Brian Schiff’s Blog

Eliminating tightness in the TFL can reduce tension in the IT band as well as reduce knee pain associated with Runner’s knee or patellofemoral pain syndrome. Foam rolling prior to stretching is a good idea, but I think this stretch is a good one for all runners to add to their toolbox whether it be prior to or after a run. Check out the stretch from my online PFP column below:

I am currently working to attain my transitional doctorate in physical therapy (tDPT) at Northeastern University. As I continue to work full time as a clinician, it has been really cool to apply the learning with my current caseload. At this time, I am in a motor control class that is both fascinating and challenging. In week three, we examined pain and the impact it has on neuroplasticity (the brain’s ability to adapt or change).

In the sports medicine realm, I generally think many practitioners solely focus on the musculoskeletal system or physical impairment. As such, interventions are developed around tissue constraints, ROM deficits, weakness, etc. Too often, we look past the power and impact of the brain and how it plays a vital role in healing and return to play. For some patients, there is a maladaptive response to injury/surgery and a hypersensitivity of the central nervous system or central sensitization that occurs. Pelletier (2015) notes that structural and functional changes can occur. (1)

Two critical concepts to consider here are:

1. Sensory amplification – sensory and motor representations change resulting in perceptual changes in body image, motor control changes, and even a persistence or amplification of pain
2. Experience dependent plasticity – patient’s response to pain is related to prior experience and may experience maladatpive imprinting where the pain outlasts the physical insult

Kleim (2008) gives a great lesson on experience dependent plasticity and states that learning is essential for the brain to adapt to damage self taught behavioral changes can be maladaptive or positive and specific forms of neural plasticity and associated behavioral changes are dependent on specific kinds of experience (2). While one would assume that chronic pain is rare in athletes, I would counter and say it is probably just overlooked as we tend to expect athletes to “push through the pain” because of the driven culture we live in. Coaches, parents and even teammates can affect the mindset around injury and recovery.

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In many cases, my clients are unable to perform traditional strengthening exercises for the lower body due to anterior knee pain or weakness. Beyond loading, using the time under tension principle is a great way to add strength for those who cannot squat, lunge, etc. Below are two great videos of isometric ‘go-to’ exercises that will help improve strength and functional capacity in those who are otherwise limited in their workouts.

I hope you can use these exercises or some variation of them to increase strength and overcome injury and dysfunction.

Knee pain is prevalent among adolescents and active adults. Patellofemoral pain and osteoarthritis are the most likely causes of pain. It may be present with squatting, lunging, prolonged sitting, kneeling, running, jumping or twisting.

Research seems to support a combination of hip and knee strengthening as a primary line of defense and treatment for knee pain. Interestingly, males with PFP do not seem to have weakness in the gluteus medusa like their female counterparts. The link below is an abstract that speaks to this difference between the two groups:

https://www.ncbi.nlm.nih.gov/pubmed/30090674

Other modalities used to address anterior knee pain include patellar bracing/taping, blood flow restriction training, dry needling/acupuncture and soft tissue work seems to bring more questions accordion to some experts.

Click here to read the 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain from the 5th International Patellofemoral Pain Research Retreat.

Clinically, I have seen good results with the following:

1. Activity modification
2. Glute and quadriceps strengthening
3. Blood flow restriction (BFR) training
4. Sequential and progressive loading based on pain response

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Every year I like to look back and reflect on things I have learned, things I have changed my mind about and of course clinical pearls that stand out.  Over the past year, I have been sharpening my IASTM skills, begun to practice dry needling techniques, and scrutinizing my hip and core exercises that I routinely use in rehab.

I look forward to sharing more about my clinical experiences with dry needling in 2014, but I feel the most critical and recurring theme of 2013 has been the overwhelming impact I have seen poor ankle dorsiflexion have on my patients.  I treat scores or runners, triathletes and clients with knee pain.  The most common issues in this group of clientele tends to be IT band friction syndrome or patellofemoral pain.

When I assess this group of patients, I routinely find the following:

1. Poor dorsiflexion
2. TFL dominance
3. Glute weakness

Any time I evaluate a runner, I assess closed chain dorsiflexion (DF) mobility.  This can be assessed in half kneeling on the floor or standing at a wall.  I suggest removing the shoes during the assessment to eliminate any rise from the heel in the shoe that may bias the movement.  In addition, I hold the ankle in subtalar neutral to get a true assessment without allowing pronation.

The image below simply demonstrates the assessment position as well as the corrective exercise that can be used to facilitate better motion.

Clients should be able to attain about 5 inches of clearance beyond the toes without lifting the heel or relying on pronation to get there. I routinely see limited mobility, and more importantly almost 100% of the time I find asymmetry on the side of the affected knee.

I recently evaluated a 29 y/o active female client who does Crossfit 3x/week and likes to run.  She has not been running much due to chronic right lateral knee pain and medial calf pain.  Her goal is to get back to running half-marathons.  Upon evaluation, her overhead squat assessment revealed pronation and external rotation bilaterally, right greater then left.  Her standing wall DF assessment revealed nearly a 1 inch deficit on the right side (about 3 inches), while her left side was 4 inches.

Below is how she looked on the treadmill video analysis I performed:

You can see the highlighted areas in the photo above.  She has a marked amount of pronation in mid stance as well as left pelvic drop due to poor gluteal activation.  The poor hip stability and activation on the right side also plays directly into TFL dominance with the repetitive femoral internal rotation and adducted position of her right hip..

This poor biomechanical chain is set into motion by poor dorsiflexion mobility.  Runners can get away with this for shorter distances (3-4 miles) in many cases, but increased mileage leads to shin splints, calf strains, IT friction syndrome and patellofemroal pain.  You can see how this poor kinetic chain movement leads to ongoing microtrauma and eventually debilitating pain and dysfunction.  No matter how much one rests, going back to higher mileage will yield the same result.

In my client’s case, she also had a trigger point in her medial soleus – another issue connected with the ankle mobility problem. Her primary treatment plan will focus on soft tissue mobilization for the gastroc/soleus complex, TFL/ITB and glutes/piriformis, ankle dorsiflexion mobility exercises, IASTM to her gastroc/soleus/Achilles, single leg balance and strengthening and hip/core activation and stability work.

I am confident all of this will effectively resolve her pain.  However, it all begins with restoring ankle mobility.  They say a picture is worth a thousand words.  I strongly believe the picture I included of my client on the treadmill speaks volumes as to how poor ankle mobility can lead to unwanted compensatory motion, gluteal inhibition and overuse injuries.  The take home message here is be sure to assess ankle mobility in the presence of any lower extremity pain or dysfunction as it is often a critical piece of the puzzle in the face or recurring injury and chronic pain.