By Rob Shaul, Founder
BLUF
Three weeks of Athletic Truth Group (ATG)/The Knees Over Toes Guy exercises resulted in minor to significant to knee pain reduction for all the lab rats who completed the programming.
Background
Knee arthritis and knee pain affect many athletes, especially those past 40. Ben Patrick is known as the Knees over Toes Guy and prescribes deep squat, heels elevated, lower leg and hamstring exercises to reduce knee pain.
We wanted to test 3 weeks of these exercises on MTI athletes who suffer from knee pain and solicited remote lab rats for this mini-study.
I am personally one of those who suffer from chronic knee arthritis and pain, which began in earnest at age 44. I’m 55 now, and standing from sitting, walking downstairs, and running causes knee pain. I can no longer load deep squats or lunges, and even at body weight, my deepent is restricted by knee bend movem pain in both knees.
I’ve personally tried over-the-counter and prescription pain pills, as well as knee injections, to no effect. I wanted to try the ATG exercises and recruited fellow knee pain sufferers to join me.
Study Design/Deployment
A small, quick mini-study is a great tool for us to accomplish several things before conducting a larger, longer, more involved study. First, we test the practicality and “churn” the testing protocols in the study. Second, mini-study results can help us quickly identify obvious paths to follow with further research. Mini Studies are the primary tool we deploy for MTI’s Mission Direct Research.
The “mission-direct” emphasis of MTI’s research significantly impacts study design. Ideally, our mini-studies deploy elements that are practical and commonly used/experienced by our mountain and tactical athlete population. As well, ideally, our mini studies are simple enough that the same study can be completed by others, without special equipment, techniques, or expertise.
This study deployed 14 veteran, remote, MTI lab rats who all completed the same programming.
The three week study followed a 2 days on, 1 day off schedule, and two training sessions alternated. Throughout the cycle the exercises were progressed in volume (more reps or time) but not loading. In all, the lab rats completed 15, 20-minute sessions over the course of 3 weeks.
Training Session 1
(1) 5-12 Minute of Backwards Sandbag Drag, or backward uphill walking on a hill or inclined treadmill
(2) 3-5 Rounds
5x Elevated Reverse Step Ups – 5x each leg, 10x total
5x ATC Split Squat – 5x each leg, 10x total. Scale as necessary by raising the front leg. Increase difficulty by lowering front leg.
10x Calf Raises – both feet at same time
Training Session 2
(1) 5-12 Minute Backwards Sandbag Drag, or backward uphill walking on a hill or inclined treadmill
(2) 3-3 Rounds
10x Elevated Heel Squat
5x ATC Split Squat – 5x each leg, 10x total. Scale as necessary by raising the front leg. Increase difficulty by lowering front leg.
10x Tibialis Raise
Prior to the program start the lab rats described their knee pain. Post-study, they again described their knee pain and specifically were asked if they’d seen any pain reduction.
Results/Discussion
The results are below.
| Name | Age | Wt | Pre Study Knee Pain History | Post Study Knee Pain |
| Anika | 38 | 145 | I am 7 years out of ACL surgery with a baker cyst. I have some quad tendon tendonitis, and go in and out of knee pain/ it explodes on me. Also have bulged disc in the lumbar that seams to correlate with it giving me SI/ lower back pain. Mostly on the right side. Bad knee is on the left. I continue to train, Dirtbike, snowmobile and ski mostly. But always have revolving pain. Curious to see if you have some magic that might finally help. | I would say there was some improvement. Right knee is my problem child, left feels great. My issue’s seam to stem with inactive glutes, and a little quad tendon tendonitis. The backwards sled pull seamed to feel good, and I feel might have contributed to the improvement mostly. The ATC split squats are necessary, and good to work on my bend. Which is still not 100% for the left knee. The elevated heal squats I really felt that quad tendon, but something about It felt good also. My tracking is off and I would get some clicking, so I have mixed feeling about those.
