Today I am going to do something that many of you have asked me to do for a while now.
In this video I am going to take a look at a video from THe Knees Over Toes Guy.
Is he legit?
Does he have any idea what he is talking about?
I don’t know, but I am going to react to his Reverse Out Knee Pain video Part 1 to
see if I can figure that out.
Hey Interns, I’m Dr. Chris Raynor and I am not your everyday ortho.
I teach you about injuries, orthopedic surgery, and medical topics in a way that is easy to
understand and entertaining.
Today I decided that that am going to watch a video from Ben Patrick, the knees over toes
guy, and share my thoughts about the statements and the ideas that he presents in the video.
Stay tuned to the end where I sum it all up for you.
Now before I get started, I will say that I have reached out to Ben Patrick and invited
him to a discussion on my other channel.
He politely declined, but he did point me to another podcast interview that he was featured
on for answers to my questions.
If you like this video and want me to do a more in depth review, let me know in the comments
down below, and I will analyze that video.
But enough of the bag of long talking, let’s get to it.
I don’t know what these exercises are yet, but it is important to remember that the knee
is a complex hinge joint that can facilitate a number of types of movement.
I has many structures that include ligaments, menisci, articulate cartilage, and bony structures,
any of which may be a potential source of pain.
While it is crucially important to optimize strength, flexibility, and mobility to maximize
function and to eradicate pain, there is no guarantee that these four exercises, or any
four exercises for that matter, will do that.
Although there are general reasons for knee pain or bad knee, the specific causes of knee
pain in each person are unique and therefore the treatment of that pain requires a unique
and tailored approach.
“Bad knees” are a multi factorial problem that can be related to dysfunction, anatomy,
trauma, infection, or disease, so sometimes something other than just exercise is required.
But having said that, I am a big fan of active, progressive exercise as a treatment for many
forms of non-surgical joint pathology.
I do like his straightforward approach to pain symptoms.
Find the cause of the knee pain and then reverse engineer exercises to eliminate that cause.
I know that this seems rather straightforward, but it is amazing how many people just want
to take a short cut to feeling better without putting in work to address the deficits at
the root of the pain symptoms or dysfunction.
Unfortunately, there are no quick fixes.
Everything requires work, sometimes a whole crap ton of it.
And not just any exercise, but exercise that is specifically directed toward the deficit
causing the pain or dysfunction.
Of course, this is most applicable to problems with strength, flexibility, or mobility and
less so for structural issues, infections, or disease.
But in general stronger is better and is associated with less pain symptoms.
Walking backwards with resistance.
This is basically a closed chain leg extension.
This is a great variation of the leg extension.
It is scalable and in this variant it is quite suitable for beginners or those with active
knee pain symptoms.
There is ongoing controversy about whether knee extensions are suitable for the rehabilitation
of post-operative patients, particularly in acl reconstruction patients.
In that population there is concern about excessive tension on the acl graft that might
cause graft rupture.
To prevent this problem, I instruct my patients to avoid open chain knee extensions, in favour
or close chain quad strengthening exercises.
For clarification, the easiest way to distinguish between open and close chain exercises is
to look to the foot.
If the bottom of the foot is touching the floor or the weight being moved, then it is
close chain.
If the weight is somewhere else, like on the shin, then it is open chain.
In my experience, I find that patients have more difficulty with open chain exercises,
so I prefer them to start with close chain exercises, and only incorporate open chain
exercises once they progress to an advanced level of training.
The most important key when performing this exercise is the position of the knee relative
to the foot and the mechanical axis when performing this exercise.
I am not sure about Ben’s level of training or what certifications that he holds so there
are two things that are key here.
First, he has regressed the exercise for beginners or for those who are actively in pain.
This is appropriate and the safest way in which to get people doing the exercise and
achieving success through the exercise.
Scale the exercise to their level and progress to higher difficulty levels as their performance
and pain levels improve.
Second, Ben advises to avoid a pace of work that causes discomfort or pain.
Again, this is appropriate for a coach without formal medical training, and the safest way
to have clients self-monitor their activity level.
For the record, I will say that rehabilitation is slightly different than pure training.
When rehabilitating, the person performing the exercises is working from a deficit of
some sort, after injury, surgery, or both.
As a result, there is usually some level of discomfort that is associated with the exercise,
and this is normal and quite often necessary.
I advise my patients while performing rehab exercises, they should work through discomfort
until it surpasses moderate levels.
This means that when experiencing pain on a scale of 0 to 10, where 0 is no pain, and
10 is pain bad enough you will pay me money to cut if off with rusty butter knife, discomfort
that is within 5-7 is acceptable.
Pain that is greater than, or equal to 8-10 is a signal to stop what you are doing.
Pain symptoms should resolve quickly after the exercise is completed.
I like how Ben has modified his body position to start challenging the knees over toes position
which really targets the VMO, or teardrop portion of the quad.
