Is the Outcome of ACL Surgery really better than Conservative Management?

August 28, 2010

If you have sustained an ACL ( Anterior Cruciate Ligament of the knee) tear and is considering an ACL surgery, you would find it useful to know more about the latest research discussion on ACL surgery versus Physical therapy management.

Written by lenia.teo · Filed Under Knee, Latest Research Findings, Treatment Option | View Comments

Management for ITB friction syndrome

June 16, 2010

Follow up to our last ITB article, we have identified three conditions that contributes to the tightening of the ITB. They are weak outer hip muscles, incorrect training methods and bio-mechanical gait issues. In this edition, we seek to address these three main problems, looking at strengthening those weak hip muscles, rectify those poor training methods and biomechanical issues, outlining the practical management of iliotibial band friction syndrome (ITBFS) associated with running athletes.

Weak outer hip muscles

Early stage of rehabilitation aims to redress muscle weakness in the hip which may be considered as a major factor in the development of this condition. Thus, strength and conditioning exercises should focus on the muscle called gluteus medius. The reason why we target the gluteus medius is because it functions as an important stabilizer to control and decelerate adduction of the thigh during running. Poor endurance and control of the gluteus medius leads to gait alteration and ultimately ITBFS. Furthermore, to decrease tension along the ITB, the use of a foam roll and performing isolated stretches for tight muscles can be particularly effective in releasing myofascial restrictions. Below are some recommended exercises.

ITB Proximal Stretch click for larger view	ITB Proximal Stretch To stretch the IT band of your left leg, stand with your left side facing the wall. Cross your left leg behind your right, while using your left hand to help balance. Put your weight on the right leg and lean against the wall by pushing your left hip towards the wall. You should be able to feel the stretch in your left hip and down the IT band
ITB distal stretch click for larger view	ITB release with Foam Roller Rest the side of the thigh on the foam roller, positioning the foam roller just above the knee. Support yourself with your right arm and right foot to keep your balance. Roll yourself down the mat, rolling the foam roller from the knee up to the hip and then down to the knee. For a trigger point release, you can sustain pressure on the painful spot for 30 seconds.
Clam shell 1 click for larger view Clam shell 2 click for larger view	Clam shell in side lying Lie on left side to work on the right gluteus medius muscle. Keep spine in neutral and not sagging down towards the mat Keep the heels together and the knees at a right angle Lift the right knee up without rotating the pelvis and back. You should feel it on the muscle behind the hip bone
Side Planks click for larger view	Side planks To work on your right, lie on your side with your right hand on the ground or use an exercise mat. Lift your trunk and pelvis up to form a plank Maintain a straight trunk and pelvis alignment Hold for 30 secs

Training methods

Having re-established muscle balance around the hip, you should now be ready to take full bodyweight on the affected leg while maintaining optimal body alignment. To start getting back to running, we recommend running every other day for the first week, starting with easy sprints on level ground. It is important to note that studies have shown that ITBFS occurs mainly at, or at slightly less than, 30 degrees of knee flexion. Thus, it is necessary to avoid downhill running because the knee flexion angle at footstrike is reduced, causing strain on the ITB. Biomechanical studies have also shown that faster-paced running is less likely to aggravate ITBFS. This is because as the foot strikes the ground, the knee is flexed more than 30 degrees, avoiding the range where the strain occurs. Incorrect training practices can also contribute to the condition, such as starting a demanding routine of sport or exercise immediately following a return from injury, or otherwise expanding your training too rapidly.

A gradual increase to your training mileage (e.g. 2-3km per week) cannot be over emphasized. Your body won't get used to running long distances, unless it has run those distances on a regular basis. As the body needs rest between those runs, thus it is recommended that there should be no more than two long runs per week and moderate distance on the other days. Long training runs should be conducted at an aerobic capacity where you can talk and run at the same time. After a run, stretch and then ice the outside of the knee for 5-10 minutes. Last but not least, always train at an appropriate intensity. Training at higher intensities (>80% of Max. Heart rate) will lead to lactic acid production, which will fatigue the muscles and increase the chance of injury. To monitor the level of training intensity, a heart rate monitor may be a useful device.

Biomechanical Gait issues

Always wear appropriate shoes that give you proper support. A wet footprint test is a common method for determining your foot type. Get your feet wet and stand on a flat surface that will allow your footprint to be shown. Compare your footprint to the images below.

foot

Now that you know your foot type, approach a knowledgeable salesperson at a running specialty store and they will be able to help you find the right shoes for you. A semi-rigid orthotic may also be useful for someone who have excessively flat feet or high arches, in bid to improve function by supporting the foot segments during gait. The orthotic is worn in the shoe and it helps by changing the position and time sequences talking place in the foot during running so that no one muscle or group of muscles have to work longer and harder than it should.

