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I’ve written a few posts about knee injuries, they are one of the most common complaints I see especially since I work with many aging clients. A recent conversation with a client with knee pain encouraged me to write this post.

A Common Scenario

Client, late 60’s, has intermittent knee pain w/walking (sometimes severe) but presents well: minimal swelling, good range of motion (pain at end range of flexion and good quad tone/strength, good knee extension). Two physical evals from orthopedic practitioners had differing opinions on the cause of pain, one suggested meniscus damage. At 60 + years old arthritis is always a concern. The client wanted an MRI to know conclusively what was wrong.

Most patients want to know why they hurt, many seek an x-ray or MRI, it is only natural they want to know the reason.  At this point things can get complicated, answers are not clear cut even though an MRI many offer a clear picture of the inside of the body and a hint at tissue damage.

Knees are particularly vulnerable to injury since they are the movement linkage between the foot (ground forces) and the hip/upper body. Body weight, loading forces, age, sports and joint alignment are factors in knee pain. One of the most common pieces of advice knee pain patients are given is to loose weight and strengthen the quadricep muscles.

While an MRI/x-ray may give a picture of what is going on inside the body the real issue is, what do you do with this information? Is the next step cortisone injections, meniscus repair/surgery or exercise?

There are studies that show meniscus surgery can lead to arthritic changes several years later. This is disappointing since relatively soon after meniscus repair the patient may be looking at knee replacement. Loosing weight is a behavioral health/nutrition issue and is never easy – more appointments/time/money. Strengthening the quads sounds good but in reality the quadricep muscles become inhibited (weak) as a result of neurological input from painful joint structures. How do you exercise when the knee joint hurts?

The Long Road

Taking the long road to addressing knee pain means there aren’t quick fixes for degenerative changes such as arthritis, cartilage damage, meniscal tears or more severe ligament damage. For older athletes my goal is to help them stay fit/active and enjoying their body, this is especially true for those who have undergone joint surgery. That said, there are hard conversations about realistic expectations for exercise. They may have enjoyed running their whole life, now they have to look at biking, swimming or walking for exercise. Strength training is a given.

The whole is the sum of its parts. Maintaining overall conditioning can improve the function of the knees, by virtue of the body is an integrated movement system – quad strength is only one component.

 

 

 

 

Fall soccer has started and I am one of the countless parents lining the sidelines watching their child play.  As a therapist/trainer I see the game from a few angles: soccer is a great sport for aerobic fitness, repeatedly kicking a ball can wreak havoc on a child’s body however. At a recent game I watched as my son and an opposing team player both went after and kicked the ball at the same time. The ball didn’t move. Watching my son limp away I knew he had injured his MCL (medial collateral ligament/knee).

When a player kicks a ball large muscular forces are generated throughout the pelvis, hip and leg. These forces can lead to muscle strains and tendon injuries. The impact of the foot striking the ball not only moves the ball: some of this force is also experienced in the bone growth plates as well as joint structures like ligaments, knee meniscus, and cartilage.

Considering that children are still growing and have open growth plates as well as loose ligaments, the repetitive stress of kicking a soccer ball can predispose a child to a more serious ligament or joint injury. I have performed joint tests on my son’s ankle and knee during the soccer season, his right (dominant kicking leg) knee and ankle was looser compared to the left. A balance test also confirmed poor proprioceptive control of the right leg. Even though there wasn’t a singular event of a ligament sprain, poor balance/proprioception is a direct result of ligament injury.

While I don’t have research to back up my claim I would speculate that non contact ACL injuries to the dominant kicking leg could be the end result of the repetitive ligament stress and associated proprioceptive changes due to the repetitive strain of kicking.

 

In Part 1 I introduced some of the issues that come into play when someone has a leg length difference. Here is my evaluation protocol when I assess postural asymmetry.

Health History

Some people are aware they have postural asymmetry. I’ve worked with father/son and mother/daugthters where the child has the same postural alignment  as the parent. I’ve also been in social settings having observed four generations of the same family, from great grandchild child to great grandmother – they all have the same postural asymmetry. People treated by chiropractors will report having their pelvis adjusted to make their legs the same length.  SI joint, spine and sacrum manipulation can “correct” pelvis and leg asymmetry if there is joint hyper mobility/fixation and muscle spasms. Manipulation cannot “fix” anatomical variations. Some folks need to have pants hemmed at different lengths. Often they are aware of one foot being smaller/larger.

Postural Analysis

I observing how someone stands, sits, walks and moves. Asymmetry in alignment or muscle tone is a red flag that needs closer evaluation. I can learn a lot  about the health of the hips and legs from observing the feet. While they are standing I palpate body landmarks such as the top of the pelvis and scapulae checking alignment, I chart findings.

