Patellar Pain: Part 2 - The Solution Step 1 - Posture

It wasn't until I began to study for my National Academy of Sports Medicine (NASM) Performance Enhancement Specialist certification that I learned about muscle imbalances that existed within the joints above and below the knee, which in turn caused the knee and foot to be out of alignment with activities, which then developed into knee pain/PFPS or worse. Then I attended Gray Cook and Lee Burton's Functional Movement Screen Seminar that I learned about faulty movement patterns and how to retrain them.

In regards to imbalances and faulty movement patterns, I tend to see this dysfunction a lot in runners. Some runners will ignore the pain or try to work around it, putting "fitness on top of dysfunction" (as Gray Cook would state). The problem there is subconsciously the body will try to adapt and find a way to run pain free, which is usually with a foot turned out appearance. This causes imbalances to exist and then the knee wobbles in.

In turn, that runner can keep wearing down the patellofemoral joint unt

il irreversible damage is already done. Whether they are age 10 or 50 at some point or another they come see me for rehabilitation on that knee.

Hopefully they see me early, which I tell the younger runners that their knee pain may be a good sign that something is not working correctly. Their pain and dysfunction can be corrected so that they do not have irreversible damage from them continually running on that particular knee with bad mechanics due to muscle imbalance.

So now I begin the process towards a healthy and pain free knee:

THE SOLUTION: STEP 1 - IMPROVE YOUR POSTURE PEOPLE!

You would not believe how many times when I see a patient for the very first time that I can usually tell which knee is the one they are having pain with. The patients/clients that I see with knee pain all seem to stand particular way, they have one or both feet turned out.

In my mind, the foot turned outward posture could have been the beginning of the problem or the end result. Overall that does not matter to me about how the imbalance began, but the importance is in the method of how to fix it. The first thing I have to educate people who suffer from any type of dysfunction or pain is to improve their posture. Their poor posture is just reinforcing those muscle imbalances and movement dysfunctions which in turn leads to pain.

Think of it this way, you come into therapy you usually get 30 minutes. For example, they may perform ultrasound or electronic stimulation to help with the inflammation, if you are lucky they will introduce you to the foam roller and the art of myofascial release, you perform some mobility/flexibility exercises, then you perform some stability exercises, then you grab a bag of ice and are on your way home. What is the first thing you do then when you get home? You go right back to that foot turned out posture while seated and standing, which just defeated everything you did in therapy.

If you perform 30-60 minutes per day of exercises to improve your dysfunction patterns, then spend the rest of the day having poor posture and reinforcing the dysfunction, how are you improving? 60 minutes of right will not cure the 10-12 hours of the wrong you did the rest of the day.

This is why one of the first things I try to educate my clients/patients is the importance of good posture. Standing with feet straight ahead, shoulder width apart, butt cheeks tightened together. It will take some practice but it is well worth it. Might feel very weird in the beginning, but over time you will become more comfortable with this good habit. You will have to look down and check to make sure you are not going back to your old way of standing and sitting. Catch yourself and then correct it. It will pay off in the long run.

Patellar Pain: Part 1 - The Problem

Everyone would probably agree with me that knee pain is one of the more common orthopaedic problems in our society today. One of the more common diagnoses for knee pain is termed patellofemoral pain syndrome (PFPS). In my mind PFPS is an epidemic. Of the 11 people who saw me in therapy this week, 9 of them came in with some type of patellofemoral pain.

A description of PFPS is that it is sort of a "catch all term" for pain around the "patella" or kneecap (kind of like how shin splints is termed for shin pain). The culprit is usually blamed on improper patellar tracking where the patella/kneecap is not staying properly within the femoral groove where it is suppose to. This can lead to many different type of knee problems (chondromalacia, cartilage damage, acute and chronic patellar dislocations). All of these and more can lead to problems and issues requiring surgery.

Image of a Right Knee

For the longest time, the problem was blamed on the inner part of the quadriceps muscle (the vastus medialis or VMO) and that it wasn't strong enough to hold the patella in its groove and the outer quadriceps (vastus lateralis or VLO) was "pulling" the patella outward and hense causing Patellofemoral Pain.

So as rehabilitation specialists we all spent all this time trying to strengthen the quadriceps muscle with leg extensions, quad sets, & short arc quads. The problem we had with rehabiliting PFPS this way was is that it did not help the problem. Looking back on it now we were actually making the problem worse.

The actual problem with PFPS wasn't the knee at all, the knee pain was just a symptom of a bigger problem. The main problem was not at all with the quadriceps musculature but with the muscles associated with the hip. There was an imbalance present in the hip musculature that caused the thigh to move inward, while the patella would then rub or track to the outside of its intended groove.

A study published in the Journal of Orthopedic and Sports Physical Therapy performed MRI studies of 6 female patients who had laterally subluxing patellas (this is what causes patellofemoral pain) in an open chain (non-weight bearing) and closed chain (weight bearing) positions. They had this to say:

"In addition, the results of this investigation suggest that the patellofemoral joint kinematics during non–weight-bearing could be characterized as the patella rotating on the femur, while the patellofemoral joint kinematics during the weight-bearing condition could be characterized as the femur rotating underneath the patella." J Orthop Sports Phys Ther 2003;33:677-685.

• Patellofemoral pain research refocuses on hip biomechanics.


