Latest / The Total Knee Success Podcast: Your Essential Resource for Navigating Total Knee Replacement / Episode 80: Prehab for Weak Quads (Strength, Activation, and Why It Matters Early)

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Episode 80: Prehab for Weak Quads (Strength, Activation, and Why It Matters Early) · The Total Knee Success Podcast: Your Essential Resource for Navigating Total Knee Replacement

• 0:00
  If your quad feels weak, the answer is not always
• 0:02
  try harder. Sometimes the answer is train smarter,
• 0:06
  and oftentimes that's the answer. Are you ready
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  to get back to what you love after knee replacement?
• 0:14
  The Total Knee Success podcast is your trusted
• 0:17
  guide with practical tips, evidence -based strategies,
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  and no fluff. It's not personal medical advice,
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  just solid education to help you manage pain.
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  regain mobility, and get back to living the life
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  you love. Let's dive in. Welcome back to the
• 0:34
  Total Knee Success podcast. I'm Michelle. This
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  is the second episode in our four -part prehab
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  series, What to Do Before You Have Knee Replacement
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  Surgery. If you want to go through the full series
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  in order, I would start with episode 79 first.
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  In episode 79, we talked about knee stiffness,
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  range, swelling patterns, and the daily habits
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  that can make your knee easier to work with after
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  surgery. Today, we're moving into the second
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  theme that shows up in almost every prehab conversation
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  I have, and that's quad -weakness. Your quadriceps
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  are the large muscles in the front of your thigh.
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  They help straighten your knee, control your
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  knee as you lower down, and support you in the
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  moments that tend to expose weakness fast, getting
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  up from a chair, taking a step, and going down
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  the stairs. By the end of this episode, you'll
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  have a clearer understanding of why quad weakness
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  is so common before surgery, why it tends to
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  show up early after surgery, and what kinds of
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  prehab choices often translate into a stronger
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  start. Most people don't walk into my clinic
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  saying, my quads are weak. What usually happens
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  is I see it in the testing. It shows up in something
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  like a 30 -second chair stand, a step task, or
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  a direct strength screen where the quad just
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  isn't giving what it should. Once we see that,
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  the next question is whether you're dealing with
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  a true loss of muscle capacity, meaning less
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  muscle mass and less force available, or whether
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  it's more of a nervous system problem where the
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  quad isn't being recruited well when you try
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  to use it. Sometimes, it's both. And that's one
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  reason pre -op physical therapy can be so helpful,
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  because it helps you train the right problem.
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  If you've lived with knee pain for a long time,
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  your body adapts. You stand with less load on
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  your painful side. You shorten your stride. You
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  use the other leg to push up from chairs. You
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  avoid stairs when you can. These are normal adaptations
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  to pain. Do any of them sound familiar to you?
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  Your body is trying to protect you. Over time,
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  those patterns can reduce strength and also change
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  activation, which is the ability to recruit the
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  muscle fully. That means your quad isn't getting
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  the same repeated loading and full -range work
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  that it used to. The muscle can lose capacity
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  And your nervous system can also get used to
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  holding back. So even when you try to fire your
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  quad, you don't get a full contraction the way
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  you expect. Now layer in swelling. Fluid and
• 2:54
  tissue pressure inside and around your knee can
• 2:57
  make the capsule tighter and more sensitive.
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  That same pressure can also change the signals
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  your nervous system sends to your quad. This
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  is one reason swelling and pain can reduce how
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  strongly your quad contracts, even when you're
• 3:10
  trying hard to get it to contract. Here's the
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  context that makes this next step more effective.
• 3:16
  If your quad feels weak, the answer is not always,
• 3:19
  try harder. Sometimes the answer is, train smarter.
• 3:23
  And oftentimes, that's the answer. Let's use
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  the same made -up example from episode 79. Someone
• 3:29
  will call Megan. She isn't a real person, but
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  she reflects what a lot of people describe before
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  knee replacement surgery. Megan has a surgery
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  date on the calendar. Her knee is stiff at the
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  start of the day and her knee swells by evening.
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  When she stands from a chair, she leans to the
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  opposite side and pushes off her arms. She avoids
• 3:48
  stairs, and when she has to do stairs, she pulls
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  up with a good leg and follows with the leg she's
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  about to have surgery on. She tells herself she's
• 3:56
  out of shape. In reality, her quad has been living
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  under a protective set of rules for a long time.
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  One reason this is worth addressing before surgery
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  is that the quad's strength before surgery is
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  linked to function afterward. In a study that
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  followed people through total knee replacement,
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  preoperative quadricep strength played a major
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  role in predicting functional performance a year
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  later on tasks like stair climbing and timed
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  up and go testing. That doesn't mean your future
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  is decided by one number. It means quad strength
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  is one of the levers you can work on ahead of
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  time. There's another reason the quad deserves
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  attention, and that's what happens right after
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  surgery. Classic research shows that quadricep
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  strength drops sharply early after surgery. And
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  a big part of that early loss comes from reduced
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  voluntary activation. Not only muscle size changes.
