Tag Archives: knee pain

The Great Toe

When you think of the most common lower body injuries, you think ankle sprains, shin splints, runner’s knee, jumper’s knee, fasciitis, or Achilles tendinitis. When you have these injuries, you treat the injured area. We might be overlooking a little, but big deal.  Dysfunction in the big toe influences every step you take, every lunge, every jump, and every stride of every run. Ultimately, it can be a direct result in many of the aforementioned common lower body injuries. If you have dysfunction (pain, instability, or hypomobility) at the first big toe joint (MTP joint), it could wreak havoc on the entire kinetic chain.

Normal range of motion of the big toe is 40° flexion, 80-90° extension, and 10-20° abduction and adduction. Lack of motion, especially extension, will create compensatory movement at other joints. Common big toe issues such as, hallux valgus (bunion), hallux rigidus, turf toe, sesamoiditis, and gout will limit toe mobility. Below is an image of a client who demonstrates normal range or motion on the right and limited toe extension on the left.

N ROM   Limited ROM

Continue reading

A Runner’s Story: From Pain to Performance

Photo_shoot_runningIn 2010, I left clinical rehabilitation and performance training. While I love my current job, I do miss the clinical aspect, which is why I seize opportunities to take on random clients with complex issues.  I’ve never written about my clients, but this case is so common, yet complex, that I thought my readers might be challenged with similar clients/athletes, or might be experiencing similar issues themselves. Here is a runner’s story that went from marathon training, to painful walking and an inability to run. Her experiences with continued failed treatment and the road we have taken to get her back to training and setting personal records. Continue reading

A Blog Inspired By and Dedicated to Runners

I have been looking for something to blog. No idea surfaced that said, “Yes, that is a great blog idea.” That was until yesterday’s tragic Boston Marathon bombing. Runners are a rare breed. You cannot keep them down. A runner’s passion for sport, resilience to challenge, and unique characteristic to rise above is unparalleled by any other athlete. I am not a runner. In fact I am the antithesis of a runner. I go in to anaphylactic shock just hearing the word aerobic exercise, but have many friends who are passionate runners. I dedicate this blog to my running friends, competitors of the Boston Marathon, the friends and family of those impacted by yesterday’s events, and runners everywhere from the competitive to non-competitive. I will keep it true to my blog site and remain sports medicine focused. I hope you find the information useful.

Running is one of the most popular recreational sports in the US. Race events can be found in almost every town. My town – Champaign, IL – has 2 events in the next 4 weeks. Some estimates say 20% of the population is runners and 10% of these people participate in race events. The benefits of exercise are well documented. Running has shown to build confidence and character, reduce stress and improve mood. However, the due to their very nature – the unwillingness stop – running does bring about an increased incidence of musculoskeletal injury.

You don’t need to be an astrophysicist to know running injury is secondary to cumulative overload. Running injuries are multifactorial; neuromuscular imbalance, poor arthrokinematics and other things such as age, nutritional status and environment are to blame. From a biomechanical point of view frontal plane knee adduction moments play a significant role in lower extremity injury. Q-angle – a measure of knee alignment – can indicate risk for running injury. An increased Q-angle can be a result of many neuromusculoskeletal inefficiencies from poor muscular hip control to limited ankle dorsiflexion and excessive forefoot pronation.

Running brings about many injuries, but the most common are Patellofemoral Syndrome, Iliotibial Band Syndrome, Medial Tibial Stress Syndrome / Tibial Stress Fracture, Achilles Tendinitis, Plantar Fasciitis, and Sacroiliac Joint Pain. What is interesting is that all of these injuries can be caused by biomechanical breakdown and neuromusculoskeletal inefficiency. The good is the dysfunctional patterns are identifiable, preventable and correctable. Below is a sample 15 minute injury prevention program from a blog I wrote in Sept 2012. Yes, 15 minutes is all you need to prevent many running injuries.

Step 1: Decrease neurological drive to hypertonic tissue – 3 minutes

  • Self-Myofascial Release (foam roll) or Manual Trigger Point Therapy
    • Gastrocnemius/Soleus – 60 seconds
    • Adductors – 60 sec
    • TFL/IT-band – 60 sec

Step 2: Lengthen hypertonic muscle or joint tissue – 3 minutes

  • Static stretch or joint mobilization
    • Gastrocnemius/Soleus Stretch – 1 set @ 30 sec
    • Kneeling Hip Flexor Stretch – 1 set @ 30 sec
    • Adductor stretch – 1 set @ 30 sec
    • Posterior joint mobilizations at the ankle – 90 seconds

Step 3: Increase neurological drive to hypotonic tissue – ~ 6 minutes:

  • Exercise: Isolated Strengthening or positional isometrics
    • Resisted Ankle Dorsiflexion – 2 sets x 15 reps (slow) (2 minutes)
    • Resisted Hip Abduction and External Rotation- 2 sets x 15 reps (slow) (2 minutes)
    • Resisted Hip Extension – 2 sets x 15 reps (slow) (2 minutes)

Step 4: Integrated Dynamic Functional Movement – ~ 3 minutes

  • Box step-up with overhead dumbbell press – 2 sets x 15 reps (slow)

Beyond the correction of movement dysfunction there are alternatives to treat running injuries which are effective and gaining popularity. This table highlights a few.