Gait & Movement Assessment

Balance tests, squats, lunges and jumping demonstrates how well someone organizes their body during dynamic movement while under load. Gait analysis is a whole body movement screen that also provides info about specific joint control. I take video/movies in my office or clients send me video of them running/biking. Video analysis is a great tool.

 

Range of Motion and Manual Strength Testing

Checking range of motion assesses soft tissue quality, muscle tone and joint integrity. For instance if one hip has significant more/less mobility or strength it will show up in posture and movement.

 

Orthopedic tests

Back muscle spasms and SIJ dysfunction can disrupt the alignment of the pelvis and create the appearance of leg length difference. The Long Sit Test is probably the most useful test to assess if there is a bony discrepancy or muscular tightness. While lying down I check the position of the ankles/heel, then the client sits up, I recheck alignment then have them lie down again. If the ankles are not even throughout this movement sequence there is good probability the asymmetry is skeletal and not muscular. If the leg length flip flops during this sequence then I am more concerned about SIJ ligament injury. If a SIJ mobilization realigns the feet, this then confirms possible SIJ dysfunction (more on SIJ injuries in another post).

Shims

I position the client in front of a large mirror in my office, we both observe their alignment. I then place plywood shims of various thickness (1/8″, 1/4″, 1/2″) under the shorter leg  foot. Adjusting the shims allows me to roughly dial in the approximate length difference. I let them stand w/the shim for a few minutes then remove it. Often people experience a sense of equilibrium, they also notice how much their body tilts to the shorter leg side. Placing the shim under the longer leg feels really awkward typically.

 

What next?

As mentioned in my previous post my assessment process is not a diagnosis. If I suspect a leg length I discuss options with the client. A true diagnosis comes via an orthopedic eval and x-ray, since most folks are not in chronic pain or need surgery an x-ray is usually not needed. One option is to consult with a podiatrist. A custom orthotic can be made to shim the foot, if the discrepancy is more that 3/16″ shoes may need to be modified, it all depends on how big a difference is and how the body has adapted to the asymmetry. Competitive cyclists usually need some modifications made to their shoes or cleats otherwise their pedal stroke, power output R/L and their comfort (they tend to shift side/side) is compromised.

For most clients w/minimal leg differences knowing they are not symmetrical helps them to modify their movement strategies. If they keep their legs and hips strong people tend to do really well w/out orthotics. The tricky part of this is what happens to a person over their life span. I’ve had a few older clients that have arthritic knees, had knee replacements and have scoliosis/arthritic spines. Perhaps if they had known about the leg length difference as a younger person and had an exercise routine that supported better postural alignment would they have had these conditions later in life?

 

Differences in leg length are fairly common, in a previous post I wrote about how leg length differences can lead to a breakdown in the soft tissues of the knee joint, mostly on the longer leg side of the body. There are other considerations and symptoms associated with leg length.

I routinely do postural screens for all clients. Postural asymmetry is a significant finding, determining why there is asymmetry is the challenging part.

My first concern is always to rule in/out spinal conditions and pelvis injuries that lead to muscle spasming and/or weakness. These injuries can distort body alignment.

Next I want to rule in/out structural/anatomical issues. Some people are born with variations in their bone length mostly in the legs but also the pelvis. Interestingly, this past winter I purchased a pair of boots, the sales person told me they measure everyone’s feet and routinely see a smaller right foot!? This is another blog post.

There are several assessments I do to determine if the femur, tibia or ilium (pelvic bone) is of unequal length. My assessment process does not diagnose. An orthopedic evaluation and x-ray is the best way to determine structural asymmetry. In Part 2 I’ll go into more detail about what I do if I suspect leg length differences.

The last issue I look for is muscular weakness and/or tightness and  how muscle function can impact posture. I test joint range of motion and manual strength tests as well as dynamic movement tests like squats, lunges, balance, jumping etc.

Why is assessing leg length important?

The body is subject to similar forces that a bridge, car or building experience. Forces like gravity (compression), vibration, rotation and shear act upon these structures testing the loading capacity of the materials. Ideally these forces do not exceed the tolerance of the structures. The alignment of the structures is also important: jumping up and down (running) places  linear, rotational and shear forces on the spine, pelvis, femur, tibia, ankle etc. If the forces of running exceed the tissue tolerance (excessive training/poor repair) or if the alignment of the skeletal structures is not within “tolerance”  excessive wear occurs at specific joints and soft tissues.

