Alan’s PRSF Ski Knee Witch Craft

 Alan’s PRSF for damaged knee cartilage: A possible alternative for the PRP procedure 

Below is my knee history and attempt at knee restoration. It is a slow fix in terms of many months but only takes a few easy minutes a day.  

I’m presenting this information now because it may help someone who has a similar experience to mine, to get ready for the next ski season.  Some people have tried the procedure that I follow and found an instant feeling of relief.  I have found a way to greatly increase the flow of nutrients to the knee using the knee’s natural structure and components. Minimally it improves the lubrication of the knee and ultimately, if lucky will repair the cartilage.  I have practice this for 7 months as a replacement for the PRP which failed me. For me the results are much better than the PRP and I name it PRSF (Plasma Rich Synovial Fluid).  All you need is to be able to count to 5 slowly, a few minutes time every day, and a compression band or 3 or 4. You can skip to the bottom for a description of the procedure if you’re not interested in how this came about.

About five years ago my right knee joint started to fail. Three years ago I mentioned this to my doctor and he recommended a joint replacement and set up a meeting with a local surgeon.

The surgeon told me that the replacement knee joint wasn’t as good as good as mine.  He gave me several alternatives. Three were knee injections and one was a brace.  The three injections were $200, $300 and $500.  I asked which injection was the best and he said the $500, which was the PRP (Platelet Rich Plasma). I opted for the latter and the brace.

I tried the brace route and found it the most painful experience. The hinges on the brace did not align with my knee centre of rotation. This caused great misalignment of all parts of the knee joint.  I gave the company a long detail note on what was wrong and eventually got a refund. That is another story.

Then, I also tried the PRP injection. After a year of 3 PRP injections the last one failed. A week after the last injection I woke up and found I couldn’t bend my knee. Very slowly I was able to bend it. The range of bending was sufficient for skiing. What to do about my knees?

I opted for a replacement and found the lineup waiting time was a year.  Then, I looked at the mechanical contraption that I signed up for and was not impressed.  So I started my research in earnest with the goal of determining what happened to cause the failure, what the PRP is supposed to do and what is the best alternative.  I’m a mechanical engineer not a medical doctor, so some of the reading was hard going. Some of the descriptions of some of the processes were not clear to me.

Platelets for instance are generated in copious amounts every day and their primary purpose is to cause blood clotting in wounds. Their secondary function is to help start healing. If not used, their life expectancy is about 8 days at which time they are processed out of the system. Doing the simple math there is always 8 days of supply in your body for damage control. I could not find a definitive answer for their use in the PRP application. Maybe bone surface coating.

I found some contradictory information. For example the general consensus is that there are no blood cells in normal synovial fluid and yet there are test to determine the white blood cell count in rheumatoid joints.  

I also found that the synovial fluid in the knee has some repair components that fix the normal wear and tear.  Failure of the knee joint is usually cause by excessive overload, infection and rheumatoid arthritis.  When the built in repair system is too slow and can’t keep up with these traumas, the knee joint fails. There is some stem cell work being explored and replacement cartilage is being grown and inplanted. This work is only in the experimental stage and not of much value to me.

In February I met a chiropractor, Jerome Fryer, who asked me to redesign a prototype chair of his for production. During our negotiations he told me about some of his work. One item he mentioned was that you can pump plasma into the lower back joints by bending over and then press on your upper thighs. This process stretches the joints in the back. It should be noted that joints are enclosed by a membrane that keeps the lubricating synovial fluid in the joint. When you stretch a joint, plasma (filtered blood) flows into the joint and fills the space created.  The time frame is in 3-5 seconds. The effect is to make you slightly taller for a while.  For several reasons I declined the project but this last thought intrigued me.

During my knee brace experience I learned about the knee construction and how it worked mechanically. I also learned a bit about all the components and how they function.  Articular cartilage, the amazing bone surface material and its lubricating liquid, synovial fluid, are the basic components that make all joints work.  There is also the membrane surrounding the joint that contains the synovial fluid and filters blood creating plasma. When in operation there is a continuous minuscule flow of fluids in and out of the joint.

The red and white blood cells are filtered out by the membrane leaving nutrient rich plasma to enter the joint.  The bone also supplies materials necessary to rebuild damaged parts.  The plasma and synovial fluid mix acts as both a lubricant and the medium for distributing these nutrients to the damaged area. When the plasma mixes with synovial fluid the viscosity of the mix is high enough to not leak back out through the membrane. (My guess, but some leaking must occurs in order to remove waste.)

