Tuesday, June 17, 2014

Injuries: BJJ and the Meniscus

BJJ hasn't been kind to my knees. Fortunately, I'm in good company. Jiu-Jitsu Vortex provided a great list of athletes who have specifically suffered knee injuries: "Kron Gracie, Xande Ribeiro, David Avellan, Dustin Hazelett, Bas Rutten, Roger Gracie, Tito Ortiz, Romulo Barral, Marco Ruas, Georges Ste-Pierre, to name a few."

The question is really "what do we do about knee injuries in BJJ?" I'm not a medical professional but I now have some hard-won perspective on the topic:
  1. Recognize that you probably will get injured. BJJ is a contact sport and injuries are common. Fortunately, we know a little bit about the types of injuries you are likely to face based on your activities. We know the MMA frequently results in facial lacerations, hand injuries, and nose injuries. We know a bit more about judo where the average risk of injury is 11-12%, consisting mostly of sprains and strains to the knee, shoulder, and finger. Throwing is the most common vector of injury. Army combatives frequently results in injuries to the knee and shoulder areas. Surgery is required 24% of the time with labral repairs being most frequent. Finally, we can also look at a 10-year study of general knee injuries. Here's the abstract in all of its glory:
    1. We have documented 17,397 patients with 19,530 sport injuries over a 10-year period of time. 6434 patients (37%) had 7769 injuries (39.8%) related to the knee joint. 68.1% of those patients were men and 31.6% were women. Almost 50% of the patients were between the ages of 20-29 (43.1%) at the time of injury. The injuries documented were ACL lesion (20.3%), medial meniscus lesion (10.8%), lateral meniscus lesion (3.7%), MCL lesion (7.9%), LCL lesion (1.1%), and PCL lesion (0.65%). The activities leading to most injuries were soccer (35%) and skiing (26%). LCL injury was associated with tennis and gymnastics, MCL with judo and skiing, ACL with handball and volleyball, PCL with handball, lateral meniscus with gymnastics and dancing, and medial meniscus with tennis and jogging.
  2. Triage if you get hurt. Do what you need to do in the short term: RICE, pain killers, etc. And stay off the mats if you have to! 
  3. Assess criticality. Get a professional assessment. If you've ruptured or severely strained something, you need to know. Your family doctor/GP can probably do a basic assessment and get you a referral to either a specialist or a physio. If something is severely wrong, see a specialist.
  4. Eliminate diagnostic noise. There likely isn't anything "severely wrong." Instead, you've got a case of crappy knee with any number of symptoms (e.g., pain, loss of terminal extension, pain when ascending and/or descending stairs, minor swelling, loss of stability around the patella, a feeling of giving way, etc.). It seems like these symptoms can be caused by a number of things such as ilotibial band syndrome, patellar femoral pain, meniscus wear, etc. You might have any and or all of these things! In my case, I hurt my knee doing cleans in the gym but the injury occurred after I had ramped up my time on the mats. My GP noted that I hadn't done anything severe and referred me to a physio. The physio confirmed that I hadn't done anything severe but noted that I had a spectrum of dysfunction so we started working on the most pressing issues that seemed to be related to ITB syndrome (e.g., some strengthening and mobility work).
  5. Refine the diagnosis. My symptoms cleared up and I continued to train but my knee was giving me grief by the end of ski season (6 months after the initial injury). Then one day we trained o-soto gari and closed guard. My knee was very sore by the next morning. And then I stepped in a hole while cutting the grass and reinjured my knee. I went back to my physio, he confirmed that there was nothing severely wrong, and that the injury was now quite clearly some damage to my lateral meniscus caused by some laxity in the LCL. Nuts. For me, the best indicator of this problem was difficulty with internally rotating my foot against resistance (e.g., kicking a ball or trying to pull off a rubber boot).
  6. Establish a baseline. It can be difficult to monitor progress with a knee injury, particularly if you're trying to deal with it via physio. I think it's important to monitor your progress. One approach is to use a formal instrument such as the Western Ontario Meniscal Evaluation Tool (WOMET). It has been validated. Another approach is use some basic tests of function. For example, take note of things that you can't do and then record when you can do them. For example, I found it difficult to get on a bike due to the required hip mobility. Other basic tests that I have used include "how long can I sit in seiza before it becomes uncomfortable?" and "how long can I sit cross-legged?". Doing these tests every couple of weeks can at least give you some indication of whether or not you are actually getting better.