Overall improvement, I think I might keep with it while adding weight to some moves. It is also ski season, and that might of been hindering progress. |
| Andrew | 35 | 162 | I’ve had reoccuring patellar tendonitis and chondriomalacias in the right knee and IT band pain and bursitis in the left. Just your generic overuse injuries. Anyhow, if that profile is interesting or useful to you, please let me know and I can provide more detail. With the aforementioned kids I have limited exercise time but am always willing to try new methodologies. | I took the backwards walk up a hill option. Initially, through the first week I felt an increase in knee pain. Since then my knee pain has slightly decreased from baseline prior to the study, maybe 1 point on a 10 point scale. However, I’ve actually been more impressed with the decrease in hip pain I’ve experienced. I’ve had hip impingement-like symptoms for several years and I think the ATC squats have significantly helped it. I intend to add them to my physical therapy/maintenance routine. |
| Meghann | 24 | 145 | Chronic knee pain due to being an endurance runner, no massive injury event, hard wear and tear | -Noticed knee pain didn’t kick in while as soon while sitting at a desk for as long after about week two
-Did programming before my PT sessions, felt better especially on heavy squats -Think the sandbag dragging is more effective than treadmill |
| Adam | 24 | 162 | Patellar femoral injury that won’t go away | 100% I have been in PT before for this pain and only reduced pain. I dont know if i’m healed, but I feel little to no pain in the tasks that used to cause me pain |
| Dave | 31 | 190 | Chronic knee pain for 5+ years, mostly after sitting for long periods of time, when knees are fully bent for more than a couple of seconds and going down the stairs. | I can’t say I feel much of a difference in my knees but I have had pain in them for 5+ years. I had a 2.5 hour drive last week and they weren’t as sore at the end of it as they usually are so that’s probably a good sign. |
| Dan | 44 | 257 | I ruptured my left patellar tendon in 2014, grew up with osgood schlatter in both knees aggravated by football, wrestling, and track and now run Spartan races a couple times a year. I have also been diagnosed with arthiritis and experience tendinitis in my right knee. | In terms of pain differences:
1) Serious reduction to MCL soreness in both knees. Worse on the left from a ruptured patella tendon in 2014, but the pain is non-existent now. No exaggeration. 2) Area of soreness in the right patella tendon reduced to half / quarter of the size and less intense. 3) Pain changes remain consistent, e.g. do not worsen, through normal day exercises and activity. Often, running aggravated these areas but so now. Maybe longer runs might. 4) Could not walk multiple flights downstairs without handrail use until I sufficiently warmed up. No issues from the start now. 5) Knees felt unstable going upstairs (and painful), not the case anymore. 6) Left knee with repaired rupture was very unstable, weak feeling, and hurt going down stairs, much improved now, getting close to not noticing it. Programming: 1) Seemed spot on all around. Would add weighted ATC splits or go from a higher box to ground level with the front foot if the individual is up to it. 2) Plan to keep these up and include Nordic Curls. |
| Brian | 34 | . | The pain mainly came out as a sharp jolt during and after running and centered on or around my kneecaps, and I would typically experience slightly worse pain for a few days afterwards when my knee was flexed and weight bearing. | Just finished the final workout and here are my thoughts. I will note that this program was very similar to the ATG/Knees over toes program in terms of some of the workouts so I was familiar with many of the exercises. A few points:
I think 2 days might be a little too much for some people starting out. I found my legs feeling pretty beat up after the second days, and think that every other day will produce better results. If need be you might consider combining exercises during the same workout. My knees did feel a little better, but sometimes on the second day they’d feel worse due to being pushed hard during the workout on the first day. Overall I think the time period was a little too short for noticeable improvement. Might consider adding stretching components, even loaded stretching like the Jefferson curl. I feel like most of my issues stem from chronic tightness so perhaps foam rolling and stretching in combination with strengthening will produce better results. |
| Jeff | 41 | 185 | Army Infantry officer 2005-2016, light assignments only. Reservist 2016-2022. L&R knee arthritis diagnosed in service. Left knee debridement surgery in 2016. Right knee MCL pain, no tears, likely due to overcompensation post-left achilles tear surgery in 2021. no ROM issues in knees, back/front squat is fine, still have full strength. | Knees feel a bit better, but I have chronic arthritis so it’s not all gone. I also got additional benefit on both achilles tendons, 1 of which was repaired in 2021.
I liked the ATG split squats, reps were manageable even with more rounds. The squats, step downs, and calf/tib raises were all exercises I did for PT on my repaired achilles. We did sled push/drag too. So I think you can use this program and change nothing for achilles therapy as well. I also liked the 3 on 1 off schedule. This would also work as a M/W/F. I used an 80# MTI sandbag for the drag over my carpeted basement. The area of greatest fatigue was in my traps. After the sessions I had a sore spine/muscles right at the spot a bar would go on a back squat. I’m not sure if it’s due to the weight or the length of the drag (7 min and up). This was surprising because I like the exercise for both achilles and knee therapy. The drag themselves were fine. My grip adapted and I was never out of breath or sweating too much. I’m going to experiment in the coming weeks with how my neck feels with a 5 min drag @80 and 10min drag @ 60 to see how they feel comparatively. |
| Randy | 63 | 207 | I have been dealing with ongoing knee pain from tightness and stiffness as well as joint pain in both knees from osteoarthritis for the last 20 years or so. Left knee had a total knee replacement in 2021. Total right quad tendon rupture in 2013 at the knee cap. Have been diagnosed with a torn meniscus in the past. Numerous knee sprains doing tactical operations, sports and judo while I was on the job. | Knees feel much improved. I weighed in with an earlier email about going downstairs and especially trail hiking and rock scrambling. I feel much stronger and more in control during these activities along with less pain Joe from my standpoint the exercises definitely helped. |
| Marc | 45 | 165 | “Jumpers knee” on one knee. | My knee feels markedly better. It is usually very stiff in the mornings, but it was significantly improved. Also, I found I could do exercises such as lunges without pain. |
| Mike | 48 | 2 x right knee surgeries for torn lateral meniscus, 1 x pkp injection, 3 x additional uflexa injection for “added lunrication”. Pain always returns… is what it is. | Overall I thought the program helped… however, n my case I missed 3 sessions, 2 on purpose due to soreness and 1 for time.
