmill (but it is just 30 mins of torture feeling like Im going to dislocate) and two 20 minutes sessions of e-stim each day.

I dedicate over 2 hours of time every day trying to rehab this leg but I just feel Im going nowhere as long as I cant get those muscles to engage without resistance.

Additionally, I would also be weary about continuing with the treadmill. Perhaps an elliptical cross trainer, or a stepper machine would be more beneficial for you. The reason being that it is low impact.

Additionally, I would suggest you do your weight-training and muscle balance exercises in the morning. As well continue with the electrical stimulation. The idea is to make sure you get normal patterns of muscle recruitment and firing. This should not be changed unnecessarily.

Hopefully this information will help to get you from nowhere to where you want to be.

[truthseeker]

Thank you very much for your responses, I intend to discuss your suggestions next time I see my physiotherapist (28th Jan).

Recently I have tried to increase weights on lunges (and other exercises) but have found that it causes such an amount of pain and swelling afterwards that it seems to be working against me.

I do ensure that I have some protein and something sugary like a juice after I exercise. Currently I exercise first thing in the morning, midday and early evening, with e-stim later on.

I forgot to mention in my earlier post that my OS says there is some degeneration (grade 2), but that he deemed it something not to worry about at this point in time.

Do you think that I will be able to stabilize this knee with continued hard work?
I dont mind not being able to run as its not something Ive done for so many years but I really would like to be able to walk comfortably - at the moment something so simple as walking into a shop to buy milk is an anxiety and pain filled experience - and has been for a long time now.

[Canuck Physio]

Recently I have tried to increase weights on lunges (and other exercises) but have found that it causes such an amount of pain and swelling afterwards that it seems to be working against me.

I do ensure that I have some protein and something sugary like a juice after I exercise. Currently I exercise first thing in the morning, midday and early evening, with e-stim later on.

I forgot to mention in my earlier post that my OS says there is some degeneration (grade 2), but that he deemed it something not to worry about at this point in time.

Do you think that I will be able to stabilize this knee with continued hard work?
I dont mind not being able to run as its not something Ive done for so many years but I really would like to be able to walk comfortably - at the moment something so simple as walking into a shop to buy milk is an anxiety and pain filled experience - and has been for a long time now.

Thanks for the update, I was wondering about the amount of pain experienced. Can you tell me is it muscular pain, or is it knee pain isolated in and around the knee cap or the joint? Either way you should not aggravate the pain, if you add weight to progress add only slight amounts at a time. If this is not tolerated, attempt the exercise with a smaller range of motion, or for lunges place your forward foot on a platform.

It is important to be smart, and that means staying out of the pain onset range.

I do believe that a positive outcome is possible, however, your current program merely needs fine tuning as well as progression. Having said that, without actually seeing your situation it is impossible to make conclusions. The advice I give is merely impartial based on what your comments are, and should only be used in conjunction with your current physio.

Unfortunately the changes that have occured as you have mentioned have take years to manifest themselves, and it is difficult to ascertain how long it will take to get out of that situation. It is important to make sure you don't 'overdo' it either. You exercise quite a bit each day, and I am worried you may be fatiguing yourself.

Additionally, Results showed that while the VL muscle was recruited similarly between the experienced and inexperienced trainers, the VM muscle was recruited differently. The experienced weight trainers recruited more VM fibers and to a far greater extent than the inexperienced lifters. This is an interesting finding and explains how people do incur knee soreness and injury. An imbalance between the VL and VM muscles is a major cause/contributor of many knee problems. Loading the knee joint, such as in the squat, exposes and compounds the weakness to cause possible future problems. No surprise the experienced lifters were stronger in their 1RMs, however they also performed far more repetitions during their 85% of 1RM squats. In doing so they recruited far more muscle fibers during the process. The researchers concluded that while recruiting more muscles fibers generates more force, the ability to recruit more fibers to exert more force is a learned skill that experienced trainers possess. Also, that recruitment pattern follows a different activation pattern from novice to experienced lifters.

The relationship between training status and intensity on muscle activation and relative submaximal lifting capacity during the back squat. J.Strength & Cond. Res; 14 (2):175-181.

This is important in your case, because it appears you have been training for some time. And careful consideration of your current ability, the pain response to exercise, the quality of movement need to be refined for further improvement

Additionally here is the information on how to perform the VMO exercise:

1. Stop doing squats for the next 12 weeks unless you want severe knee problems. You have some serious rehab work to do. Your rehab objective is to correct the balance in strength between these two muscles (the weak tear drop and the strong lateralis). ·Peripheral stability exercises are based on functional (unfixed) unilateral (single leg) movements, performed in a very controlled, precise manner. This means no machines and no conventional two legged exercises.

2. Incorporate "one leg exercises" such as the one leg squat (a lunge type stance, one foot in front of the other etc), step-ups and step-downs off small (less than 1 foot) blocks. Initially use light dumbbells held by your sides, then as you progress move to holding a barbell on your shoulders. This progression is important as it increases the requirement for stability.

3. For the first 6-7 weeks work only though the first 30 degree of range of motion of the knee joint. That is, not going too deep in any of your movements. The deeper you go (knee flexion) the greater the shearing force on the platello-femoral joint. This will equate to more pain. You have to teach your patella to stay in its grove. So perform very slow, ¼ and ½ range movements with static (held) contraction in the flexed position for 2 to 3 seconds every rep.

4. Now you have to re-learn these movements correctly.

5. As you get stronger in this 30o range of motion venture down to 45o for the next 6 or so weeks

6. Taping the patella correctly may help sensory neural impulses remind those medial fibers to work. See a physiotherapist to show you how to do this.

7. Concentration is required the entire time, every rep, every set - something most people are not used to doing in the weight room. The focus is on making the weak medialis muscle work.

8. Worked in this manner, the vastus medialis will fatigue quickly. Initially, limit your sets and perform only reps of 5-6, until this muscle becomes more conditioned. Let me know how you progress.