Powerlifting after total knee replacement – Part 1.

I discovered I had osteoarthritis in both knees in early 2015. I found strength training very helpful and I took up powerlifting, competing at national level from 2017 to 2021 in the 60-64 then 65-69 year age category. I had a total knee replacement (TKR) of the left knee in March 2022. 

Before doing the TKR, I spoke to my surgeon about what I would still be able to do with a TKR and also searched the web for information. My surgeon echoed the standard advice that high impact activities such as running and jumping should be avoided completely, as should activities that involve aggressive pivoting (tennis, basketball, most martial arts). A few specifically mention Olympic weightlifting as involving high impact and should be avoided (for example here). Even so, I have come across people who have continued to run or do martial arts after joint replacement.

Skiing is sometimes mentioned as an activity that is feasible after joint replacement, though often with the caveat “only if you are already an experienced skier”. My doctor made a point of saying that I would be fine to ski again, once he knew that I was an experienced downhill skier.  I was particularly interested in whether I would be able to continue strength training, powerlifting in particular, after joint replacement. My surgeon said flat out I should not try to lift heavy weights after joint replacement and the internet search I did found only a handful of examples of people who had done so. But I found lots of advice from doctors and physios to avoid any heavy lifting. Some of this was clearly nonsensical. For example, here is advice from an orthopedic and sport medicine centre in 2019: “You’ll need to mind your artificial knee for the rest of your life. Avoid lifting anything more than 20 pounds.” Or another physiotherapist who advised to never deadlift after joint replacement.

A world record squat of 525 kg nine years after TKR

The most startling example of powerlifting after TKR I came across was Vlad Alhazov. He is a Russian-born powerlifter who set a world record for equipped squat (multi-ply) in 2008, squatting 567 kg (1250 lb).  However, the following year while attempting 590 kg, his left knee caved resulting in his needing a full knee replacement.  Nearly a decade later, he returned to powerlifting, this time raw (unequipped) and in 2018 set a world record for squat (with knee wraps) of 525 kg.  His squats can be seen here.   His best deadlift is 375 kg, limited by grip strength. With straps he has lifted 442.5 kg. But this man is clearly not only crazy, but a freak of nature. So his experience may well be a very unusual outlier.

The other thing I discovered from my searches is that there are almost no long-term studies of outcome for people who do continue participate in “strenuous sports” or high impact activities such as running. TKR tends to be done predominantly in older people and very few older people do serious strength training. I was unable to find any follow-up studies at all for strength training, let alone long-term ones.  So, it’s possible that the usual medical advice is not evidence-based and coming from a lack of understanding or experience with strength training.  After all, advice from health professionals with no experience of strength training is often of the form “squats are bad for the knees” and “deadlifts are dangerous for the back”.

My total knee replacement

I went ahead with TKR of the left knee in March 2022. My strength training helped me recover relatively rapidly and I worked hard with a physiotherapist over the next two months to recover full function and range of motion of the knee. In particular, the physio got me doing various forms of scaled bodyweight squats, including single leg squats that were quite intense.  I decided that there was no reason I could not start squatting with light weights to a bench (for safety if I lost balance or control of the bar).

My left knee, three weeks after surgery

On the day the photo above was taken, I started barbell training again, doing 3×5 box squats with the empty bar (20 kg) to somewhat above parallel (touching the bench). A week later I was squatting 3×5 at 60 kg somewhat above parallel. Two months after surgery, I also started doing Romanian deadlifts, initially 50 kg for 8 reps, increasing to 75 kg for 3×8 at three months.

I was somewhat concerned about the potential for damage to the stability of the prosthesis or wear on the polyethylene cartilage replacement and decided to do a more systemic search for evidence and for examples of people doing strength training after TKR.

An unsystematic search for examples of strength training after TKR

The currently common advice is very conservative (understandably) and not based on evidence. The first step toward overturning an excessively conservative recommendation generally involves uncontrolled observational studies. If researchers observe that an allegedly dangerous behavior doesn’t appear to result in the predicted bad outcomes, it is a first step towards controlled cohort studies of the behaviour.

Using google searches and social media searches I found 13 examples of deadlifts and 15 of squats after joint replacement, with some information on the weight lifted and on the lifter.  The majority of these examples were TKR of one knee. For the deadlifts, there was one hip replacement, one TKR+hip, two double TKR and one double TKR+hip. For the squats, there were two hip replacements, one TKR+hip and three double TKRs.