  7. Do your physio. Seriously. If you've got a program, do it... every day. If you can't comply with your program then you need to see your physiotherapist more often. I like to see my physiotherapist every two weeks. This interval keeps me engaged in the program and gives us enough time to introduce exercise variations.
  8. Give your physio enough time. It's going to take some time. Give yourself 12 weeks. Establish a baseline, monitor your progress, and -- most importantly -- do your physio.
  9. Get a good physio program. My physiotherapist gives me programs and they work... I don' t know why but I can share what he tells me. Basically, my program is always:
    1. Heat (5-10 minutes)
    2. Friction massage of the lateral knee
    3. Some sort of resisted dorsiflexion with a band around my quad or the back of my achilles
    4. Some sort of squat that gaps the joint (i.e., a towel behind the knee or a voodoo band wrap)
    5. Some sort of one-legged hip rotation with resistance
    6. Glute work (clam shells, monster walks, etc.)
    7. General strength (e.g., Romanian DL, dumbell press, etc.)
    8. Ice
  10. Ask: "Do I really need surgery?" Meniscus injuries are surprisingly common, particularly after the age of 35. A common clinical intervention is surgery. It is, perhaps, too common. After I injured my knee I was told that if I was an elite athlete, or under the age of 35, I would be a candidate for surgery. But since my future most likely has more arthritis than gold medals, I should probably adopt a conservative approach. I was thankful for the advice. BJJ Europe recently reported on a recent Finnish that study noted sham surgery (i.e., a placebo) was as effective as  arthroscopic partial meniscectomy. Furthermore, there are a number of studies that report that physio is as effective as surgery at six month and twelve month follow-up. That said, if you've got something "severely wrong" or if your knee locks up -- something my wife described to me as "like a stick in your spokes" -- you need surgery. If not, give 12 weeks of physio a try.
  11. Adjust your game. My GP is also a friend and I asked him if I should stop training. He said: "The last thing a guy your age needs is an excuse to be less active. Keep training!" So I keep on training. That said, I've had to radically change my game to minimize the chance of injury. For me, the goal of BJJ is no longer "submit the other guy". It's now "keep training without screwing up my knee." Certain techniques are -- for now -- out of my repertoire. Unfortunately, some of them were pretty fundamental! I now avoid closed guard and most takedowns. My goal is to keep my game as closed chain as possible (e.g., foot on the floor) to avoid sheer stresses through the knee. This approach greatly limits my game. For example, I can't really pull guard so much as pull someone down on top of me (i.e., pull side control). It's not a great position but at least I can still roll. I have also taken some inspiration from Gordo Correa and really started to work on my deep half guard game. Again, it's a really terrible position for me but at least I can keep training (n.b., if you spend a lot of time on the bottom of deep half you might want to invest in some head gear to protect your ears!). My top game is largely unchanged but I try to play a pressure game using the Tozi pass. In short, embrace the opportunity to train from a position of weakness!
  12. Adjust your training. It's not enough to change BJJ; adjust the rest of your training. Use the basic rule that if it hurts a lot, don't do it. But if it hurts a little, it's might be okay. That said, ask yourself: "Do I really have to do ass-to-grass squats?" Maybe a few months of Romanian dead lifts aren't such a bad thing. 
UPDATE! A few more things...

  • Get knee sleeves. They really help. I've started using my classic Tommy Kono's (available at Rogue) and they're great. They just seem to keep my patellas in the right place and provide a sense of stability, particularly for no-gi. That said, they're not perfect in that they slip and bunch up behind the knees. I've talked to a few people who swear by the Cliff Keen air brace. 
  • Try supplements. I don't completely believe in their effectiveness but they seem to help. I've been taking Webber Osteo Joint Ease and my knee is getting better. That said, the supplements might actually remind me to do physio... 
I hope this helps!