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!

 

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.

Hamstrings bend my knee right?

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The hamstrings are a misunderstood group of muscles. When most people think about hamstring health, the first things that come to mind are usually stretching by touching your toes, standing or seated, or strengthening by seated hamstring curls on a weight machine. Do these stretches/exercises target the hamstrings? Absolutely. Do they teach the hamstrings how they are supposed to behave in functional movements? Hardly.

So this begs the question: what do your hamstrings do and how do we properly train them? The answer: it depends. It depends on what you do. This will look different for a runner compared to a farmer, or a soccer player compared to someone sitting in a desk all day. For the purposes of this post, we’ll keep it in the context of running. Quick anatomy lesson: the hamstrings are a group of three muscles that originate from the ischial tuberosity (sit bone) and extend past the knee, two out of the three on the inside of the knee, the other attaches to the head of the fibula on the outside of the knee.

There are three primary phases for each leg with running: 1) swing phase, 2) loading phase, and 3) push-off phase. The hamstrings have different functions during each phase and it’s important to understand what’s supposed to be happening at each. Also, most of the discussion will focus on the sagittal plane of movement (forward/backward), as this is the most obvious direction to observe. There are movements and forces in the transverse plane (rotational), and frontal plane (side to side) that we’ll touch on, but focusing on the sagittal plane will help keep details a little cleaner.

Swing phase: This is the ‘open chain’ portion of the cycle where the foot is off the ground swinging forward. During this phase the knee should bend as the hip flexes. The hamstring is not responsible for this knee bend, but rather the hip flexors driving the femur forward and momentum of the lower leg created by the push-off. The hamstrings during this phase are partially responsible for slowing down hip flexion as the swing phase ends, but are relatively quiet at the knee.

Loading phase: This is where the fun begins. As the foot touches the ground and body weight is loaded onto the planted foot, the hamstrings become more awake. At the knee, the hamstrings are mainly responsible for keeping the knee stable, not allowing terminal extension too quickly, nor allowing the knee to further flex. (The soleus is mainly responsible for controlling the knee during loading phase, but the hamstrings also assist with this.) At the hip the hamstrings eccentrically control anterior pelvic tilting, which translates to preventing trunk/pelvic flexion and ultimately keeping your upper body upright. The tricky part about this phase is that the hamstrings are responsible for both the knee and hip. As long as the knee and hip are behaving, than all is good, but if there is dysfunction in any of the adjacent joints or muscles, than this can cause a brief, unhealthy, tug-of-war which can quickly translate to a strain or pull.

Push-off phase: At the transition from loading to push-off, the hamstrings act like a catapult helping to propel the hips forward over the fixed lower leg. The hamstrings assist with extending the knee at this point to allow for full push-off. Then the leg is back into swing phase.

Again, when considering hamstring health, it’s most effective to train them in a way that translates most directly to what they need to do for the specific activity. The majority of the hamstrings’ contribution to running occurs with the foot planted on the ground. Because of this, the most effective hamstring exercises are done with the foot on the ground or planted on something, and the upper body mimicking the movements that occur during running. Here are a few examples.

First, a stretch for the hamstrings with rotational reaches to target different parts of the muscles.

Next, a strengthening progression, essentially a single leg deadlift, then hip rotations to strengthen the hip rotators.

Lastly, a variation of the single leg deadlift with theraband around the knee to challenge control in keeping the knee out of early terminal knee extension.

Give them a try or pass these on to someone who may appreciate better hamstring strength or flexibility. Let me know how you do with them!

Medial knee pain due to ankle restriction

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This week’s rock star is Jack. He has done a marathon in the past and is returning from a running hiatus to dominate a half marathon in a few months. Overall his training is going well without significant concerns, but he does have intermittent right medial knee pain. Let’s see what jumps out during video of him running before we start monkeying with anything.

The area that jumps out to me most is his feet, more specifically his right forefoot. What I notice is a slight apprehension to load onto his right forefoot and thus little push-off on the right side. It’s subtle, and more noticeable from behind. He also demonstrates a moderate overstride, as viewed from the side with his foot strike occurring in front of an imaginary vertical line from his hip to the ground.

After running, he performed single leg squats also as an assessment for stability.

Anytime a single leg squat is performed (which is essentially happening briefly with each stride that you take!), there should be a natural pronation of the foot, slight inward motion of the knee (valgus), as well as slight hip lateral translation (adduction). Neither leg is perfect, but what I notice in this video is how much wobble there is in his right forefoot at the transition point from loading to pushing off. This creates increased values forces at the knee which I believe is causing his intermittent knee pain. While running, this will create an instability that most people will find a way to avoid. In Jack’s case, he avoids pushing off.

As our session progressed, he mentioned having multiple ankle sprains on the right side as well as the feeling of instability. We looked at it closer and found limited ankle inversion, which will limit push-off, as well as make him more susceptible to rolling that ankle. Ankle inversion is needed as part of the push-off process, if it’s lacking than it’s more easy for an ‘inversion sprain’ to occur, which is the most common way to roll an ankle.

So, here’s what we did about it. First, an exercise to gain ankle motion.

Next, an isolated foot/ankle stability exercise on a half-roller.

Next a global stability exercise again to encourage stability with rotational motions.

And lastly, a drill I like to call ‘penguin running’ to amp up forefoot strength and control.

Again, notice how his right foot doesn’t seem to be able to point inward as easily as the left foot. This is another sign of limited ankle motion.

For a couple running drills, he simply ran on his toes to build up forefoot strength, and ran with high knees to encourage a more powerful push-off.

After all this, we turned him loose again.

Notice less of an overstride, viewed from the side, as his foot is landing more underneath his hip. His foot mechanics also are improved, as his push-off looks more symmetrical. Not hugely dramatic changes, but I expect that he will steadily improve in these areas which will translate to greater efficiency with running and less likelihood that he will have ankle injuries. Great job Jack!

Hip extension: is it due to hip flexor tightness?

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This week’s spotlight is on Kaylie. She is a collegiate runner and softball player. A real common combination right? Only a superstar could pull it off. She presented with history of hip and knee issues without significant injury, but also wondering if being in a catcher’s stance was affecting her running gait. Her coach has been working with her on improving her hip extension, mostly with stretching the hip flexors and strengthening her hip extensors. Indeed, this is a very common place to start, but we’ll see how it plays out. Here are videos of her running initially.

The most obvious thing in the side view is the lack of hip extension, indeed her hips never really reach neutral. This is certainly not ideal. But again, is it due to tight hip flexors? behind it is difficult to discern much in the sagittal plane (forward/backward), but there are some inefficiencies with how her upper body moves.  Upon exam, her hip flexors were moderately tight, but the most glaring deficit was a lack of external rotation in both hips, as well as excessive internal rotation. She also had a substantial amount of myofascial tightness in her lateral hips, which we addressed through manual techniques.

So we started with stretches for posterior hip flexibility.

Next she did a stability exercise using a step to accentuate hip flexion, which also will improve hip external rotation.

And another stability drill to ensure control during hip extension.

So after these stretches and stability drills, here is what her form looked like.

Notice the improved hip extension, as well as the improved efficiency in her upper body more visible from behind.

Again, her form is deceptive initially because it appears to be just an issue of stretching her hip flexors. But she has been faithfully doing this for some time. The lack of external rotation of her hips is playing a huge role because it also limits her functional hip flexion, which causes a quicker push-off on the rear leg limiting the extension. She responded well to these drills and should make steady improvements with consistent performance of these. Great job Kaylie!