How I Help Athletes Overcome Knee Injuries Through Load Management

Danny Dinh

Physiotherapist

May 20, 2022

Intro

If you ever had a knee injury or even any sports injury, this article will speak to you. In it, I will cover a knee injury patient I treated in the past year, give advice on knee pain management, and discuss the importance of a progressive return to activities.

Before reading about my treatment of this patient, you can read more about my treatment philosophy to better understand what I do and why I do it.

Case study: knee injury while playing soccer

Ms. L. was a university soccer player who injured her right knee when turning fast to intercept another player; her right foot caught into the grass, which caused her knee to rotate internally, resulting in an injury. Initially, she seemed to recover fast: after 2 weeks of rest, she was able to walk and climb stairs with no pain. She even returned to soccer practices with minimal issue: just a slight ache in her right knee that occurred with fast turns.

6 weeks after the accident, she felt ready to return to an actual match. Unfortunately, it did not go well: towards the end of the match, her knee twisted again and she felt the exact same injury as the first time, except that it was worse.

This time, she decided to consult a physical therapist.

Her situation had worsened since the initial injury: even walking fast or climbing stairs was causing her pain, now. Going back to practices was out of the question, let alone returning to full games. She was in deep despair: she felt like she was letting her teammates down and losing her opportunity to compete at the university level.

Ms. L.’s rehabilitation can be summed up in two words: load management.

During the early weeks following her re-injury, her pain level was still high, so we tried multiple exercises to find the lowest load exercises that she could perform without aggravating her pain. In her case, this turned out to be partial lunges and mid-range bodyweight squats.

Through a combination of proper loading and time, Ms. L. eventually progressed back to where she was before her second injury: she was now able to run pain-free. This time, however, she wanted to be more careful and wait longer before returning to practices.

Now that she was almost pain-free, we conducted a thorough biomechanical assessment of Ms. L. to identify any problematic areas: muscles that were significantly weaker on the right side and movement patterns that still reproduced pain.

Then, we began to troubleshoot by strengthening those muscles and movement patterns. This process included exercises such as jumping, squatting very deeply, and fast turns.

After 6 weeks of rehab, Ms. L. was finally ready to begin her return to soccer. This was a gradual process from participating in soccer drills with her teammates to playing in mock matches, and then finally returning to actual matches against other universities.

Once we were sure that Ms. L. could perform in those matches with no issue, we concluded physiotherapy. A phone call appointment that took place three months following discharge ensured that Ms. L. was able to finish her season pain-free and without any re-injury.

What is load management?

The IOC (Internal Olympics Committee) defines the aim of load management as “to optimally configure training, competition and other loads to maximize adaptation and performance with a minimal risk of injury”. 

Basically, load management is the act of increasing or decreasing the intensity of training to achieve as many improvements as possible while keeping the risk of injury as low as possible. This is evidently important in any sports but doubly so when recovering from an injury.

Load management when injured

After an injury such as Ms. L.’s, load management is done by first finding the ideal load. This is done by first listing exercises that use the same movement patterns as those required in your sport. The ideal load would be those exercises performed at an intensity that is reduced enough so as not to irritate your pain.

For example, a movement pattern very relevant in soccer, Ms. L.’s sport, was squatting. Jumping, dashing, and sprinting, these essential moves all utilize the same muscles as squatting. However, after her second injury, squatting was too painful for Ms. L. This is why she was given chair squats to do at home instead, which cut down on the range of motion of a squat and allows for a break between each repetition. 

The “load managed” exercise plan Ms. L. was given comprised of the chair squats and a host of other exercises to which we applied load management principles.

Good pain and bad pain

One key thing about load management is the differentiation between good pain and bad pain. This may sound counter-intuitive, but not all pain is bad. Pain is a stimulus that your brain emits when it perceives a threat. However, after an injury, it can tend to overreact to any little movements out of precaution, even if those movements do not present any risk. This is called central sensitization, which is a hypersensitivity to stimuli from things that are not typically painful.

Think about it this way, after you burn your hand while cooking, just lightly brushing it with a clothe would elicit some pain. Does this mean that that is dangerous? Of course not! Your brain is simple centrally sensitized to that stimulus and makes you interpret it as more harmful than it actually is.