Leg length inequality always results in asymmetrical loading and body alignment. For a runner the gait pattern is not smooth: typically the body sways side/side, one arm may swing wider to aid balance and the pelvis dips to the shorter leg side. Often the longer leg hip has discomfort and stiffness – the hip flexors work hard to “brake” the forward fall from longer to shorter leg. One leg is often significantly stronger, this varies depending on the person.

Cyclists with leg length differences can suffer from a variety of issues, typically back and knee dysfunction. Since a bike is a fixed ergonomic device the pelvis/body will shift side/side when pedaling, the low back experiences excessive lateral movement. Often quadricep muscle force production is significantly different, the longer leg often does more work. Careful bike fit which includes alteration of pedal cleats and saddle are essential.

Curiously the fascia from hip to shoulder on the long leg side may be stiffer. Clients often complain about feeling “tight” along their rib cage and up into the arm pit. The longer leg “pushes” the body to the opposite side, the latissimus dorsi, abdominal obliques and quadratus lumborum are chronically contracted in order to maintain erect posture.

Asymmetrical muscle tightness continues up to the shoulder, neck and head as well. The head will tilt to the longer leg side as the neck muscles are over active maintaining the head/eyes in a neutral position. It is not uncommon to see cranial bone distortion – the eyes are displaced due to the constant tilting to maintain visual and vestibular equilibrium.

These are some of the issues with leg length differences, in part 2 I’ll continue with how I assess leg length as well as discuss pelvic asymmetry.

 

 

 

One morning, after being out all night Gus limped across the yard dragging his right back leg. I picked him up and moved his knee joint, it was barely hanging on his body. If he was a human soccer player this would have been severe knee ligament (ACL, MCL, LCL) damage from a nasty slide tackle. I have no idea how Gus was injured.

The knee was pinned and bandaged, Gus lay around and went into deep healing mode – he was very quiet and didn’t interact. Eventually the pin worked itself out of his body which was a surprise. We kept him indoors to keep him safe.

Initially he limped holding the leg up in the air when he walked, gradually over many months he put more weight on the leg, he could walk and run a little. The knee alignment wasn’t the same, in orthopedic terms he had valgus knee alignment – the knee buckles in instead of lining up straight. Consequently athletes that have long term knee ligament/meniscus/cartilage damage also develop the same alignment presentation.

Gus would straighten (stretch) the damaged leg a lot! As you can see from the picture he would lie on his left side and straighten the right back leg/knee joint. The leg would shake and tremble. Gus kept up with his stretching routine many times a day for the rest of his life. Over a period of about 2 years he eventually regained most of the knee function back and was able to go back outside.

I tell an abbreviated story about Gus’ injury and healing ability to my clients with orthopedic injuries. They want to know how long it will take before they can return to their activities/sports. They often ask how many times a week they should exercise. I tell them Gus kept his leg safe, modified his activities, exercised and stretched many, many, many times a day for the rest of his life.

The body is an amazing self healing mechanism whether it is a cat or a person. The simplest rehab protocol: rest, graduated exercise and diligent attention to mobility is often what works best.

 

 

For many collegiate athletes, and certainly for professional athletes, sport injuries are addressed in a comprehensive manner. Sport coaches, athletic trainers, doctors, orthopedists, physical therapists, strength/conditioning coaches etc. collaborate as a team to address the athlete’s condition.  An analogy is to think about rehab as a ladder: at the bottom is acute injury management (AT, MD/orthopedist), the middle is about regaining initial flexibility, strength, and proprioception (PT). At the top of the ladder (strength/conditioning) is where athletes engage in sport specific exercises at an intensity that is equal to sport participation. If the athlete can perform at the top level without pain or functional deficits they “step off” the rehab ladder, if not they go back down. The goal for everyone on this team is to return the athlete to as close to pre injury status as possible. Easier said than done.

For adult, recreational athletes addressing symptoms like decreasing pain and increasing mobility can be a relative easy task for certain injuries. Massage, therapeutic exercise, stretching, movement re education etc. are good tools in the beginning of the treatment process. Unfortunately many people stop the rehab process when they start to feel better. Using the ladder analogy, they can get can stuck in the middle. They may feel better but they haven’t done the hard work of really making their body work optimally. They return to their sport activities but their body is not prepared/conditioned to handle the stress. Continuing down this road leads to re injury, chronic pain, joint degeneration, more practitioner visits etc. Appropriate strength training is one of the most effective “treatments” for sports injuries and for long term injury prevention.