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  You can be motivated and still feel like your
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  quad is not responding. So, prehab for weak quads
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  is not about getting a perfect strength score
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  before surgery. It's about giving your quad as
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  much capacity and as much activation practice
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  as possible. so the early phase is easier to
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  navigate. There's also evidence that prehab can
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  help in the early window after surgery. Across
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  studies, prehab programs tend to show the most
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  consistent benefit before surgery and into the
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  first few months after, which is when strength,
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  walking in stairs, can feel most demanding. That's
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  why this series is focused on what shows up early.
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  What changes when you train your quad with knee
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  pain in the background is how your body responds
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  in the moment. If Megan does a classic seated
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  knee extension, which is just kicking her leg
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  out, and it hurts, she may tense up, cut the
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  set short, or unconsciously shift the motion
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  a little bit, maybe use a little momentum just
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  to get through it. If she does a squat and her
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  knee swells more that night, she might back off
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  the next time, which is understandable. If she
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  does a step up and her knee feels unstable, she
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  stops trusting her leg. This is where a lot of
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  people assume their quad is weak because they
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  are not tough enough. And that's really not what's
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  happening. When pain and swelling are present,
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  the nervous system can create an activation deficit,
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  sometimes called arthrogenic muscle inhibition.
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  The quad is not just weak, it's inhibited. And
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  that's your body protecting yourself. That doesn't
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  mean you can't train it. It means you may need
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  a plan that works with that reality. So what
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  does that look like in prehab? First, You train
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  quad strength in positions your knee can tolerate.
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  For some people, that starts with isometrics,
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  pushing without movement. For some people, that
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  starts with a partial range. And for some people,
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  that starts with more hip dominant work that
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  still load the leg. The goal is not to avoid
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  knee work at all. The goal is to build a bridge
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  from what your knee tolerates now to what you
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  will need after surgery. A lot of quad prehab
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  ends up looking like a few simple building blocks.
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  Quad sets and short arc quads help you practice
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  turning the muscle on without provoking the joint
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  too much. If you tolerate more, straight leg
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  raises or a small amount of knee extension work
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  can build strength through a limited range. Then
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  you carry that into a functional drill like supported
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  sit to stand or a small step up where your quad
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  learns to do the job it will be asked to do after
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  surgery or with function in general. This is
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  a great place to work with your physical therapist
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  because they can help you pick the right exercises.
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  Adjust the range and make sure you're getting
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  a real quad contraction without flaring up your
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  knee. If you're looking for additional education,
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  I'll be publishing a prehab handbook soon called
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  the knee replacement game plan. Stay tuned and
• 7:42
  if you want to be notified when it's ready, sign
• 7:44
  up on TotalKneeSuccess .com. Second, you train
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  activation on purpose. This is where people often
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  miss the mark. They do the reps but they never
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  practice the skill of turning the quad on. And
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  that skill is important for walking, for getting
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  up from chairs, and for keeping your knee from
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  feeling like it's buckling when you're tired.
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  But this can be challenging. This is also where
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  neuromuscular electrical stimulation, NMES, fits
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  into the conversation for some people. And let's
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  be clear about what the evidence base is here.
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  Most of the research support for NMES in knee
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  replacement is after surgery, when the quad can
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  struggle to turn on and early strength drops
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  are common. When NMES is started early after
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  surgery and used at a meaningful intensity, studies
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  suggest it can help improve early quad strength
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  and early function. Before surgery, the evidence
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  base is smaller, but there are two reasons some
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  people and their therapists consider using NMES
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  in prehab. There may be more, but I'm going to
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  cover two of them here. It's in the activation.
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  If your quad activation is poor, NMES can help
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  you practice producing a stronger contraction
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  then you're getting on your own, which can make
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  your strengthening work more productive. The
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  second is familiarity. If your therapist plans
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  to use NMES after surgery, learning the setup
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  before surgery can make it easier later because
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  you already know what it feels like, where the
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  electrodes go, and what a real contraction should
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  feel like. NMES tends to work best when it's
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  used often enough and at a dose that actually
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  creates a strong contraction. And that can be
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  hard to accomplish if the only time you use it
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  is during occasional clinic visits. That's why
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  a home unit can be a viable option for some people,
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  as long as you're using it properly and following
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  a plan that your therapist recommends. The best
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  path is to learn it with your therapist first,
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  confirm it's appropriate for you, and get clear
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  instructions for placement, intensity, and how
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  often they want you to use it. NMES isn't appropriate
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  for everyone and can be dangerous in some cases.
