Tag Archives: Knee

The Long Femur and Squat Mechanics

The squat is one of the best exercises to improve performance, period. Athletes incorporate the squat into their workout regimen because it increases strength and power of the entire lower extremity and significantly activates the core muscles. Unfortunately, performing the squat improperly can lead to significant injury.
Without getting into too much detail, there are 4 main reasons why a person may not be able to squat with good technique.
 
  1. Poor ankle mobility, primarily dorsiflexion
  2. Poor hip mobility, primarily hip flexion and external rotation
  3. Muscle weakness/muscle imbalance of the lumbo-pelvic-hip complex
  4. Long femur (a high femur to torso length ratio or high femur to short tibia ratio)
 Three of the above can be fixed with corrective exercise. This might shock you but there is no corrective exercise program that will lengthen the torso and shorten your femur (yes, that is sarcasm). Unless you are skilled at removing portions of the femur with a chainsaw you’re not going to fix #4.
Squatting with a long femur can lead to low back injury. In the image here you can see that the individual with the long femur has an increased forward lean. The excessive lean increases load at the low back.
I love the video here. If you move to the 3:40 mark the video shows an individual squatting with long femurs squatting.

It drives me bonkers when a provider (athletic trainer, personal trainer, therapist, etc.,) attempts to correct a client’s squat mechanics by forcing changes in items 1, 2, or 3 when the real problem is the unfixable number 4. Before you waste a client’s running them through a corrective exercise program make sure it is something that can be fixed.
If you have a long femur to short torso ratio you do have options!
  1. Widen the stance
  2. Externally rotate the legs
  3. Raise the heels
 If you continue watching the video (around the 5:30 mark) you will notice how the individual’s squat mechanics are improved by making subtle changes in body positioning.

All of these options change the lever arms and evenly distribute the weight between the low back, knees, and feet. Thus, one joint is not excessively loaded more than the others. You can try adjusting one of the above items or mix and match any three of the above.
 

The Squat: Should Your Knees Travel Past the Toes?

Should the knees migrate past the toes when performing a squat? I posted this question on downloadsocial media, and the immediate response by most was “No!”. I expected this answer from most everyone, from novice to advanced lifters. To you, I happily say, you’re wrong! The debate on proper squat mechanics will never die, but I am going to steal a line from Randy B., an athletic training, and performance enhancement peer, who answered my question: “Absolutely, [the knees] should [go past the toes]. Don’t believe urban legends or follow sports med sacred cows!” I couldn’t have said this any better! Randy is spot on. This urban legend could lead to injury. The purpose of this blog is to shed some light on the debate and provide the rationale for proper squat technique.

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Arthritis: Causation, Symptomalogy, and Management

According to the CDC approximately 1 in 5 adults and 50% of older adults (> 65 yrs of age) have been diagnosed with some form of arthritis (1). The physical pain associated with arthritis is well documented, however, there is a large social impact on arthritis suffers. From an outsiders perspective, arthritis goes undetected. Outsiders do not see the pain or suffering that arthritic patients must suffer through. They are often labeled as weak, malingerer’s, or even lazy. Point is, many people with arthritis are having difficulty performing simple activities of daily living.

The purpose of this blog is to provide a high-level overview of the disease and share basic exercise and dietary guidelines that can provide a holistic approach to reducing symptoms, improve quality of life, and functional outcomes.

Disease Overview: 

There are more than 100 rheumatic diseases and conditions that affect joints, the tissues which surround the joint and other connective tissue (1). It is the most common chronic musculoskeletal condition in older adults. The two most common forms of arthritis include osteoarthritis (caused by damage or wear and tear) and rheumatoid arthritis (autoimmune causes).

