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Andy Reed
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Hi Josh
Sorry to hear about your injury.
Typically lower limb tendons respond well to heavy, slow loading protocols. This typically involves (for the achilles) a slow eccentric lowering of the heel off the edge of a step. You go up on tip toes, then slowly lower the heel down (over 3 or 4 seconds) for 10-12 reps. Normally I recommend 3-4 sets every second day. Pain during this is fairly normal.
As soon as these are feeling easy/tolerable, additional weight should be added (hold a kettle bell/heavy pack etc). A smith machine also works really well for these (https://youtu.be/1lKjFPrYqf0).
I also prescribe bent leg calf raises such as seated calf raises with additional weight – some gyms have a calf raise machine, or a Smith machine works well (https://youtu.be/Nd25-BniuGQ). The key is to introduce some heavy, slow eccentric loading as soon as possible, using both straight knee and bent knee variations.
I find most people are able to train through this injury, though if things get worse, I wouldn’t hesitate to see a physio or sport medicine doc. Hope that helps.
Good question. If you are truly overtrained (and I say this because it is worth a medical check up to evaluate for other causes) then I would not recommend significant strength training until you have rebuild your aerobic base. Whilst most of the published work on Overtraining Syndrome (OTS) has been done in the endurance realm, there is some evidence that pure strength based athletes, such as power lifters, can become overtrained, though it does seem to be much less common. Heavy lifting adds significant load and stress to the system, so it definitely makes sense to limit this as you recover, at least until you “rebuild the aerobic house”. I think the best approach for you and your goals, if you are feeling better after a period of rest, is to get back to some easy aerobic paced activity, probably just short flat walks initially, and build from there. Use nasal breathing to guide intensity, or perform a walking Aerobic Threshold test on the flat to get some idea of your target HR. Unfortunately it takes time to rebuild this base, but with patience you will get there. I think that some mobility and light core work is quite acceptable however, as the overall global load for this type of activity is low.
Hi there!
Scott is absolutely correct. Surgery, with bed rest, and the significant stress that comes along with this, are a huge hit to your aerobic fitness. This detraining effect that you describe, can certainly take place in the time lines you describe, but the good news is that by sensibly returning to easy aerobic efforts, you will be able to get back to your pre-surgery levels of fitness.
I would recommend keeping your efforts very easy at first and listen to how your body reacts, taking rest days as needed. Once you are able to consistently walk of jog for an hour, perform a HR drift test (described in our Knowledge section) to establish your Aerobic threshold HR. You will then need to spend time in zone 2 to rebuild your fitness. Everyone is different, and I don’t know the details of your surgery, but it can take months or even years to maximise your aerobic fitness. Err on the side of caution at first – don’t be tempted to do too much too soon. Be deliberate and consistent however, and your fitness will return.
If you wish to discuss things in more detail, I am happy to arrange a phone consult with you, and we can get more specific about your particular medical issue, if that would be beneficial.
Good luck.
Thanks for your query. In general I agree with most of what has been said. Being on your feet is going to be the most specific activity for your planned summer goals. You are inevitably going to spend a lot of time hiking on the Trans Alps run if you do go, so uphill hikes should make up some of your training in any case! Use hiking poles if you have some, as these will help offload the achilles as well. Most runners for these events end up training too much at too high an intensity, and they forget about all of the hiking that will be done. If you can get your HR up towards your AeT HR whilst hiking, without flaring the achilles, it will provide the best ‘bang for your buck’; but I am also a fan of adding in additional volume on the gravel bike if you need. Let’s say that your achilles will tolerate an hour of hiking, finish your hike, then jump on the bike for an additional hour.
Also remember that heavy, slow and controlled lower limb strengthening should help your achilles recovery, so don’t neglect this.
Hope that is helpful.
Hi Keith – sorry to hear about your knee.
It sounds like you are still very acute. Typically we hold off surgical reconstruction until the knee has settled down, swelling resolved, and you have regained a lot of function in the quads etc. Most patients are typically looking at surgery 8-12 weeks post injury (unless you’re in the NFL/NBA etc) so in terms of what to do right now – a good PT is gold, and can help you maintain quads strength and mass, hip and hamstring strength. Stationary cycling can be initiated as soon as you can pedal a circle. PT will advise on the use of a muscle stim, cold therapy etc, and in fact you can maintain mass and strength in the injured leg by exercising the uninjured side (muscle cross education).
