Marc Surdyka, PT, DPT, OCS

Marc Surdyka, PT, DPT, OCS Rehabilitation and Performance

11/10/2021

ISOMETRIC LEG EXTENSIONS
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Most people perform banded leg extensions through the full arc of motion. While not necessarily wrong, it may not be optimal for strength and hypertrophy. The resistance is greatest when the knee is straight and virtually non-existent when the knee is bent (which is where you want it most). You also want the resistance to remain perpendicular to the tibia throughout, but this usually isn’t the case with resistance bands, ankle weights, and machines that use externally loaded plates.
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In most cases, I prefer isometric leg extensions between 90 and 60 degrees of knee flexion.
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Oranchuk et al 2019 found that isometrics at long muscle lengths (compared to shorter muscle lengths) leads to greater hypertrophy and strength throughout the range of motion, leading to “greater transference to dynamic performance.” Isometrics at high intensities (70% or greater) at long muscle lengths can also lead to beneficial tendon adaptations.
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For rehab purposes, training in this manner puts 0% strain on the ACL. Additionally, patellofemoral joint stress is ~30% less at 60 degrees of knee flexion compared to when the knee is straight which may be helpful in some cases of patellofemoral pain.
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The systematic review by Oranchuk found that more volume and longer holds lead to more hypertrophy. Therefore, an easy prescription is 3-5 sets of 30-45 seconds at 70% intensity or higher.
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You can also do a myo-rep set by kicking into the band for 20-25 reps to burnout your quads, resting 10 seconds, performing another 5 reps, and repeating that process for 2-3 more sets.
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If you want to try to improve your rate of force development, you’re better off performing lower rep sets for 3-5 second holds.
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If you train legs twice per week, you can implement these 1 to 2 times per week.
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If you want to learn more, check out the new blog with references at E3rehab.com
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Shoes:
Band in video:
Band in picture: Rogue

The Spanish Squat can be an effective weight-bearing exercise for isolating the quads, especially if you have access to ...
11/09/2021

The Spanish Squat can be an effective weight-bearing exercise for isolating the quads, especially if you have access to minimal equipment. However, people often make the mistake of using their normal squat mechanics. This isn't necessarily bad or wrong, but it's not the most effective way to perform the exercise.
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Since the goal of the movement is to maximally challenge the quads, you actually want to sit back as far as you can comfortably while maintaining an upright torso position. The bottom position of the squat will look very similar to a wall sit since your shins and trunk will be vertical while creating 90 degree angles at your knees and hips.
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This is reflected by Needham and colleagues - A biomechanical investigation of a Spanish squat: The effect of trunk inclination on quadriceps activation.
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When you shift your weight posteriorly, the quads have to work harder. It'll feel like you're going to fall back the first few times you try it, but once you get the hang of it, you'll notice just how difficult it is on the knee extensors.
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The Spanish Squat can be used for regular training purposes or during the rehab of conditions like patellar tendinopathy and patellofemoral pain.
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3-4 sets of 6-12 reps or 30-45 second bouts of isometrics is more than sufficient.
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I don’t know why it’s called a Spanish Squat. I’ve also heard it referred to as a banded sissy squat.

11/04/2021

How Much Knee Extension Do You Need?
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Ideally, the same amount as your uninvolved side. If you can achieve 5 degrees of hyperextension on your uninvolved side, then your goal is to regain 5 degrees of hyperextension on your involved side. You’re aiming for symmetry. If you’ve had surgery on both sides or your uninvolved side isn’t a good reference due to a prior injury, then I would recommend, at the very least, aiming to get the knee completely straight.
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Exercises
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There are two things that I want to emphasize about the exercises: do them early and do them often. Put rehab at the top of your priority list after an injury or surgery. There is some evidence to suggest that early outcomes are related to later progress.
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The absolute easiest thing that you can do throughout the day, every single day, is active quad contractions. I’ve never had anyone overdo this. If you’re sitting in your office chair, lounging in bed, relaxing on the couch, etc. and you think of it, straighten your knee, squeeze your quads for 10 seconds, relax, and repeat 10 times.
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If you need to intensify the movement, you can use a towel or some other object to aid in creating a calf stretch while straightening the knee as you contract your quads.
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The other thing that you want to do is prop your heel on a towel at least 3 times per day for 10-15 minutes. Remember this phrase, though: low load, long duration. You do not want to be writhing in pain for that 10-15 minutes. You want to create a stretch that might feel a little uncomfortable, but it’s tolerable for that entire 10-15 minutes. If you’re holding back tears or gritting your teeth, that’s too much and it’s counterproductive. Try to keep the toes pointing up and relax into the position. Contract your quads periodically throughout or follow up with active quad contractions and generalized movement (it may feel stiff after).
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You can progress the movement by increasing the frequency, duration, height (if needed), or adding weight. You can either add weight directly on top of the thigh or by placing it in a handbag that you place over your leg.
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Full video on the YouTube channel.
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Tag a friend who needs to see this!