During the training after the 3rd session I always tended to feel soreness and experience some fluid in and around both the lateral meniscus and the lower knee cap. I typically get this when I got at things intensely for longer than the knee can comfortably handle. An every other day program may do my knees better particularly as I am still on skates 3 times a week with hockey. As far as exercises ATC squats always helped with range of motion with both knees and my groin. Deep, unweighted squats typically aren’t an issue for me but tenderness and continued soreness are. Backward drags tend to make the knee sore especially when we increased to 7 min and beyond. |
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| Steve | 37 | 185 | Chronic Patella area pain on my right knee. Symptoms seem to have started after high volume heavy ruck training. Likely aggravated injury due to some reduce mobility on my right leg. Injured right leg in high school, broke tib and fib near ankle. Reduced ankle flexion on right side, lower hamstring pain after sprinting or long duration runs. | Overall, knee feels better than at the start. I experienced way less pain while snowboarding and throughout my day. Stairs felt better. Still work to be done but I’m on the right track for sure.
I did a real mix of the backwards variations. Sled when available, homemade rigs when there wasn’t snow on the ground, some backwards hills and incline treadmill. The sled felt most effective and I’ll be making a drag sled for home use. I think I made a mistake by loading too much too fast. I’ll be continuing with a much more gradual progress. Sled time based progression didn’t seem to cause an issue but I experienced more inflammation when I went heavier with the other movements. I moved pretty quickly to 60# elevated heel squat and ATG lunge. It was a bit much at this stage of my knee rehab, although, it didn’t feel too heavy. 25-35#s seems to be more comfortable. Let me know if you have any questions. |
| Jeff | 47 | 180 | Had ACL replacement in 2011. I still play rugby and recently had ankle surgery after tearing some ligaments. This has recently caused knee pain the physio says is related to calcium build up around the scar tissue. | Really interesting program. I can honestly say while my knee is not 100% pain free but there is noticeable improvement. Before I would struggle both up and down stairs but now there is reduced pain generally going up stairs. I am pain free going down stairs. Additionally, resting knee pain is a light dull ache and that’s probably from just sitting too long.
I did not get to the point of incorporating weight (aside from sled drags). I also mixed up the elevated treadmill walking with the sled drags. My range of motion was beginning to improve this last week. I played a rugby tournament a couple of weeks ago and used the program to reduce swelling and pain following those games. I curious about the theory behind the exercises. I only have persistent pain in one knee and have a loss of mass and strength in that leg. The program definitely helped strengthen that side so I’ll expand on this going forward. Feedback is: great progression on quick and effective exercises. I personally could have used some of the science behind it but otherwise excited to read your conclusions. Hopefully there is something there to reduce the pain further and enable more activities. Many thanks for putting this together. |
| Rob Shaul | 55 | 160 | Chronic arthritis in both knees – used to warm up and go away, but now the pain remains. Deep squats, running over 2 miles and other activities are painful. I’ve tried over the counter and prescription pain killers to no effect. Have also tried knee injections. | 5-10% improvement when standing and walking after resting. There is no difference walking downstairs or deep squatting. Was unable to progress the depth and/or load of the prescribed lunges/squats over the cycle. However, the improvement has me pessimistically hopeful and I plan to continue the exercises every other day for another 4-6 weeks. |
Overall, 14 lab rats completed the cycle and all noted some reduction in knee pain. Some, much more reduction than others.
I personally saw a 5-10% reduction in knee pain after resting. However, pain prevented me from progressing the prescribed exercises in neigher range of motion nor loading.
Next Steps?
I’m personally going to extend the study, but tighten up the training session to just one, and add in nordic hamstring curls for more hamstring/back of knee development. As well, go to a day on, day off schedule.
Then re-evaluate at 6 weeks.
Questions, Feedback, Comments? Email rob@mtntactical.com
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