Brian Schiff’s Blog

If you have been following my blog, you are aware one of my marathoners has been battling increased medial knee pain.  I initially suspected and diagnosed it as patello-femoral irritation.  I have known she has some chondromalacia (softening or weakening of the cartilage behind the kneecap)  ever since I began training her 2 years ago.

I spoke with the MD Thursday and he confirmed by MRI she has no meniscus tear and just patello-femoral arthritis and inflammation.  I was relieved to know I had hit the mark (remember the chiro said meniscus tear).  The MD I referred my client to wants me to do a specific PF strengthening program with her.  The good news – no surgery needed that will derail training for the Columbus Marathon.  The bad news – she may have to contend with some discomfort related to the pounding for now.

It is always hard to tell a runner to rest.  That is one four letter word that really ticks them off!  So, the answer for my client is relative rest (avoiding excess mileage, not running down too many hills, and increasing recovery windows when possible) as well as implementing a more specific PF rehab program.

We have been doing lots of quad (VMO specifically) work and gluteus medius strengthening already.  So, what I will be adding or changing?  Well, we will be integrating more repetitively the following:

1. Weighted straight leg raises in flexion and adduction
2. Modified box step-downs in the terminal range of knee extension to emphasize VMO contraction in a closed chain manner
3. Modified lunge and squat progressions working around the pain

I will be continuing with single leg strengthening for glutes, hamstrings and quads, while challenging hip stability in the frontal plane as she may be experiencing unwanted force transmission here with impact.  Additionally, I will continue with IT band rolling/stretching and hamstring flexibility.

This client is tough and will run through the pain if need be.  My job is to reduce and eliminate the pain without taking her running away.  That is never easy but it can be done with careful progression of exercise and cooperation from the client.  The key point for strength and conditioning specialists is to modify programming based on the client, while the key point for all runners out there is to be open and honest about pain, as well as willing to comply with modifications in the short term training plan to achieve the same long term goal – finishing the race.

Below is a picture of a modified squat progression (an isometric single leg stability ball wall squat/sit).  I use this exercise with athletes and runners with patello-femoral pain issues when they can’t squat due to pain.  If you want to see exactly how to do this exercise, subscribe to PFP Magazine and read my online column, Functionally Fit, here.  My newest column will be out next week and address double and single leg isometric squats for patello-femoral pain.

Shallow Single Leg Wall Sit

Ever have a persistent ache in the shoulder with certain exercises in the gym?  I am talking about a nagging pain along the top or end of the shoulder with bench press, flies, dips, military press or even pull-ups?

Well, one of my staff members has just this type of pain.  He first asked me to look at his shoulder about 6 weeks ago.  I felt there was nothing substantially wrong with the rotator cuff or labrum and recommended he work on rotator cuff and scapular strengthening while backing off the heavy strength training (he is a natural body builder preparing for a show).

He told me about 2 weeks ago that it was still not better.  He complained of more site specific pain along the AC joint.  There was no obvious subluxation present but he was tender right along the end of the clavicle.  I suggested he see a shoulder specialist I know.

The AC joint below (joined by ligaments not visible on x-ray)

His MRI results revealed a micro fracture of the distal clavicle.  Doc says he can continue to train but needs to back off the weight on bench press and avoid pull-ups.  I also suggested he skip dips and he has been now for some time.  So, what caused it?  Good question as he only recalled pain when doing flies during a workout a few months back. 

Could this have caused it?  Maybe.  Pulling the arm across or toward the mid line of the body brings the clavicle into close approximation with the acromion of the shoulder.  There may have been a loading moment (especially with heavy dumbbells) where he strained the joint.  Or, perhaps it was the result of repetitive micro-trauma as the result of lots of heavy chest work.

Regardless, the take away points here are:

• Repetitive upper body lifts (especially those requiring lots of clavicle spinning, elevation and rotation like pressing, dips, pull-ups, and upright rows) may cause stress to the AC joint. 
• Flies do cause approximation and in people with any AC joint arthritis mild compression of the AC joint as the arm comes toward mid line
• Chest movements are likely to affect pain as the pecs attach directly to the clavicle
• Obscure chronic shoulder pain may be related to AC joint irritation that does not show up on an X-ray
• Shoulder pain with lifting may be related to AC joint pain rather than rotator cuff dysfunction in some cases

As a general rule, I caution all my clients over the age of 35 to go easy on the dips for sure as I find this one exercise more than any other tends to flare up an arthritic AC joint fast.  That is the double edged sword of strength training – repetition is necessary to get results but the repetitive nature is capable of taking good exercises and wreaking havoc on the body long term.  Form matters as does avoiding harmful range of motion with lifting.

