The Injury
The ACL (anterior cruciate ligament) is the most important of the four ligaments which stabilise your knee. It’s is a strip of connective tissue which inserts at the front of the bony plateau at the top of your tibia (in your lower leg) and crosses to the back of the distal part of the femur (in your upper leg.) Its major functions are to resist your lower leg being drawn forward and/or twisted in relation to your upper leg.

The other three ligaments in the knee are the PCL (posterior cruciate ligament) which, by contrast, inserts towards the back of the tibial plateau and runs forward to the front part of the femur. It forms a cross with the ACL, hence the name “cruciate” and the “anterior/posterior” part comes from where the ligament attaches to the \emph{tibia} (not the femur.) (The other two ligaments are the LCL, or Lateral Collateral Ligament (on the outside of the knee) and MCL or Medial Collateral Ligament (on the inside of the knee.)

The major ligaments of the knee.

ACL tears are common sports injuries, especially in sports that involve a lot of darting, landing, or changing direction, such as football (both the American and soccer varieties) and basketball. One man I met at physical therapy had torn an ACL on five separate occasions (getting it reconstructed in between, of course, he only had the two legs.) Women are more likely to tear an ACL than men, but at the time it happened to me, the only ACL tearing incident I’d heard about was that of the male English footballing legend Michael Owen, who tore his ACL in 2006 World Cup against Sweden. You can actually watch him do it here: https://www.youtube.com/watch?v=LoFimQmMrbM You’ll see that Owen isn’t touching anyone, or kicking the ball at the time. Non-contact tears like this are very common; you don’t need to be tackled or kicked to tear an ACL.

Unlike many, mine was not a non-contact tear. I was doing stand-up randori with a friend at my martial arts class. We were the only two people in the class at the time, so our instructor, Robert Miller, was watching us closely. We were outside on grass, and wearing athletic shoes. My friend is a fair bit bigger than I am, so was really putting my all into my attempts to throw him. I was feeling pretty good, because I’d just managed to get an seoinage throw to work. We were in the last few seconds of the round and I managed to line everything up for a good osotogari leg sweep with my right leg. I didn’t get it cleanly and he didn’t go down right away. So I did what you do to force it: I planted my sweeping leg, and attempted to use every atom in my body to force him back over it. He bore down to resist. I pushed hard…but instead of him going back, there was a pop from my right knee and I found myself on the ground, yelling and clutching my knee, with a very worried looking practice partner looking down at me and wondering what the hell had happened.

The intense pain didn’t last long, and within two minutes I was able to get to my feet and limp away. (We finished the class there.) The back of my calf felt tight at the top, near my knee (I now know that was because when your ACL isn’t there to resist anterior draw of the tibia relative to the femur, your gastroc muscle tries to do that job instead. The tightness was my gastroc freaking out at all the new work it was going to have to do.) But I was ok, I thought, I’d just strained my knee or my calf in some way, and a little ice and elevation would have me fixed up in a couple of days. Deep down I knew that the popping sound I’d heard was a bad sign—that people reported hearing such noises when their ACLs went—but, honestly, I thought I was ok—it just didn’t hurt that much any more. Anyway, I iced, I elevated. I walked funny. But I didn’t think I I’d done anything that wouldn’t heal itself in couple of days. More fool me.

The next night I was teaching karate at Washington University. I was demonstrating a technique, shifting forward in stance to block before grabbing and pulling someone into your punch. And as I shifted forwards there was another crack from my forward knee—this time it felt like the noise was from the femur slipping against the tibia—and I found myself back on the ground, with more yelling, this time with a few more alarmed people looking down at me. Everyone had heard the crack. And my knee had just collapsed on me.

Diagnosis
That collapse was surprising and unexpected enough that I called my GP the next morning. Robert Miller came with me when I went to see her. She asked me what had happened and performed a few tests for knee stability, including one with which I am now very familiar— the Lachman test—the standard clinical test for ACL function. Then she said: “I’m not totally sure, but going from what you’ve said, the way you are holding your leg when you stand, and from manipulating it, I think you might have torn your ACL. Anyway, I’m going to send you to an orthopedist, so we can find out for sure.”