This is an effective means to direct the benefits of this exercise to the desired area of the
muscle.
I like that he states that every exercise is scalable to whatever level.
By changing body position, lever length, or a host of other aspects you can tailor exercises
to whatever skill level is required.
Occasionally, this may require some creativity when determining what aspect of an exercise
to modify, but most exercises will have several variations that will allow the exercise to
be tailored to each individual.
Backward walking is a great way to introduce close chain knee extensions and to facilitate
VMO/quadriceps strengthening into your day to day routine.
It will strengthen the quadriceps effectively, particularly if you are walking up an incline,
and strong quadriceps are beneficial for optimal patellar tracking and the elimination of knee
pain.
However, to my knowledge there are no studies that directly tie backward walking to a reduction
in the incidence of cartilage degeneration and knee osteoarthritis.
Backward walking when combined with conventional physical therapy has been shown to reduce
pain and functional disability, and to improve quadriceps strength in patients with osteoarthritis;
balance and stability in patients with rheumatoid arthritis; and muscle strength and gait mechanics
in patients with ACL rupture.
While it can be said that backwards walking is a beneficial exercise for a number of reasons,
it cannot be said that it will prevent cartilage damage and prevent
knee replacement.
STronger in reverse of what is hurting our knees, the less chance of knee pain.
This is a simplification to be sure, but I think that from a functional standpoint this
is true.
I don’t think that this applies to structural problems which often require a structural,
or surgical solution, but functional problems are certainly fair game.
REverse Step-Up is a variation of a Poliquin step-up.
This is a great exercise for quad strengthening with
a VMO focus.
Ben has successfully rehabilitated himself after suffering injuries to his right knee
and debilitating degenerative changes to his left knee.
This is admirable and I commend Ben on his persistence and diligence to his rehabilitation.
Furthermore, I will always recommend that patients should maximize their strength and
flexibility as part of their rehabilitation and rehabilitation programs.
However, it is important to understand that there are many causes of knee pain or pathology,
some of which require treatment other than strength, flexibility, and mobility training.
Ben gives clients and viewers permission to scale the exercise demonstrated as required
to suit their level of ability.
Patients need to feel comfortable with the exercises that are being presented as attainable
for them.
Allowing them to scale the exercises to their level of confidence is a good way to maintain
a high level of confidence with the exercise program to improve compliance and adherence.
I also like how he clearly outlines the level of scaling that are applicable: negative body
weight, bodyweight, positive bodyweight
Variations of the Reverse Step-Up: Patrick - flat foot
Poliquin - with supported foot plantarflexed ankle
Peterson - with unsupported foot plantarflexed ankle
Ben encourages people to take their time working through the progressions rather than rushing
to achieve a particular goal.
In this manner, the process is the goal rather than trying to achieve some particular number.
He encourages people to understand what the process is doing and to use it to it’s full
advantage rather than just doing the exercise for the sake of doing the exercise.
The goal is to strengthen the knees as much as possible.
This will be achieved by maximizing the time under tension.
Taking time with the exercise repetitions will accomplish this task.
I also like how Ben discusses different ways
for scaling the exercise.
He points out that simply adding more weight is not the only way to scale the exercise.
Other exercise adaptations such as decreasing the surface area of the support foot, or changing
the length of the lever can help to ramp up difficulty when required.
Ben encourages his partner to not worry about failure while doing the exercise.
Failure may occur when challenging the muscles, but is of no significance to the overall outcome
and at times may be necessary to achieve the desired goal.
9:36 Repetition.
Ben uses this tool frequently to hammer home his ideas and concepts and to reiterate his
key concepts.
Repetition is a very effective education tool and a great way to underscore the importance
of a particular message.
It usually takes 7 exposures to a particular idea before a person will take action on it,
so Ben uses repetition to compel you to do something.
So what do I think about Ben Patrick, the knees over toes guy?
After watching this first video I see a guy who has taken his own experience with knee
pain and pathology, and turned it on its head in an effort to be pain-free and become functional.
He has distilled his rehabilitation down into a few key exercises and he has developed an
effective system of scaling these exercises to make them accessible to people of all levels.
He has encouraged and empowered people to take charge of their health and given them
a potential treatment that may alleviate their pain symptoms and improve their daily function.
All of that is good.
But the most important thing that his video demonstrates is the concept that when it comes
to rehabilitation of an injury, the only one who is going to make it better is you.
The only one who is going to put in the work is you.
There are no quick fixes or instant solutions.
There is only you, and the work that you put in to solve your problems.
Physicians, therapists, trainers, Ben Patrick, we are only here to guide you.
You have to put in the work yourself.
Period.
So those are my initial thoughts on the knees over toes guy.
If you want a deep dive into his podcast interview then let me know in the comments.
Thanks for watching, I will see you for rounds next week.
And as always, that’s been a word from Dr. Chris, not your everyday ortho.