The process during loading (walking, riding, etc.) the normal joint discharges a very small amount of the synovial fluid from the loaded surface and when unloaded the same amount is replaced. The displacement, of how much the cartilage is compressed is very small, about the thickness of a sheet of paper. The flow of liquid into the joint is similarly very small when the load is released and this is most likely the reason that the repair process takes so long.

When the knee cartilage is failing or failed, a relatively large space is created. The leg can now be bent both in the normal front to back motion but also very slightly from side to side. The surgeon checked the degree of damage this way. Bending the damaged knee sideways opens a gap about 100 times larger than in normal use.

The knee has two pressure contact points, one on the inner side (medial) and one on the outside side (lateral) of the joint. Either one or both of these surfaces can be damaged. One is a fulcrum in the below process for bending the knee sideways.

Muscles  Pushing Knees Together

So here is my solution for my right knee analogous to the back extension above:

•   I press with very low force, my right foot ankle against my left foot instep. This bends my right leg sideways, using the muscles for pressing my knees together. My right leg knee is slightly bent.  The gap between the upper and lower bones open about 2 to 3 millimetres( on the medial side).  (I can feel the top of the tibia and the space that opens.) (After 7 months the opening is much less.
•  I hold pressure 5 seconds then release it. (The plasma fluid in-flow time. 
• Then I quickly flex and straighten my right leg 5-10 times in the normal direction to mix the plasma and synovial fluid. It helps if the limits in both directions are reached. 
•  I repeat this process 4-6 times until I feel the fluid fill the space.  It feels cool (in the temperature sense of the word) as I feel the fluid spread across the joint space. No more is necessary.

·         I do this 2 times a day on my bed or sofa, once I get up in the morning and once when I go to bed.

When I stop with my knee bent 90º I can feel the added fluid around the base of the patella (water on the knee). The knee joint is now slightly over filled with a Plasma Rich Synovial Fluid, hence PRSF.

One caveat is that I use a compression bandage biking and walking for exercise but not usually around the house.  I believe a compression band helps to increases the fluid flow between the front and back of the knee engineering wise.  For Skiing I use a compression band with side braces built in for some torsion (twisting) stiffness. At night I use a very light pressure band to keep the fluid in working space of the joint.

Some stress is necessary to ensure appropriate repair. Biking and walking are normal now. I’m holding off on running.  Something is happening and I know it is better. Unfortunately, I don’t have the equipment to determine what it is.  It took me a long time to cause the problem so I figure that it will take a long time to repair. I will know when and if this process stops working, the joint space will be filled and that my cartilage is repaired. The procedure has no effect on my good left knee.

Dare I say that some cartilage is being replaced?  Witch craft!

Next, my rheumatoid arthritis fix for skiers of course. AR

Where to Start: Flat Land Training

    Before you start down a hill with your skis on it is best to learn a few simple skills. This will prevent you from being permanently damaged or maybe permanently turned off the sport. 
The whole process can proceed quickly if you do the flat land exercises first.  Then proceed slowly on a gentle hill first learning how to stop and then learning how to change your speed from slow to faster and back to slow.
The flat land training teaches how to use feet and legs in order to accomplish a certain feeling or action. It also introduces you to the rudiments of how skis are made to turn at your command.  Spreading your feet wide  wearing your boot without  skis attached you can simulate the same feeling you will encounter when making a ski turn.  
For instance when you lean forward you will feel both pressure on the ball of your foot behind your big toe and on your lower shins. By shifting your upper body from side to side you will feel the pressure needed to make your skis turn. 
If you repeat this motion without pressing on the front of your boot you will be in the perfect stance for you when skiing down hill.  
(When you become an intermediate skier the only difference is that both your feet will be side by side. You will also be facing down the hill with your skis on and starting a turn.)
     Next when gliding on one ski by pushing forward with the other starts your training for sliding and gliding on skis.  You can either make a square or go back and forth in a straight line.  At the corners or the end of a short glide line you make a turn by scraping the snow with your ski. By pressing out with your heel you can make you ski fan out in a wedge shape. If you use your right foot you will make a left turn. The process is similar to spreading peanut butter or mayonnaise on bread.  Give both feet a chance to go around several squares or lines. This motion simulates slowing down or finishing a turn. 
By completing these moves and exercises you have practiced all the rudimentary skills necessary to ski.
All the above is included in my free Manual noted at the top right corner of this blog.