And honestly, I thought—naah. What does she know? She’s just a GP. My leg is probably fine. I’ll go and see the orthopedist and they’ll tell me it’s just a strain. (Looking back I find it easy to recognise the element of denial— a commonly reported response in the sports psychology literature—in my own process.) So I went to see the orthopedist. He repeated the Lachman test, immediately diagnosed an ACL tear and scheduled me for an MRI to try to find out what other damage I might have done. He also gave me a brace for my leg, to try to minimise any extra damage I might to the soft tissues until we figured out just how stable my leg was (at this point there was some question about whether I might have damaged the LCL at the same time as the ACL.)

One of the sad things about the injury and brace was that it took me out of FSRI's 2010 demo at the MoBot Japanese Festival. Here I am mic-ed up to present, with Chris looking sad about lacking a partner to demonstrate with.

As it turned out, I only had to wear the brace for a week, but that week was miserable. You wouldn’t think it would be such a big deal—the brace only weighs a few pounds and since I was injured anyway, it’s not as if I was walking normally before I started wearing it. So let me break down the ways in which wearing it was bad. First, it locked my leg in extension, making it impossible to bend my knee. I couldn’t ride my bike, and I couldn’t walk normally—a major disruption to my lifestyle, though since classes hadn’t yet started at the University where I teach, I didn’t need to get to work each day, and so didn’t need to ride my bike as much. But you only have to go without bending your knee for a few hours to really, really develop a serious yen to bend your knee. When I took the brace off to shower I would attempt to bend it but the hours of extension had shortened the quadriceps around it to such a degree that bending it was slow torture. The additional weight of the brace puts extra strain on your hip flexors as you walk (you end up walking as if your braced leg was a pendulum—something you have to swing forward as one piece, like a crutch) tightening them on the side with the brace. This in turn puts extra pressure on your lower back, leading to much achey-ness. I also to sleep in the brace, which is not so easy, and meant that I was getting less sleep, and with it less recovery.

I haven’t mentioned the worst part yet, which is that in the week of wearing the brace the muscle melted off my right leg like warm butter. All those years of training and building up quad and hamstring strength disappeared in a few days, leaving my right leg about half the size of the left. It was this, I think, that really brought home to me that I had to take the injury seriously. I couldn’t look at my shrivelled right leg next to the as-yet still muscular left one in the mirror and not realise that something had gone very very wrong here.

The results of the MRI came back, confirming that I had a complete ACL tear, but no other serious problems (except that I was as incapable of lying completely still for 40 minutes as a 2 year old on Red Bull. Doctors from then on would frown and shake their heads over the “movement artefact” on my MRI.) I was allowed to take the brace off, and proscribed physical therapy for a few weeks while the inflammation from the initial injury went down, and while we considered options for surgery—the topic of a future instalment of this account.

We invite you to follow us as we kick off a wider exploration of the fighting arts and combat sports and all related topics. If you found our old site useful, the new one will be packed with even more research, news and training ideas.

And we’re just getting started.

Although the muscles of the core are often targeted (efficiently or otherwise) in conditioning exercises, the numerous articulations of the spinal column will be involved in transmitting the forces of all motion that occurs in all three planes of movement (sagittal, frontal and transverse). Conditioning the core is important and useful, but martial artists in particular place much stress on the spinal column through conditioning exercises, skill training and either competitive or training sparring/Randori etc. Overuse injuries develop over time, making them harder to notice and correct, especially in settings where training practices that aggravate them are given inflated value and encouraged with no thought to long-term injury prevention and performance.

