Brian Schiff’s Blog

In the last post, I identified the issue I believed to be going on with player x.  Keep in mind the player returned to  see me the week of 12/15 intially.  The first line of treatment for PF issues in most clinical scenarios involves the following:

1. Rest
2. Ice
3. Stretching (quads, hamstrings, IT band and hip musculature)
4. Straight leg raises
5. Short arc quads (mini-knee extensions from 30-0 degrees if you will on a bolster) although I am not a huge fan of these
6. Mini-squats
7. Calf raises

I advocated relative rest, ice and stretching with my athlete in addition to the following exercises initially:

1. Single leg step-downs (side progressing to front version) in pain free range
2. Single leg stiff legged dead lifts
3. Single leg bent knee floor hamstring bridges
4. Lateral ankle band walks for gluteus medius work
5. Multi-planar lunges in pain free range of motion

She did well with all of the exercises after week one but noted pain with front step-downs and deeper lunges.  On 12/22 I made a significant discovery: she had adopted a compensatory hip strategy to avoid normal knee kinematics with deceleration.  What am I referring to?  I call it a quad avoidance lunge pattern.  She would shift her trunk into extension with foot contact when lunging onto the affected knee as a result of anticipation of pain. (See video clip below as I show a normal lunge pattern, a quad avoidance lunge pattern and the exericse I use to break it)

To help break this cycle, I used an 18 inch box to elevate her unaffected foot and force her into more normal hip flexion on the affected side in a pain free range.  This seemed to work so we added this to the home program using a stair step and eliminated front step-downs altogether, choosing instead to focus on the side step-down in the 40-0 range if you will.  I also added single leg soccer kicks (no ball) forward and in a crossing fashion to work on stability, strength and proprioceptive control.

The athlete returned on 12/31 and seemed to be progressing but still had discomfort with running.  So, I felt she was not ready for full go as of yet.  She also still had discomfort with short and long shuffles moving to the involved side.  At this point, her mom wanted to know what I thought. about practice.

I advised her that player x needed to continue with strengthening 3x/week and try to ease back into jogging as able.  She said the first indoor practice was coming up the week of 1/4.  My thoughts? Indoor soccer fields and PF pain are a bad fit – period.  But, I told her to let her daughter warm-up and do a few drills to get a feel for things.

The verdict?  I got an email on Saturday saying she could not practice due to the same discomfort.  Her next stop is back at the surgeon’s office for a closer look at the knee tomorrow.  I will keep you posted on the diagnosis and treatment as this is an issue that all of us who work with athletes face and struggle with.  Finding the right balance and progression between rest, rehab and return to play is tricky.  So stay tuned for more details.

I have posted on the perils of patello-femoral pain in the past on this blog.  Today, I will share how surgery to fix one knee problem may lead to a new problem.  For privacy reasons, I will refer to my client as player x. 

History: Player x is a 15 y/o healthy female soccer player who suffered a lateral menscus tear in the summer of 2009.  She had arthroscopic repair followed by a brief stint (4-6 weeks) of rehab.  Surgery went well, but she did not regain full extension in rehab (she has about 5 degrees of hyper extension naturally).

Prior to fall high school season, player x came to me for sport reconditioning.  She had obvious quad atrophy (particularly the VMO) and lacked speed and explosiveness.  She worked with me 1-2x/week for 4-6 weeks and made good progress but did note some mild persistent soreness in her knee.

She played the entire fall season without injury/limitation but continued to have the same mild persistent knee pain.  The first week she began club practice (fall high school season had ended), her club coach had the players do a lot of plyometrics.  The exercises did not seem hazardous, but player x immediately had a significant increase in knee pain.

Her mother contacted me and she recently came back in for an assessment.  Ironically enough, her single leg squat and single leg broad jump were within 90% of her uninvolved leg.  However, she had mild swelling, Quad atrophy (about a 1 1/2 inch deficit) and she had significant pain with lateral movement to the side of her involved knee and could not decelerate without pain.