Beginner Skiers Second Lesson Notes and Tips

SFS    FAST Slow Slow to Stop

Beginner skiers must learn to control speed, to stop and to turn.  This requires you to make your skis slide sideways to the direction that you are going.  You sort of scrape the snow with the edges of your skis. The harder you scrape by increasing the angle the slower you go.  If you scrape hard enough, you will stop. This is shown in the sketch to the left, Fast Slow and Slow to Stop.  Your first 2 lessons using my method are all about this scraping process.
  
The next picture shows me in the stop position.  Legs apart and almost straight, tip of skis close but not touching. Ski back ends spread wide. Me bent forward at the waist and arms wide.  Poles dragging.  A beginners stance for maximum scraping effect.

Beginners Stance

The last pictures show the effect or pattern in fresh snow of going fast and slow.  Where the pattern is narrow I was picking up speed, less scraping effect; and slowing down where the pattern is wide, more scraping effect.  You can see this in motion by clicking on the Free ski lessons video.  

Slow Fast Slow 

Tip:  The first few lessons are performed in slower motion, about walking speed.  The closer you can come to a stop without stopping will give you a measure of your skill development. The theory is that it is best  to learn first how to do a particular move and the necessary skills slowly and well, before you apply any speed.

Notes:  For a beginner to stop on a beginner hill the legs must be pushed as far apart as possible.  If you can't stop then using this method, then the hill is too steep for a beginner or you may be bowlegged like me. In order to get the maximum ability to stop it is necessary to have at least one ski at 90 degrees to the direction you are travelling, lesson 3. 

Eventually when you have finished the six lessons and can ski parallel with some confidence then try stopping with both feet side by side, a so called hockey stop. Stopping with two feet is by far the best way to stop and takes the least amount of effort and energy

Good News, Video and Trip

East Glacier Park, Montana, 2 days from home.

      In my last post in the spring, I promised a video of my lessons.  Andreas Ruttkiewicz, my collaborator in this venture, finished tuning the final cut and so it is now Public on YouTube.  I am really pleased with his work. For fun, he added my bloopers.  Here is the link Video: Learn to Ski, AlanR Method . The site is a work-in-progress and fine tuning will continue.  
My process for learning how to  ski is now complete. You can see and try each lesson.  You can reinforce each lesson by reading the manual for details. You can reinforce what you learn in the lessons by reading and understanding the third section of the manual. In this last section, you can find the answers to many of the Why questions.
There are some differences between the manual and the video which I will edit over the next year.  I like the part in the first lesson on mobility.  For going around in a circle, I show how to push out with your heel in order to turn your skis.  This is a fundamental move which includes 4 of the basic skills and is repeated often in different forms in the following lessons.  In lesson 3, you continue the first portion of alternate stopping but instead of stopping you just slow down to almost a stop and then continue with the next partial stop. I forgot to video this last portion of lesson 3. We will work on it.  
I know the current trend is to let the student try and explore and to learn by experience.  But I am old school in that I believe that skiing is potentially a dangerous sport and some basics should be learned before any attempt at open-field skiing.  I also believe in introducing the 5 most important skills in the very first session.  People stall out at the intermediate stage because some of the skills were not emphasized.  Pivoting is a good example.  
My trip home was wet for a couple of days. But Ontario to BC in 8 days, on a large scooter and camping along the way, is not bad ( 4400 km). The next day after the above picture was taken, it rained for 2 hours in the morning, going from Troy, Montana to Osoyoos, BC. The last day through the mountains of southern BC was spectacular. 

