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Part 2 - Why load management is important


So let’s continue from where we last left this conversation of managing your knee pain.


[If you missed the last article (Part 1 – Knee Pains, Osteoarthritis and Hyaluronic Acid Injections) worry not as the article is for viewing over HERE]




Managing load to manage knee pains



Most people want the best of both worlds…..being physically active, participating in your sport of choice…and being relatively pain free.

[I use the term ‘relative’ as sometimes the pain has been in the background but it is mostly negligible and does not affect yo[ur sport (high performance or leisure)]



If you fall into this category, then the ultimate aim for you is to properly and adequately manage your load. To a lot of you, load management may be a new way of looking at things but it is the core of all sports injury risk reduction and management (sports injury prevention).


Let me explain how I categorize LOAD….


(1) Body weight load

(2) Musculoskeletal adaptation load

(3) Training volume load

(4) Environmental load

(5) Nutritional load


We go through one by one to discuss how each affect your knee joint pains (this can also be translated to other injuries)



1. Body weight load


- The heavier you weigh, the more load will be placed onto your knees (and other joints for that matter). In fact, there is about 4x your body weight worth of load onto your knees when you stand and walk. It then multiplies to about 10x when you run. The heavier you are, the less likely your physical trainer or your Sports Physician will encourage you to take up high intensity exercises with a lot of jumping and pounding of the joints from the get-go if you have not been very active for a while....because this will inevitably lead to synovitis (synovial lining of your knee joint that can get inflamed) and subsequently swelling of the knee joint. This will then cause the sensation of tightness in your knee and the feeling of pain (due to stretching of the knee capsule from the swelling).

- For many patients that are categorized as Obese by BMI (body mass index), it is quite common that the exercises that we prescribe to you are less daunting to your knee joints, such as cycling, swimming and perhaps even brisk walking.

- And for everyone that goes “Oh dear I can’t go jogging? How am I ever going to lose weight?”, I would retort with the fact that dietary change (ie caloric deficit) does a lot more for weight loss than exercise ever will…unless you are training for a full fledge Ironman and exercising 20 hours per week without increasing the amount of food you are currently eating (I’m exaggerating but you get the point, right?).



2. Musculoskeletal Adaptation Load


- Your muscles surrounding your knee joint (quadriceps, hamstring, calf muscles and to some degree a further up muscle, the glutes) are your “load manager”. The bigger and stronger these muscles are, the better they can handle and withstand the load placed on the knees from your everyday and sporting activities. And to buff up those muscles, you need to exercise.

- When I say exercise, I do not mean lace-up-your-joggers-and-head-out-to-run-a-10k-without-training sort of thing. What I meant was strength training to build muscle strength and increase muscle size (muscle hypertrophy). And to have very solidly strong muscles, the exercises applied must progressively be more difficult (ie lifting more weights week to week, doing more squats than the week before). This increment in training load (ie progressive overload) will make your muscles (1) increase in size and (2) also increase in strength. Continuously doing the same exercise with the same amount of intensity/volume/load is not going to make you stronger as your body easily adapts to it and you will stop seeing results. Our bodies are not cooperative in that manner (if our bodies were a bit more cooperative, we would all be lean and mean, and obesity would be a rarity in this world).

- Aside from stronger muscles being more able to withstand whatever masochistic physical activities you throw at your body (ie suddenly signing up for an ultra marathon at the end of the month when the longest you have ever gone on foot is a 21km – by the way, absolutely not advisable), strength training also strengthens the tendons that connects the muscles to the bones and makes all other connective tissues more resilient to stressful loads (your ultramarathon!)

- In fact, it is advisable to do some form of strength training at a minimum of 2x per week involving large muscles for optimum health (not to mention performance!) and it reduces future health issues such as osteopenia/osteoporosis (weakening of the bones) and overuse injuries.



3. Training volume load


- Having known from the previous point that you have to slowly and progressively add on training volume, intensity and load to improve in your performance, it is no wonder that most training plans get progressively more difficult week to week. However most training plans also schedule in some relative rest (a short duration where there is reduction in intensity/volume/load before it increases again) so that the body can adapt and improve.

- Most people mistake that the training ITSELF is what makes them stronger. Training or any exercise for that matter actually breaks you (your muscles and connective tissues) down. The body reacts by healing, recovering and growing stronger to adapt to the exercises you throw at it. This healing and growing stronger occurs when you are RESTING, and NOT during training. Therefore in all training programs or a good exercise regime should have rest and recovery pre-planned ahead.

