Gary’s Fitness Blog

In my last post I discussed the topic of Patellofemoral Pain and Tendionopathy. Specifically, I mentioned the special communication that was put out in the November, 2007 issue of Medicine and Science in Sports and Exercise.

Over the past year, I have been collecting articles, reading and researching this topic of injury prevention for runners and strength training. The special communication has once again peaked my interest and I thought I’d share a brief synopsis of a few articles that I have reviewed lately.

The next few posts will all be short reviews of articles discussing Patellofemoral Pain. Here’s the first article:

Source:

Crossley, K, Bennell, K, Green, S, et. al. (2002). Physical therapy for patellofemoral pain. A randomized, double-blinded, placebo-controlled trial. The American Journal of Sports Medicine, Vol. 30, No. 6. Pgs 857-865.

1. One of the first things I found interesting was that in the introduction they say that patellofemoral pain is the most common diagnosis cited by many authors. And that while it is a common issue to be seen and treated, the “pathologic origin of this disorder is not clearly understood.”

2. The jargon is wide ranging describing this issue. Patellofemoral Pain, Chondromalacia Patellae, Anterior Knee Pain, Patellar Malalignment, and Patellofemoral Arthralgia have all been used synonymously.

3. “The rationale behind the use of physical therapy for alleviation of patellofemoral pain includes restoration of patellar alignment through active or passive interventions, including quadriceps muscle-strengthening exercises, stretching, patellar taping or bracing, biofeedback, and use of corrective foot orthoses.”

4. The purpose of the trial was to find out if physical therapy was effective in managing and treating patellofemoral pain in comparison to a placebo group.

5. The physcial therapy used consisted of: patellar taping, biofeedback of vastus medialis oblique (VMO, which is the quad muscle on the inside of your leg), gluteal muscle strengthening exercises and stretching.

The exercises that they uses were the following:

• isometric VMO contraction at 90 degrees — basically a leg extension done isometrically at 90 degrees
• squats to 40 degrees with isometric gluteal muscle contraction (4 sets of 10 reps)
• isometic hip abduction standing against a wall (4 sets of 15 seconds)

added exercise after 2 weeks:

• step downs — stand on step and slowly lower leg in front (3 sets of 5 or 10)
• increase the hip abduction to 30 seconds.

6. They were instructed to do these exercises 2x a day while in the program.

7. They concluded that there was a significant difference between the two groups in three measurements: worst pain, usual pain and anterior knee pain scale. But there was no difference between groups in the functional index questionnaire.

My thoughts:

As many of the articles that I find, this article discusses the rehabilitation of knee pain not the prevention of knee pain. But there are some interesting insights that I feel I can pull from this article:

The exercises that they chose strengthened the gluts and hip abduction. This is a common theme that I have seen in runners that end up developing the worst knee issues - they have weak glut and hip abduction.

One easy way to see how stong and stable your hips are (those two mucles groups involved) is to stand on one leg and try to do a 2 or 3 inch squat. Make sure you are not holding onto any table, chair or wall for balance. Can you do it? Does your knee try to cave in towards your other leg or push out away from you midline?

If it appears that you can’t balance or do the squat, it might be that you are a little weak.

Now relate this to running. Each gait cycle you have to do a very small version of the single leg squat. You flex and extend at the hip, your knee flexes and extends, your foot dorsiflexes and then you plantar flex to toe off. What happens if each time you go through this cycle your leg isn’t strong enough to carry through the movement and your hip or knee has to adapt?

Let’s do a quick calculation: Let’s say each leg goes through this cycle 90 times a minute (the 90 rpm cycle many coaches suggest today), you run for 1 hour (60 minutes). That equals 5,400 times each leg will make that movement. Now go run a marathon!

My thoughts are obviously an attempt to make a somewhat educated discussion based upon my experience and the knowledge gained from this article. As I continue to be aware of the issue of injury in runners, I continue to be more convinced that some runners will benefit by including strength training in there regular programs. For no other reason then they will be able to handle more miles without injury.

One of the biggest questions becomes, What exercises should I do? One place to start would be with a post I wrote some time ago called, Improve Muscle Imbalances with Strength Training - Hip Stabilizers. I plan to update that post soon, but I still believe it is a good starting place.

Next Post:

I plan on looking at an article called “Hip Strength in Females With and Without Patellofemoral Pain.”

