Physics...Physiology...Physical Therapy

Lateral knee pain due to IT band tightness

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This week’s spotlight is on Elizabeth. She is in training for her first half marathon and began experiencing left lateral knee pain following a 10 mile training run. She has been very active with team sports and plyometric workouts in the past, but running 10+ miles is uncharted water for her. Here is video of her running initially.

The thing that jumps out the most is the apprehension to load the left leg. The load-to-push-off transition should look very smooth, but her’s is certainly a little jerky (there’s probably a more technical term out there but we’ll roll with this one!). This type of pattern can come from the foot, calf, knee, hamstrings, or hip. Upon closer exam, she was very tight in the lateral hip and IT band.

These areas are especially critical during the loading phase of gait as the lateral hip should be where the majority of the shock of impact is absorbed. If this doesn’t happen gracefully than the IT band can easily tighten up and cause increased friction at the knee.

The other thing that jumps out is how much her arms and upper body rotate, a little more than ideal. The arms often tattle on how well the hips and core are dealing with the forces entering and leaving the body. See the last blog post for a little more on this and what to do about it!

But here’s what we did to get Elizabeth going again. First the good old foam roller to her IT band.

Next a two-stage stretch for the lateral hip.

After the foam roller and stretch, her hip flexibility already showed improvements, so here’s footage before we monkeyed with form drills.

As you can see, her left leg looks much smoother, but we’ve still got the extra rotation of the upper body and arms. So here’s what we did to address the form. First, power skips.

Lastly, she ran with her arms out to the sides. This increases the rotational lever arm and forces her lower core to be more stable while running.

As she did the last drill, she commented on how hard it was to keep her arms from swinging around. Again, what this does is teaches the lower core and hips to be able to more quickly and efficiently load and rebound to push off, rather than pass the buck to the upper body.

After all this, here’s the new and improved form.

Again, her landing and push off look much more efficient. Her upper body has less rotation to it, even though she looks a little over cautious in the last video. Ideally the arm swing is relaxed and relatively forward/backward. Her’s is certainly a step in the right direction. With consistent attention to her flexibility and improved form, this will keep stress off her knee and improve her efficiency. Great job Elizabeth!

 

Core is a movement, not a place

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‘Core’ is such a buzzword in the health and fitness world. But what muscles comprise it and what does it actually mean? We can all think of ‘core’ exercises (e.g. planks, crunches, etc), and we’re core-rect about that (sorry, couldn’t help it!), but we’re selling ourselves short if we are satisfied that these will get us the results we want. Let me also be clear, if the results you want are simply to look good, then planks and crunches will go a long way, but if you want a functionally strong core, then we’ve got to dig deeper.

Since this is a running blog, we’ll keep it in the context of running. Someone please stop me if this gets too geeky.

Think of your core as the place where movement initiates from and pivots. This can vary slightly from person to person. As you lift your knee to take your first step, a series of muscles need to fire to make it happen, this should start around the lower abdominal region, then the hip flexors, quads, tibialis anterior, etc. From there, every time your foot hits the ground, there is a force that travels up your leg (think Newton’s law: for every force there’s an equal and opposite force), as a result of your body weight striking the ground. As that force travels up your leg, your leg muscles should contribute to the shock absorption (think bucket brigade). When that force hits your hip and lower torso area, it should be able to be quickly and readily absorbed, which loads those muscles and allows them to push-off for the next stride. At this point, your upper body should be helping to leverage your lower half in order to make it easy for the next push-off.

So essentially, the forces of your body should pivot around your belly button when you are running. Quite often, this is not the case. Quite often, due to weakness in our lower core, that force has to travel further up our torso before enough other muscles are involved to effectively put the brakes on and send the force back toward the ground. When this is the case, what it can often look like is excessive arm swing, straining of the neck and shoulders, forward trunk lean, or a head that moves too much. Here are a few examples.

What these all have in common, is that their arms and upper bodies are tattling on their cores. Essentially, they have to use their arms and upper bodies differently to help absorb and leverage the forces that should be taken care of in the lower core. This amounts to decreased efficiency and performance and higher susceptibility to pain.

So, let’s pick on traditional core exercises again for a moment. What’s typically lacking is the vertical component for how the muscles need to work. This often means that key muscles (gluts, pelvic floor) don’t get strengthened in a way that actually translates to the demands of running. Can’t you just hear your six-pack muscles saying ‘thank you! can I get some help from below?!’ Here’s an example of a progression that engages your core in a way that translates to running.

There are several ways to modify this also. By using a 5-10# weighted object, that will increase the load, and make you work much harder. By taking bigger strides and going deeper into the lunge, that will increase the workout also. This can also be done as a run form drill, by holding in your arms in any of the 6 positions, based on what tendency you may be trying to overcome. What you should be feeling is the your hips and lower core region is working much harder to keep stability, since you are effectively taking your upper body out of the equation, or biasing it toward a direction of weakness.

