Training for 2009 USAPL Raw Nationals

[Gary Gibson]

4/26/2009

SQ 45x5x2, 135x5, 225x3, (belt, sleeves) 245x2, 295x3, 295x1, 225x5, (belt off) 225x5

My greed caught up with me. Completely bombed on attempt at Smolov Day IV and possibly aggravated the existing medial plica injury. The knee just didn't feel right even on the bar-only sets. Felt like I was catching the "shelf" in the joint at the top of the reps. I pushed on anyway to 295 which felt like a ton and moved very slowly. Considering the high intensity/high volume sessions I just did three times--the last of which was just yesterday--I really shouldn't be surprised that all explosive ability has vanished and that 85% felt like 95%. I wasn't able to hold perfect form; the knee buckled inward a bit and I could feel the condyles grinding against the plica, could almost hear it.

It was pretty damned stupid a) to go from one squat session per week to four very intense sessions and b) to do so with a lingering knee inury. Now I'm overtrained and freshly injured. I drained 9 cc's of fluid from the suprapatellar sac last night and I would not be surprised if my synovial membrane went into overdrive tonight. Taking 800 mg every few hours today to stave that off.

Even worse, I felt the left leg taking over on those heavy sets. I tried to make up for it with a couple backoff sets with 225 in which I successfully got the right leg to be an equal partner. One good thing about this experiment: I discovered that higher rep squats seemed to have a rehabilitative effect on my right leg and to wake it up. Probably helped add a little mass, too. Parts of my quad that are noticeably "flat" were aching deeply the day after sets of 9.

I'm not sure I'm going to continue to train for the Nationals. I could probably place 3rd or 4th with my current strength levels, but I want to go in with a shot at first place. I think my next goal should be to recuperate, rehab my right leg with higher rep squats, build my bench and ultimately to break my own raw MD records at the Larry Garro Memorial (conveniently held just a few miles north of my neighborhood). Time to start a new thread.

[K.Diesel]

Sorry to hear you may not be doing Raw Nats, Gary, but do whatever you must to get back to 100%. We should still hook up sometime though. I'll PM you soon.

FYI - In case you didn't know, the "Larry Garro" meet is not a USAPL meet this year. It's in the same location by the same promoter, but 100% Raw. According to the entry form, no spectators are allowed which may make for an interesting environment. I was hoping it would be like last year, so I could test my gear before States, but oh well.

[Gary Gibson]

Thanks. I'm very sorry too. And I'm just stupid and greedy. I only started powerlifting semi-seriously last year. Before that I could barely squat 245. I'm not a born athlete, neither preternaturally quick nor strong. I had a lot of nerve to shoot for first place on a national level!

Looking forward to your IM. I will be cheering you on as you train toward the Nationals!

I'm a little sad to hear that the meet that I could most easily get to won't be USAPL. I may still go. Have to see how the knee holds up and how the squat progresses. For the next few weeks I'll be doing what I normally do when I'm out of commission for squatting; training the bench, chin up and SLDL harder.

Last Injury Update
Out of containers so I just drained the excess fluid into the tub and then into cup which. I estimate that at least 30 cc went down the drain and another 30 or so into the cup. This time I went laterally into the infrapatellar bursa. Turns out that it was this bursa that had been bulging out on either side of my patellar tendon when I flexed my right knee. My knee is looking almost absolutely normal after nearly two years!

A few hours later...
Got to thinking: maybe what I thought was plica syndrome was just another bursa filled to bursting with synovial fluid..?

Did a bunch of online research and discovered that there is indeed a medial bursa simply called the MCL bursa and it lies between the superficial and deep fibers of the MCL. Not talked about very much apparently. Also it mimics plica syndrome. I couldn't find much on the anatomy side of things, but I did discover that the bursa is more exposed when the knee is in flexion; the MCL covers it in knee extension.

Sanitized the area, steeled my nerve and punctured the area. I was afraid of hitting ligament. Dry tap initially; pulled out slightly and angled inward and pushed again. Was rewarded with a steady drip of synovial fluid. About 20-30 cc's ran out into the tub and then I grabbed a 10-cc container and extracted another 7. Knee is now feeling the absolute best it has in two years.

I've now aspirated nearly 100 cc's from the suprapatellar pouch, about 100 from the infrapatellar bursa and about 40 from the MCL bursa. The knee looks so different now. There's still some fluid left to get, but I'd say the job is much more than half done.

This last bit out of the MCL bursa has had the profound effect of allowing my knee to extend forcefully without pinching much of anything. I thought it was an inflamed plica, but it was just a fluid-filled bursa that was getting pinched. All my stiffness, lack of ROM and impingement seem to have been from bursitis. Even my Baker's cyst is just synovial fluid. And to think: not one of the six doctors (including four specialists) that I saw came up with that diagnosis.