Osteoarthritis:

Osteoarthritis (OA) is characterized by the gradual deterioration of cartilage within a joint (2). It is commonly developed in load-bearing or highly mobile joints, such as the knee, hips, fingers, lower back, and feet. Often, those who suffered a significant injury to a joint are at an increased risk of developing OA. For example, knee OA is very common following ACL tears and surgery. The internal joint damage caused by the injury compounded by incomplete rehabilitation (prolonged inflammation and muscle weakness) are the perfect ingredients for OA development.

The synovium of a joint produces the lubricating substance, synovial fluid. Healthy cartilage functions much like a sponge, it is receives nourishment by absorbing synovial fluid during joint movement. As we age, the synovium decreases its production of synovial fluid, we move less, and inflammation the articular cartilage increases resulting in dehydrated / malnourished cartilage). This creates a vicous inflammatory cycle.

Inflammation causes pain, loss of function, which eventually leads to muscle wasting and cartilage deterioration. Overtime, the poor cartilage condition can result in the formation of exotosis (bone spurs) that further damage the joint structures, increases pain, and creates a loss of function.

The most common symptoms of OA are pain, inflammation, reduced range of motion, and grinding sensations upon movement. As cartilage continues to detoriorate, pieces of cartilage my break free and float withing the joint (osteochondritis dissecans). The floating bodies will sometimes lock or catch the joint during movement. This locking or catching is very uncomfortable and sometimes painful.

There is no cure for osteoarthritis. Since pain is alleviated with rest, many of those afflicted tend to avoid regular exercise for fear of pain or flare-ups. Despite this, a recent study demonstrated that older adults who regularly participate in aerobic and resistance exercise are effectively able to relieve arthritic pain and improve joint function (4, 5). This creates a paradox for optimal treatment (movement vs. rest).

Rheumatoid arthritis:

Rheumatoid arthritis affects approximately 1% of Americans. It is an autoimmune disease where by the body’s own immune system attacks joint structures, including cartilage, synovial membrane, and ligaments. Rheumatoid arthritis is a systemic condition characterized by periods of activity and remission where affected joints are painful and swollen in addition to whole body symptoms of fever and malaise. Currently, there is no cure of rheumatoid arthritis, but there are medications designed to relieve symptoms.

Rheumatoid arthritis of the hands

 

Holistic Approach to Arthritis Treatment and Prevention:

Although I have great respect for western medicine and the research that pharmaceutical companies do to help cure chronic diseases, I have always been a believer in the holistic approach. The body is a self-healer – its own internal mechanic.

As I mentioned previously, cartilage gets nourishment through dynamic pressure gradients caused by movement and joint loading. Most people with arthritis can safely participate in physical activity programs to help the disease. Many studies have shown physical activity to have a positive effect on the reduction of arthritic pain. A 2010 agenda released by CDC lists physical activity as a priority intervention to improve arthritis symptoms and prevent arthritis-related limitations in activity (6). Unfortunately, there is a fine line; arthritis causes pain and subsequently, sufferers will not move due to pain. The perpetuates the disease and worsens symptoms. So movement is prudent, however we must be careful and be cognizant of exacerbating the issue. Below are some exercise guidelines.

Exercise Guidelines:

Things to avoid:

  • Rheumatoid arthritis results in early morning stiffness, so avoid early morning exercise.
  • Avoid end ranges of motion exercise as extreme cases may allow you to move in a small mid-range of motion only.
  • Be certain to distinguish between exertional pain in the muscles and pain in the joints.
  • If any movement causes moderate pain in a joint, stop immediately and modify or regress the exercise.
  • Always move joints through a slow and controlled range of motion.
  • Avoid fast or jerky movements.
  • Progress and increase exercise intensity very slowly.