- Let’s say you do not actively participate in any sports or exercise regime at the moment and the most that you do are house work and gardening (depending on how huge your residence is and how much domestic help you do not have, that could actually be quite a task on a regularly basis), this also applied to you, so hear me out. Let’s say you are used to the load of weekly housekeeping of sweeping and mopping of floors with laundry (the “training” volume and intensity) and that does not cause you any aches or pains. Come holiday season, that regular “training” load of sweeping/mopping/laundry will INCREASE to sweeping/mopping/laundry/cleaning windows/dusting all the higher cabinets/bringing out the good cookware and fine China/rearranging the furnitures/baking cookies and cakes/the list goes on. Suddenly in a very short duration of time, your “training” volume and intensity went up exponentially. Your body is not use to this extra load and there is not enough recovery time. Thus, something will hurt and it is going to hurt quite a bit depending on how much excessive load was place onto your body.



4. Environmental load


- This is a bit of a vague territory of “load”. It can involve things such are terrain, elevation, footwear, surrounding temperature and humidity. You might be wondering how this might worsen your aches and pains in terms but let me explain.

- In terms of sporting activities, changes in terrain (tarmac vs trail/off road) changes the way you use your muscles and changes the load placed onto your body/joints. 5km run on the road vs 5km run on trail is an entire different ball game. 5km run on the road may take someone an average of 30minutes to complete whereas taking this run off road may take the same person up to an hour to finish, depending on the technicality of the route. The difficulty of the task and the time spent doing the activity have increased. Obviously this increases the load on the body.

- As with the change in terrain, the change in elevation is very similar. Walking on even ground or minimal incline may feel very easy or score very low on the Rate of Perceived Exertion (RPE) score [please refer to Dr Kavitha’s write up on this topic]. However if the route suddenly threw in a few 5-6 degree inclines for a few kilometers, the RPE would have increase tremendously. You will need more strength to walk up this hill compared to flat surface. Obviously this will be increased load.

- In terms of footwear (especially for runners), everyone has their own preference whether it be minimalist soles, very well cushioned soles or even barefoot. After many months of training (or just walking in a mall, doing daily activities) in a certain type of footwear, the body adapts to the activities in those said footwear. If you suddenly change from minimalist type to maximal cushioning shoes (and vice versa) that changes the load placed on the feet and thus your knees and body (the body works as whole) and if not given adequate time to adjust and adapt (changing the type of shoes worn and then running a full marathon the next day) then definitely there will be aches and pains.

- Temperature and humidity when not in favourable conditions, changes how difficult you perceive the task at hand. Which is why when one races a marathon, they most likely will perform better and finish with a faster timing racing in a colder and less humid country compared to how Malaysia usually is (extremely hot and chokingly humid).

- The reason for this is FATIGUE. In hot and humid environments, you fatigue faster. When you are in a fatigue state, your muscles are tired and likely will not perform at its best. And remember, when your muscles are strong they handle the load placed onto the body much better. This is why your usual physical load will not be managed well by your body once it fatigues.



5. Nutritional load


- Let’s refer back to point (1), (2) and (3).

- Body weight management is a combination between managing your nutrition and your energy expenditure (not necessarily exercise per se, but Total Daily Energy Expenditure or TDEE is a whole different subject which we may touch on in the near future). Having said this, in most weight loss situations, nutrition is key and maintaining energy deficit (taking in less than what you use) is KING.

- Building bigger and stronger muscles not only requires you to strength train with progressive load but also proper nutrition to build those muscles. Adequate protein intake is needed to build those muscles that is necessary. Also what you eat eventually becomes you. I don’t know about you…but I quite like my muscles (tendons, ligaments and what-nots) to be made out of high quality protein wit organic vegetables here and there, and not from McDonald’s French Fries.

- When training for a race or just exercising for optimal health, you break down then recover to become stronger and faster. You need the nourishment with adequate macronutrients and micronutrients for recovery. If you minus our this important factor, you are not going to bounce back stronger.




I hope this article helps you understand a bit more about load management and how you can help yourself to in managing your own aches and pains.


In part 3, we shall look into supplementations for knee pains and what science says about them.

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