The table below summarizes the data for these lifters.

The figures in red were missing and estimated either from appearance (for bodyweight and age) or based on averages for the non-missing data. Where the weight lifted was for multiple reps, I estimated the 1 rep max (1RM) using an online calculator, and ignored the fact that true maxes may be higher than the numbers reported. Sources for the data are listed at the end of this blog post.

It is important to emphasise that these data in no way are a representative sample of people’s experience after TKR.  People who self-post videos and results to the internet are more likely to be people who have been training seriously before and after joint replacement, and people who are lifting heavy weights and want to post about their progress.  For almost all the examples, there is data for a single time point only and the pattern of results cannot be interpreted as providing any information about rate of progress with time after joint replacement.

With those caveats, I did of course plot the results to get some sense of them. To do so, I converted all the results to 1 rep max results, and then adjusted them using Wilks weights for bodyweight and McCulloch weights for age, so that the adjusted 1 rep maxes relate to a 50-year-old person with bodyweight 85 kg. Also, for the sake of comparability, I plotted males only (there was only one woman in the dataset) and excluded Vlad Alhazov (apart from being an outlier, he was the only data point with more than 3 years since surgery).

Here are the results for males excluding Vlad, with of course linear trend lines that should absolutely not be interpreted as saying anything about progress with time since surgery.

I was surprised to see a couple of men who were lifting moderately heavy weights within a month or two of surgery, and also just how heavy on average the weights lifted were.  The median adjusted 1RM (for 85 kg 50 year old) were 157 kg for deadlift and 155 kg for squat. Of course, this is almost certainly due to self-selection of experienced lifters who thought their results would be of interest to others.

I am one of the data points. Five months after my left TKR, I also had a replacement of the right hip, so my data is for TKR + hip.  Twelve months after the TKR and 7 months after the hip replacement, I deadlifted 150 kg and squat 120 kg (above parallel) at age 70.

Views are changing on strength training after joint replacement

In my recent internet searches, I came across a number of research papers reporting medium term follow-up studies for people who had continued to run or participate in various sports and found that their outcomes were no worse than those who were not doing those activities.  I also found several medical and physiotherapy websites that explicitly recommended resistance training after joint replacement.  Part 2 of this post will look more closely at these recent studies and at data on joint replacement failure.  In the meantime, I will conclude this post with a couple of quotes:

According to Beacon Orthopedics and Sports Medicine:

“Patients are often most surprised to learn that they are not only permitted to lift weights but are encouraged to lift weights after receiving a joint replacement. In fact, lifting weights is the best thing a patient can do for the prolonged life of their artificial joint.

“When done with proper form, weight lifting—also called resistance training—strengthens muscles and increases bone density, all while being relatively easy on the joints. With that said, improper form can severely damage joints, so it is imperative that you use proper form to ensure the longevity of your artificial joint.”

Dr Luke Peterson, knee replacement physical therapist, explains that strength training has huge benefits, resulting in more knee stability and bone density and firmness of knee implant in bone. It is important to use good technique, slow progression and start low intensity and build up slowly.

Kevin Stone, orthopaedic surgeon, writing in 2015, said that “After your knee replacement, our advice is to exercise more than you have in years. Focus on total body muscle building and weight optimization. You can likely return to most sports when you are fit enough to protect your joints.”

If you would like to contribute to my unsystematic dataset, please make a comment with some information on your age, weight, surgery, and time since surgery, as well as 1 rep max for squat or deadlift.

Data sources

1.      https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s

2.      https://youtu.be/LZSgavGGwao

3.      Matt Vincent. https://www.youtube.com/watch?v=WLHuwD_4c2Y

4.      Shelley Kresan. https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s

4.      Shelley Kresan. https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s

5.      https://youtu.be/xRCnO5Sr5bs

6.      James Burnett. https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s

7.      Colin Mathers. Blog post

8.      Cameron Bucek. https://games.crossfit.com/athlete/225539

9.      https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s

10.   https://youu.be/bA25mwVIP1g

11.   Vlad Alhazov . https://www.youtube.com/watch?v=MzOXefrlWYM

12.   https://youtu.be/VjL7Q9rwdRQ

13.   https://www.youtube.com/watch?v=08mOL1amDNw

14.   https://youtu.be/YSVsIlHjY5M

15.   Rob Schmidt. https://youtu.be/dtozQJ6A5Is

16.   https://forums.t-nation.com/t/total-knee-replacement-and-squatting-again/246850

17.   Michael Clark. https://www.elitefts.com/training-logs/total-knee-replacement-required/

New World record set in Swiss Powerlifting Championship

My younger son Felix Strong trained hard this year for the Swiss Full Powerlifting Championship in Lausanne on 25 March. He competed in the T2 (16-17 year) age category having turned 17 a month earlier, and in the 75-82.5 kg weight class. 