• Patellofemoral Kinematics During Weight-Bearing and Non-Weight-Bearing Knee Extension in Persons With Lateral Subluxation of the Patella: A Preliminary Study 2003


• Management of Patellofemoral Pain Targeting Hip, Pelvis, and Trunk Muscle Function: 2 Case Reports-2003


• Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain -2009

It wasn't until I learned this that I began treating my athletes/patients/clients by working on their muscular imbalances at the trunk & hip that they started to become pain free and able to resume their regular activities.

Next blog, I will talk about the process you should take to bring your body back into balance and become pain free in your knee.

Our Success Roadmap

Our RKC, David Whitley, asked our class if we would like to participate in a sort of "contest".  Being the competitive couple we are we absolutely said yes.  It is actually pretty cool, almost like a fantasy football league but for our bodies.  We get points for weekly and daily tasks (see below) and then at the end of the week our top score is 101 points.  the person with the highest point total gets a "prize".  Nikki had a perfect score of 101 this past week.  I had a 98 (not bad).  In all of this competitiveness I ended up losing 4 pounds in the process.  Very cool.

So get a group of your friends together and figure out a diet scheme and put a point total on it.  Don't do "total pounds lost".  That is stupid, and usually not fair.  If I lose 20 pounds but put on 10 pounds of muscle then I would only lose 10 pounds on a scale.  Strive for something better.  Overall what the contest does is makes you accountable to make good decisions about your health.  

Here are the totals for daily points in our little contest:

• eat at least 5 meals per day 2-3 hours apart (1 point)
• have a protein and a vegetable with every meal (1 point)
• Attend KB bootcamp that day (3 points)
• Review your short and long term goals (fitness, life, health, whatever) 1 point
• log food into a food journal (2 points)
• took a multivitamin (1 point)

Other ideas on point totals could be:  burned more calories than you ate that day, ate within 100 calories of your calculated daily total that you need to eat, 

Weekly point options

• Plan meals ahead of time for the week (10 points)
• Cook food in bulk and package for quick preparation (10 pts)
• Set a personal record in your workout (achieve 10pts, attempt 5 points)
• try a new healthy food (10 points)
• Log onto the nashvillekettlebell.ning.com and talk about your goals (10 pts)

Other options for the week.  Of your total meals (35) you ate a cheat meal less than 4 times that week.  Never eat more calories than you burned that whole week.  Did something nice for a stranger.  (the sky is the limit!)

Is Your Personal Trainer Qualified to Teach Kettlebell?

Terrific Blog I read from John Scott Stevens R.K.C. he teaches kettlebell courses/classes back in my home state of Nebraska. Please read it if you have time.

Getting Started with Kettlebells

If any of you might be interested in getting started with training with kettlebells there are a few options to consider.

1. The best option is to look onto Russian Kettlebell Website and search for instructors in your area where you can train with the best.



2. If #1 is not an option you can also purchase the Men's Russian Kettlebell Quick Start Kit &/or the Women's Russian Kettlebell Quick Start Kit. The package includes a kettlebell, enter the kettlebell book (a must have) and the enter the kettlebell DVD. The Women's starter kitgets all the above but they get the new Kettlebell Goddess DVD instead of the enter the kettlebell DVD.

Let me know what you think and if you have any questions, Nik and I are always here to help and if we cannot answer the question we can pass it on to our RKC, David Whitley.

Shoe Selection

Hey everyone. Hope all of you are doing well this new year. Been pretty crazy on my end. I have been working on a presentation on the Functional Movement Screen for the Tennessee Athletic Trainers Society and have been having some software and computer problems.

Upon the idea of shoe selection, any Physical Therapist and Certified Athletic Trainer (ATC) will instruct you to go to the runners store and get measured and fitted for a very good pair of running shoes. At least they should, the off the shelf brands aren't for everyone, many different people run in different ways. (And please stay far far away from Nike Shocks, its like you are running in high heels! BADBADBADBADBAD

Does anyone tell you what type of shoes you should wear to lift in? I learned the hard way from my RKC (Dave Whitley) and it was reinstated to me when I read Enter the Kettlebell by Pavel that any type of running shoe or workout shoe with a high heel is no good for lifting for a few reasons:

• The heavy padding takes away from your "proprioception" or balance. The proprioceptors in your body help to communicate to the rest of the body on where your body is in space, lets just say they are muffled somewhat when you have shoes on with a padded heel
  
• They take away from you using your biggest muscle, YOUR GLUTES! Think of it as this, if you come up from a deadlift or squat and are on your toes coming up you cannot fully initiate your glutes. You need to be able to drive force through your heels when performing squats and deadlifts, not the toes.
  

Your glute muscles are very important to your body and provide stability to your spine and lower body. As a society we suffer from "glute amnesia" (due to the fact that we sit all the time and do not use our glutes like we should, hence all the ankle, knee and back problems I see in therapy that are usually fixed with flexibility and good glute training).

I know, I know. Now you have to buy ANOTHER pair of shoes, but it will be worth it. I changed shoes and hit a new personal best on my snatch test on the 2nd day of training with them. You don't have to spend a lot of money actually. Pavel likes to wear Converse Chuck Taylors, Nikki and I spent $30 each and bought a pair of indoor soccer shoes, alot of RKC's wear Nike Free brand shoes. If is has a flat sole and is comfortable, then you are set!

From this day on if you walk into my clinic for therapy and you are not running that day, I will ask that you workout in flat soled shoes or I will have you work out in socks or bare feet. It makes a very significant difference when training and even in rehabilitation. As for running shoes, stick to running/walking in them. When its time to work on strength, take them off.