There’s a misconception that total hip replacements are just for older individuals. They’re not.—I had a right total hip...
11/02/2021

There’s a misconception that total hip replacements are just for older individuals. They’re not.
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I had a right total hip replacement in the summer of 2009 secondary to avascular necrosis (AVN).
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I put off the surgery as long as possible because I was terrified. I also felt like a failure for needing a total hip replacement at such a young age.
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I’m here to tell you that being worried is completely normal. However, you are not a failure for needing the surgery. It’s much more common than you think, and there are a variety of reasons it may be required.
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Regardless of the reason, the surgery is meant to open doors, not close them.
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I’ve played basketball, soccer, flag football, ultimate frisbee, softball, racquetball, pickleball, golf, and probably a dozen other sports I can’t think of off the top of my head right now.
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I’ve hiked Mt. Whitney in a day during a snowstorm (20 miles at 14,505ft elevation).
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I’ve been skydiving. I’ve boxed. I’ve even done some grappling.
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I’ve used my bicycle as my primary means of transportation for years.
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Most importantly, I stay active and get to do the things I love with .nicolept and our dogs.
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Is this a recommendation for you to do the same? No, this isn’t medical advice. But it’s meant to show you that life doesn’t end with a total hip replacement. It gave me a new start.

Your Hips Don’t Go Out Of Place—A hip out of place is called a dislocation. If your hip was dislocated, you wouldn’t be ...
10/27/2021

Your Hips Don’t Go Out Of Place
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A hip out of place is called a dislocation. If your hip was dislocated, you wouldn’t be able to walk into the office of your physical therapist, chiropractor, or functional trainer. I’ve never seen one because I don’t work in an emergency setting.
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The sacroiliac joint also doesn’t go out of place. It has millimeters of movement and may even naturally fuse in elderly individuals.
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And neither of these joints go out of alignment.
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It’s certainly possible to FEEL like your joints are out of place or misaligned, but that doesn’t happen outside of severe trauma. And it’s certainly okay if you describe it as such to your physical therapist, chiropractor, or trainer. Pain and other symptoms can be weird, hard to explain, and unique to each person.
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However, no one should be convincing you that your bones are out of place and you need to see them to put them back into place. That person is creating a sense of fragility.
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You’re a lot stronger and more capable than you think.

VMO—The VMO became very popular in the treatment of patellofemoral pain (PFP) because the thought was that patellar mala...
10/24/2021

VMO
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The VMO became very popular in the treatment of patellofemoral pain (PFP) because the thought was that patellar malalignment or maltracking was contributing to wear and tear of the patella which then caused pain and dysfunction. In order to treat this, the things pulling laterally on the patella like a “tight” IT Band had to be released while the things pulling medially like the VMO needed strengthening and neuromuscular re-education. This theory hasn’t panned out.
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Females with PFP have shown to get better without any change in how their patella is tracking.
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Atrophy of the quads in individuals with PFP isn’t unique to the VMO.
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Intramuscular quadriceps coordination between symptomatic and asymptomatic individuals isn’t significantly different.
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Trying to do specific VMO retraining vs general quadriceps strengthening doesn’t make a difference in the long run.
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And a lot of this is based on trying to find and change a 10ms difference in activation of the VMO. That’s .01 seconds. Who cares?
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Also, the exercises aimed at retraining the VMO are usually extremely low level such as squats or bridges with a ball squeeze.
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To close the case on VMO specific training for PFP, Smith 2009 state “it is therefore recommended that clinicians should not focus on VMO strengthening” since it likely cannot be preferentially activated.
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Whether it’s for pain, performance, or aesthetics, you shouldn’t be singularly focusing on trying to strengthen or “re-educate” the VMO.
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Patellofemoral pain responds to comprehensive hip AND knee strengthening and including a variety of exercises is likely best for performance and aesthetics as well. There are a lot of compound and isolation, and weight bearing and non weight bearing exercises to choose from including single leg stepdowns, split squats, back squats, heel elevated squats, sissy squats, reverse nordics, leg extensions, etc.
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Be consistent, use a large range of motion, and incorporate progressive overload and the vastus medialis will get worked plenty.
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If you want to learn more and have all the links to the research, check out the YouTube video on the topic.

