When a weak quad isn’t…
OK, I've been sitting on this one for a while now just to make sure that what I'm seeing is actually happening.
I have a fair number of patients who exhibit functional quadricep weakness during squatting activities, and not all of these folks have knee pain. I regularly do a squat test during my initial evaluation on most of my out-patient orthopedic clients. Ironically, I have also observed a pelvic rotation (in the transverse plane) on these folks.
So, to cut to the chase, try this test:
3 repetitions of a single leg squat using the TRX or other strap to allow them to use their upper extremities to assist. Don't worry. Even if the "cheat" this a bit, it will be evident which leg is weaker.
Perform 3 x 12 of the kneeling tubing punch using the opposite hand of the weak quad. Here are the specific instructions:
1. Hold the tubing (must be strong resistance) in one hand and allow it to pull the body into rotation to that side.
2. SQUEEZE THE GLUTEUS MAXIMUS on that side to drive the ASIS forward and correct the pelvic rotation.
3. While maintaining this squeeze, have the person perform 12 repetitions of a punch while maintaining that pelvic position and gluteal squeeze. Rest. Reset the gluteus maximus and perform for a total of 3 sets of 12 repetitions.
THEN, repeat the squat test. You just might be amazed at what happens. The quadricep often displays marked improvement following correction of a pelvic rotation.
Give this a try and let me know if it works for you and your patients. Then stay tuned for a little "add on" bonus on how this exercise can improve gluteus medius strength.
Until next time...
A knee that won’t bend
Ever seen a knee that has a hard time bending after a total knee replacement?
Next time before you stretch them, ask them if they feel the pain in the front or the back of the knee. More times than not, the limitation isn't due to scar tissue formation...and more times than not the pain sensation is in the back of the knee instead of the front.
If this applies to you, there is a real solution that doesn't require a manipulation. This is often due to a posteriorly displaced fibular head and is fixable with a simple technique.
What causes this displacement? Our best intelligent guesses are:
- a lack of subtalar joint eversion (stiff ankle)
- a tight lateral hamstring
- walking toed-out usually due to tight calf muscles
It takes about 120 degrees of flexion to walk up and down stairs normally, put your pants on standing up, get your socks on easily or ride a bike!
If you have this problem, I'd love to hear from you and help you fix it.
After all, spring is here. It's time to pull out the bicycle and enjoy it a little...and it doesn't hurt to have pants on while you do it. 
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...
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