[Gary Gibson]

Went to the OS again today. Got scolded a bit for doing the self-draining and finally got a recommendation for arthroscopic investigation/intervention...

But it seems that the constant draining is actually doing the trick. Doc said that it's all one big cavity, not separate bursae. That adds up. The consistently best tap spot has been that lump a few cm medial to the patella; every time I go in there, I get an easy flow. Initially it was a stream, but even a steady drip would mean an easy draw of 15 cc. I did it twice tonight and the entire knee looks and feels different. I don't think the cavity is refilling; rather the fluid just readjusts every time I make a successful draw.

At this point, there is zero catching and pain on the medial side when I forcefully extend the joint. The knee is still a tad fuller looking than the normal one, but the lumpish accumulation proximolateral to the patella is virtually gone now and even the distolateral bunching upon flexion is greatly reduced. The knee just feels better overall with all that fluid removed (over 300 cc at this point!)

The OS found all the ligaments to be sound with the various drawer tests. There was no laxity and no pain. Since I can't afford the arthroscopic treatment (funny how no plan doctor would recommend that when I had insurance...), I have to hope that there is no underlying condition, that this fluid was all from the initial injury and that there will be no re accumulation. Based on my progress with the current level of withdrawal, I estimate that I have less than a half dozen more aspirations to go. That's if there is only redistribution of existing synovial fluid and no production of excess.

[Gary Gibson]

Said I was going to abandon this training thread, but I figure I should follow up with more injury reports here till I get another training cycle+thread going.

Drew another 30 cc from the lump medial to the patella. Took three attempts because each entry was only good for about 6-12 cc. Two dry taps when attempting to go into the distolateral lump.

Found this.

A case highlighting the influence of knee joint effusion on muscle inhibition and size

Summary

Background The patient sustained an injury that caused knee joint effusion. The patient had undergone reconstruction of the anterior cruciate ligament on the right knee approx8 years before this injury.

Investigations The influence of knee joint effusion on the isometric and dynamic torque characteristics, neural drive and muscle size of the knee extensors was analyzed during the first 11 weeks of recovery. Maximum knee extensor torque and electromyographic (EMG) activity were assessed on a weekly basis. MRI scans of the thigh were taken to quantify vastus medialis muscle cross-sectional area.

Diagnosis Initial knee joint aspiration resulted in an 85?399% increase in isometric knee extensor torque and a 9?706% increase in vastus lateralis and vastus medialis muscle EMG activity, indicating muscle inhibition due to effusion. The knee extensors were inhibited to a greater extent in the most flexed position than in the more extended knee joint positions. After the initial aspiration, the knee extensor torque?velocity relationship increased by 56?453% with a corresponding increase in EMG activity.

Management Repetition of aspiration and instigation of a resistance training program resulted in the injured leg having a torque and muscle size comparable with the contralateral healthy leg 11 weeks after initiation of the rehabilitation program.

The patient was a 27-year-old male (height 1.78 m, body mass 75 kg, left leg dominant) who participated in a number of sports at a recreational level, including soccer and running. The patient sustained a non-contact injury to the right knee whilst landing from a jump; the knee became swollen and painful. The patient had undergone reconstruction of the anterior cruciate ligament (ACL) on the right knee using a patellar tendon autograft approx8 years before this injury.

Owing to the considerable swelling around the right knee joint, and the potential inhibitory effect this might have had on the knee extensor muscles, a decision was taken to aspirate the knee under aseptic conditions. The patient gave written informed consent to participate in a series of measurements following treatment and rehabilitation (Figure 1). This patient was followed over an 11-week period; management initially consisted of knee joint aspiration, followed by rehabilitation exercises. We examined the influence of knee joint effusion on strength characteristics of the knee extensor muscles and neural drive. The recovery of torque characteristics, neural drive and muscle size were assessed over the 11-week period.

For each aspiration, approximately 150 ml of clear fluid was collected. Light microscopy and microbiological examination did not detect any abnormalities, and the fluid was diagnosed as being synovial fluid. A diagnosis of traumatic synovitis was formulated.

...in patients with chronic knee joint effusions, knee extensor isometric torque has been reported to increase by 14% following a mean aspiration of 53 ml from the knee joint.5 In our patient, however, the increase in knee extensor torque following aspiration (85?399%; pre-program to post 1; Figure 3A) was much higher compared to these previous reports, likely reflecting the volume of knee joint effusion present in our patient (150 ml) compared to previous studies (maximum of 60 ml).