Prolotherapy This has been around since the late 1800’s, but has since become popular. The basis of prolotherapy is that it expedites healing by increasing fibroblastic activity and collagen repair.
Autologous Blood Blood is the medium that carries tissue repairing materials to injury sites. However, sometimes, blood cannot deliver adequate amounts of material to the injured area. Thus, injections directed right at the injury site deliver tissue repairing material.
PRP Like autologous blood, Platelet Rich Plasma (PRP) is injection of a concentrated mix of tissue repairing blood components, specifically platelets, which facilitate tissue repair healing.
Bone Marrow Aspirate Concentrate Despite the negative press and belief that stem cells are only derived from an unborn fetus, stem cells do come from other sources – such as bone marrow. By taking stem cells from bone marrow and injecting in to damaged areas will facilitate tissue repair.
ESWT Extracorporeal Shock Wave Therapy might best be known as lithotripsy. Lithotripsy is a procedure in which sound waves blast and destroy kidney stones. ESWT is the use of sound waves to destroy calcific tendons and ligaments.

I prefer preventing and rehabilitating injury through correcting neuromuscular inefficiencies and dysfunctional movement. The problem with the above treatments is that they are treatments. If an injury is caused by dysfunctional movement patterns and those patterns are not corrected it is likely the above treatments will simply serve as a Band-Aid because the true problem was not fixed.

If the person(s) responsible for the Boston Marathon bombing were looking to put fear in people, they chose the wrong population to target. Runners are the most stubborn and prideful athletes. No means yes, and yes means do more. If you took a graphical representation of marathon registration numbers from last night through the end of this week I would bet you’d find a spike, rather than a decline. Social media is exploding with a rise of the runner. A quote from a friends Facebook page: “If you’re trying to defeat the human spirit, marathoners are the wrong group to target” –unknown. Other movements like, wear a race shirt tomorrow, donations, and wear yellow and blue (Boston Marathon colors) have already begun. So, thank you runners for inspiring this blog post!

Recommended Readings for Health and Wellness Geeks: March, 2013

Each day we are bombarded with new data. My goal is to share a breakdown of what I have discovered and read this past month. There is a little something for everyone here. How do I choose which articles to share? Is it clinically relevant? Does the story share something new or raise an interesting question? Most studies have some internal flaw that can be poked and while I try to only share those having high quality, my number one goals is to share something unique, progressive or surprising.

Published research:

In the recent release of The American Journal of Clinical Nutrition there is a good article supporting the benefits of a high-protein breakfast. Data reveals that a high-protein diet alters ghrelin and peptide YY concentrations subsequently leading to decreased appetite and also curbed late night snacking. Is this study perfect – no. But it is pretty darn good – Yes. I have been blogging on this topic for sometime. Where, when and why did the public begin thinking high protein intake is unhealthy? Did you know quality of protein is measured by how it compares to egg protein? That is because the protein in egg, albumin, has near perfect amino acid distribution. Yet many consider eggs bad.

Here is another topic area I have been yapping about for some time – risk factors for hamstring strains. This systematic literature review was first published online and is now in print in the latest edition of the British Journal of Sports Medicine. This SLR included 34 articles for review, which is a pretty good number to include. Unfortunately, only 1 evaluated hip extension strength. Three found decreased hip extension ROM measures indicating shortened hip flexors. It baffles me as to why studies do not look at glute weakness and hip flexor tightness as a risk factor for hamstring strains. I’ve written about this and hope someday a good study will come out and study the correlation.

Mild Traumatic Brain Injury – MTBI is getting a lot of media attention lately and rightfully so. NFL labor union disputes and an enormous amount of published research has athletes and parents taking MTBI seriously. If that wasn’t enough, Junior Seau’s suicide was linked to depression secondary to chronic TBI. In the Archives of Physical Medicine and Rehabilitation, April 2013 issue, an article discusses depression after TBI. It’s a nice short quick-hitting synopsis, with full-text available.

