Brian Schiff’s Blog

Anterior knee pain, aka chondromalacia, patellofemoral pain (PFP) and patellofemoral pain syndrome (PFPS), may be the most difficult condition to remedy in the clinic or gym.  There is always debate and speculation when it comes to taping, bracing, orthotics and exercise.

In the latest edition of the JOSPT, there was a summary from the findings presented at an international retreat held in the spring of 2009 in Maryland.  The publication covered the keynote addresses and podium presentations.

Before I give you the quick and dirty details, I want to emphasize a key point that was made and one I happen to wholeheartedly agree with.  It is this:

When assessing and evaluating those with PFPS, it is important to recognize that these patients/clients do not necessarily fit under one broad classification system.  The anterior knee pain issue is multi-factorial and not every person has the same issues or abnormalities.  As such, the exercise prescription most likely will need to be tweaked accordingly for best results.

Okay, now on to the highlights that may impact your training/rehab.  Some researchers from Belgium have been conducting prospective studies looking at intrinsic risk factors for developing PFPS.  They looked at physical education students and novice runners.  Major findings are included below:

Study #1

There were 4 variables identified as risk factors:

• Decreased flexibility of the quadriceps
• Decreased explosive strength of the quadriceps
• Altered neuromuscular coordination b/w the vastus lateralis (VL) and vastus medialis oblique (VMO)
• Hypermobility of the patella

Study #2

• More laterally directed plantar pressure distribution at initial (foot) contact during walking and more laterally directed rollover are risk factors for developing PFPS

Study #3

• Unable to link hip muscle strength (or weakness) to increasing risk for PFPS
• No apparent correlation with frontal plane motion of the knee and hip strength (so hip weakness will not automatically cause knee pain)

Finally, what does this mean for therapists and fitness pros?  It means…….

1. They should address the 4 intrinsic risk factors by stretching and strengthening the quads, with a particular emphasis on balancing the VMO strength in relation to VL strength.  This is not new information.  Spending time on closed chain terminal range strengthening is important. 
2. Second, keenly observing a dynamic disturbance in foot alignment at contact is important  for predicting PFPS and will undoubtedly impact dynamic training protocols for the entire kinetic chain. 
3. Lastly, continue to strengthen the hip even though the final study revealed no apparent link.  However, perhaps focus more on this when there is a definitive weakness side-to-side that has been identified.  So, don’t fall back on the weak gluteus medius by default; rather use dysfunction as a driver for exercise inclusion.

PFPS is and will continue to be a difficult problem to treat and remedy with exercise.  Further research is needed to determine and evaluate more specific gender differences, kinetic chain links, the efficacy of taping/bracing, and the most effective classification and treatment algorithms for those of us in the trenches.  In the meantime, listen to the body and use the best available science and information to move forward with your training. 

Reference: JOSPT March 2010

It is fairly well accepted in medical/rehab circles that much of the lateral knee pain felt by runners is related to the IT band.  Researchers report that frictional forces are greatest between 20 and 30 degrees of knee flexion (this occurs in the first part of stance phase with running).   But what about the differences in hip and knee kinematics between healthy and injured subjects?

I currently train two competitive female marathoners.  Both are in their thirties.  One has run Boston and the other is training with me to qualify this year (she missed by 36 seconds last year).  Many female runners deal with iliotibial band issues during their training.  My client trying to qualify for Boston has issues on her right side.  My other runner does not.  The client affected by this also has some ankle instability which certainly affects closed chain mechanics.

Historically, researchers have felt increased rear-foot eversion has contributed to such injuries.  Why?  well, increased rear-foot eversion leads to increased tibial internal rotation, and by the ITB’s attachment point distally on the tibia this would in turn increase strain.  In addition, it has been postulated that gluteus medius weakness leads to greater hip adduction moments and undue strain.

One recent prospective study done by Noehren et al. concluded that runners who developed ITBS exhibited increased hip adduction and knee internal rotation angles compared to healthy controls.  Today, I wanted to briefly update you on a study just published in the Journal of Orthopaedic and Sports Physical Therapy looking at the running mechanics of those with previous bouts of ITBS and those without.  The study observed 35 healthy female runners and 35 age matched runners (ages 18-45 who run no less than 30K/week) with a history of ITB issues.  They measured:

1. Hip, knee and ankle kinematics
2. Internal moments during stance phase

So, what did the results say?  In a nutshell, the ITBS group did in fact exhibit increased hip adduction angles and peak internal rotation angles at the knee.  There was , however, no significant difference among groups with respect to the rear-foot eversion.  This particular study did not measure hip abductor strength.

As far as limitations to the study, one primary one was the fact that the ITBS group was healthy during the study (meaning they had some time in the past suffered ITBS).  With that said, the results did mirror the prospective study by Noehren.

The practical takeaways for runners and trainers are:

• Prior ITB issues may increase risk for recurrence due to increased strain
• Prior ITB issues indicate atypical hip and knee kinematics may be present
• The rear-foot position may have a lesser role in causation of ITBS
• Addressing hip stability, strength and eccentric control is paramount to injury prevention
• Observing frontal/transverse plane knee mechanics is prudent

In training, I recommmend video analysis or using a mirror independently to observe what I term a single leg hop and stick maneuver.  I teach it to all my cutting and impact athletes.  Simply begin on the left leg and hop forward onto the right and lower down into a lunge type single leg landing position.

Observe the foot/ankle, knee and hip as the body declerates.  This image and sequence of events leaves strong clues about the strength and force dissipation that is or isn’t happening.  Perform at least 3 trials and repeat on the other side.  This evalaution technique then also becomes a training tool to correct imbalances and improve deceleration mechanics – the very essence of the injury problem to begin with.

I routinely have my athletes with assymetrical or atypical kinematics engage in this drill no less than 2-3 times per week.  I have them perform 2-3 sets of 5-10 quality reps on each side (alternate sides).  Focus on preventing the femur from adducting too much or the patella moving inward.  In addition to this drill, obviously include steady glute max and medius work in your programs to help reduce ITBS.  With all that said, happy running!

Well, I have an update on player x.  She saw my preferred soccer/knee orthopedist in town on Wednesday.  He examined her and read the comments I gave to her mother as well.  In summary, he agreed with me that she had patello-femoral pain/inflammation.

He also told the mother she had just gone back to soccer too quickly and never fully regained her quad strength.  He told her if she continued to work around the deficit, she would likely suffer another injury.  This is often the case.  So, at this point the plan of action is to take a one month hiatus from soccer and do formal rehab three times per week.

While this process will be much slower and less active for player x, it probably will be for the best in the long run.  In the short term, she may suffer some loss of fitness, but she needs to focus on strengthening right now.  I will keep you updated on her progress as time goes by.  She will likely return to me for conditioning to transition her safely back to full soccer once therapy winds down.

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.