Although the patient was walking unaided throughout the examination period, it is likely that the knee extensor muscle inhibition resulted in reduced habitual loading. The VM muscle CSA decreased by 10% compared to the pre-program value after 4 weeks (rehab 2; Figure 5). The atrophy that occurred approx4?5 weeks post-injury in this patient is similar to the 7% reduction in knee extensor muscle CSA reported after 4 weeks of unloading.11 Considering that the subjects in the latter study underwent complete unloading of one limb, the extent of muscle atrophy caused as a result of knee joint effusion in this patient is alarming, particularly since this patient underwent knee joint aspiration when appropriate, was walking unaided throughout, and performed a progressive resistance training program. Muscle atrophy might be even more severe in patients who do not undergo aspiration and resistance training. Muscle atrophy was greatest 4 weeks after the treatment program began, at the rehab 2 testing session; thereafter, CSA recovered towards pre-program values. At the end of the 11-week examination period (rehab 6), the VM muscle CSA was actually 11% greater than that measured at the pre-program testing session, and was similar to the VM muscle CSA measured in the contralateral (healthy) leg (Figure 5). It is likely, therefore, that some atrophy occurred in the week following the injury, prior to the pre-program measurements.

Conclusion

This case highlights the importance of removing joint effusion, by aspiration, to alleviate muscle inhibition. Removal of joint effusion is important to minimize muscle atrophy and strength losses caused by reduced levels of muscular loading, and will also maximize the effectiveness of rehabilitation programs by enabling greater production of muscle force.

This mimics my case very closely. I'm even about the same height and weight as this patient. I injured my MCL at the same time as I suffered the traumatic synovitis that resulted in all that synovial fluid buildup. I've experienced over a year of diminished quadriceps function.

I've now removed nearly 400 cc of synovial fluid in about two dozen attempts over the course of two weeks or so. With each sizable aspiration, my knee function and appearance has improved significantly. Range of motion has tripled. Passive ROM is normal, though the end range of flexion is still painful and I can't quite get the right heel to touch the right glute. General tightness and pain I had during distention is almost entirely gone and I can descend into a full crouch/squat without too much discomfort in the right knee. This was impossible two weeks ago.

Quad activation seems to be returning to normal. I haven't been able to contract my right quadriceps properly since the effusion started. Since the recent aggravation of the area, there has been a pinching sensation (due to distended tissue pushing into the joint?) with forceful extension. The continued draining seems to have eliminated that.

Have been wearing neoprene sleeve overnight after the aspirations to reduce refill.

Next week I'll start the four day split: Bench (pullup, kb press) Day, Squat Day, Rest Day, Press/Weighted Chin (db bench) Day, Deadlift Day (SLDL alternated with Sumo). I'll do 9-12 reps for the squat for a few weeks to rehab the newly reawakened right knee extensors, maybe encourage the smaller side to put on a little mass to catch up with the more developed left.

[Gary Gibson]

I (foolishly) did several sets of bodyweight-only deep knee bends a couple nights ago in a misguided effort at rehabilitation. The next morning my knee was full of synovial fluid again. I limped around Central Park, but the pain diminished over the course of the day. After napping in Sunnyside I awoke to find the pain almost entirely gone. I was able to walk hard and fast from the East Village to Penn Station without incident.

I used the always successful medial approach when I got back to B-more. This time I milked the effusion by compressing the suprapatellar bulge and I got a copious amount of fluid pouring into the tub: steady drip for over two minutes before I used a plunger to draw out the remainder. Tried a few more approaches later and all were dry taps. Suprapatellar tap was spectacularly unrewarding. An attempt to the front of the infrapatellar area had similar lack of results and a reinjection to the usually rich medial area got nothing.

There is still a significant infrapatellar bulge which to me suggests that that area is NOT communicating with the rest of the cavity. So later I tried again and went in slightly from the back of the bulge with knee bent sharply. I was rewarded by a warm gusher of synovial fluid. I still don't note any reduction of the bulge when knee if fully flexed, but I do have nearly 100% ROM in the knee.

Going to keep making aspiration attempts as the need is perceived. I expect some refill as a matter of course because this was an obscenely large and long-standing effusion. It seems clear that excessive load-bearing (like those squats I was doing) irritates the synovial lining and will result in a lot of fluid being produced. Seems I should treat the area with kid gloves for several weeks to let it calm down. Have been doing those little rehab moves I normally hate: unweighted leg extension and quadriceps tensing. Looks like they have their place; there is a pain about halfway through extension that has diminished since I started.

The self-administered aspirations have carried some risk (infection, damaging cartilage with the bevel), but the results have been excellent. Vastly increased ROM, no more catching and pinching of synovial lining in joint due to effusion. Also, the quadriceps cannot contract properly with so much effusion, which meant the knee was more prone to reinjury or aggravation whenever I tried to use it to lift or run. This also meant muscle wasting/atrophy and it would have held me back from making strength improvements.

I will focus on the bench press (Smolov Jr) for a few weeks and avoid all squats and pulls. In a few weeks I'll reintroduce SLDL and after that I'll start squatting again.