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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: anterior knee pain

Every year I like to look back and reflect on things I have learned, things I have changed my mind about and of course clinical pearls that stand out.  Over the past year, I have been sharpening my IASTM skills, begun to practice dry needling techniques, and scrutinizing my hip and core exercises that I routinely use in rehab.

I look forward to sharing more about my clinical experiences with dry needling in 2014, but I feel the most critical and recurring theme of 2013 has been the overwhelming impact I have seen poor ankle dorsiflexion have on my patients.  I treat scores or runners, triathletes and clients with knee pain.  The most common issues in this group of clientele tends to be IT band friction syndrome or patellofemoral pain.

When I assess this group of patients, I routinely find the following:

  1. Poor dorsiflexion
  2. TFL dominance
  3. Glute weakness

Any time I evaluate a runner, I assess closed chain dorsiflexion (DF) mobility.  This can be assessed in half kneeling on the floor or standing at a wall.  I suggest removing the shoes during the assessment to eliminate any rise from the heel in the shoe that may bias the movement.  In addition, I hold the ankle in subtalar neutral to get a true assessment without allowing pronation.

The image below simply demonstrates the assessment position as well as the corrective exercise that can be used to facilitate better motion.

half-kneeling-ankle-dorsiflexion-assessment-finish

Clients should be able to attain about 5 inches of clearance beyond the toes without lifting the heel or relying on pronation to get there. I routinely see limited mobility, and more importantly almost 100% of the time I find asymmetry on the side of the affected knee.

I recently evaluated a 29 y/o active female client who does Crossfit 3x/week and likes to run.  She has not been running much due to chronic right lateral knee pain and medial calf pain.  Her goal is to get back to running half-marathons.  Upon evaluation, her overhead squat assessment revealed pronation and external rotation bilaterally, right greater then left.  Her standing wall DF assessment revealed nearly a 1 inch deficit on the right side (about 3 inches), while her left side was 4 inches.

Below is how she looked on the treadmill video analysis I performed:

pronation-hip-drop-rear

You can see the highlighted areas in the photo above.  She has a marked amount of pronation in mid stance as well as left pelvic drop due to poor gluteal activation.  The poor hip stability and activation on the right side also plays directly into TFL dominance with the repetitive femoral internal rotation and adducted position of her right hip..

This poor biomechanical chain is set into motion by poor dorsiflexion mobility.  Runners can get away with this for shorter distances (3-4 miles) in many cases, but increased mileage leads to shin splints, calf strains, IT friction syndrome and patellofemroal pain.  You can see how this poor kinetic chain movement leads to ongoing microtrauma and eventually debilitating pain and dysfunction.  No matter how much one rests, going back to higher mileage will yield the same result.

In my client’s case, she also had a trigger point in her medial soleus – another issue connected with the ankle mobility problem. Her primary treatment plan will focus on soft tissue mobilization for the gastroc/soleus complex, TFL/ITB and glutes/piriformis, ankle dorsiflexion mobility exercises, IASTM to her gastroc/soleus/Achilles, single leg balance and strengthening and hip/core activation and stability work.

I am confident all of this will effectively resolve her pain.  However, it all begins with restoring ankle mobility.  They say a picture is worth a thousand words.  I strongly believe the picture I included of my client on the treadmill speaks volumes as to how poor ankle mobility can lead to unwanted compensatory motion, gluteal inhibition and overuse injuries.  The take home message here is be sure to assess ankle mobility in the presence of any lower extremity pain or dysfunction as it is often a critical piece of the puzzle in the face or recurring injury and chronic pain.

Unearthing the cause of anterior knee pain and ridding our patients and clients of it is one of the never ending searches for the “Holy Grail” we participate in throughout training and rehab circles.  I honestly believe we will never find one right answer or simple solution.  However, I do think we continue to gain a better understanding of just how linked and complex the body really is when it comes to the manifestation of knee pain and movement compensations.

We used to say rehab and train the knee if the knee hurts.  It was simply strengthen the VMO and stretch the hamstrings, calves and IT Band.  Slowly, we began looking to the hip as well as the foot and ankle as culprits in the onset of anterior knee pain.  The idea of the ankle and hip joint needing more mobility to give the knee its desired level of stability has risen up and seems to have good traction these days.

Likewise, therapists and trainers have known for some time that weak hip abductors play into increased femoral internal rotation and adduction thereby exposing the knee to harmful valgus loading. So, clam shells, band exercises and leg raises have been implemented to programs across the board.

theraband-single-leg-hip-rotation-finish

Single Leg Resisted Hip External Rotation

As a former athlete who has tried his hand at running over the past 5 years, I have increasingly studied, practiced and analyzed the use and importance of single leg training and its impact on my performance and injuries.  As I dive deeper into this paradigm, I continue to believe and see the benefits of this training methodology for all of my athletes (not just runners).

As a therapist and strength coach, it is my job to assess movement, define asymmetries and correct faulty neuromuscular movement patterns.  To that end, I have developed my own assessments, taken the FMS course, and increasingly observed single leg strength, mobility, stability and power in the clients I serve. Invariably, I always find imbalances – some small and some large ones.

What are some of the most common issues I see?


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