Formthotics

Written by Admin · Filed Under Hip, Injury Management, Injury Prevention, Knee, Running, Treatment Option | View Comments

Stretches For New Runners

March 20, 2010

It is important to include some stretching exercises before your running routine. If done correctly, stretches can help to improve your flexibility and joint range of motion, and can decrease your risk of injury to joints, muscles, and tendons while running. In this article, we will show you top 5 stretches to do before a run.

Disclaimer: Note that stretching is not warming-up. It is a common misconception that warming-up equates to stretching. ‘Warming-up’ literally means raising your core body temperature. It is advised that before you begin on your stretches and run, a general warm-up such as brisk walking between five to ten minutes be performed to prevent injury to your ‘cold’ muscles. (see To stretch or not to stretch before an event?

Top 5 stretches:

Hamstrings Stretch

click for larger view	Start off with your body close to your thigh and your knee about 90 degree
click for larger view	Straighten the knee gently while keeping your body close to your thigh Hold for 15 seconds and repeat 3-5 repetitions

Calf Stretch

click for larger view

Upper Calf stretch

Place hands on front thigh, with one leg to rear
Keep the rear leg straight and foot flat with toes pointing forwards
Bend the front leg and feel the stretch through the rear leg
Hold the stretch for 15 seconds and repeat 3-5 repetitions.

click for larger view

Lower Calf Stretch

Place hands on front thigh, putting your weight on your rear leg
Keep the rear foot flat with toes pointing forwards
Bend rear knee forward over rear foot and feel for the stretch over the lower calf
Hold the stretch for 15seconds and repeat 3-5 repetitions

Quadriceps Stretch

click for larger view	In standing, bend your knee and take your heel towards your bottom, keeping your back straight until you feel a stretch in the front of your thigh
click for larger view	To further stretch the front of your thigh, extend your thigh and bring your heel closer towards your bottom Feel for the stretch at the front of your thigh Hold the stretch for 15seconds and repeat 3-5 repetitions

Iliotibial Band (ITB) Stretch

click for larger view	To stretch the IT band of your right leg, stand with your right leg crossed behind your left.
click for larger view	Put your weight on the right leg and lean your body towards the left. You should be able to feel the stretch in your hip and down the IT band along the right side of your right thigh Hold for 15 seconds and repeat 3-5 repetitions

Glueteus (Buttock) Stretch

click for larger view

Sitting on the floor with one leg straight out, bend the other knee and place the foot over the straight leg
Using your hands, gently bring the bent knee up towards the opposite shoulder. Feel for the stretch in the buttock
Hold the stretch for 15 seconds and repeat 3-5 repetitions.

Written by Cindy Tan · Filed Under Ankle and Foot, Exercises/Tools, Hip, Injury Management, Knee, Shin | View Comments

Why is my MCL strain not getting better? Because it is Pes Ancerinus Tendinitis.

March 18, 2010

When long-distance runners complain about knee pains, it is often complaints about pain in the front of their inner knee, below the knee cap. Pain comes about especially when climbing uphill or up stairs. Given the location, this pain is sometimes misdiagnosed as a MCL (medial collateral ligament) strain when it is actually Pes Anserinus Tendinitis.

What is Pes Anserinus Tendinitis?

click for larger view

It is essentially a inflammation of the tendons between your shinbone and muscles that form parts of your hamstring and thigh, .Three tendons (Semitendinosus, Sartorius¹ and Gracilis) join up to form the pes anserinus tendon. Pes anserinus in latin means 'goose feet' roughly describing the webbed look of the three tendon coming together.The pes anserinus tendon joins to the shin bone where the pain is usually felt.

Is it often mis-diagnosed as MCL or medial-menicus strain because of the close location of the pes anserinus tendon to the MCL and medial menicus.

What strains the Pes Anserinus Tendon?

Things that strain the pes anserinus tendon are

Severe pronation of the feet – this causes the tibia (one of the lower leg bones) to rotate inwards which strains the tendons
Weak hamstring muscles – when combined with an intense running programme, the hamstrings may not be able to cope with the high workload. This is often an overlooked areas in a runner's strength training regime.
Tight thigh muscles (quadriceps) – weakens the opposing hamstring muscle. Muscles tightness here is further encouraged if you have a deskbound job that requires you to sit at the your desk all day long.
Sudden change on the volume and intensity of training

Diagnosing Pes Anserinus Tendinitis

Patients typically complain about pain climbing stairs, squatting, running and in severe cases, standing from a seated position.The pain would also appear gradually and for runners, following an increase in their training volume and intensity (uphill, or running faster).