After surgery you will be able to begin linear activities like stationary cycling almost immediately. Once your wounds have healed swimming and pool running can begin. In terms of Nordic skiing, many patients can begin classic skiing on the flat at around 12 weeks, usually in a brace, but obviously it depends on strength, balance, pain/swelling etc, and a brace would be advised to minimise re-injury. Every knee is different though and these timelines would simply be a guideline. We run our patients through a battery of functional testing before we clear them for return to sports. The biggest risk when classic skiing is actually having to step out of the tracks on a hill to snow plough so it makes sense to stay flat and non-technical.
Because skate skiing involves more rotation through the knee, as well as a higher risk of catching the ski tip etc, I typically don’t allow my patients to skate ski until around 6 months, and even then, I would recommend a brace. For downhill skiing, 12 months minimum (and in general, the longer the better) to allow the graft to fully integrate/heal/vascularise. It is never wrong to go slow after ACL reconstruction and you can get creative with linear activities to avoid re-injury, maintain fitness and to stave off the boredom. Hope that helps!
Hi Ryan
Great question. Tendon adaptations, in general, are very slow, and 2 weeks will not be enough to make a lot of difference.
Things I would recommend looking at in this “acute” stage – isometric holds. There are a variety of ways to achieve this – iso-lunges, wall sits, seated leg extensions, isometric leg presses etc – you can google these. Isometric holds are quite useful early on, as they reduce pain, and trigger some of the necessary adaptations in the tendon structure; holds are usually in the 20-40s range. There is some evidence now that taking a collagen/Vit C supplement 30-6- mins before these exercises can promote more rapid healing (look up Baar et al, UC Davis’ work).
Isometrics can be done daily. After this I would usually progress to some sort of heavy eccentric or eccentric/concentric work. The weight should ultimately be challenging – 3-5 rep max. These are challenging and should NOT be done daily – 2-3 times per week is good.
I love the Spanish Squat for patellar tendons – look it up.
The final part of the equation is to introduce more explosive work – box jumps, box drops, drop squats – plyometrics basically. Again – these can be very challenging – 1-2 times weekly max.
Hope that helps – a good therapist will be able to check your form, do a biomechanical assessment, add in some additional manual therapy/modalities and confirm the diagnosis.
Hi there
Sorry to hear about your ACL. I see 4 or 5 of these daily in clinic right now, so can imagine your pain. Your first two weeks post surgery will be tough – it’s couch time, crutches and icing unfortunately, but after this (and with clearance from your surgeon) you will likely be able to start some easy spinning on the bike. Some of this will depend on whether you have a meniscal repair and the type of ACL graft used. Once cleared to bike though, this will be a good option for maintaining some fitness. You would be advised to keep the resistance low and work up to a high cadence to limit stress on the knee as it heals – and also better to get the HR up. Other options would be swimming (once wounds are healed up) – feels good, low impact, promotes healing, and then treadmill walking as you say.
You will need to be steady on your feet with no significant pain or swelling afterwards if you use a treadmill, so you will have to go very easy at first. Alter G treadmill also effective if you can find one, and there are also underwater treadmills, would you believe! We typically allow our patients to run at 12 weeks, again dependent on other patient specifics. I like the idea of the ski erg.
Hope that helps. I’d say most of our patients feel almost 100% by 6 months, though we don’t clear them for high risk sports until 12 months post op.
Your PT and surgeon can provide more tailored advice of course. Good luck!
Assuming that your HR zones are correct (have you done an AeT test yet?) and if you are just starting out, and the achilles can handle it, I’d recommend a hilly hike as you’re more likely to climb into zone 2 which is where you’ll build most fitness. As fitness improves, you can add weight to these efforts.
Typically with MAF there is an adjustment based on health or medications, so I would definitely make a subtraction; by how much though is anybody’s guess, but a minimum of 5. Nasal breathing is another good option here, especially in the aerobically fit, which it sounds like you are, so I’d guesstimate that your true value (on beta blockers) lies somewhere between 125 and 140. Without more detailed testing though, it is hard to know, and as I say, a high volume of easy training is never a bad idea!
Great question, and one which I am not sure has an easy answer. The first thing I will ask is whether you’re on beta-blockers for a cardiac or a non-cardiac issue (and I don’t expect you to divulge any specific medical information on this forum), because this can obviously influence the exercise prescription. If you’re coming back from a heart attack, for example, then caution is needed at higher intensities.
Coming back to your question, and assuming that you are healthy from a cardiac standpoint, HR becomes a far less reliable indicator of exercise intensity when beta blockers are being used. Studies have also shown that amongst individuals, the response is quite individual, and the HR response to exercise is non-linear, and therefore there is no easy or reliable formula to correct for beta blocker use. It likely depends on the condition being treated, the beta blocker dose, time of day etc, etc.
