Ouch My Knee!! [Part 4]

Pain in Zone 3 could possibly be caused by quadriceps tendinitis. Quadriceps tendinitis is not as common as some other conditions, however, this condition could cause some serious pain while running and jumping.

The quadriceps are a very large muscle group which are made up of four different heads (illustrated below). 

 The quadriceps are primarily used to extend the knee into a straight position, but are used in basically all standing or dynamic movements (like jumping, sprinting, running, walking). The quadriceps are literally the most important muscles in the leg. This huge muscle group that is so important to all movement of the knee attaches to a very small bone called the patella. 

We have talked about the patella at length in other blogs so I encourage you to read parts 1-3 of this series. One interesting part of the patella tendon is that it is what is called a “floating bone” meaning that the patella or “knee cap” has no ligamentous connection to any other bone. Most bones are connected to other bones through ligaments but the patella actually just "floats" on top of the knee connected to the body only though tendons [Just as a side, tendons connect bone to muscle, whereas, ligaments  generally connect bone to bone].

Because the patella does not have any ligamentous connection it is a very unstable bone that is affected by outside forces such as the quadriceps. The attachment of the quadriceps on the patella is called the patella tendon (muscle to bone).  

What does quad tendinitis feel like?

• Pain right above the patella with running, jumping, squatting
• Swelling in the area above patella
• Pain when rubbing quad tendon

What causes quad tendinitis?

• Lack of stretching of the quadriceps
• Lack of warming up of said muscle group
• Inappropriate progression of exercise program

What is another condition that could be confused with quad tendinitis?

 A quad strain could be confused with quadriceps tendinitis. A quadriceps strain will cause pain in the thigh could be located anywhere along the quadriceps muscles.

What are some treatments?

Resting and ice are a good first step, but all painful activities should be stopped. Stretching and modification to exercise should be considered when returning to exercise routine. Of course physical therapy is a good option if pain does not improve in 3 weeks. 

Ouch My Knee!! [Part 3]

Knee pain in Zone 2 is very common and can possibly mean patella femoral syndrome. Now this might sound really scary but it’s a very common and benign condition (if you are inactive). For those of you that exercise regularly this can be a very difficult condition to deal with.

What is Patella femoral syndrome?

The patella is your “knee cap” is that bone that sort of floats on top of your knee. This “floating bone” is connected to your body by muscle, tendon, and fascia (or tissue). The patella is supposed to move in a predictable and set “tract” that should not deviate. The patella sort of glides along set grooves that dictate where it should go, this occurs when you bend and straighten the knee.  If you ever have seen floats during the Thanksgiving Day parade you will notice that the balloons are being controlled by several different ropes pulling in different direction. The people pulling the ropes are controlling the tract of the balloon.

When you have Patella femoral syndrome is it caused by an imbalance pulling of the patella to one side or another, this causes undo pulling and rubbing on the grooves that the knee cap glides in. So if you imagine that the parade balloon is like the patella, it means that something is pulling on the balloon too hard and it deviate to one side more than another. You could imagine that during a parade this would cause a problem.  I could envision a 50 foot Snoopy taking out the north side of Macy’s.  The patella is supposed to glide up and down the knee in a way that it doesn’t rub the sides of the grooves; much like the 50 foot Snoopy is not supposed to rub the sides of Columbus Circle.

What does Patella femoral syndrome feel like?

• Pain with jumping, running and sometimes walking
• Pain when sitting for prolonged periods
• Pain feels like stiffness that you can’t shake off
• Pain persisted after sitting down

What causes Patella femoral syndrome?

• Tightness of ITBand (iliotibial band) which is the band of tissue on the outside of your thigh. It’s the thing that hurts when someone gives you a “dead leg”.
• Tightness of the tendons and fascia pulling on your patella
• Imbalance of muscles pulling on your knee cap
• Poor running mechanics
• Poor exercise form

What is another condition that can be confused for Patella femoral syndrome?

• Chondromalacia patella – This is mild arthritis on the bottom surface of your knee cap which causes grinding and pain.

What are some treatments?

Of course, physical therapy is suggested. A physical therapist would be able to best assess what limitations are causing your condition and would address them appropriately. Patella femoral syndrome does not often go away on its own so early treatment is important. If you suspect that you have patella femoral syndrome please discontinue painful activities until cleared by a physical therapist. 

Ouch My Knee Hurts!!! [Part 2]

Knee pain in Zone 1 could indicate a couple of things but most often times leads to patella tendinitis.

What is patella tendinitis?

Patella tendinitis is inflammation of the patella tendon. The patella tendon extends from the patella (knee cap) and attaches to the tibial tuberosity.  This tendon connects the entire muscle group of the quadriceps to the body. The patella tendon is therefore placed under significant force during running and jumping activities. Imagine a shoe lace holding a 100lb bucket from a pulley system; this is just a fraction of the forces placed of the patella tendon. Although the patella tendon is incredibly strong and can handle these forces sometimes these incredible forces can take its toll and can cause injury.

What does patella tendinitis feel like?