Another example of sensitization is when we’re watching a movie and seeing someone get kicked hard in the stomach (or another place known to hurt a lot when kicked…). We may clutch at our stomach and “feel” the actor’s pain for a second, even though we obviously have not been harmed ourselves.

This is not to say that all pain is negligent and that you should see painful activities after an injury. What I teach my patients is the difference between good pain and bad pain.

Good pain during exercises or activities:

• Easily tolerable and doesn’t worsen when prolonging the activity.

• Makes you feel like you are regaining control and strength over your body despite being injured.

• Leaves rapidly once the activity is done. An arbitrary benchmark to use is a 15-minute time limit for the pain to leave to still be called “good” pain.

• Does not affect how you conduct the rest of your day.

Bad pain during exercises or activities:

• Not tolerable and/or worsens when prolonging the activity.

• Forces you to adopt uncomfortable positions and compensations during that activity. An example would be walking for too long after a knee injury leading to putting too much weight on the opposite leg.

• Persists for a long period of time once the activity is done.

Forces you to adjust the rest of your day due to the ongoing pain.

A proper load management rehabilitation plan, like the one given to Ms. L., aims to produce either good pain or no pain. This is not to say that all is lost if bad pain is produced. It only means that the “ideal load” has not been found yet and we need to reduce the intensity so that good pain is produced instead of bad pain.

Why is load management better than complete rest after an injury?

It is perfectly fine to take a couple of days off from exercise and sports following an injury. However, once the pain has calmed down and you feel secure in moving your body (and that serious injuries such as fractures or dislocations are off the table), it is ideal to restart gentle exercising, provided that proper load management is applied and that you are well monitored.

Load management is superior to complete rest following an injury for the following reasons:

• It prevents your injured and your uninjured muscles from atrophying and losing strength. When Ms. L.’s knee was re-injured, we did more than knee exercises. We also gave plenty of hip and ankle strengthening exercises since we knew that she would need her entire leg to be strong to restart sports.

• It allows you to slowly regain confidence in your capacities before attempting to return to sports. By performing tolerable exercises every day, you will be more in tune with your body and its limitations, which will better prepare you mentally for your ultimate goal of returning to the field.

• It allows you to test yourself to know exactly if you are on the right track. To explain this further: undergoing load management rehab with a physical therapist means testing different movements and activities even while you’re injured. This helps us see if you’re mobility, strength and function are recovering as your pain level is decreasing. If we see that one aspect of your recovery is slowing down, we can adjust your exercise plan to stay on track!

• It empowers you to participate actively in your recovery rather than simply wait. Something many of my injured athletes asks me during our first session is “Is there anything I can do to recover faster?”. While we can’t speed up nature’s greatest healer (time), we can ensure your mobility, strength, and function recover as well as your tissues by working together to create an efficient exercise plan.

The eventual return to sports

I prepare my athletes’ eventual return to sports with the following steps:

1. Load management rehab to normalize mobility and strength.
2. Replicate sports activities in the gym (available upstairs of my offices).
3. The patient returns to team practices and can participate in drills.
4. If all the above steps go well, I encourage my patients to participate in partial friendly games of their sports.
5. If those games happen with no incidence, then we finally progress into returning to full official matches.

Moving forward

If any of the information or stories in this article speaks to you, feel free to check out my profile to read more of my articles or to book a 1-hour private room evaluation with me.

If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at dannydinh.physio@gmail.com or by phone at 438-801-0417. I currently offer free no-strings-attached 15-minute phone call sessions to discuss how I can best assist you.

Further reading

Here are some suggestions of articles I have written recently, organized by topics.

An in-depth explanation of my physiotherapy philosophy: Part 1, Part 2

Neck pain: a case study, answering common questions from patients

Low back pain & sciatica: case study 1, case study 2

Knee pain: case study 1

Shoulder pain: case study 1

An explanation of referred pain

Why choose telerehabilitation

7 reasons why I love my profession

Images courtesy of: Pain Bloc, Propel Physiotherapy, Health Line, Self, Shutterstock