However, even if your symptoms match those listed above, it is advisable to ensure that it is not other possible condition such as Patellar-Femoral Pain (PFP), MCL strain and medial-menicus strain

Treating Pes Anserinus

During the initial inflamed painful stage, your doctor may prescribe NSAIDs to help reduce the swelling and inflammation and recommend rest for the first 24-48 hours. Ice or cyrotherapy can help speed up the recovery by reducing the inflammation.

Once less painful, your therapist may suggest the following treatment depending on your cause of the tendinitis as list above.

For severe foot pronation – orthotics can help correct over pronation of your foot
To strengthen the weak hamstrings – see Hamstring Exercises for Long Distance Runners
Release tight thigh muscles with sports massage and a stretching programme.
A training programme that appropriately increases your training volume and intensity.

¹ Ed note. The Sartorius is the longest muscle in the human body

Written by MCR · Filed Under Knee, Shin | View Comments

Osteoarthritis Knee

December 25, 2009

Osteoarthritis (OA) of the knee is a degenerative condition where the cartilages of the knee wear away. Pain, stiffness and swelling are common symptoms of an OA knee. In this article, we look at the three factors that lead to the development of OA knee – Aging, Physical Attributes and Muscular Causes. Of which two of these factors, Physical Attributes and Muscular Causes, can be addressed with physiotherapy management. We will focus more in detail on the exercises and treatment for OA knee in a follow-up article.

Aging

OA Knee

OA knee usually afflicts the older population as our cartilage thin naturally as we age. If you have a past history of knee injury or long history of activities that overloads the knee joint, degeneration may set in much earlier. Unfortunately, these events are irreversible, so it is important that we look after our knees during our early adult life.

Physical Attributes

The three key physical attributes are:

Obesity - A heavier person will load their knee joints more, wearing out their cartilages faster than a lighter person.
Knee alignment – A bow legged or knock-knee appearance will cause an uneven compression of the knee. Either the outer or inner compartment knee respectively will take up most of the load upon weight bearing and cause more wear and tear.
Foot type -
- People with flat feet or whose feet over pronate tend to roll their knee inwards upon weight bearing similar to a knock-knee above.
- A person with high foot arch or whose feet under-pronate absorbs less impact with each foot fall. More impact goes up through the leg and the knee will have to work harder to cushion the impact.

Muscular Causes

When the muscles around the knee do not contract strong and fast enough in a coordinated fashion to absorb the impact of walking or running, the knee joint takes up the remaining forces of the impact.

Tight muscles pull joints closer to each other.In an OA knee where the joint space is already reduced, tight muscles will increase the compression of the joint space. Muscles with reduced flexibility are also less coordinated and slower in reaction time. The muscles that tend to be tight are the quadriceps, hamstrings and calves.
Weak muscles. The quadriceps muscles is the main muscle group that help to support the weight of the body and off loads the knee joint. It is very common for this muscle to atrophy because of disuse. The knee pain deters the patient from loading the knee and this will gradually lead to weakness of the knee which will affect the ability to cushion the impact. This pain, disuse, weakness cycle will continue without treatment.
Weak gluteus medius muscle can aggravate the degeneration of knee cartilage because its function is to keep the hip joint stable, especially in walking. This is often seen as a waddling gait where the hip sway with big movements side to side. The thigh muscle have to work a lot harder to stabilise the wobbly hip and if they are unstable, the knee joints will have to bear the weight.

The management of these factors are summarised in the following table. In our upcoming article, we will further discuss the specific exercises and treatment for OA knee.

Physical Attributes	Management
Weight	Weight loss programme
knee alignment	- training of muscles – orthotics
foot type	- orthotics

Muscular Causes	Management
Tightness	Stretch Quadriceps, Hamstring and Calves
Weak	Strengthen Quadriceps and Gluteus Medius

Written by chyetuan.chng · Filed Under Knee, Knee (NonSport), Running | View Comments

Q angle and knee pain

November 25, 2009

What is Q angle?

The Q angle describes the angle of the knee from a frontal view. The Q angle gives an idea how the thigh muscles functions to move the knee and also how the knee cap (patella) tracks in the groove of the knee joint. A normal knee cap should move up and down within the groove with flexion and extension of the knee. When the Q angle is excessive, the knee cap tends to track out of alignment and hence causes wear and tear (degeneration) of the cartilage behind the knee cap.

