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

One of my favorite tools I use in the gym with my clients is the BOSU.  Admittedly, it is really easy to get carried away with various tools and equipment when training clients or ourselves.  But, the BOSU is awesome if you are into building strong stable shoulders and safeguarding them against injury.

Many people focus on open chain (the hand is free in space) shoulder training, but in overhead athletes such as swimmers, volleyball players and throwers, it is essential to build a solid level of scapular strength to absorb force and enable the shoulder to move freely and effectively generate power.

I routinely include BOSU stability work in the following ways:

1. Dynamic warm-up
2. Core training
3. Upper body work & scapular strengthening

One of my favorite exercises is what I term the “BOSU clock.”  I wrote a column on this exact exercise for PFP Magazine a few months back.

Click here to read more and learn how to use this exercise to improve shoulder stability and reduce pain and/or injury risk related to shoulder instability, rotator cuff pathology and muscular imbalances.

This is just one great way to use the BOSU in your training.  If you are interested in getting your very own BOSU, head on over to my OpenSky Shop and check it out – http://brianschiff.theopenskyproject.com/

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!

So, do you own a TRX? I honestly think it may be one of the best fitness training pieces around for the money. It is versatile, travels well and builds strength, stamina, balance and stability.

I use the TRX to train clients of all ages and abilities from my elite swimmer to the middle age woman with knee arthritis.  Some of the biggest objections to getting in shape I hear are:

• No time
• Hate the crowded gym scene
• No money for personal training

So, my solution is to buy a TRX.  In this short video, I outline a continuous sequence of 7 exercises.  They are not intense, but they can be made more challenging by altering the body vector (moving your body in relation to the attachment point) and adding more time and sets within the circuit all with very little rest.  The sequence of exercises in the video are:

1. Single Leg Squats
2. Rows
3. Push-ups
4. Biceps Curls
5. Triceps Press
6. Saw Plank
7. Hamstring Bridges

I demo 5 reps of each exercise in the video to show you how to do it, but in reality you crank through each exercise for at least 30 seconds.  Using the TRX over the door anchor you can do this workout at home or on the road (and far more advanced exercises as well) in less than 20 minutes and see results.

So, say goodbye to all the objections and get yourself a TRX and door anchor if you don’t have one yet.  I am 100% confident you will love the workouts and add a new dimension to your fitness routine. 

From now until March 11, all my readers can save 15% on the TRX door anchor by visiting my OpenSky shop and using the promo code ANCHOR15.  Click here to visit my shop.  In addition to this discount, you are eligible to receive 10% off any of the spring promo items at OpenSky.   

To see the entire collection of items in the Spring promotion click here.

The longer I train (myself) and my clients, the more and more I gravitate to bodyweight and bodyweight plus training.  Why?  Namely because I find people struggle to control their bodies in space against gravity.  No matter what sport or work task people need to complete, they must be able to move, stabilize, and resist and apply force effectively with respect to their body.

I also find myself looking to integrate systemic, progressive and kinetic chain based core strengthening exercises for maximal efficacy.  The lack of proper core stability and strength will often leave the back and other limbs of the body vulnerable to unwanted force dissipation.  That means increased chance for injury. 

Adding a stability ball (when you are ready) to abdominal exercises will add spice to your routine and surely FIRE UP your core too!  In today’s post, I want to share some pics of core based training related to my most recent column in PFP Magazine.  Before I share one of my favorite ball exercises with you, consider the following pre-requesite steps before attempting this particular exercise:

• Master floor based planks
• Master static stability ball planks
• Master static holds in hand supported plank position (balance/stability)

Pictured below is the stability ball ab circles.  This is great exercise for shoulder stability training and core activation.  Trust me when I say you will feel it after 10 good slow reps.

Ab Circle to the Left

 Click the image below to check out my column on how to execute the stability ball ab circles.

I have used Thera-Band Stability balls for years and love them.  If you are looking to add a stability ball to your training tool box, click on the stabilityball images below to grab your very own today.  The 55 cm ball works great for the ab circles for most people.  Enjoy!