With time, we learn. Advances are made daily, but sometimes the original concept is better. Injury rehabilitation is a great example of both progression and regression. In this article, I will show you when “out with the old, in with the new” is good for lower body rehab, and when it's best to “get rid of the new, and go back to the old!” Here we go …
Treat Ankle Injuries with METH
Let me start by telling you about my experience with METH.
The date: Tuesday July 19, 2011
The place: my backyard
It was a hot summer day, and I decided to finally trim the branches that were rubbing against my shed. I hopped on the fence behind the shed, did what I had to do, then I jumped down. The distance was a little further than I expected, and I ended up rolling my ankle over some river rock.
At first, no pain. A few hours later, lots of pain! There was no time for discomfort, though. I had a slew of training sessions ahead of me. But as the night progressed, so did the swelling and pain! By the time the last person left I could barely move, let alone walk. That's when I took action.
The standard procedure for an injury like this involves anti-inflammatories and pain-killers along with RICE: rest, ice, compression, and elevation.
What did I do?
Almost the exact opposite!
No rest and no compression – I used movement with trafficking instead. According to Dr. Tim McKnight (2010), rest will lead to atrophy and weakness and may disturb balance and proper body positioning. Furthermore, compression can shut down blood flow to the area; whereas, traction will release the pressure and movement will encourage blood that is rich with healing factors, such as oxygen and white and red blood cells, to flow to the area. In addition, movement with traction reduces pain, improvements lymphatic removal of inflammation, improvements flexibility, and restores normal joint alignment.
Absolutely no ice – I used some moist heat instead. Again, the key is blood flow. If you want something to heal, it requires blood! Do not slow down this process with ice. However, I did use varying degrees of elevation through the process. I learned this procedure from Dick Hartzell, co-author of the book Do not Ice that Ankle Sprain . (Keep in mind that this procedure is for grade 1 or 2 sprains only.)
I term this approach METH: movement, elevation, traction, and heat.
Did I take anti-inflammatories and pain-killers? Well, yes and no. I took proteolytic enzymes (natural anti-inflammatories), and I took them by the boatload on an empty stomach.
The end result: no pain and full function the next day, full leg workout 2 days later, and medicine ball circuit at a local soccer field 4 days later. This injury was rehabilitated in mere hours, not days or weeks. I bet you if I used the RICE approach, it would have taken much longer!
Bottom line: Forget RICE, do METH instead of heal injuries fast!
Volume Training for Knee Rehabilitation
Now we'll cover knee injuries, specifically post-surgery rehabilitation of knee injuries … but first let's touch on a topic that is very popular in strength training, volume training.
There are many excellent volume routines out there. One of the most popular systems involves the 10 sets of 10 reps method, like the German Volume Training (GVT) protocol that was introduced in the July 1996 issue of Muscle Media 2000 . This type of routine is geared toward rapid and maximum hypertrophy – a lot of size in a short period of time!
Is it a new concept?
Not really. You will see this system scattered among the literature over the decades from various sources. For instance, in a paper originally published in the Russian journal Teoriya i Praktika Fizicheskoi Kultury , authors Vaitsehofsky & Kiselev (1989) discuss a protocol involving 10 sets of 10 pull-ups where the weight is reduced every second set (ie, additional loading is used to start such as 9kg, then down to 6kg, then 3kg, and then body weight to finish) or the grip is altered in the later sets to draw new, unfatigued fibers into work. Long-time Ironman contributor George Turner outlined a similar approach in his Real Bodybuilding audiotape series in the nineties.
What does this have to do with injury rehabilitation?
Well, think about it for a second. What are three things you need to reestablish after an injury, especially post surgery? If you said range of motion (ROM), muscle mass and strength, then you are correct. The quicker you can achieve these objectives, the quicker you can return to your activities of daily living and / or athletic endeavors. Intensity initially will be low because strength levels are low (pain and inflammation can inhibit strength), but in order to accomplish your objectives in short order, you must repeat a sufficient stimulant frequently. A volume training routine may fit the bill nicely if it is properly connected.
You with me so far?
Okay, let's take a Pulp Fiction moment and go off on a tangent.
The Famous DeLorme Scheme
If I asked what the most popular set / rep scheme in strength training is, most people would respond with 3 sets of 10 reps. It seems to be the universal training prescription, but where does it come from?
The concept stems from a 1948 paper by Dr. Thomas DeLorme and Dr. Arthur Watkins where they recommend 3 sets of 10 reps using a progressively heavier weight in the following manner:
Set # 1 – 50% of 10 repetition maximum
Set # 2 – 75% of 10 repetition maximum
Set # 3 – 100% of 10 repetition maximum
In this scheme, only the last set is performed to the limit. The first two sets can be considered as warm-ups. A few years later in their 1951 book Progressive Resistance Exercise, DeLorme & Watkins state: “By advocating three sets of exercise of 10 repetitions per set, the likelihood that other combinations may be just as effective is not overlooked.” Still, the majority of trainees today automatically adopt the 3×10 scheme as if it were written in stone.