Felix sets a new world record of 245 kg for the unequipped deadlift during a full powerlifting competition

He did extremely well, setting new Swiss records for all three lifts and for the total: squat 172.5 kg, bench press 110 kg, deadlift 245 kg and total 520 kg (1146 lb). His deadlift was almost 15 kg higher than the current world record of 230.5 kg and the Swiss Drug Free Powerlifting Federation has submitted it to the world body (WDFPF) for approval as the new world record. Short videos of his three lifts are below.

In a full powerlifting competition, the athlete has three attempts for each lift. If he sets a record on his third attempt, he can request a fourth attempt to see whether he can improve his record. Fourth attempts do not count towards the powerlifting total.  Felix squatted 165 kg on his third attempt, and so his powerlifting total was 520 kg, also a Swiss record.

The hammer he carried with him raised a few eyebrows. Was it for deep tissue massage? Or dealing with other competitors? Or just to hammer a lug, which kept sliding out, into place on his belt?

My son sets powerlifting records at age 16

I equipped a garage gym during the Covid-19 lock-downs at the urging of my older son and my younger son has now also caught the strength training bug. My older son is focusing on Olympic weightlifting, which involves explosive lifts to chest or overhead. The competition lifts are the snatch and the clean and jerk. My younger son has shown an aptitude for powerlifting with its three competition lifts: the squat, the bench press and the deadlift.

I suggested he compete in the Swiss Drug Free Single Lift and Powerlifting Championships 2022 on 25 September. He set new Swiss single lift records for bench press (95 kg) and dead lift (210 kg) in the 16-17 year age category and the under 82.5 kg weight category. The short video below shows his 210 kg deadlift.

Three months later, Felix competed in an informal powerlifting competition in Geneva on 17 December. He improved all three lifts with a squat of 160 kg, bench press of 107.5 kg and deadlift of 230 kg. This short video shows the 230 kg deadlift. He also lifted 240 kg, but there was some slight hitching before lockout, and I’m not sure it would count as a valid lift in a formal competition.

240 kg deadlift in December 2022

He has been training with a strength training coach for more than a year, now. His coach tested his progress a week ago and he succeeded in squatting 170 kg and bench pressing 110 kg, still at the age of 16 years.

For the deadlift, he lifted 225 kg without any trouble. He then attempted 240 kg followed by 250 kg. In both these lifts, he got the bar moving off the floor but could not get it past his knees. He is close to being able to lift 250 with some more training. He successfully lifted 240 kg for reps a couple of days ago using the trap bar.

Competing at the SDFPF Powerlifting Championship 2021

Last weekend, I competed at the Swiss Drug Free Powerlifting Championship 2021, held in Basel on 25 September. This was my first national powerlifting competition since competing in the last SDFPF Championship in February 2019. The 2020 Championship was cancelled due to the Covid-19 pandemic.

During the pandemic I managed to lose around 10 kg bodyweight and competed this year in the 82.5 – 90 kg category at a body weight of 87.3 kg, almost 10 kg lighter than my weight of 96.5 kg in 2019. Despite my efforts to improve my squat and ensure that I squatted below parallel, I discovered by filming my squats in the week leading up to competition that I was only getting clearly below parallel around 50% of the time.

I opened my squat attempts conservatively at 90 kg, and succeeded in getting a below-parallel valid lift. However, I was disappointed to fail the next two attempts at 100 kg with inadequate depth.

For the other two lifts, I exceeded my anticipated results with a 100 kg bench press and 190 kg deadlift. These were both new Swiss records for the under 90 kg Master M6 age category (65-69 years), as was my powerlifting total of 380 kg. Below are short videos of the deadlift and bench press.

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The trap bar deadlift

The conventional deadlift is done using a standard 20 kg barbell in powerlifting. Trap bars have a hexagonal shape which you stand in (which is why they’re sometimes called “hex bars”) with sleeves on the end that let you load weight, and they have handles on either side that allow you to grip the bar with a neutral grip.