Taking a Break

Late Spring Morning in the Mountains

The season has ended and time to give skiing a break.  
The season ended well for me with two highlights.
One, Andreas Ruttkiewicz, a cohort in VISAS, offered to video my lessons.  It turned out that he became my mentor, director, story board creator, camera man, and editor.  We did some preliminary takes one afternoon to find out what we needed to make it work.  Then we spent a day doing the video.  Andreas, who has an Ultralight Flight School, is putting together the final video in his  precious spare time. I am waiting on pins and needles for the result.  If all goes well we should publish in plenty of time for the new season. Who knows? It may be on YouTube for those down under this winter season, July?
And the other highlight involved a mother and her  two kids, boy about 8, and girl 10.  The mom I found, just starting down the beginner hill, fallen on the snow and two snowboarders trying to help her up. It was a cluster problem, so I swooped down and offered to help.  The two kids were in a similar situation just further down the hill.  
Because I love the opportunity to teach, I offered them a lesson and was accepted.  They had arrived too late for Snow School lessons and thought that they could muddle through on their own, being good hockey players. My progression took 2 hours and by the end, they were racing down the cat track at full speed under complete control.  The girl is a natural athlete who did everything I showed her perfectly first time. The boy was a little awkward, trying to make the skis act like his hockey skates.  He fell a few times but once he learned how to get up he just popped up.  The mom was happy because this saved their Spring break holiday.  As I have mentioned before, hockey  players are the easiest to teach and it is still true.
For me it was another great, enjoyable, feel-good situation.
My skiing related goals for the summer are to publish the video and make some minor manual revisions. Like in the manual, re-arranging lesson one and putting the alpine instead of the cross country skiing code, etc.
Anyway, have a good summer, keep in shape. I'll contact again in the fall. 
AlanR.

One Thought At a Time

It can be lonely on a foggy day.

I was reminded by Andreas, a fellow skier, that, as a ski instructor, one should give the student just one thought at a time.  So in my manual lessons, you could filter out the details and background information (often the whys of doing) to concentrate on the primary thought.  For example, in the first lesson, the primary thought is feeling your feet. This should be top of mind in the rest of the lesson, making a wedge, getting mobile on the flats, learning how to snowplow-stop and slow fast slow. 

Making a wedge requires more pressure on the heel in order to make the back of the ski spread the snow like a fan shape.  Similarly when turning during the mobility exercise you push with your heel to turn.  During the snowplow, to stop, you must press on your heel in order to push your heel wide enough to stop.  To go fast and slow and fast, you must modulate from low pressure to higher pressure and then low pressure repeatedly. This control of extra pressure on the heel is how you control your speed, the amount you turn and how you stop. All of this requires awareness of your feet. 

The third lesson is about the start of the turn, where pressure is concentrated on the toe pad. While skiing, your pressure is constantly changing from toe to heel. 

Leaning to Ski is not Rocket Science

 Basically, skiing is about turning and stopping.  When I learned to ski the first time, there were only wooden skis and the way you turned was either a semi snowplow or a telemark turn. No such thing as steel edges or parabolic shapes. The first big improvement was the addition of steel edges which greatly increased the number of days you could ski. The skill of edging became important and skiing became easier. Over the years our skiing techniques changed mostly as a result of ski equipment improvement. It has always been a challenge to explore and adapt to these changes.  The most significant change recently for recreational skiing has been the parabolic shaped ski. All of a sudden this invention changed the time it takes to learning how to ski from weeks and year to a few hour and days.  Unfortunately, some of the teaching methods are still catching up.
My frustration as a ski instructor was that we are still teaching skiing the way we did 30 years ago. But I couldn't find a better way out until I finally discovered, that the transition from one turn to the next is the most important part of skiing.  It is the end of one turn and the start of the next, and this is where I started.  
My first attempt at a manual was really a collection of notes, about 150 pages. Much too long and disjointed.  I knew that I had all the information and parts but I needed to find the basics of moves and skills.  Mike McPeek  first showed me a rough sketch of the diagram above which I believe is a snapshot of the important first skills to learn and their relationship. If you examine my lessons closely you will see a trend. If you examine even further the lessons mirror the transition between turns. 
There is a progression. The first lesson starts from the outside ring and move directly into very rudimentary core of control skills and blending.   The subsequent lessons then concentrate on embellishing and finessing these skill and are arranged in a sequence of increasing difficulty.  
I'm continuously testing my method to find ways of improving or vindicating that my process is valid.
 Last week I saw a beginner give a most spectacular display of athletics, arms and legs all moving in different directions. What I  really saw was great balance and determination.  I couldn't resist and offered my services. Within 2 hours he was parallel skiing.  When that happens I think I am the most spectacular instructor but in reality it is the student that makes the difference.  In this case the student was a boarder, an quick learner and as I said has great balance and determination.   It is not rocket science.