In the end, let your shoulder guide your decision making in the gym.  In my staff member’s case, he will be fine and recover 100%, although he will likely have to modify his lifting and endure some pain as he pushes on toward his competition.

So, my client saw the orthopodic doctor I sent her to on Wednesday.  He called me and said he felt it was primarily patello-femoral arthritis and some irritation of the medial retinaculum (fold of tissue along the inside portion fo the kneecap).  When I pressed him about the mensicus (remember the chiro suspected this injury), he felt my client at 35 was young to have an attritional meniscus tear, but he did decide to get an MRI to be 100% sure she did not have a tear of the medial meniscus. 

For now, the plan is to let her run and train with me while we await the results fo the MRI and progress training based upon her pain/symptoms.  So, what are good exercises for PF pain in runners?  Obviously, I focus a great deal on strengthening the hip musculature, particularly the gluteus medius, as well as the quads and hamstrings.  Essentially, reducing the amount of pronation, valgus load at the knee, and IT Band tigthness is important for female runners. 

Below is a list of a few key exercises I include in this particular marathoner’s routine with me:

• Single leg stiff-legged dead lifts
• Single leg squats with opposite leg hip/knee drive
• Lateral ankle band walks
• Single leg lateral reaches
• IT Band foam rolling

Note: It may be necessary to modify the range of motion on single leg squats based on pain or specific hot spots on the kneecap.  In this case, I typically work above or below the pain zone.  I included pictures of the lateral band walks and lateral reach below (these really target the gluteus medius).

Lateral Band Walk

Single Leg Lateral Reach

Have you ever experienced sudden intense anterior knee pain or pain along either the medial or lateral joint line?  What about catching, popping or locking?  Well, if so you are not alone.  Many people suffer from patello-femoral pain and meniscus tears.

I am currently working with a marathoner who recently ran her own personal best 3:34 at the Boston Marathon.  She has had various overuse injuries over the few years I have worked with her as distance runners often do.  However, after I came back from vacation the second week of this month she had an increased pain along the medial part of her knee.  It all began after running hills 5 days in the same week.

My initial thought was she probably had increased inflammation of the patello-femoral joint as all the downhill running creates a more compressive load between the back of the knee cap and the femur.  Not to mention 5 days in one week was simply too much.  Needless to say I did not advise her to do as much.

Her initial exam revealed some mild medial joint line tenderness, no swelling and no gait deviation.  Her biggest issue was with squatting below 45 degrees and pain near the medial border of the patella.  She also had no pain with rotation of the knee with that foot fixed on the ground (I was particularly looking at valgus loading with rotation to tweak the medial meniscus).  My initial assumption was that the pain would resolve with relative rest and minimizing compression at the P-F joint. 

Relative rest really does not enter into the realm of reality for marathoners.  So, my client continues to complain of knee pain after running (not so much during).  Her chiropractor feels she may have torn her medial meniscus.  I re-evaluated her yesterday.  Findings: mild medial joint line tenderness, no swelling, no locking, negative Apley compression and McMurray testing.  But, she did have pain with internal rotation of the femur when standing on just the affected leg.  Hmmm???

Now, most meniscus tears occur with trauma that typically involves twisting and compression or an associated ACL tear.  However, in runners, the repetitive nature of running can cause a gradual degeneration of the meniscus particularly if there is arthritis present in the knee.  For more info on meniscus tears click here. 

So, she will be seeing the sports medicine doc next week.  She may have a small tear.  She may just have an irritated P-F joint.  She may have both.  The take home message is really this: the most sensitive test for meniscus tears (whether medial or lateral) is joint line tenderness so we need to be sure in her case.  If you work with female clients, you can safely bet most of them will have some form of patello-femoral arthritis by the time they are in their thirties.  If they are overweight, the relative chances and rate of progression are simply higher. 

I will keep you posted on the verdict with my client as she does not have a straightforward case in my opinion.  She exhibits an inconsistent pattern of symptoms so I am not willing to rule out the tear at this point.  Regardless, this situation calls for rest (as much as she will concede to), modification of strengthening to reduce P-F compression, and also evaluating hamstring work greater than 90 degrees as this too will pull on the menisci and can potentially increase pain and strain on that tissue.  Stay tuned and keep your knees fit!

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.