Youth sports injuries can be the most difficult to treat effectively using the team approach. They’re kids after all, they want to play sports with friends, having fun and not spending time doing rehab exercises. Some parents don’t want their kids to stop playing sports as well – often the family routine revolves around sports. I have had difficult conversations with parents of injured young athletes – what is more important the health of the child’s body or the team?  Rest is often the missing component for many kids. Overuse injuries are almost always a product of fatigue and lack of adequate recovery/repair time. Middle school – high school aged athletes who are focused on sports can and should engage in strength and conditioning. The team model used for professional athletes can be adopted for youth athletes. The challenge for parents is often assembling a team – the sports medicine MD, physical therapists and personal trainers that collaborate and communicate effectively.

The importance of appropriate rehab and return to sport participation for everyone means taking the long view. It is often essential for the athlete to step away from sport participation and focus on developing their body in new ways. Getting stronger, developing better joint alignment, flexibility or joint mobility can be an essential for life long participation in sports and recreation activities.

 

There is a lot of “hard science” behind effective injury rehab, sport performance and fitness training. I need to know how a particular movement/exercise or manual therapy technique is going to impact a client’s joint, muscle, skeletal and nervous system. For example movement can be analyzed, joint angles measured, muscle strength tested and graded. The nervous system can be divided into separate components of sensation and motor control and tested individually to determine what level of the spine/brain corresponds to a particular body part/region. It’s about collecting and analyzing data, then applying a systematic approach to increase or decrease values: better range of motion, more strength, less pain etc.

Without diminishing the quantitative, evidence based approach there is an equal amount of “soft science” that encompasses the “art” of movement training/injury rehab. I work with people not body parts. People move and are moved by human experiential qualities. Through movement and posture we communicate nonverbally our inner feelings and thoughts. Dance and great works of painting/sculpture are examples of how we communicate the human experience nonverbally.

The postural habit of leaning off to one side while standing can convey muscular weakness, hip/knee pathology, emotional indignation or other “attitudes”. Torticollis/stiff neck can start with the habitual tilting of the head to one side a person adopts when conveying attentiveness while listening.

Pain will distort body posture and impose new movement patterns that compensate for the lack of pain free movement. The psycho/emotional fear of pain can be even more limiting. Statistics of post ACL reconstruction surgery reveal rather low numbers of athletes who return to a high level of sport performance, fear of re injury being one of the biggest hurdles.

Rest and the avoidance of movement is one the most common recommendations concerning pain or injury. While rest may be an important therapeutic variable it needs to be balanced with other modalities. Too often people stop moving/exercising altogether and “wait” till the pain goes away.This scenario leads to chronicity and deepens the psychological fear of pain and movement.

Injuries impact the psyche as well as body structures, the opposite is also true – traumatic emotional experiences impact the body. Muscle tone high/low has a direct relationship to psycho/emotional states. A traumatic psycho/emotional injury can “lock in” a high level of nervous system input turning on stress hormones of the fight/flight response. In this case turning down/shuting off the stress response can difficult. For some people the experience of trauma means a down turning or suppression of body processes.

These scenarios highlight the complex overlapping of the mind/body experience. Disciplines like Yoga, meditation, Tai Chi, Qi Gong, etc. can be effective in helping people develop awareness and sense of self control over their mind/body experience.

Blending evidence based practices and the mind/body approach is at the center of what I do. Combining these approaches is what I originally set out to do when I started Integrated Muscular Therapy. Integrate: combining parts into a whole.

Whenever I see a new client with a history of low back pain I ask specific questions about their stretching, exercise and self care routine. Many folks have symptoms/injuries spanning several years, they also have worked with numerous practitioners who prescribe exercises.  In fact I will have them demonstrate for me exactly what they do. I often find that the exercises or stretches are actually contributing to the back pain.

The science of back pain treatment, injury rehab and strengthening has changed a lot over the past ten years. Low back stretching, like the knee to chest stretch (pictured left), used to be a staple of low back pain management. It is also part of most general fitness stretching programs. Current research highlights the role of muscle activation and spinal stabilization over stretching as a means of reducing spinal pain. I’ve treated several patients that over – stretch their low back as part of their Yoga/Pilates/fitness training practice.

Pain is a neurological signal that will shut down muscle function (inhibition) this leads to muscle atrophy and weakness. Muscle control is the first line of defense against joint injury. If someone stretches a lot on top of decreased muscle function deeper tissues like ligaments and discs will become compromised. It’s a domino effect.

