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.

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 have trained hundreds of soccer players over the years ranging in age from age 8 to the ranks of MLS professionals.  The sport has taught me such an acute appreciation for body control and field agility.

For years, I have focused my lower body training on ground based movements such as lunges, squats, and multiplanar reaching progressions with great success.  To me, the lunge has always made great sense in terms of the apparent functional carry over or at the very least the related muscle activation pattern with sprinting, cutting and changing direction, not to mention acceleration.

A recent study in the May Journal of Strength and Conditioning Research looked at how walking forward lunges and jumping forward lunges impacted delayed onset muscle soreness, hamstring strength and sprinting performance.

Interestingly enough, after 6 weeks of training, the group doing walking lunges showed a 35% increase in concentric hamstring strength, while the jumping group had improved sprint running performance.  In past studies of 10 weeks of training using Nordic hamstring exercises, soccer players typically showed an 11% increase in eccentric hamstring strength. 

Meanwhile, neither group expereinced an increase in quadriceps strength, but the  control group actually saw a 7% reduction in quadriceps strength.  This would lend credence to my belief that while all the running in soccer is quad dominant, running itself does not increase quad strength per se.

Now, in regard to muscle soreness, there were no significant differences between groups per se, but delayed onset muscle soreness as measured 2 days after exercise did negatively impact running and jumping, but not strength.  No real surprise here.

The takeaways for coaches is that incorporating lunge walks and jumping lunges in training may bring about dual benefits.  Improved sprint performance is desirable as well as better hamstring strength for the prevention of muscle and knee injuries.  Increasing hamstring strength obviously is helpful in balancing Quad/Ham ratios for the reduction of ACL injuries as well as hopefully decreasing the likelihood of hamstring strains at ground impact through mid stance in running.  On the latter point, I favor deeper or reaching lunges to provide a greater stretch or elongation of the proximall hamstring fibers as well. 

I also like to employ a walking lunge with trunk rotation as part of my dynamic warm-up with my soccer players.  I ask them to rotate the trunk to the side of the lead leg which helps encourage hip abduction thereby activating the gluteus medius and reducing the internal rotation and valgus moment at the knee.  So, if you coach or train young soccer players, be sure to consider adding these body weight lunge exercises to your program 1-2x/week in the off-season and pre-season.