Balance is the primary skill in skiing.

Pressure scale

Balancing on your toes and heels

Balance is the primary skill in skiing.

I took these sketches from my manual , as this is a good place to start the season. 
When on the hill, an instructor will tell you to have a good centered stance. Translated, this is shown as Neutral in the above left diagram with your weight spread equally on all 4 pressure points on your feet.
The purpose of the exercise here is to feel your weight change concentrated on these pressure points. 
You can practice the following on a hard surface in your bare feet or anywhere else with your shoes on. 

• It is best to first spread your feet apart until you feel pressure only on the pressure points of both feet shown in the diagram. 
• Then move your weight front to back, left to right on both feet, balancing on your toe and heels to feel the pressure change on 2 pressure points at a time.  
• Finally, apply full weight on each of the 4 pressure points. Note how you have to shape your body to make this happen.
• Experiment a bit with your arms out, at your sides and forward; they make a big difference.

You will only be applying pressure one foot at a time; the other foot is used for balance. Balancing is finessing where you shift your body, arms and legs, to apply pressure to your feet.  

Later, when on the snow in your skis and boots, repeat the above with the tops of your boots loose, both standing still and moving.  Boots are different from bare feet and shoes because it is possible to push on the tongue when putting pressure on the toe and on the boot back when applying pressure on the heel.  For a centered stance there should be almost  no pressing on the tongue or boot back. Your body position should be bent at the waist, both forward and to the sides.

When skiing, this exercise is equivalent to what you  feel when tilting your knees in the direction you wish to go. In order to turn quickly and efficiently, you start the turn on your toe pad and finish the turn on your heel. This is a much better method than trying to rotate your skis with your leg. It is called steering and takes a little practice. Maybe a season?  
Balance is the primary skill in skiing. This is just the start.

AlanR. 

More Than You Want To Know About Skis

 During the past summer I received some pamphlets from Elan about their new shape of skis. The top surface on the back half of the ski is concave and on the front half is convex.  From an engineering point of view I am not sure what these shapes can do better than a standard rectangle cross section.  Elan was one of the first skis with the parabolic shaped sides that changed the way we ski and made turning skis much easier.  So when they bring out a new idea it is worth taking a look at.  My wave skis from Elan, that I like a lot, baffles me because I can’t see what the wavy surface does. 

When laminate skis first came out many years ago all the engineering test data was given in the ads.  For a mechanical engineer this was wonderful stuff.  Pictures of the ski cross section showed all the laminated layers.  Diagrams showed the bending characteristic and some show the dynamic behavior.  You could compare skis just by looking at the data.  Unfortunately this added information confused more than helped and this practice of telling you what you were buying died out. 

Ski manufacturers now have many options in terms of material and ski shape. The odds are good that you can find skis that you will like.  The trend over the last few year is less camber.

 What is the effect of low camber or rocker? It effectively shortens the ski contact edge on the snow.  This causes a sort of barrel stave shape in the snow.  If you work it right there is enough stiffness under the foot so that you can still have enough edge for grip on ice. My guess is that a low soft camber gives you less fore and aft stability and a slower ski. My impression is that low cambered ski is like a shortie ski with higher flotation characteristics. It can also be super fast turning.  I saw a kid last year just standing line, counter rotating his skis.  Normally this is almost impossible on cambered skis.

Skis with camber when laying on a flat surface will have some space under the bindings.    When you step into a ski with camber it will flatten out and look like it has no camber. What happens depends on the ski stiffness along the length front and back from the boot and bindings.  When loaded my Elans,  appear to be stiffer in the front and parabolic in shape, while the back seem to be softer and circular in shape .  The snow in turn is loaded heavily under the foot tapering off gradually towards the tip and tail. You can see the short flat sections in front of toe and heel pieces and the softer ends.

First you should know that changing the thickness of the ski a little bit can make the ski either very stiff or very soft.  The math equation included the thickness T cubed (T³). This applies to the also the high strength material on the top and the bottom of the ski.  By changing the thicknesses and material along the length, a ski can be made to flex and twist to any requirement.

Normally I ski on 165 to 170 cm skis but last year I used some 150 cm skis donated to the Disabled Club. I was surprised how well they worked even in deep snow.  

My thoughts are when buying a ski try several different makes.  When you find one you like then try a size shorter and a size longer to get the best characteristic for you.