Several styles of karate, tae won do and other arts place a strong emphasis on long and deep stances. The rationale given for this is typically that it will develop strong legs, although the training may involve static holding of the posture or moving in sport-derived distances, which don’t necessarily resemble the movements common to actual fighting. The front stance of these arts tends to look highly similar, and the movement dysfunctions that excessive practice may lead to are a common sight among longtime practitioners. Many long time karate or TKD stylists exhibit a lordotic posture with excessively protracted shoulders, anterior pelvic tilt (the front of the pelvis tilts down towards the feet) and hip/foot turnout. This posture may be encouraged in lordosis-prone individuals and can lead to altered muscular recruitment patterns and the accompanying reduction in performance and increased overuse injury risk (prime movers are ‘turned down’, synergists take over, movement quality and joint health suffer). The resulting muscular impairments lead to changes in spinal posture, such as increased lordosis or kyphosis. Both are naturally present in healthy spinal columns, but an excess of either creates a cycle of muscular impairment and altered joint action. Both conditions may exist singly or overlap (see Norris, 1995), and in either case are associated with predictable patterns of injury and performance deficits. Recall the image of a tower stabilized by guy wires; if one cable is slack or too tight, what happens to the other cables? What happens to the distribution of force on the tower?

Since the long stance that leads to exaggerated lordosis is often encouraged by instructors who value a particular set of aesthetic qualities, the pattern may be reinforced without correction for long periods of time. Overuse injuries occur when a joint, muscle or other component of the kinetic chain is subjected to repetitive physical stress without an adequate amount of recovery or corrective programming.If conditioning exercises reinforce these movement patterns, or if one is unable to perform exercises without the altered posture, the stresses placed on the spinal column are multiplied.

With regard to posterior element (i.e., the rear aspect of the body) overuse injuries from long stances, Zetaruk (in Kordi, Mafullli, Wroble & Wallace, 2009) advises that:

…inadequate abdominal strength, poor stabilization of the trunk, or   increased lumbar lordosis may develop low back pain by placing additional stress on their posterior elements in a front-stance position. Pain is typically  present on spine extension, but some tightness in the lumbar region may benoted on flexion. (Kordi, et al., 2009)

Ironically, it is these very muscles and structures that will be further injured through use of long stances without appropriate pelvic stabilization. These individuals will eventually show signs of Dr. Vladimir Janda’s lower crossed syndrome (as cited in Norris, 1995), in which the abdominal muscles and gluteals are chronically inhibited while the erector spinae and hip flexors are shortened and dominant. This posture inhibits the action of the gluteal and abdominal muscles’ ability to stabilize the lumbar spine and hips (Norris, 1995), altering the recruitment patterns involved in moving or executing a technique. In the case of arts that also place an emphasis on generating impulse by rotating the hips, the posterior facets of the lumbar spine are subjected to compressive and torsional forces as the anterior facets are stretched. More time spent moving in the ways that cause such overuse injuries will only contribute to the problem.

Zetaruk (2009) mentions several strategies for addressing this cluster of problems, primarily through strengthening and corrective exercise programs targeting the muscles and movements. One major intervention that can produce results is to simply shorten the length of the stance, especially in adult populations with already-developed lower crossed syndrome. De-emphasizing static stance training and incorporating more natural movement is recommended. The “appropriate” length of a stance can be a hot topic of debate and rancor in some circles, and tend to have little practical value. For this discussion, the use of the term will refer to a posture that allows one to move efficiently and freely for evasive or offensive actions without placing undue stress on any element of the lower limb, hip, pelvic or spinal joints. Regardless of the specific art or sport, if one’s forward stance is so long that posterior pelvic rotation and the maintenance of a neutral spine becomes difficult, spinal overuse injuries and accompanying overuse of the ankles, knees, hips and shoulders will develop.

As mentioned but not elaborated upon by Zetaruk (2009), corrective programming to counter these problems is necessary. A strengthening and stretching/SMR program can be created, which might include the following:

• Regular post-training static stretching and SMR of the latissimus,  erector spinae, and hip flexor muscles; Pre training stretching and SMR as appropriate; thoracic mobilization with a foam roll before and after class, if kyphosis is an issue.
• activation and functional strengthening for the abdominals, gluteus maximus and hamstring muscle groups before training, with an emphasis on isometric and eccentric endurance before rapid force production is prioritized.
• Replace full situps with crunches and isometric, multidirectional planks as well as eccentric-phase emphasis crunches. Full sit ups place more of the work load on the hip flexor groups (particularly the psoas), which create more forward pelvic tilt, placing stress on the lower back and aggravating lordotic postures and the associated abdominal-gluteal inhibition.
• Respect the need for recovery. Pay attention to how strength programming may effect skill work. Periodize your training to provide higher or lesser intensity in areas prone to imbalance, and whenever possible link it to the demands of skill training so that overuse and overload can be avoided.