Website finds:

I subscribe to daily email updates from ScienceDialy. Two or three times per week they share something good that I get caught reading. Two articles they shared link positive benefits of Vitamin D. One shows that Vitamin D replacement improves muscle efficiency and another found Vitamin D may lower diabetes risk in children. Now I am not advocating to go overboard on Vitamin D, but I am saying drink Vitamin D fortified milk and cereals and get outside in the sun to ensure you are getting adequate vitamin D.

ScienceDaily also had an write-up that I loved regarding foods to help fight inflammation. The article states citrus fruits, dark leafy green vegetables, tomatoes, and foods high in omega-3s, such as salmon are anti-inflammatory foods. Notice none of these foods are grains, breads and/or pasta. All are earth foods and not processed. This supports and is similar to blogs I wrote previously: how the US Food Guide Pyramid and MyPlate could be to blame for our chronic disease epidemic, another which is very similar linking arthritis and osteoarthritis to diet. Finally two of my most popular posts written Stop Destroying Your Body and Is Your Diet Making You Sick discuss the link between diet and disease.

Must Read Blogs:

There are so many smart people out there and I enjoy learning from them all. Here are some good blog posts from this month.

The first is from Sport Injury Matt (@SportInjuryMatt – twitter handle). He had two posts about foot mechanics and foot wear. Part I shares good crucial information on foot mechanics. Part II of this post talks about what one should run in and considerations when selecting certain shoes.

My good friend Jay Barss (@sportsrehabtalk – twitter handle) is new to the blog and twitter world. He is a smart dude and deserves some following. His most recent post talks about the a new perspective on management on patellofemoral pain management. As we all know, correction of faulty movement patterns is critical in management of the oft-diagnosed PFPS.

Last is a series posted by  Allan Besselink (@abesselink – twitter handle). If you have not followed Allan’s blog I highly recommend it. In fact his blog was recently nominated as top choice for health and wellness. Everything he posts is high quality. I particularly liked his three-part series titled the Low Back Pain Paradox. Low back pain effects 80% of the adult population and Allan does a great job covering all the bases in Part I, Part II, and Part III.

Stay healthy and well!

Knee Pain? Ignore it; Fix the Hip!

I have posted on this topic many, many times. Unfortunately, many still revert to antiquated rehabiltiation protocols. Thus, I feel compelled to keep talking about it.  If you or a client has knee pain focus on the hip, not the knee. There is so much data out there on linking decreased glute strength to knee pain. A weak or inhibited glute medius is unable to control femoral internal rotation and obligatory knee frontal plane motion.  These motions are a primary cause in knee pain – traumatic and acute. Today I discovered two, recently-published, systematic reviews to prove my point.

The first review examined 47 studies which looked at factors causing Patellofemoral Pain Syndromeknee_patella_intro01  (PFPS) (1). This review identified decreased muscle strength for hip abduction and hip external rotation as an important factor associated with the cause of PFPS. The pooled data also found increased Q-angle and sulcus angle to be factors – both of which have been linked to muscle imbalance.

The second systematic review was more specific by evaluating gluteal muscle activity – via EMG – and PFPS (2). The authors identified ten studies to be included in their review, with six of these studies considered to be high-quality and eight studies having a score of 8 or higher on the Downs and Black scale. The authors conclude there is moderate to strong evidence linking delayed or short Glute medius muscle activity to PFPS. The authors also state, “If gluteal muscle activation is delayed, frontal and transverse plane hip motion control may be impaired, leading to increased stress on the PFJ and subsequent symptoms associated with PFPS.”

Rehabilitation practitioners should note this when developing rehabilitation programs. Specifically targeting glute weakness and inhibition will limit hip internal rotation and obligatory knee frontal plane motion. Correcting faulty movement patterns will allow for optimal neuromuscular recruitment and joint kinematics, ultimately relieving or preventing pain.

If you are wondering which exercises will target the glute medius look at the study published in the recent JOSPT (3) and my recent blog titled “The Glute vs TFL Muscle Battle: Proper Exercise Selection to Correct Muscle Imbalance. The data represented in the JOSPT article demonstrate the bilateral bridge, unilateral bridge, side step, clam, squat and two quadruped exercises are best for activating the glute medius.

Are you ready to change your rehabilitation program?

References:

  1. Lankhorst NE, Bierma-Zeinstra, SMA, and van Middelkoop, M. Factors associated with patellofemoral pain syndrome: a systematic review.  Br J Sports Med.  2013;47:193–206.
  2. Barton CJ, Lack, S, Malliaras, P, and Morrissey, D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013; 47:207–214.
  3. Selkowitz, DM, Beneck, GJ, and Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther. 2013; 43(2):54-64.