A common concern for people is knee crepitus, which refers to a variety of sounds and descriptions - grinding, cracking,...
10/22/2021

A common concern for people is knee crepitus, which refers to a variety of sounds and descriptions - grinding, cracking, popping, etc. Many people associate it with “bone-on-bone,” “wear-and-tear,” and long-term joint damage.
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A study by de Oliveira Silva et al in 2018 investigated the relationship between crepitus and function, physical activity level, and pain in women with and without patellofemoral pain. Although the participants with patellofemoral pain were more likely to present with crepitus, the authors concluded that “knee crepitus has no negative impact on function, physical activity level, and pain of women with patellofemoral pain.”
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Crepitus was also present in 33% of the asymptomatic group!
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While the noise may be unpleasant or undesirable, it appears to be quite common and is NOT an indication that exercise is dangerous or harmful. Whether you have patellofemoral pain, knee osteoarthritis, or a total knee replacement, some form of exercise is ALWAYS beneficial. You may just have to find what works best for you.
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And if you have noisy knees and no symptoms, don’t worry about it! I worked with an older gentleman whose knee sounded like a firework, but he had absolutely no issues!

Chondromalacia patellae is a diagnosis sometimes given to individuals with knee pain. “Chondro” refers to cartilage, whi...
10/20/2021

Chondromalacia patellae is a diagnosis sometimes given to individuals with knee pain. “Chondro” refers to cartilage, while “malacia” means softening. Therefore, chondromalacia patellae refers to a softening or breakdown of the cartilage on the back side of the patella.
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However, a 2016 consensus statement by Crossley et al suggested that we shouldn’t even use that terminology.
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The same paper (cited above) by van der Heijden et al in 2016 concluded: “Retropatellar cartilage damage has long been hypothesized as an important factor in the pathogenesis of patellofemoral pain, but study findings suggest that diminished patellofemoral cartilage composition is not associated with patellofemoral pain.”
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Chrondomalacia patellae is an unhelpful and potentially harmful diagnosis.
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As with most cases of rehab, the goal is to restore function and improve tolerance to various activities without putting too much stock in changes on imaging.

09/07/2021

The functionality of an exercise is not determined by its appearance, but its ability to serve a specific goal or elicit desired adaptations.
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What do you think I’m trying to accomplish?

Let me explain with a short story.—Several years ago, I went to a course that was, and is, probably one of the most well...
09/06/2021

Let me explain with a short story.
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Several years ago, I went to a course that was, and is, probably one of the most well-known and highest attended courses by trainers, coaches, and clinicians.
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One of the instructors asked another instructor, a well-known individual on social media for their movement capabilities, to demonstrate a “segmental” cat-cow.
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The instructor declined because they recently hurt their low back and were afraid that their demonstration wouldn’t be perfect.
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That’s it.
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The story is a reminder that Instagram is a highlight reel. No one is bulletproof or pain-free for life.
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Also, a bulletproof vest does not prevent all injuries or death, but it may reduce the likelihood of both.
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Similarly, specific exercises and careful programming cannot prevent all injuries, but they may play a role in reducing your risk of certain injuries.
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It’s also not possible, or desirable, to be pain-free for life.
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Everyone has setbacks from time to time. Even those who claim to be bulletproof and pain-free. It’s normal.

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