None of this helps you however, but in general, the HR effect will be blunted, so if your AeT HR off betas blockers is 135 bpm, then it will very likely be lower on beta blockers foer the same metabolic intensity. That’s about all that one can say, and the drift test will not be accurate.
RPE (rating of perceived exertion) is probably more reliable, especially if you are very experienced and in tune with your training intensities, but some people struggle to gauge their RPE, and other things can throw it off.
The only way to reliably determine your thresholds would be in a lab, with either lactate determinations or gas exchange. These can be costly tests, and aren’t available everywhere.
A couple of other quick points: (1) the chart that you added above looks to show almost no drift to my eye (I could be wrong though on that) but as I have said, I would not rely on a cardiac drift test to determine AeT HR.
(2) There is some suggestion in the literature that the long term training effect whilst on beta blockers is blunted, though there is limited published work on this. Is there an alternate treatment? Some patients take beta blockers for migraine prevention, for example, and there are other effective treatments now for this condition.
(3) Have you applied the MAF HR formula to your particular scenario? I am somewhat interested in where it would put you (purely out of curiosity). Do you have any thoughts on RPE at your ‘calculated’ AeT? Does it feel sustainable?
(4) Lastly, remember that ‘all training works’. Some is just more effective. So this may be a moot point, and I do not know what your goals are, but there is rarely anything negative to say about a large amount of low intensity work!
I am interested in whether any of the other coaches on this forum have encountered this scenario, and how they handled things.
Thanks for posting the BJSM link. This was the framework we utilised early on in the pandemic, though our experience was that it was frustratingly slow for most athletes with mild illness, many of whom reported that had they been living in ‘normal times’, they would likely have trained through it (although this isn’t necessarily a good approach!!). There are some newer updated guidelines available now, but I have found that the following (link below) gives a good, pragmatic overview, and most athletes with mild illness can be back to normal training in 7-10 days. However, if in doubt, it is never a bad idea to be conservative.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9170595/pdf/main.pdf
Hi there – and thanks for the question. I am going to assume a relatively mild case of COVID, and that you were healthy, with a solid base of training leading up to the infection? COVID19 illness with significant cardio-pulmonary symptoms needs additional testing (ECG, stress, Echo etc) and clearance by a physician, before return to training, so if this was more than just a mild illness, you should get things checked out.
If this was a mild illness, then in terms of managing return to sport post COVID, the consensus is to limit intensity initially; I recommend keeping your HR in Zone 1 for the first 3 days, with a gradual increase in volume, keeping in Z1. If no issues, you may then resume your prior training regime, up to your AeT. By day 10, you should be back on track, so you should be able to get in a solid month of training before your climb. To answer your question, then, yes, I would focus on Z1 hiking.
I would not try to ramp up the volume too quickly ‘to make up’ for missed training. You have more to lose by doing too much too soon, than by starting slow and easy, and ramping up gradually. Cramming in additional volume, is just likely to leave you feeling fatigued. Remember to monitor for any worsening or new symptoms – cough, chest pain, dizziness, palpitations etc, and don’t hesitate to get things checked out by a physician. Problems for most fit athletes are fortunately very rare, so in all likelihood, you will be fine as you resume training. Good luck!
A couple of thoughts on this one. My advice for this particular event would be to gradually increase your easy volume over adding in an extra ME workout. It appears that you have some strength training already programmed into your training, and the Bryce 50 isn’t going to have a ton of vertical (I’ve run the 100 mile edition). There is a fairly substantial long and relatively flat section here, and I think in terms of specificity, more Z1/2 would be the best bang for your buck, as it is for almost all ultra events. If you can get in 3 or 4 downhill training sessions in the final 6 weeks, that should get your quads ready for the downhills. You don’t need a lot of this downhill stimulus however, and remember it does risk injury, so don’t go crazy – try to mimic your race pace and overall grade if possible. Good luck! Let us know how it goes!
Something I have found very useful for some athletes is monitoring HRV – the app HRV4training is the best. A few good studies have looked at HRV guided training, and anecdotally I have used this myself. I use HRV as ‘one last final check’ – a green light if you like, before going hard. Once a good baseline HRV reading has been achieved (several months is ideal) you can then use HRV with decision making. If you’re feeling good, and the effort is easy, as in the above scenario, AND the HRV is good, then I believe that is an IDEAL time to add in some intensity, whereas if the HRV is a bit off, I would tend to hold back. I would certainly not let HRV guide all of my training, but it’s a good confirmation that all systems are go!
https://pubmed.ncbi.nlm.nih.gov/31490431/
https://pubmed.ncbi.nlm.nih.gov/26909534/