For examples of the above stretches and exercises, drop one of us a line. For consultation, weekend seminars or corrective programming guidance specific to your group and practices, contact Bob or myself.

 References:

Kordie, R., Mafulli, N., Wroble, R.R. &Wallace, W.A. (Eds.) (2009). Combat Sports Medicine. Springe-Verlag, London Limited. 162-163.

Norris, C.M. (1995). Spinal stabilization 4: Muscle imbalance and the low back. Physiotherapy, 81 (3), 127-138.

Rhabdomyolysis is the destruction of skeletal muscle leading to the release of the muscular tissue components  creatine kinease (CK) and myoglobin into the bloodstream (Huerta-Alardin, Varon & Marik, 2004). These components can pose a potential serious risk to the kidneys as they are cleared from the blood stream. Rhabdo can be caused by numerous factors, and can cause symptoms ranging in severity from mild to life threatening. Classic symtpoms include muscle pain, weakness and darkened urine (ranging from pinkto cola colored). Blood tests reveal elevated serum CK and myoglobin levels. More severe cases may present symptoms such as malaise, fever, tachycardia, nausea and vomiting (Huerta-Alardin et al., 2004). In severe cases acute renal failure can result, requiring medical attention.

Drugs such as statins and antipsychotics, antidepressants, sedatives, antihistamines, amphetamines and alcohol can also cause rhabdo via abnormal muscular action (or inaction). For fighting arts and sports coaches, students or athletes taking these drugs present a possibly higher risk of rhabdo, particularly in higher risk environments, such as prolonged heat or muscular injury. Overuse of diuretics or cathartics can contribute to this in high heat and humidity environments (Huerta-Alardin et al., 2004). Careful review of a client’s PAR-Q (physical activity readiness questionnaire which teachers of fighting arts would do well to adopt when accepting new students) or an athlete’s medical history are valuable sources of preventative information.

Strenuous exercise is also a common cause of rhabdo (Huerta-Alardin et al., 2004).  Excess strenuous muscular activity in general can pose a risk, and neurological conditions such as dystonia or tonic-clonic contractions Exertion in high temperatures poses an increased risk, as muscle may be damaged by thermal or traumatic factors (Huerta-Aladin et al., 2004). Trainers and coaches can mediate this risk by maintaining a sensible level of exertion and providing adequate recovery and hydration. Crush injuries and general muscle injuries also account for many cases of rhabdo (Huerta-Alardin et al., 2004). For activities that involve high amounts of contact, such as American football, pugilistic arts/sports or high-impact sports like Judo, the risk of muscular trauma is higher, indicating that participants may be more likely to suffer rhabdo by this cause. An athlete who has sustained such an impact(s) should be monitored closely for signs and
symptoms of serious complications.

Interestingly, anecdotal stories of “hard training” in martial arts circles often mention “pissing blood” or dark colored urine in the days following significant trauma. In consideration of rhabdo’s causes and physiological mechanisms, I wonder if the majority of practitioners who recount such training are actually describing rhabdo, as opposed to the results of direct kidney trauma per se. Tales of forced, extreme stretching or hard forced sparring “slaughter lines” of fresh opponents for long durations are often equated with some honorable or admirable aspect of training, but such practices are usually a sign of questionable instruction. Considering the risks posed by such significant muscular trauma such practices have no place in a responsible school or club.

Among the causes of rhabdomyolysis impact trauma is of particular interest to practitioners and coaches of the fighting arts and sports. Although literature on rhabdo as a specific result of physical violence (in the form of beatings or participation in a combat sport or recreational martial art) are relatively few, the role of direct muscular trauma as a causal factor is associated with the condition (Huerta-Alardin, Varon & Marik, 2004).