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  so make sure your therapist or provider clears
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  it based on your medical history and any implanted
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  devices. If your therapist recommends a home
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  unit and helps you choose the right setup, I
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  do have an option in my Amazon store, and I'll
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  link that in the show notes. If you purchase
• 10:03
  through that link, I may earn a small commission
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  at no additional cost to you. It helps support
• 10:08
  these podcast episodes, so thank you. Third,
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  you connect your quad work to the movements that
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  will show up right away after surgery. That's
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  getting up from a chair with less reliance on
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  your other leg, stepping up with control, and
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  practicing the lowering part of a step or sit
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  down so your quad learns to handle the work instead
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  of avoiding it. You're not training for performance,
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  really. You're building familiarity with these
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  exact patterns that tend to be hardest early
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  on. Later on, you can train for performance.
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  And even though this episode is focused on your
• 10:42
  quad, it helps to remember that your quad does
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  not work alone. Your hip muscles, especially
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  the glutes and hip abductors on the side of your
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  hip, help control how your leg lines up when
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  you stand and walk. Your calf muscles help with
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  push -off and with controlling lowering when
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  you go down a step. When those muscles are undertrained,
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  your quad has to do more of the job, and your
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  knee can feel less stable. In prehab, it's often
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  useful to include a few exercises that strengthen
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  the hip and calf alongside quad work, so your
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  whole leg is supporting you, not just one muscle
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  group. And this is where Megan changes her story.
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  Instead of thinking I'm out of shape, she starts
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  thinking my quad is undertrained and underused
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  and I can work on that. She starts with a few
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  sessions a week that focus on strength and activation
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  and she puts the work earlier in the day when
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  her knee is less swollen. She keeps the sessions
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  short enough that her knee does not swell and
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  make the rest of her day harder. She practices
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  getting up from a chair with more symmetry. She
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  practices a small step up with support and pays
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  attention to her quad doing the work. Over a
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  few weeks, her knee is not magically pain -free,
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  but her leg starts feeling a little more dependable.
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  That's what reassures Megan because she can feel
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  her leg starting to cooperate again. There's
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  another important point here for weak quads.
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  People often think prehab strength has to be
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  heavy to count. It does not. The best plan is
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  the plan that you can actually do. If your knee
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  tolerates heavier training, great. If it does
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  not, you can still build strength through consistent
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  effort, appropriate load, and enough weeks of
• 12:22
  practice. If your surgery is close, the benefit
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  may be less about building huge strength changes
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  and more about building familiarity and confidence
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  with the movements you'll be asked to do soon.
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  Sometimes people start to worry that strengthening
• 12:35
  will wear down their knee faster, especially
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  when surgery is coming up. And that concern makes
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  sense, but the research on exercise and knee
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  osteoarthritis does not support the idea that
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  appropriate exercise accelerates joint damage.
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  For most people, strength work is protective,
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  not harmful, as long as it's dosed appropriately.
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  Dosed well in real life usually looks like enough
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  work to challenge the muscle without a flare
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  that hangs around for days. If strength sessions
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  consistently lead to a big spike in swelling
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  or pain that lasts, it usually means the dose
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  is too high, the timing is off, or the exercise
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  choice needs to be changed. That's a great conversation
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  to have with your physical therapist. One more
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  thing that can help you set expectations. Even
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  if you do excellent prehab, your quad will still
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  feel different after surgery. Early weakness
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  is common, and activation can be slower to return
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  than you might expect. The point of prehab is
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  not to prevent that. The point of prehab is to
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  make you more prepared to work through it. One
• 13:42
  quick safety note. If you have sudden major swelling,
• 13:44
  redness, fever, or other symptoms that concern
• 13:47
  you before surgery, make sure you contact your
• 13:49
  provider. And before we wrap up, if you're listening
• 13:52
  and thinking, yep, that's me, make sure you're
• 13:55
  signed up for the Total Knee Success Insider
• 13:57
  Newsletter. You'll get practical education that
• 13:59
  matches your phase of healing and helps you know
• 14:02
  what to expect. Click on the link in the show
• 14:04
  notes or go to TotalKneeSuccess .com. And if
• 14:07
  you want some extra support making sense of pain
• 14:10
  after surgery, my book Making Sense of Pain After
• 14:13
  Knee Replacement is on Amazon and Kindle. It's
• 14:16
  a practical guide to interpreting swelling, knee
• 14:18
  stiffness, soreness, and setbacks after surgery.
• 14:22
  And I'll link that in the show notes. In episode
• 14:25
  81, we'll stay in prehab and shift the focus
• 14:28
  to low stamina, steps, pacing, and building capacity
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  before surgery without lighting your knee up.
• 14:36
  Thanks for joining me. I'm Michelle and this
• 14:38
  has been the Total Knee Success Podcast. This
• 14:44
  podcast is for educational purposes only. Discover
• 14:47
  more at TotalKneeSuccess .com and be sure to
• 14:51
  subscribe and share because every step forward
• 14:54
  takes you closer to living the life you love.