Exercise tips and suggestions:

  • Exercise sessions should be relatively short and of low to moderate intensity.
    • Use circuit training (to give body parts a rest between exercises)
  • Aerobic exercise should be comprised of multiple sessions of using various cardio equipment (treadmill, to bike, to rower, etc)
  • Flexibility:
    • Self myofascial release (foam rolling) might be painful, but try it.
    • Static stretching as tolerated but avoid end range of motion for the joint
  • Resistance:
    • Low intensity
    • 1–3 sets of 10–12 repetitions 2–3 days per week
    • Work on core musculature
    • Use a circuit or peripheral heart action training system.
    • Avoid high reps or high loads.
  • Use thera-bands or cuffs when possible to avoid gripping if hand and grip strength is a problem.
  • In severe cases training sessions maybe have to be limited to short bouts (8-10 minutes at a time).
  • Emphasize the development of functional flexibility and eccentric control through simple reactive training exercises.
    • forward lunge with emphasis on lowering.
    • Eccentric training will improve soft tissue to absorb ground reaction forces and reduce the force transmission to damaged joint structures.
  • Water aerobics or swimming may be the best environment for clients with severe arthritis.

Dietary Considerations:

Arthritis is a chronic inflammation cycle, where inflammatory mediators remained elevated and a continued process of degradation ensues. Individuals with chronically elevated inflammatory markers are at high risk of chronic disease and now research shows that poor diet can also contribute to increased inflammatory markers. I wrote about this in a previous blog entry titled “Is Your Diet Making You Sick?”.

Excessive consumption of refined carbohydrates and low dietary fiber intake is strongly associated with the production of proinflammatory molecules (7). One large study compared a western diet, which contained more red meat, refined carbohydrates and saturated fat to a paleolithic diet (8). The Western diet group had greater levels of inflammatory markers, including C- reactive protein (CRP) and E-selectin when compated to those following a paleo-like diet (8).

Clinical studies in found frequent nut and seed consumption is associated with lower levels of CRP, Insulin-like growth factor (IL-6) and fibrinogen(9). Consuming an almond-enriched diet for four weeks significantly decreased serum E-selectin compared with the control diet in healthy men and women (9).

The rise of these inflammatory diseases over the past few decades may be linked to the Western diet of saturated fats, low antioxidants, and refined carbohydrates. A diet rich in omega-3 fatty acids such as fish and nuts as well as whole grains and high fiber have been shown to reduce chronic inflammation markers in the blood.

Summary:

Arthritis is a serious chronic inflammatory disease which has both physiological and psychological effects on overall health. Pharmaceutical companies continue to search for a magical cure for arthritic conditions, but to date nothing has been found. Thankfully, we can do something to help relieve the pain and symptoms of arthritis. Creating a safe and systematic physical activity program can help prevent cartilage deterioration and improve overall function. In addition, a dietary change can also help. By limiting intake of refined carbohydrates, excessive sugar, and foods high  in saturated fat we can lower chronically elevated inflammatory markers that are responsible for chronic diseases such as arthritis. I hope these tips help you or someone you know improve quality of life.

 References:

  1. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm. retrieved August, 23, 2012
  2. Ferrini AF, Ferrini RL. Health in the Later Years. 4th ed. New York, NY: McGraw-Hill; 2008.
  3. Hills, B. A., Ethell, M. T., and Hodgson, D. R. Release of Lubricating Synovial Surfactant By Intra-Articular Steroid.  Br J of Rheum. 1998;37:649–652.
  4. Petrella RJ. Is exercise an effective treatment of osteoarthritis of the knee? West J Emerg Med.2001; 174(3): 191-196.
  5. Ettinger WH, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997: 277(1): 25-31
  6. Centers for Disease Control and Arthritis Foundation. A National Public Health Agenda for Osteoarthritis. 2010
  7. Neustadt J. Western Diet and Inflammation. IMCJ. Vol. 10: 2  Apr/May 2011.
  8. Lopez-Garcia E, Schulze MB, Fung TT, et al. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am JClin Nutr.2004;80(4):1029-1035.
  9. Rajaram, S, Connell, KM, and Sabate´ J. Effect of almond-enriched high-monounsaturated fat diet on selected markers of inflammation: a randomised, controlled, crossover study. BR J of Nut.  2010: 103, 907–912.