Here is a picture of a client’s low back who has a long history of low back pain. They also practiced yoga and regularly stretched their low back. In this picture you can clearly see the vertebrae sticking out and the lack of muscle mass. The usual lumbar curve (lordosis) is absent as well. In a healthy/non injured lumbar spine the vertebrae in the low back are usually not visible because of the spinal curve and the mass of muscle tissue on each side of the spine.

Stretching of the spine needs to be carefully considered for those who have a history of back pain and injury. Everyone has a unique collection of genetic/anatomical considerations including health status and injury history.  Added to this are athletic and functional considerations that all play a role in spinal health and care.

 

 

Plantar fasciitis (PF) is often a blanket diagnosis for foot/heel or arch pain. The common approach to treat this condition is ice, rest, stretching the calf and wearing a night splint that passively stretches the plantar fascia. The next phase in treatment is wearing custom orthotics and cortisone injections. Some of these interventions may provide some relief, in my experience they provide limited benefit.

Foot and ankle pain is often the end result of poor biomechanics throughout the whole movement system: spine, hips, legs and feet. Every time your foot hits the ground (running) a force 2-3x your body weight gets transmitted up through your body. The alignment of your bones/joints as well as the health and function of your soft tissues like ligaments, tendons and muscles determine how well that force is absorbed or dissipated. People with PF often have deficits in all these areas: poor joint alignment, weak muscles, compromised ligaments and poor movement efficiency (ability to absorb and generate force).

The picture above illustrates severely pronated feet (possibly genetic since it is bilateral), without an arch the foot can’t effectively absorb force or react very well to surface conditions. I often see some degree of ankle pronation with PF. A thorough evaluation of the hips/legs as well as gait analysis is essential to identify where the dysfunction is stemming from.

In all PF cases I treat I teach self massage (address fascia pain) and use corrective exercises to re educate muscle function to ensure optimal joint alignment. In addition to reduction in pain runners and athletes often see an improvement in running function.

Running: Hamstring Pain & Weak Glutes

Many runners take exceptional care of their bodies: they are diligent about doing all the right things, fine tuning their running performance. That said small deviations in joint alignment or poor muscle activation can contribute to pain and decreased running efficiency. How? The repetitive strain of training, racing etc. means high reps, sometimes at high intensity over a long period of time. This process can eventual lead to a breakdown in soft tissues. Diligent stretching, foam roller work, strength training, diet/nutrition and rest are all good injury preventative habits for runners. What do you do when you still have recurrent hamstring pain even when you do diligent prehab?

Hamstring pain is a common complaint of runners. They typically come into my office saying their hamstrings are “tight”, they’ve been stretching but the pain persists. There are several reasons why anyone would have hamstring pain, the big red flag is sciatica and lumbar spine dysfunction, sacroiliac dysfunction is another red flag injury. Ruling these out is an important first step in the assessment process.

Muscle “tightness” is not a predictor of pain, in fact I prefer to see some hamstring stiffness in runners, too much hamstring mobility is not good for long distance runners. A range of motion test is more than measuring angles: I listen to knee/hip joint, nerve and soft tissue movement with my hands. If movement of all these tissues is adequate then it’s onto other tests to determine muscle function.

Muscles work in concert to produce movement, individual muscles can be injured (strain) and individual muscles can be weak as well, it all depends on what muscle: what does it do and where in the body is it located. The hamstrings are a group of three muscles, they span both the hip and knee joint contributing to hip extension and knee flexion. They work in concert with the gluteus maximus to to produce hip extension (leg goes behind body). They work with the gastrocnemius (calf) muscle to flex the knee. The hamstrings also slow down the forward swing of the leg. Sprinting can be hard on the hamstrings: the rapid, forceful forward swing of sprinting  is typically when and how the hamstrings are torn or spasm.

Since the hamstrings work in concert with these other muscles it is important to assess muscle firing (contraction) patterns. With certain cases of hamstring pain it is not uncommon to find that the gluteus maximus is not firing in conjunction with the hamstrings to produce hip extension. In these cases the hamstrings will often cramp with exercise since they are bearing a heavier movement load. In other words the gluteus maximus should be helping the hamstrings and they aren’t.

In the cases where I find an under active gluteus maximus the focus shifts from addressing pain to re educating the gluteus maximus to fire appropriately in conjunction with the hamstrings. Specific “reactivation” exercises combined with gait re – training is usually very successful in reducing pain/cramping. In the process of activating the gluteus maximus the runner will improve their running mechanics and stride. Hill running will be much more efficient with stronger glutes.

Changing how someone activates their muscles or changing how they run is not an easy task however. Some athletes are better than others at listening to their body, doing the exercises and making mechanical corrections. It takes focus and discipline to listen to the body and turn switches on that were previously shut off.