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Southern Orthopaedic Sports Medicine
Where the science of medicine meets the art of living.

Maximum Benefit, Minimal Risk

By Evan F. Ekman, M.D. and Cynthia Ekman, PT

Whether it’s investing in the stock market or working legs, life is about minimizing risk while maximizing benefit. In fitness, we want the biggest bang for our buck. We want results in an effective, time-efficient workout. One question we often ask our patients is, “Why perform an exercise that predisposes you to injury if you can alter it and decrease your chances of injury, without sacrificing results?” Can you get the legs of a champion without developing the knees of an arthritic? Yes! The concept is simple: Maximize benefit, minimize risk.

Done improperly, quadriceps strengthening exercises pose a risk of injury to the cartilage between the kneecap (patella) and the thigh bone (femur)-the patellofemoral joint. When you work the quads, the paella acts like fulcrum to extend the leg. The harder you fire the quads, the more you increase the pressure between the kneecap and the thighbone (the patellofemoral contact force). Also, the further you flex (bend) the knee, the more you increase patellofemoral contact force. Simply put, patellofemoral contact force is not good. It contributes to cartilage softening, wear and injury. This is sometime called chondromalacia. Let’s assume that, at times, you are going to want to work your legs as hard as possible. You can significantly decrease the risk of injury if you pay attention to the flexion angle of your knee. Regardless of the quadriceps drill, don’t allow the knee flexion angle to pass 90 degrees-a right angle- between the thigh and the shin.

Before you start your leg workout, there are two things you can do to minimize your chance of injury: Warm up and stretch.

Warmup: The goal is simply to increase your body temperature. The increase on body temperature increases the blood flow to muscles and joints, promoting flexibility and lubrication of the joints. An increase in blood flow to specific muscles and tendons also decreases the likelihood of overuse-related damage to the tissues. Also, increasing the body temperature allows nerve impulses to travel faster, leading to better performance and a more efficient workout. A simple activity like three to five minutes of brisk walking, jogging or biking will suffice. Although it may seem counter-intuitive until you embrace the science, the warmup should be done before the stretch.

Stretch: Stretching accomplishes two things, both of which decrease our chance of weightlifting-related injury. First, it increases the resting length of the muscle and its adjoining tendons (the musculotendinous unit). This decreases the chances of injury to the muscles by ensuring elasticity of the soft tissues are improving the mechanics of physical activity. Second, stretching increases the elasticity of the lining of joints, also known as the joint capsule. This, in turn, improves mechanics and decreases the possibility of certain ligament sprains and tears in joints. We all know how to stretch, but just to be complete, here are some basic guidelines: Gently stretch a muscle through the specified motion and hold it at then end range for 10 to 20 seconds. Use constant pressure and don’t “bounce.” Perform each stretch two times and do it on both sides of your body. To avoid and prevent injury, stretching should be a slow, deliberate and painless process.


Leg extensions (quadriceps)
Cynthia: “I do a total of four sets, beginning with a weight that I can do 10 to 12 times. Increase five to 10 pounds per set for sets two and three. On the second set, I do 10 to 12 reps and on the third set, eight to 10 reps. On the fourth set I drop the weight 20 pounds and so as many reps as possible, usually around 15.”

Evan: “Set the leg pad on the end of your shim as opposed to the top of your foot. Turn your feet out 10 degrees to increase the workload in the VMO. That’s the teardrop shaped muscle just above your knee on the inside. Strengthening the VMO improves the way your kneecap tracks in the thighbone groove, decreasing wear on the chondromalacia. A strong VMO is a crucial element to a healthy patellofemoral joint. Don’t forget the 90-degree rule. If you have pain in the front of your knee during this exercise, try sliding the pad closer to the knee.”

Dumbbell squats (quadriceps, hamstrings, glutes)
Cynthia: “I use a controllable weight. My goal is three sets of 12 to 15 reps. I focus on keeping a straight back with consistent abdominal tone. Foot position is slightly outward at the toes and such that my knees don’t go in front if my ankles at 90-degrees of knee flexion. I sometimes use a Smith machine to give me an element of control.”

Evan: “This is a drill where Cynthia and I differ as to its utility. While she is thrilled with the results seen in squats, I go back to the risk/benefit thing. In squats, not only are your knees at risk, but so is your back. So if you are going heavy, use a belt. Always be in complete control of mass that loads through your spine and with dumbbell squats use a spotter. If you have a history of pain in the front of your knees or a prior injury to your back, you’re probably better off using the leg press.”

Calf raises (gastrocnemius and soleus)
Cynthia: “I prefer to do calf raises on the leg press. It is a comfortable position and it saves me time supersetting with leg press. My recommendation is for higher reps than in most exercises. Three sets of 20 creates a nice burn and, of course, I want to feel it in the calf muscles (gastrocnemius and soleus) and not in the Achilles tendon.”

Evan: “While most of us think if this as a fairly safe exercise, keep in mind that if you are over 30, ruptures of the Achilles tendon can happen. If it is going to occur, it will be when your heel cord is at its greatest length. Often you will have pain prior to it happening. To avoid tendonitis and the possibility of rupture, listen to your body and respond appropriately. If you begin experiencing pain, shorten the range of motion or decrease the weight. Ice is a potent anti-inflammatory that decreases and promotes healing. Use it if you need to.”

Lying leg curls (hamstrings)
Cynthia: “A warmup is especially important to me prior to working hamstrings. Three sets of 12 reps is my normal routine. After lifting the weight the first time, I want to make sure that the machine does not force my knee into hyperextension. This would increase my chances of injury to the hamstrings where they cross the knee joint and strain the capsule on the back of the knee. To get the most out of hamstring curls, I focus on bringing my heels up to my rear. The 90-degree rule doesn’t apply here.”

Evan: “In hamstring training, the patellofemoral joint is not at risk for injury. The quads are quiet; hence the patellofemoral contact force is low. At greater risk of injury are the hamstring muscle units themselves. Muscle strains and injuries where the tendons insert onto the bone are common. To avoid these possibilities, start with a light weight and, after muscle contraction, move slowly back towards your resting position, as most muscle strains happen during eccentric contraction (muscle contraction while the muscle itself is lengthening). If you want to do very heavy weight, have your spotter help you on the eccentric portion of the lift.”

Leg Press (quadriceps, hamstrings, glutes)
Cynthia: “This is a power exercise designed to develop mass in the legs and glutes. I perform three sets of 12 to 15 reps, using the same weight each time. A warmup prior to this is a must. With the back of the leg press machine raised, my trunk keeps my knees from going too deep into flexion.”

Evan: “Set your feet shoulder-width apart for stability. This decreases the chance of your knees giving way and creating injury to the shock absorbers in the knee, the menisci. Keep your body still and back relaxed. Don’t lock your knees out at the top of the motion.”

At a Glance
Leg Extensions 4 sets
Leg Press 3 sets
Squats 3 sets
Lying Leg Curls 3 sets
Calf Raises 3 sets

Here is the end result: Fewer injuries, better results. This is an effective workout with low potential for injury or lost time due to rehab. While the concepts seem simple and everyone has heard them before, we often modify what we do to save time or simply to try something new. One fact remains constant, however: Preventing sports-related knee injures is easier than fixing them, Minimize your risk. Maximize your benefit.

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