The Season Ending ACL

What is happening in the world of sports? Last week sports talk radio was abuzz over significant injuries to Derrick Rose and Iman Shumpert of the NBA. Now we lose yet another sports star – future hall of famer, Mariano Rivera of the New York Yankees – all three stars suffered ACL tears. This rash of injuries has created much debate on the issue. People are asking why? Did the shortened pre-season lead to this rise in injury? Did the condensed schedule lead to the injury? Are these just chance freak injuries? The answer to all is yes. However, each of these injuries could have been prevented.

Many original research studies and systematic literature reviews have shown a significant reduction in ACL injuries following implementation of neuromuscular training. In fact, a systematic literature review was recently published in the Journal of Bone and Joint Surgery (March 2012). This showed that ACL injury prevention programming provides a significant reduction in ACL injury. Many others literature reviews and research papers have also shown the effectiveness of neuromuscular training programs. A shortened pre-season may have led to the increased injury rate, because players were not exposed to the pre-season neuromuscular training. Unfortunately, not all teams apply injury prevention programming as part of the workout routine.

As for the condensed season schedule; a condensed season schedule with limited recovery dates will yield higher incidence of injury. A study published in the American Journal of Sports Medicine (2011) shows that injury rates in a short recovery group demonstrated a significantly greater overall injury rate, practice injury rate, and game injury rate compared to those in the extended recovery group. The injury rates were 6.2 times greater for overall injury, 4.7 times greater for game injury, and 3.3 times greater for practice injury in the short recovery group. That said, these injuries could have been prevented, even if neuromuscular training was not implemented during the pre-season. As the season progresses a gradual decline of neuromuscular efficiency occurs. This leads to the breakdown of mechanics and subsequent injury. ACL injuries can be prevented. Identifying faulty mechanics as the season progresses and then applying corrective techniques to fix those mechanics will go a long way in preventing non-contact ACL injuries.

Women are Wimps!!

STOP! Before you start throwing knives at my head I don’t really think women are wimps. If I did my wife would be waiting for me when I get home to prove me wrong. In fact, it is quite the opposite. Women have demonstrated continued increase in sports endeavors and are much faster, more aggressive and powerful than in past decades. However, secondary to the increased participation in sport, women are sustaining many more injuries.

Females between the ages of 15-25 years are most often injured, with the majority of these injuries are to the anterior cruciate ligament (ACL).  Females are 2-5 times more likely than males to sustain an injury to the ACL. This injury is primarily noted in basketball and soccer, but is still prevalent in many other sports such as volleyball, softball and gymnastics.  Women over the age of 25 are also more susceptible to recreational sporting injuries compared to males.  Many of these injuries are also musculoskeletal in nature, such as ankle sprains, shoulder tendinopathy, and chronic knee pain such as chondromalacia, PFPS and ITB Syndrome. Looking at the glass half-full though,most of these injuries can be prevented with correction of movement dysfunction.

With the increased participation in sport and the commonality of musculoskeletal injuries it is prudent to understand typical movement dysfunction patterns that bring about these injuries.  Secondary to genetics, body morphology and muscle recruitment females are susceptible to lower extremity impairment syndrome.

Lower extremity impairment syndrome is a combination of muscle imbalances, joint dysfunction, and poor muscle recruitment patterns from the low back to the foot. The impairment syndrome can be characterized by foot pronation, knee valgus, femoral internal rotation, and lordosis at the low back.  When performing functional activities, such as running or cutting, these characterizations are amplified. Ultimately, this leads to ACL tears or the aforementioned chronic pain syndromes.

The good news is these poor biomechanical patterns can be corrected following focused rehabilitation techniques designed to improve muscle synergy as well as joint mechanics. Many studies have been done to show a significant reduction in the incidence of injuries, such as ACL tears, by correcting these impairments. If you are having chronic pain in the lower extremity, it might be a result of lower extremity impairment. This is a good thing, because it can be corrected.