• Pain with jumping, running and sometimes walking
• Pain when rubbing the patella tendon
• Pain feels like burning and sometimes throbbing.
• Pain persisted after sitting down (not aways)

What causes patella Tendinitis?

• Repetitive jumping activities such as volleyball and basketball
• Not warming up before activity
• Tight quadriceps and a lack of stretching of said muscles

What are some treatments?

Of course, Physical therapy is suggested. In the short term, avoid painful activities, ice and resting. Taping and patella straps are sometimes beneficial. Talk to a professional before purchasing braces.

Other Possible diagnoses

• Patellofemoral syndrome
• Chondromalacia patella
• Knee arthritis
• Osgood Schlatters disease (NOTE: If you are complaining of pain similar to patella tendinitis but you are younger than 17 it is possible that you are experiencing another condition. Individuals that participate in repetitive jumping activities, that have yet to go through puberty, could have this condition) This is a condition where the patella tendon starts to pull away from its boney attachment (Tibial tuberosity). 

Ouch! My Knee Hurts!!! [Part 1]

This Blog is going to be one of a series of blogs. The next few weeks we will be discussing the knee and the variety of diagnoses and treatments related to it.

Among athletes and non-athletes one of the most common complaints I hear is of knee pain. The knee probably seems to be a straight forward joint compared to other joints of the body.  Although the knee may seem less complicated than a shoulder or the back, the knee is extremely dynamic and can pose several different problems.  The key to figuring out how to fix the problem, is to ask the right questions. Answering these questions accurately is the imperative to being able to accurately diagnosis any knee issue.

Where is the pain located?

It is important to note where the pain is located when you experiencing knee pain.

1. Patella tendon – Possible patella tendinitis
2.  Either side of the patella tendon – Possible patella femoral syndrome
3. Quad tendon – Possible Quad tendinitis
4. Joint line– Possible  medial meniscus (a), lateral meniscus (b)
5. Posterior knee – Possible Hamstring strain, popliteal tendinitis
6. Whole anterior knee – Possible L4 peripheral symptoms, arthritis, internal tear (ACL, PCL)
7. Inside joint line – Possible MCL issue
8. Outside joint line – Possible LCL Issue

What causes pain?

•  Is the pain caused when standing?
•  Is the pain caused by sitting?
• Does it hurt to run?
• Does it hurt to turn?

What does the pain feel like? What Else are you feeling?

• Burning?
• Tingling?
• Throbbing?
• Sharp?
• Stabbing?
• Was there a pop or a snap?

In the next few weeks we will go over each possible diagnosis. We will review the possible causes, treatments and how to avoid these issues. 

Fitness FAQ’s from your resident CSCS

How do I lose my arm or stomach flab?

I think I get asked this question more than any other question in my professional career! My wife alone has asked me this question about fifty times and she is always dissatisfied with the answer. It’s a simple answer to a simple question that people usually don’t want to hear. This is my fat loss golden rule:  To lose fat anywhere, you must lose fat everywhere! It really is that simple. It’s physically impossible to lose fat locally without total body fat loss. You can do 1,000 crunches a day and you will not see any stomach fat loss unless your calorie intake is less than your calorie output. Meaning, that what you eat (calorie intake) has to be less than what you put out during your daily life and exercise (calorie output). A recent study has shown that it is not just about exercise but that diet contributes most to weight loss.

[Small tangent: Women have a tendency to pool fat in certain areas of their body in subcutaneous fat (below the skin). These areas are the upper arms, stomach, thighs and buttocks. Men have a tendency to pool fat viscerally (below the muscle, around organs in the abdomen) Subcutaneous fat is harder to lose than visceral fat… Sorry, ladies.]

How do I lose weight?

So let’s get one thing straight. You should not just aim to “lose weight.” Instead, you should aim to lose fat mass in relation to lean body mass (muscle). There are plenty of very, very unhealthy “skinny” people. Take for example, an anorexic female that has very low fat mass but also has critically low muscle mass and is malnourished. Although the anorexic female may be skinny, she is also incredibly unhealthy. Your focus should be on being fit and healthy—NOT skinny!

Losing fat mass and gaining muscle mass is critical to achieving health and fitness. Losing fat mass and gaining muscle mass does not only improve your aesthetics,  but also improves blood chemistry, reduces the risk of certain heart conditions, improves bone density, and increases overall strength, along with a whole laundry list of other benefits. Therefore, exercise is critical to overall health—although your diet is most important factor in losing weight.  With that said, I think it’s important to note that you should not just cut your calorie intake by eating less or simply not eating.

How should I diet?

Crash diets will work in the short run but will always fail! I do not say “always” lightly. The reason why these diets always ultimately fail is because the body is designed to require nutrition and will always seek it out. If you think of an engine, it is designed to require several elements to run. The engine requires gasoline, air, a spark, coolant and oil among other things. If any of these elements are eliminated, the engine will not run correctly or fail to run at all. The same goes for the human body. If you’re not eating correctly and you’re lacking elements of nutrition, your body will not run correctly. Likewise, if you’re consuming all the necessary elements but you’re not consuming them in the correct ratios, your body will not run correctly. These elements at the basic levels are the following: Protein, Carbohydrates, Fat and Fatty Acids, Minerals, Vitamins, and the most often forgotten—WATER!!! (Coffee and diet coke DO NOT COUNT.)  If you’re finding that you’re lacking in some of these areas, a good place to start is our Maven Shake, which combines the basics with a little extra something that’ll give you an extra boost. (Note: This isn’t just a shameless plug. I started drinking the Maven Shake every morning and I notice a legit difference.) 

