Patellofemoral Pain – Runner’s Knee 501
After a week hiatus due to the Thanksgiving holiday, I am back into blogging action. Today's post will wind up our look at the five most common running injuries, and we picked the best for last.
Patellofemoral pain got it's nickname for obvious reasons. It is prevalent in runner's and information regarding its diagnosis, cause or treatment are vague at best. I thought I would start with a lesson about how the knee is built.
Crash Course in Knee Anatomy:
The knee is made up of the femur (thigh bone) and the tibia (shin bone) and the patella (knee cap). The patella has an interesting position in that sits between two big bumps of the femur (the femoral condyles), but it is tied to the tibia via the patellar tendon. Therein lies the rub (no pun intended). The femur takes it's cue from the hip. That is to say, the position of the seat the patella sits on is controlled from the hip above. The tibia takes its cue from the ankle and subtalar joint. The knee really is stuck in the middle with nowhere to run and nowhere to hide.
Can it be fixed?
Enough of that. Here is the point. It can be fixed, but not with just rest or medications. Sure, stopping running will eliminate the pain. But the pain will resume once you start running again if you don't address the cause of the problem.
For you runners out there, this means normal hip flexibility and normal ankle flexibility.
Try this test!
The squat test is a great test to try. Stand with your feet shoulder width apart and toes pointed straight ahead. Squat down as far as you can without your heels coming up off of the floor. What happens?
- If your knee falls in - stretch your calf muscle and strengthen the gluteus medius and maximus (your butt)
- If your knee falls out - stretch your ITB and gluteus medius and work on balancing on a foam roll to unlock your subtalar joint
- If your toe turns out - stretch your calf muscles and your lateral hamstring (the revolving triangle is our favorite for this)
- If you feel like you have to lean way forward or throw your arms in front or you will fall backwards, this is a sign of tight proximal hamstrings. We love the downward dog, the triangle and the revolving triangle for this!
To the clinicians:
Most people with unilateral patellofemoral pain have a pelvic asymmetry stemming from an SI joint problem. This will create a functional leg length discrepancy that can cause medial or lateral patellofemoral pain.
On your patient with this problem, make sure to check the following:
1. The Three Key Hip Test - 90/90 hamstring, piriformis and FABERS - and fix what you find!
2. Pelvic alignment - innominate flares, upslips, rotations and sacral torsions
3. Ankle dorsiflexion - in standing with gravity drop or anterior reach with the leg
4. Subtalar joint eversion - in standing with medial reach w/ the leg
Fix what you find on the table and then support your findings with a solid exercise program. Remember, if it is done right, exercises to solve patellofemoral pain rarely should be focused on the knee.
Now, get to work... there are a lot of laid up runners out there!
Until next time...
Plantar Fasciitis 501
And then there were four...
Plantar fasciitis is number four in the series on the top five running injuries, but certainly at the top of the list for many runners out there. When you climb out of bed in the morning and your first steps are plagued with excruciating heel pain, you just might have this problem.
Here's the thing... the cause of the problem has little or nothing to do with your heel.
The plantar fascia is located at the bottom of your foot and attaches to your calcaneus (the medial calcaneal tubercle, specifically). It's job is to help add spring to the arch of your foot and dissipate the forces of your body weight when your foot hits the ground.
If it is crying out in pain, it is probably overstretched. So don't stretch it! This is a common misconception. Instead, make sure you stretch your calf and hamstring muscles and wake up the gluteus maximus (your butt muscle) on that leg!
For you clinicians out there, here is a short list of things to check on someone with plantar fasciitis:
1. Tight gastroc/soleus - Make sure they stretch with their toes pointed straight ahead
2. Weak gluteus medius - The gluteus medius is responsible for limiting valgus at the knee. Test this with a medial reach with contralateral arm at waist level. Strengthen it with some good mini-band lateral walking or hurdle step 0vers.
3. Tight medial hamstring or gastrocnemius - Trigger points or myofascial restrictions are often found in these muscles on people with plantar fasciitis. For the more curious of you, here is the breakdown:
- Medial hamstring or medial gastroc trigger point signals an internally rotated femur (strengthen the gluteus maximus in the short position)
- Lateral gastrocnemius trigger point signals increased knee valgus (probably due to a lack of ankle dorsiflexion)
4. Anteriorly rotated innominate (creating a functionally longer leg) - fix this with muscle energy techniques
5. An opposite leg that won't pronate (check subtalar joint eversion)
Remember, if the plantar fascia is screaming at you, keep your ears on it, but put your eyes somewhere else. Good luck!