By their nature, pugilistic arts such as boxing, kick boxing, Muay Thai, MMA and the many forms of “knockdown” full-contact fighting exposure athletes to impact trauma from strikes of varying intensities. Wrestling and grappling arts, such as Greco-Roman wrestling or Judo, expose athletes to regular impacts with the floor from various heights and angles and at various intensities. And among the various so-called traditional and modern martial arts, practitioners may engage in any of the practices above, as well as “impact conditioning” of various body surfaces. The latter may take place in each class, or may be irregularly practiced in a given duration (it’s worth noting that such “hardening” is particularly common in many branches of Chinese martial arts and the Naha schools of Okinawan karate and it’s offshoots; many of these schools feature it as a specialty).

Given that specific information regarding rhabdo and the fighting arts and sports is harder to come by, useful information can be drawn from case studies of rhabdo as a result of violent assault, although the examples may be more extreme than the physical violence typical to martial arts training in general and most competition. A review of two case studies of punitive beatings in South Africa by Bowley & colleagues (Bowley, Buchan, Khulu & Boffard, 2002) describes two men who received severe, prolonged beatings from both punches and kicks and from a whip-like weapon. In both cases, extensive soft-tissue damage resulted, leading to the classic physiological signs and symptoms of rhabdo (Huerta et al., 2004), including acute renal failure. One of these individuals survived ARF due to aggressive haemodialisis treatment , eventually regaining normal renal function within several months (Bowley et al., 2002). The second of these individuals did not receive medical attention until two days after a severe beating, and died before haemodialysis could be started. In the latter case the delay in presentation seems to have led to a fatality that may have otherwise been avoidable with prompt initiation of treatment.

Although the cases presented by Bowley & colleagues (Bowley, et al., 2002) are not an exact match for the conditions that a fight athlete or recreational martial artist will likely face, they are instructive as reminders that fighting arts and sports carry a higher risk of direct musculoskeletal injury. A review of boxing, wrestling and “martial arts” injuries presenting in emergency rooms in the US (out of 7290 cases of visits attributed to one of the three activities) (Pappas, 2007) found that contusions and fractures were among the most common injuries. Contusions were reported at 27% of total injuries from boxing, 16% in wrestling, and 23% in martial arts (Pappas, 2007). Given that the probability of a musculoskeletal injury is high in these sports and arts, coaches, athletes and participants need to be knowledgeable of the causes and the early signs and symptoms. Fight athletes competing in high-contact activities or training should be advised as to the necessity of rapid medical attention and treatment in suspected cases. Recreational martial artists participating in vigorous, high contact training should be similarly informed, and the need for such intensity should be carefully determined and placed in a training program that allows adequate recovery between such intense practices. Participating in abusive training is to be discouraged, and seeking treatment for suspected cases of rhabdo should be encouraged and supported by the instructor(s) and culture of the group.

Students who have sustained muscular impact trauma from various forms of conditioning (“kitae”, etc.) should be monitored for the signs and symptoms listed earlier in this article. In extreme cases, 24 hours is the window of opportunity to begin aggressive hydration and dialysis before kidney damage or failure sets in. “Extreme” workouts or stretching, especially with unconditioned or under prepared students are to be avoided, and students should be advised to maintain adequate hydration and recovery rates between training session following intense training or in predisposing conditions (heat, prolonged heavy impact, use of certain drugs, etc.). If you regularly practice impact conditioning, consider programming it into a training schedule that allows for  a few days to a week of recovery between sessions, and that separates it from intense weight training or impact from falls and strikes by days or weeks.

References:

Bowley, D.M.G., Buchan, C.,  Khulu, L.,  Boffard, K.D. (2002). Journal of the Royal Society of Medicine 95, 300-301.

Huerta-Alardin, A.L., Varon, J, & Marik, P.E. (2004). Bench to bedside review: Rhabdomyolysis- an overview for clinicians. Critical Care, 9 (2), 158-169.

Pappas, E. (2007). Boxing, wrestling and martial arts related injuries treated in emergency departments in the United States, 2002-2005. Journal of Sports Science and Medicine, 6 (CSSI 2), 58-61.

Tea or Cola Colored Urine Associated with Rhabdomylosys