Hmmm…..   So what is the issue here?  After carefully evaluating her and performing functional testing I was able to rule out quadriceps tendinitis.  Her pain occurs primarily at or beneath the superioir and lateral portion of the knee cap at 30-40 degrees of flexion when she is weight-bearing.

I am fairly confident she has patello-femoral joint irritation with excess compression along the lateral facet.  Why?

1. Perhaps the slight extension deficit allowed her to run more on a slightly bent knee (more PF force)
2. Weak VMO is overpowered by the vastus lateralis creating abnormal lateral translation of the patella
3. Pain is worse with deceleration and eccentric strength exercise going past (greater quad pull and patellar compression occurs with these activities)
4. Pain with lateral movement and change of direction suggest lack of proper medial stability and dynamic control of femoral internal rotation which would subject the kneecap to abnormal joint reaction forces especially laterally where her pain is felt
5. No pin point tenderness consistent with soft tissue inflammation

The entire scenario has likely been perpetuated by the volume of training/running in soccer and was then exacerbated by the plyometrics.  She compensated and ignored the mild pain all fall, but the knee finally reached a breaking point with the plyos (keep in mind she did no plyos in the high school fall season).

I see patello-femoral pain all the time in female year-round soccer players.  What is the solution?  Stay tuned as I will share more details about patella balancing training and my corrective exercise program for player x in the next post.

Well, with Turkey Day nearly upon us, I am gearing up for a 4 miler on Thursday morning.  I have run 5Ks, 10Ks and half marathons, but this will be my first 4 miler.  They give you a bottle of wine at the end of this one so it is pretty popular in my neck of the woods. 

As I expand my own running and train more and more runners, I often find that many lack good single leg stability and hip strength.  If you are a runner and not doing any strength training or simply focusing on traditional machine-based exercise, you need to shift gears and incorporate single leg exercises to maximize performance and prevent injuries.

In today’s post, I am going to give you an excellent progression of single leg hip drives or lifts to improve stance leg stability, gluteus medius strength and swing leg hip flexor strength.  In addition, this exercise will improve knee stability and ankle proprioception thereby reducing excess tibial rotation/pronation along the way.  That matters if you have experienced IT Band issues or shin splints along the way.  The exercise sequence is as follows:

1. Single leg hip drive holds (3-5 seconds)
2. Supported single leg hip drive
3. Unsupported single leg hip drive
4. Unsupported single leg hip drive with resistance
5. Unsupported single leg hip drive (unstable surface)

You should progress through this sequence of training to ensure best results.  I suggest 1-3 sets of 10-15 reps of each sequence.  The unstable or most advanced version is suitable for cross country runners, runners with poor ankle stability (chronic sprains or hypermobile) or those with poor closed chain mechanics from the ground up.  I have included a few sample reps of these in the video below:

I hope you can put these exercises to good use.  They are great for increasing stance leg strength and stability, while simultaneously improving swing leg strength and mobility. Happy running and have a great Thanksgiving everyone!

As I was preparing a talk on body weight training for the knee today, I came across a new article in September edition of the Journal of Strength and Conditioning Research.  The article discusses the effects of  lower limb plyometric training on body composition, explosive strength and kicking speed.

In short, the authors looked at 20 elite female soccer players over a 12 week period.  Half of the players were assigned to a control group who did normal conditioning (including general strength training but no weights) on M,W and F, while the plyometric group did just the plyometrics on those same days.

Assessments were done 1 week prior to starting, 6 weeks in, 1 week after cessation and 5 weeks after the program is finished.  In summary the results for the plyometric group were:

• No significant change in body composition
• Players were able to increase explosive strength in 6 weeks
• Kicking speed improved after 12 weeks of plyometric training
• Players were able to maintain these gains for weeks after training ceased just with regular soccer training

I have long advocated soccer players do plyometrics on the field after the warm-up period to increase power and reduce injuries.  Now, it appears the increased explosive strength gains may be transferred to a sport specific skill in terms of kicking speed.