What is the normal Q angle? The normal Q angle measured in standing is about 15 degrees and anything more than that is considered a risk factor for knee injuries. Ladies tend to have a wider Q angle due to their wider pelvis compared to their males.

Q-angle

How to measure Q angle? The Q angle is an intersection of two lines. First line joins the ASIS (bony protrusion in the front of the pelvis) to the middle of the patella. Second line runs from the protrusion on the top of the shin bone (tibial tuberosity) below the patella and upwards through the middle of the knee cap.

Common injuries related to a wide Q angle:

Iliotibial band friction syndrome (ITBFS)
Anterior knee pain or Patella Femoral Pain Syndrome (PFPS)
Anterior cruciate ligament injury (ACL)

Injuries because of an excessive Q angle can be categorised into 3 main reasons.

1. Muscle imbalance :

A large Q angle pulls the knee cap outwards due to the stronger lateral pull from the quadriceps and tight ITB. Coupled with a weakness of the inner aspect of the quadriceps (Vastus Medialis Oblique, VMO) the knee cap will track laterally instead of smoothly up and down within the knee groove. This maltracking causes the cartilage behind the knee to wear off or degenerate and hence the pain.

2. Biomechanical compensation:

An excessive Q angle can alter the movement pattern especially in the foot. The knee will tend to point inwards (valgus or knock-knee appearance) which encourages the foot to roll inwards (pronates). Over-pronation can lead to a number of injuries especially in runners.

3. Joint laxity/instability:

When the knee point inwards, the ligaments on the inner aspect of the knee gets overstretched and lax, therefore compromising the stability of the knee joint. The Anterior Cruciate Ligament (ACL) also undergoes a lot of stress in this position. Interestingly the larger Q angle in females has been attributed as a main reason why females are at a higher risk of sustaining an ACL injury.

How to manage a wide Q-angle?

You can reduce the risk of injuries by targeting the reasons above.

Muscle imbalance: Stretching on the ITB, strengthening the VMO and Glut medius to enable proper tracking of the knee cap.

Biomechanics: Get a customised orthotics to control excessive pronation and reduce the stress to the knee.

Joint Laxity/Stability: Balancing exercises to train knee proprioception and stability.

Written by lenia.teo · Filed Under Featured, Injury Prevention, Knee, Netball, Running, Soccer, Sports Injury, Women & Sports | View Comments

ITB friction animation

November 20, 2009

Iliotibial band friction (ITB) syndrome is a common running injury due to a tight ITB. In a previous article, we explained the reasons why the ITB tightens up. To make it easier to understand how a tight ITB causes friction and inflammation, click here to see an animation of ITBS.

Written by chyetuan.chng · Filed Under Injury Management, Knee, Running, Video | View Comments

Ladies! Stronger Thighs, Lesser Knee Pain

September 30, 2009

Knee pain is one of the most common, if not the most common complain of pain in the elderly. In the USA, nearly 4 million sufferers of knee pain above the age of 45 are ladies.

Why are females more prone?

There are quite a number of reasons why ladies are more pre-disposed to developing knee pain. The reasons range from wider hips to increased Q-angle, tighter ilio-tibial band (ITB) to weaker physique. However, what is the most common cause of knee pain? The answer lies in the weakness of the quadriceps or thigh muscles. Read more

Written by MCR · Filed Under Injury Prevention, Knee, Knee (NonSport), Treatment Option, Uncategorized | View Comments

Warning! Is this how you stretch your hamstring?

August 5, 2009

Stretch A
click for larger view

Stretch A may aggravate your pain if you have a history of lower back nerve injury. When you bend from your hip with your knee straight the tension is at the back of your thigh, behind the knee. This focuses on the lower hamstrings and also pulls onto the sciatic nerve which originates from the lower back.

Written by chyetuan.chng · Filed Under Exercises/Tools, Injury Prevention, Knee, Sports Injury, Thigh | View Comments

Anterior Knee Pain in Runners

July 22, 2009

Do you feel pain in your knee on climbing stairs or even squatting after your run? Feeling weird that it doesn’t hurt while you run? Then, chances are, you might be suffering from anterior knee pain. Knee pain is the most common running injury, occurring in approximately 55% of recreational runners. Of this number, 65% will have severity of symptoms that will require them to seek medical attention or contemplate cessation of running. Anterior Knee Pain (AKP), otherwise known as Patellar Femoral Pain, has been found to be one of the most common condition resulting in knee pain. It has been estimated to have an incidence of 25% of all knee injuries.

Written by MCR · Filed Under Injury Management, Knee, Running, Sports Injury | View Comments