Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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It has been a while since my last post. To be honest, I have been busy with preparing/presenting my live seminar last week and webinars, as well as fulfilling my writing obligations and clinical role. So, I have been taking a “break” from blogging and recharging the battery so to speak.
Now I am getting back to it. The great thing about presenting though is that I am consistently reading and reviewing the latest research on topics related to my presentations and closely examine my rehab and exercise philosophy. In my clinic, I treat many runners for knee pain.
The average profile is an experienced runner b/w the ages of 25 and 50 who logs 20 – 35 miles per week and routinely competes in half marathons or some sort of triathlons.
Common injuries include IT band problems versus lateral meniscus tears versus patellofemoral pain. Often, I uncover the following things related to kinetic chain deficiencies:
- Elevated or rotated inominate
- Ankle dorsiflexion restriction (OH squat assessment)
- Poor single leg stance
- Weak lateral myofascial chain
- TFL dominance
- Excessive femoral internal rotation/adduction with single leg squats
- Tightness in hip flexors, ITB and soleus
Many currently debate the efficacy of foam rolling. Is it worthwhile? Some say yes, while others say no.
Let me start off by saying I have the privilege to assess and treat many avid runners on a weekly basis. Some of them are triathletes and others just dedicated runners. While the age and experience level varies, I see more female runners in all.
Recently, a woman in her mid thirties came in for PT after being referred by a physician’s assistant (PA) with a working diagnosis of hip flexor tendinitis. She had developed pain running in the past few weeks. It was now at a level preventing her from running despite using NSAIDS to reduce inflammation.
Specifically, she complained of increased pain with figure 4 sitting, difficulty and pain getting up from a chair, and increased pain with running. Her pain level at the eval was 2/10 but went as high as 9/10 with running. Lots of things can cause pain in the hip joint.
Summary of clinical findings:
- Poor single leg stance on the involved hip with mild pain
- No leg length discrepancy
- Subtle antalgic gait
- AROM for hip and L-spine are within normal limits
- No pain with quad or hip flexor stretching
- Manual muscle testing reveals 5/5 strength for hip flexion (SLR and seated), abduction and adduction
- Pain with FABER testing
- Positive hip impingement sign
- Pain with deep squat
I have been a bit behind on blogging as of late. I try to aim for one per week, but I also strive to deliver sound and relevant content. Additionally, I do not seek outside contributors so finding time to write can be tricky with work and family life too. So, forgive me for any apparent inconsistency in posting. Just know that I will always try to provide valuable content. Today’s post centers around an article in the July 2012 edition of AJSM.
My work at the Athletic Performance Center has provided me an increased opportunity to work with FAI and athletic hip injuries. This is an area of evolution and growth in our field, so I find it particularly interesting to see rationale and thought processes centering around the timing, contribution and selection of hip exercises for active patients/athletes.
This article comes from the Steadman Philippon Research Institute in Vail, CO. The purpose of the study was to measure the highest activation of the piriformis and pectineus muscle during various exercises. The hypothesis was that highest pectineus activation would occur with hip flexion and moderate activity with internal rotation, whereas the highest activation with the piriformis would be with external rotation and/or abduction.
Methods: 10 healthy volunteers completed the following 13 exercises:
- Standing stool hip rotation
- Supine double leg bridge
- Supine single leg bridge
- Supine hip flexion
- Side-lying hip ABD with external rotation
- Side-lying hip ABD with internal rotation
- Side-lying hip ABD against a wall
- Hip clam exercise with hips in 45 degrees of flexion
- Hip clam exercise with hips in neutral
- Prone heel squeeze
- Prone resisted terminal knee extension
- Prone resisted knee flexion
- Prone resisted hip extension
All of these exercises have been reported to be used in hip rehab following arthroscopy or recovery from injury. The exercises were executed slowly and methodically with a metronome to reduce EMG amplitude variations.
So, a very common issue I see in runners is iliotibial band (ITB) syndrome. In a nutshell, it involves excessive rubbing or friction of the ITB along the greater trochanter or lateral femoral epicondyle. It is more common along the lower leg just above the knee and typically worsens with increasing mileage or stairs.
The ITB is essential for stabilizing the knee during running. Several factors may contribute to increased risk for this problem:
- Muscle imbalances (weak gluteus medius and deep hip external rotators)
- Uneven leg length
- High and low arches
- Increased pronation leading to excessive tibial rotation = friction of the band
- Improper training progression
- Faulty footwear
- Poor running mechanics
- Limited ankle mobility (specifically dorsiflexion)
- Tightness in the tensor fascia latae (TFL) and glute max
Related information on this topic include a 2010 study published in JOSPT on competitive female runners with ITB syndrome:
Click here to see the abstract of the study
Click here to read an earlier blog post analysis of the above research article
Common signs and symptoms include stinging or nagging lateral knee pain that worsens with continued running. Hills and stairs may further aggravate symptoms. Some runners even note a “locking up” sensation that forces them to stop running altogether. How do I treat this?
It is clear that our society loves shoes and fashion. The problem is that fashion often does not equate to good function. Keep in mind your feet set the tone for the rest of your body’s biomechanics so it stands to reason that one would want to pay close attention to their foot structure and use the RIGHT shoes more often than not.
I treat and evaluate lots of runners on a weekly basis. I use the FMS, selective testing and gait analysis to help them resolve mechanical issues, overuse problems and improve running efficiency. However, when it comes to making footwear choices, I can only counsel them on what is best.
Recently, I wrote a column for Endurance Magazine on the impact of high heels and flip flops as it relates to injury risk. At the end of the piece, I give some exercises to address shortened muscles and soft tissue. I think all women who enjoy running (symptomatic or not) should give this a read. Click here to read the article.
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