Achilles Tendonitis 501
I am kind of enjoying putting 501 at the end of my blog titles. I realize that is a weird way to start a blog, but at 5:30 in the morning anything can happen.
Today I wanted to talk about an often very misunderstood problem, Achilles Tendonitis. This is #3 on the top 5 running injuries.
Achilles tendonitis is defined as inflammation of the Achilles tendon. Often, the patient will complain of pain along the length of the tendon or at the insertion into the calcaneus. These, in fact, can be two very different problems.
The role of the Achilles tendon is to help decelerate dorsiflexion at the ankle shortly after heel strike by way of the gastroc/soleus complex. During running or stair climbing, forces in the lower extremity can reach upwards of seven times a person's body weight. Due to the shape of the calcaneus and its insertion point, it is also a mild decelerator of pronation of the foot.
If that was all it had to do, then there probably would never be a problem.
To solve the case of Achilles tendonitis, one must look up. Up to the knee, that is. The gastrocnemius muscle plays a role in the transverse plane at the knee, with the lateral head assisting in deceleration of internal rotation of the femur, which also occurs at heel strike. That means the lateral gastrocnemius (LG) is functionally synergistic with the gluteus maximus.
If the gluteus maximus is insufficient or neurologically inhibited (which can happen with trigger points in the iliopsoas or piriformis), then the LG has to work eccentrically at both ends during pronation of the limb. This creates a huge potential overuse scenario and may be classified as an overuse injury.
In common language, your Achilles tendonitis may be injured because of your weak butt!
The other scenario, the one which often causes pain at the insertion on the calcaneus is quite different. Usually, when the weak point of the tendon is its insertion at the calcaneus, this means the Achilles tendon is too tight. Adaptive shortening of the tendon usually occurs with a lack of pronation at the foot...an over supination problem.
When the foot hits the ground, the first contact point is the lateral calcaneus. This helps facilitate a fall into pronation, thereby eccentrically loading the lower extremity muscles. However, in the presence of subtalar joint eversion hypomobility (which may originate in the joint, or be due to a trigger point in the medial gastrocnemius), the weak link becomes the insertion point.
So, to recap. There are at least two possible causes for Achilles tendonitis:
1. Over pronation due to lateral gastroc overload from a weak gluteus maximus. Strengthen the gluteus medius first, then the gluteus maximus (first in the saggital plane) to help take the stress off of the tendon. This also tends to show up in a functionally longer leg (i.e. anteriorly rotated innominate).
2. Over supination due to subtalar joint hypomobility, a leg that feels to short or a medial gastroc tender point. Teach the subtalar joint to evert, lengthen the gluteus medius and load the gluteus maximus first in the transverse plane. If this is the case, ditch the motion control shoes!
In Greek mythology, Achilles was a war hero and the central figure of Homer's Iliad. He was known to be strong, handsome and a mighty warrior. When he was little, his mom, Thetis, tried to make him immortal by dipping him head first into the river, Styx. As a warrior, he was fierce, but he was taken down by an arrow shot through his heel, the only part of his body that didn't get dipped in the river.
I'm not trying to change Greek mythology, but perhaps someone should look into the story. I'm thinking his mom grabbed onto his waist and dipped him in head first...leaving his derriere high and dry.
Until next time...
Shin Splints 501
I just read a series of short articles on Active.com entitled Shin Splints 101 which contained some conventional thinking on this common running injury. I just wanted to contrast and compare ideas for evaluation, treatment and exercise based on our findings at the MIHP Think Tank. Are you ready for an advanced course on shin splints? Here we go:
Our work in muscle injury revolves around two basic physiologic principles:
1. Sherrington's concept of reciprocal innervation: If one muscle is short and tight (or over facilitated), then it's antagonist will neurologically become long/weak (inhibited)
2. Synergistic dominance: If one muscle become over facilitated, then it's synergist may become inhibited
Another premise uphold when looking at muscle injury is this: The muscles that come in crying out in pain are not usually the short/tight ones, but the ones that are long and weak. The underfacilitated. The overused.
What is a shin splint? It is an injury resulting from overload to the anterior compartment muscles of the lower leg (primarily tibialis anterior and tibialis posterior). These muscles are responsible for decelerating dorsiflexion (tibialis posterior), plantar flexion (tibialis anterior) and pronation (both of them).