The Not-So-Famous DeLorme Scheme
Now, let's take a little journey back in time to 1945 when the same Dr. Thomas DeLorme unleashed a powerhouse of a paper titled “Restoration of muscle power by heavy-resistance exercises” published in the Journal of Bone and Joint Surgery . Back then, far more than 3 sets were recommended per exercise with great results. The clinical observations made on 300 cases showed a “splendid response in muscle hypertrophy and power, together with symptomatic relief”, as DeLorme put it. Why change the system then? We'll explore that a little later, but first things first …
The 1945 DeLorme method consistent of 7-10 sets of 10 reps per set for a total of 70-100 repetitions each workout. The weight would start off light for the first set and then get progressively heavier until 10RM load was achieved. The workouts were short (on average about half an hour), but they were repeated frequently during the week. In GVT, for instance, each body part is trained once in a 5-day period. With the 1945 DeLorme system, the injured body part is trained once a day for 5 days straight! Of course, the difference is due to the direct relationship between intensity and recovery – the greater the intensity, the more recovery is necessary, and vice versa.
If you adopt this approach, will you be sore initially?
Will the soreness subside after a week or so?
Will you be ecstatic with the improved hypertrophy, strength, mobility, and function after just a few weeks while others are complaining that they can barely move and are in an extreme amount of pain?
Now, here is where it is important to read the entire paper and not just the abstract. DeLorme insists that a pulley system (common with most selectorized machines today) must not be used. Instead, use an iron boot, plate-loaded machine, or simply ankle weights to overload the terminal end of knee extension. This method will increase the overload on the vastus medialis oblique (VMO) muscle, a prime stabilizer of the knee (weakness of this muscle can impair function and cause pain of the knee.)
Of course, there are many ways to skin a cat. Terminal knee extension can be performed as a more “functional” closed kinetic chain (CKC) movement (ie, standing with a band or cable attachment strapped behind the knee or by performing a low amplitude step-up) rather than the separated, open kinetic chain (OKC) option mentioned previously. However, DeLorme points out that weight-bearing exercises produce symptoms of pain, thickening, and fluid in knee joints that are controlled by weak, atrophied muscles. It may be best to implement CKC movements only after strength is matched in both limbs through the use of non-weight-bearing OKC movements.
Also, many patients are told to stop all activity until the pain goes away. I do not agree! I have talked about this issue many times in the past so I will not dwell on it much further; however, if you feel that you should rest the area, get some treatment here and there, and everything will return to normal, think again! You can do all the soft tissue work in the world to try to break down fibrotic tissue – the muscle will still be weak, atrophied, and hard! If you really want to make progress, stop “pampering” the muscle and start exercising with progressive resistance. DeLorme makes that quite clear.
Back to the question: Why change from as many as 10 sets to only 3 sets?
This is what DeLorme & Watkins (1948) had to say: “In the initial publications concerning progressive resistance exercise, 70 to 100 repetitions were advocated, the repetitions being performed in 7 to 10 sets with 10 repetitions per set. Figure to be too high and that in most cases a total of 20 to 30 repetitions is far more satisfactory. Fewer repetitions permit exercise with heavier muscle loads, thereby yielding greater and more rapid muscle hypertrophy. ”
That sounds reasonable, but before we go on let's establish two relationships:
- There is an inverse relationship between intensity and volume (ie, the higher the intensity, the lower the volume, and vice versa).
- There is an inverse relationship between intensity and frequency (ie, the higher the intensity, the lower the frequency, and vice versa).
If intensity starts to increase yet the frequency lasts the same, something has to give! At a higher intensity, one all-out 10RM set can be performed 5 days a week. It's really only a total of 5 sets spread through the entire week. (Yes, I know that there are 3 sets performed each workout, but as mentioned earlier the first two sets are merely warm-ups.) Contrast 5 sets to as many as 50 sets (although not all of those 50 sets are taken to the limit), and you'll quickly realize why the 1948 “3×10” method was considered superior to the 1945 “10×10” method, but hold on a second. DeLorme still experienced quite a bit of success with that original method, and I do believe that it still has merit and can provide a “more satisfactory” result if it is implemented in a specific manner.
Here it goes: If intensity increases and volume lasts the same, the variable that must decrease is frequency to allow for sufficient recovery. Using the 10×10 method may in fact be more superior if the frequency is altered as follows:
Stage # 1: 5 days a week (Mon, Tues, Wed, Thurs, Fri)
Stage # 2: 4 days a week (Mon, Tues, Thurs, Fri)
Stage # 3: 3 days a week (Mon, Wed, Fri)
Stage # 4: 2 days a week (Mon, Thurs)
Stage # 5: 1 day in a 5-7 day period
Now, how long each stage will last will depend on the individual and their injury, but the key is to make progress each week and once that starts to stagnate, it's time for the next stage. Think of it as progressive resistance meets regressive frequency! By Stage # 5, muscle strength, mass and ROM should be back to normal – this is the frequency used in most volume training routines.
Try this new twist to the original concept introduced by Dr. DeLorme over 60 years ago.
Here are some take-home points:
- Read an entire study not just the abstract, and as much as possible check the references.
- The 10 sets of 10 reps method is by no means a new method, nor is it meant strictly for bodybuilders. This form of volume training may be an excellent way to rehabilitate an injury.
- The primary objective during injury rehabilitation is to restore muscle strength, hypertrophy and range of motion. Endurance training can be counterproductive to these objectives and should only be implemented when the strength of the limbs involved is approximately equal.
- During injury rehabilitation, pursue active (not passive) treatment with the use of progressive resistance exercises conducted at regular intervals with maximum effort.
Captain Thomas L. DeLorme, MD, a retired orthopedic surgeon at Massachusetts General Hospital, developed some novel methods to speed up the rehabilitation of injured soldiers during World War II. A true pioneer in the strength game, Dr. DeLorme passed away on June 14, 2003 at the age of 85, but his concept of progressive resistance exercise lives on today.
References available upon request.