** Below is a copy of an email I sent to a few runners I’m currently coaching**

I was reading through the latest issue of the Medicine and Science in Sports and Exercise yesterday and found a special communications from the organization (American College of Sports Medicine) to team physicians. In that communication they gave suggestions to physicians about “selected issues in injury and illness prevention”.

The one injury area that I thought was relevant to us runners was their thoughts around Patellofemoral Pain and Tendinopathy.

Risk Factors they associated with this are:

1. muscle weakness and imbalance and inflexibility including quadriceps shortening
2. trauma, overuse, training errors or previous injury
3. patellar hypermobility
4. hip muscle weakness

Prevention Interventions Include:

1. implement sport / activity conditioning program with periodization emphasizing the proven interventions of quadriceps strengthening and increasing hamstring flexibility

2. other interventions may include core / lower extremity strengthening, hip abductor and external rotator strengthening, improving motor control.

My thoughts:

I come across a lot of issues in runners and general population with weak hip stabilizors and pelvic mobility/control. Incorporating some adductor exercises / abductor exercises have seem beneficial (I’ve especially seen this in a cyclist that I’ve worked 2 years with). The other thing that they talk about is “motor control” … I’ve recently seen a need to incorporate some balance training (single leg balance exercises) to help develop the hips / lower leg stability so that it can properly move through the gait cycle.

Some beginning exercises that can help in these two areas can be found at this link: http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/479.html

One thing to remember is that when running your body can’t rely on a machine for stability or movement patterns, so when incorporating a strength, stability and balance program… don’t use machines.

Last thought:

Everytime you run, your body has to work to strengthen itself and adapt to the workout. If the first law of training is “specificity” (which it is one of the first four by the way) then we should appreciate that regular running is likely the best way to strengthen our body to run. In other words…

… if you are not running regularly, it doesn’t matter how many single leg squats you do on a balance pad, your long run is going to likely cause injury…..

…. But if you have been running regularly, these exercises are a great addition to help boost your body’s ability to handle your runs…

…. In other words - these exercises are In Addition To, not In Place Of your running …

…. unless you are already dealing with an injury, which changes the entire ball game …

**** End of Email ****

Those are some thoughts that I felt were worth sharing with everyone. Since that email, I’ve come across a couple situations that have driven home the importance of these injury prevention interventions even more.

When motivation is high, which often is the case in an individual taking on a marathon for the first time, there can often be a disconnect between what is “optimal” and what is “practical”.

I put “optimal” in quotes because there are a lot of people out there willing to give advice about the proper way to train for a marathon. But the question we always have to ask ourselves is this: Is it the proper way to train for me? The truth is that there are many ways to get to the finish line of a marathon (or triathlon), choosing the best path for you is the key.

Someone who has run 10 (or 50) marathons may have a program that works well for them, but may not necessarily be proper for you. Do they have the same biomechanics as you? What was their history with running before they began?

There are so many variables. The interventions listed above are a good starting place if you are starting to see some patellofemoral pain during or post running workouts. They are also a good hedge against injury development if you have poor biomechanics or running form.

If you feel like you need more individual guidance, look me up and I’ll try to help if I can. My email is garyditsch at gmail dot com.

This past week has been Jimmy V week on ESPN. I have now seen the video of his ESPY speech on tv, heard it on the radio and just watched it on you tube. If you have never seen it, you really need to watch it right now. There are two great action plans for everyone to use that he puts into this short speech. The messages are:

1. Everyday you need to laugh, think and be emotional to the point of tears.

2. You need to remember where you are from, know where you are and know where you want to be.

Great lessons I believe we can all implement and use. Jimmy V was battling cancer at the point he gave his speech (Jimmy V Foundation) and he knew what he wanted to accomplish through the Foundation. That is what I enjoy about his speech so much - he was also living out the very ideas he was trying to motivate others to use.

Thanks Jimmy, I’ve been moved to tears 3 times this week alone through your speech.

The motto of the foundation is “Don’t Give Up, Don’t Ever Give Up.” While it may seem trivial in my daily life to use a phrase like that just to get through another work day or get myself out the door for another run, I don’t think Mr. Valvano would be insulted by using that phrase for the more trivial daily obstacles. His speech had a lot to do with personal accomplishment and for most of us, making those daily decisions to maintain our plan and goals is what we need to do in order to obtain that level of personal satisfaction that we desire.