Who are their antagonists? The gastrocnemius is the antagonist to tibialis anterior. That is, if the gastrocnemius (calf muscle) is short/tight, then the tibialis anterior becomes long and weak, and thereby prone to injury.
Who are their synergists? The gastrocnemius is the synergist to posterior tibialis (i.e. they both decelerate dorsiflexion). If the gastrocnemius become short and tight, then the posterior tibialis may become inhibited.
Pronation v. supination: Because both the TA and TP are located on the medial side of the ankle, they are prone to injury in someone who over pronates. Remember, pronation should only occur for 25% of the stance phase. Any more time spent pronating will result in overload to the tendons and ligament on the medial side of the ankle and lower leg.
The two most common causes of over pronation: Believe it or not, it isn't a lack of an orthotic in your shoe! Before you slip an orthotic in your shoe or invest in motion control running shoes, consider that the two most common causes of over pronation are a weak gluteus medius (hip abductor) and a lack of ankle dorsiflexion (tight calf muscles).
Conventional wisdom says: Strengthen the gastrocnemius (calf muscles) by doing heel raises and the tibialis anterior by doing toe raises. Stop over pronation by purchasing supportive shoes.
ReBUTTal on conventional wisdom: The tibialis anterior didn't get hurt because it was too weak. It got hurt because it was inhibited and/or overworked. Don't work an already overworked muscle. Instead stretch the gastrocnemius (calf muscles) with the toes pointed straight ahead AND strengthen your gluteus medius and maximus (your butt muscles).
For you clinicians out there:
1. Check pelvic alignment. An anteriorly rotated innominate or inflare can create a functionally longer leg, creating an over pronation scenario.
2. Check for trigger points in the iliopsoas and piriformis as these will externally rotate the leg (creating over pronation forces) and inhibit the gluteal muscles. Counterstrain them.
3. Check for trigger points in quadratus lumborum. The quadratus lumborum and gluteus medius are functionally antagonistic in the frontal plane. If QL is short/tight, then GM becomes long and weak. Counterstrain it and then teach QL to work long and GM to work short.
4. Normalize ankle dorsiflexion. If this is just due to tight gastrocnemius, the gravity drop or downward dog exercise are excellent. If the restriction is felt in the anterior ankle then a posterior talar glide will be necessary to normalize dorsiflexion.
Enough said. Now, go and chase those runners down and help get rid of their pain!
Until next time...
Iliotibial Band Friction Syndrome
Iliotibial band friction syndrome is often described as an overuse injury that produces pain on the lateral knee. In fact, it is listed among the Big Five of running injuries, along with Achilles tendonitis, chondromalacia, plantar fasciitis and shin splints.
Unfortunately, it is also often misunderstood.
For instance, the quick fix for this injury (and many of the others in the list) is simply to stop running for awhile. Just rest the area and let it recover. The premise is that running, in and of itself, created the problem.
But the question that really needs to be asked is, how come the other knee isn't hurting if both legs ran the same mileage? Is it simply a cause of overuse?
Yes and no. Running isn't bad for you. Bad running is bad for you.
The most common scenario that causes ITBFS is a limb that won't pronate. Under pronation. You won't see that too much in the literature.
The normal gait pattern is such that heel strike is designed to occur on the lateral (outside) of your heel with pronation occurring for 25% of the stance phase. This act of pronation not only acts as a shock absorbing mechanism, but also transfers the force to the thicker and larger structures of the medial knee.
Someone so spends more than 25% of stance phase in supination is going to make the ITB very angry. After all, it isn't designed to have to cushion the blow of force dissipation for such a long time.
Some common causes of a limb not pronating?
• Tight gluteus medius (lateral hip muscle) - See the photo? Can you do this move equally on both sides?
• A leg that feels too short (pelvic malalignment, quadratus lumborum or iliopsoas trigger points)
• A subtalar joint that won't evert (Is there a history of ankle sprains in the past?)
• A tight lateral hamstring (Does the revolving triangle in yoga class make you fall over?!?)
• And... a shoe that offers too much support (Check to see if there is a gray bar on the medial side of your shoe last!) We are fans of neutral shoes for these folks.
The good news is... it's fixable! And it doesn't require tons of time away from running.
Oh, and by the way... if you understood what I just said, then you will realize that the ITB is overworked and overstretched in this scenario. Why on earth would you want to stretch an already over stretched muscle?
If you have this problem, or know of someone who does... do them a favor and look up at the hip and down at the subtalar joint. Fix that stuff and then send them back out on the road.
Until next time...
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