Hopefully that all makes sense. Perhaps a more lengthy video with verbal explanations and demonstrations would be helpful. Please let me know if you would like to see this explained in more detail. Let me know how this goes for you!

Knee pain in a jumper

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This is Jeremiah, he is a stud high jumper and runner who has had right anterior knee pain, which is his jumping leg. Our discussion today is in the context of jumping, but the biomechanical principals certainly carry over to running as well. We didn’t take any footage of him running, but this video of a single leg squat tells us plenty!

There’s a lot that can we can draw from watching him do a single leg squat. As you can imagine, every time he jumps off his right leg, he has to load that leg in a squatting movement. The biggest muscle groups that are responsible for propelling upward to jump are the gluts, quads, and calf. So the question that helps us is, how do these muscles know when they have been loaded enough to propel him skyward? There are a few factors that go into the answer. In order to engage the foot and calf, the big toe and medial forefoot have to be driven into the ground to their end-range. In the video, you can see his forefoot pronate heavily, which causes his knee to fall inward rather dramatically. In order to push off, he needs to have a rigid forefoot to propel with, which happens at the end-range of forefoot pronation. Only when his forefoot reaches the end-range of pronation, do the bigger muscles further up the chain (calves, quads, gluts) get the signal that it’s time to push off.

I realize that became a little geeky with the biomechanics, but stick with me. What it boils down to for his knee, which is where the pain has been, is that when it comes time to push off, his knee is at an awkward angle, which means that the quads are pulling on the tendon (front of knee cap) from a direction that is dysfunctional and weaker. This causes increased stress on the tendon and certainly affects his ability to perform.

So, what to do about it. What is tough to discern from the video, is that structurally he has forefoot varus, which means that when his ankle and heel are in a neutral position, his big toe is off the ground. This is a common thing, and most people with this type of foot appear to be flat-footed. One of the first things we did is put a little pad under the base of the big toe. This will hopefully be a temporary measure to cause the forefoot to load more quickly and keep the knee in a happier position. We also did this exercise to encourage the whole leg to stay in more proper alignment. The pull of the thera-band forces his gluts to fire more quickly, as well as strengthens the medial quad (VMO), and helps teach the foot and knee to stay in better alignment.

As you can see, his foot has to struggle to keep proper alignment. It certainly will take some work to build a better habit with this. Here is another simple exercise to strengthen a foot that demonstrates these types of patterns.

Again, with constant practice to build strength and consistency, this will help keep his knee in better alignment and get rid of the knee pain. Keep up the good work Jeremiah!

These principles also carry over to running. If you think this may be an issue for you, watch yourself do a single leg squat in a mirror, if your knee is dipping inward excessively, you might respond well to these exercises as well. Let me know how it goes.

Forefoot pain and hip weakness

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This is Jasmine. She is a superstar runner who is beginning her track season. Some of the issues she has dealt with include forefoot pain and calf stiffness. Her low back has also been sore at times. She is not limited with running, but these are frequent annoyances. Another quirk is that toward the end of a race or tough workout, her head tends to move a lot, sort of like a bobble-head. We don’t have any footage of that sadly, but you can catch a glimpse of it when close up! Here is video of her at the beginning of a run.

From behind, the most obvious parts are the increased loading time in the hips both sides and slowness to push-off through the feet. From the sideview, she has a forward trunk lean. What these indicate is weakness in her hips and core, especially in the context of loading in the sagittal plane (forward/backward). Essentially, every time her foot hits the ground, her hip and lower core region should be able to quickly absorb the force of the ground traveling up and transfer that to an efficient push-off. Instead, it takes extra effort to absorb that load, so she’s forced to lean forward and leverage her head and neck to pick up the slack. Ideally, her head and upper body should be fairly quiet and relaxed because the work is mostly picked up by the lower half.

So, what to do about it. We have already been working on the flexibility of her hips and calves, mostly working on posterior and anterior hip flexibility, which videos of others doing these can be found in previous posts of similar runners, as well as calf stretches with twists thrown in. Again, these can be shown in recent posts. So these videos focus on the running form aspect.

First, another assessment video. The instruction given was simply to stay on her toes. This can be a great way to discern how strong the forefeet are. Often, if the form worsens when running on the toes, that’s a dead giveaway that lack of foot strength is part of the equation. Indeed that’s what we see with Jasmine.

Here is a simple drill to emphasize quickness with the loading phase and power during push-off phase. I’ve heard these most commonly referred to as ‘power skips.’

Next, to develop proper core control in the sagittal plane, she ran with the most convenient object with a little weight to it, a purse!

What this accomplishes is that it forces her to stay more upright and stable through her upper body. This can be done with any object that weighs a few pounds, a backpack, a rock, or a small weight. From the side, her upper body certainly stays more upright, which is a great sign! From behind, her head and shoulders stay more stable, also a great sign!

After these drills, here is what her form looked like.

From the side, she certainly looks more upright. From behind, her feet and hips look quicker and more efficient. So these are good indicators that the drills will be helpful for developing better patterns for stability and efficiency and should translate to better performance. Great work Jasmine!