During my 8-week wave cycling program for the squat, I had also been using the trap bar to do some deadlifting once a week during the last half of the program. Prior to that, I was doing Romanian deadlifts at about 60% of my conventional deadlift 1 rep max to work on improving hamstring strength. After I tested my squat 1-rep max, I also decided to see whether I could lift more than my current 1 rep max of 210 kg. The video below shows me setting a new personal best at 220 kg, and I felt I still had a little more in the tank.

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Improving my squat using wave cycling

After a week skiing in February 2015, my knees became inflamed and painful and I had trouble walking up and down stairs. I found that deadlifts improved my knee function and started powerlifting training for deadlifts and bench press. For the first months, I avoided the squat completely, and only gradually started to squat with relatively light weights around 50-60 kg. In the last couple of years, I’ve discovered that my knees are fine with squatting with good technique to parallel or below. I still have trouble getting below parallel with heavy weight on the back but am working on improving mobility. In my last pre-pandemic competition in December 2019, I squatted 107.5 kg with depth that was only just below parallel and one of the judges told me afterwards he thought they had been lenient in judging depth. This was substantially behind my deadlift at 190 kg. Most powerlifters have squat somewhat less than they can powerlift, but the difference is on average only around 20% and is narrower at 15% at the elite level (see here for averages based on over 7 million lifts).

So I decided to focus over the last 8 weeks on improving my squat, to do only a minimal amount of deadlifting, and no bench press (instead to rehabilitate an AC joint injury). I had been reading Pavel Tsatsouline’s book Beyond Bodybuilding: Muscle and Strength Training Secrets for The Renaissance Man and decided to do the 8 week wave cycling program that he describes on page 80 of the Kindle edition.  Here is how it worked for my squat:

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Strength training in the time of coronavirus

Geneva is about to ease the restrictions associated with the second wave of the pandemic. During this wave, average new cases per day in Geneva peaked at close to 3,000 confirmed cases per 100,000 population in the 14 days to 8 November. This was the highest recorded rate at regional level in western Europe. In other words, 3% of the population were confirmed new cases in that fortnight, and the real incidence would have been higher than that.

As can be seen in the figure above, the social restrictions introduced in most European countries have worked quite rapidly in turning the second wave downwards. The exceptions are Germany where it has plateaued by not yet coming down, though it never reached the levels of nearby countries, and Sweden where it is about to pass Switzerland on the way up. Daily new cases per million population in the USA now exceeds that in Switzerland. The USA now has 12 million confirmed cases, and the CDC estimates that the true number of infections is around 50 million, or 1 in 7 of the total population. Trump of course has gone AWOL and I suspect the USA is in for a bad winter.

My gym closed down again during this second wave. During the first wave it closed down for around 2 months and I tried to continue some light weight work at home. I had borrowed a couple of kettlebells from the gym and was somewhat aimlessly swinging these from time to time. However, my son took up a kettlebell challenge to do 10,000 swings of a 24 kg kettlebell in 4 weeks. He upgraded to 28 kg partway through.  That’s 500 a day, and he broke them up with some kettlebell presses every now and then.

I was inspired, and bought a 16 kg and 28 kg kettlebell and started using them 3 times a week. Initially, I was doing kettlebell swings at 28 kg and various double kettlebell routines with two 16 kg kettlebells (see video), though my favourite routine was the kettlebell snatch (second video). By the end of the lockdown I was doing 100 snatches, 100 clean and press and 100 double handed swings.

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Approaching retirement from full-time work, the last thing I would have foreseen doing was to take up powerlifting and get involved in competitions. I had plans to spend more time walking and climbing in the Alps, but increasing knee problems (osteoarthritis) around 2014-2015 put that on hold. I stopped doing Crossfit classes in 2015 and instead started to focus on weight training apart from squats.

I had also been reading various books and research relating to exercise and ageing, and became convinced that to maximise my health and functioning into older age I needed to maintain and improve my strength, and that this was probably more important than the endurance cardiovascular training that I had been doing for many years.

I found that I really enjoyed training with heavy weights and low repetitions (usually in range 3-6) and that my knees felt a lot better after a workout. With some coaching on good technique, I was able to substantially increase the weight and volume I was working with and would often leave the gym with an endorphin high and pain-free knees. Occasional lower back pain (related to an old injury during jujutsu training) also became rarer.

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