In the article the procedure utilized horizontal hurdle hops, depth jumps and horizontal jumps.  For coaches and players looking for a simple field routine, consider the following drills:

1. Squat jumps – Squat down to load the muscles and then jump straight up and down continuously for maximal height.  Continue jumping in one smooth fluid motion for 10 repetitions focusing on soft landings and the knees staying in line with the knees and not caving inward.  Perform 1-2 sets.
2. Split jumps – stand in the lunge position and then jump straight up and back down with maximal explosion.  Repeat 10 times with the left leg forward and then repeat with the right foot forward.  Do 1-2 sets.
3. Consecutive broad jumps -perform 5 consecutive broad jumps for distance.  Rest 30-45 seconds and repeat 1-2 times.
4. Power speed skater – drive off the left leg moving laterally and land on the right leg, then immediately drive off the right leg and land on the left leg.  Perform 1-2 sets 0f 10 repetitions continuously (back and forth = 1).

These four basic plyometric drills require no equipment and are very effective for improving performance.  Consistency is key to get the best results.  Blending the plyometrics with body weight and core strengthening will only serve to enhance the neuromuscular training effects in my opinion as well as to serve to prevent injuries.

I recently relased an article on coaching mistakes in our local market.  In it, I talk specifically about 5 critical mistakes coaches make with respect to athletes.  The article will likely ruffle some feathers.  I am not anti coaches in any way (I am one).  However, I do believe coaches need to be educated about how to integrate training to maximize sport performance and reduce injury risk.

Today, I witnessed another example of how good intentions coupled with lack of proper insight about the impact of conditioning can harm an athlete.  We had a new lacrosse athlete in our facility today working with one of my performance coaches.  At the end of the session, my coach asked me to look at the athlete’s knee as the client apparently had anterior knee pain.

The staff member and father informed me that the lacrosse player’s coach was having everyone on the team not participating in a fall sport train for the Columbus half marathon coming up in October.  The aim was simply to accomplish team building (an admirable goal) and keep them fit.  You may know where this is heading.

I performed a movement screen on the athlete and discovered decreased hip strength and reduced ankle mobility.  The player had obvious imbalances on both sides, left greater than right.  The player then mentioned shin splints on the left leg as well for the past week (now 3-4 weeks into the 1/2 marathon training).

So, after performing a thorough knee eval, I concluded the athlete has anterior knee pain and left sided shin splints related to muscle imbalance and overuse with the recent addition of 4 days of distance running.  Is running bad?  In a word, no.  But this type of running for this particular athlete is not helping further performance goals.

The father enrolled the athlete in our program to work on speed, agility and power for lacrosse.  The bottom line is that this 1/2 marathon training is going to work against the very training adaptations my staff is working to achieve, not to mention now causing more knee pain and shin splints.

I am not opposed to the idea of scheduled conditioning for athletes not participating in a sport.  However, coaches need to step back and ask themselves what is the best way to condition their players for optimal performance and injury prevention.  In this scenario, I have all the confidence in the world the coach has the very best intentions for his players. 

Unfortunately, the results may be less than expected here – more importantly they may be counterproductive as the wrong energy system training and adaptations are being emphasized, while some players may suffer injury.

In my professional opinion, the player should probably consider dropping out of the half marathon training for three very important reasons:

1. Resolve pain and shin splints
2. Focus on fixing muscle imbalances
3. Maximize the training with us

This seems so simple, right?  Well, I see situations like this every week in my facility.  I see too many injured athletes.  Why?  In many cases it has to do with faulty conditioning principles or over training.  My mission is to educate coaches about how best to blend injury prevention with performance conditioning relative to their respective sport.  We have to remember that one size never fits all either.

Thoughts, comments or questions?  Let me know.  I am happy to address them in a constructive and positive public forum.