My Achilles Heel! Is my Achilles heel…?

So as the weather warms I am seeing an influx of Achilles related injuries. So I wanted to shed some light onto what the Achilles is and what injuries are associated with it. 

What is the Achilles tendon?

-          The Achilles tendon (calcaneal tendon) is the common tendon of the ankle that attaches the calf to the foot. The “calf” muscle is comprised of 2 major muscle groups of the gastrocnemius (gastroc) and the soleus. These two muscles are in charge of flexing the foot down towards the floor or technically referred to as plantarflexion. You can feel your Achilles tendon by touching the back of your ankle and feeling for the large cord like tendon that extends down to the heel.

Why is the Achilles often injured?

-          

     The tricky part about Achilles issues is that it can caused by many things. The Achilles plays a major function in all weightbearing movement from standing to sprinting. Any issue with the Achilles will drastically affect ones function throughout a normal day. Some problems with the Achilles are the following:

o   Located in a vulnerable area susceptible to injury from outside forces such as a slide tackle.

o   Takes the majority of the load during jumping activities.

o   Used constantly throughout day and exercise.

o   Relatively small tendon for girth of muscle it attaches to.

o   Tendon attaches to calcaneus (heel) but also shares tissue with bottom of heel and effects plantar fascia.

What are some common injuries?

-           Some common injuries sustained to the Achilles tendon and possibly associated with the Achilles tendon are:

o   Achilles tendinitis or tendinosis – Inflammation of Achilles tendon. This is indicated by pain when touching the Achilles and pain with all running and jumping activities. May see slight swelling of tendon.

o   Achilles rupture – Tendon ruptures are very painful and require immediate medial attention. Full Achilles ruptures are immensely painful and require surgical repair and can be diagnosed by use of the Thompson test. The Thompson test is when the effected calf is squeezed and a positive finding is when the foot does not flex down (plantarflex).  Partial tears can be seen when a dip in the actual tendon (looks like a pothole in the tendon).

o   Achilles apophysitis (mostly just children) – Also called Severs Disease, Achilles apophysitis is when the Achilles tendon pulls away from the heel causing pain and swelling. Much care must be taken to avoid over stretching.

o   Heels Spurs (secondary) – Tight Achilles will sometimes contribute to heels spurs which are boney growths are an attachment of a plantar fascia.

o   Plantar fasciitis (secondary) – Inflammation of the plantar fascia of the foot (arch of the foot). Tightness of the Achilles will contribute to plantar fasciitis by placing the foot in poor alignment and causing increases stress across the plantar fascia.

What are some causes for injury?

-          Some causes for Achilles injuries are often preventable

o   Over use – Weekend warriors and avid runners with poor running technique will sometimes develop Achilles tendinitis.  See my last post about running technique.

o   Tight calves – Stretching is very important. One way you can tell if your calfs are tight is if you are unable to flex your foot towards your head >90 degrees. Be sure to warm up >10mins before stretching any muscles.

o   Improper footwear – High heeled shoes and flip flops do not support your foot properly and could eventually cause Achilles injuries. 

Running Tips For the Dog Days of Summer

As the temperature rises and beach season approaches we see more and more runners come into the office. Not all complain of the same issue but most boil down to the same root causes, poor running form. You might think to yourself, “I know how to run! You just go out there and run!” Although running may seem intuitive there is more to it than you might think. Here are a few things you should look out for:

1.       

• Wear the right shoes: So many people don’t understand that footwear is of the utmost importance. Get yourself fitted for the correct shoes at places like…

a  .     Road Runner Sports - http://www.roadrunnersports.com

b.      Jack Rabbit - http://jackrabbitsports.com      

      

These stores will be able to fit you for the proper shoe for your foot and your running level

• Heel – Toe is wrong: Traditionally we think we should be running on our heels but actually you shouldn’t. Running heel to toe actually puts a large amount of force on the shins and the lower leg and can possibly lead to “shin splints” or knee problems. You should land on your mid-foot or slightly behind the balls of your feet.
  
•  Running not jumping: There should be very little vertical movement with proper stride length. Next time you take a run, pass by a store front and look at how much your head bobs up and down, I think you’ll be surprised.
  
• Running surface: Running on asphalt and concrete all the time will eventually take its toll on your knees, hips and back. Change up your running surface every now and then. Try running on a soft track or grass every now and then.
  
• Treadmills are not always good: Running on treadmills all the time can sometimes lead to alterations in stride length, poor body mechanics and poor posture. This is mostly due to the fact that treadmills do half of the work for you by propelling your body. 

Hopefully these tips are helpful! But if you are currently in pain because of your running get assessed by a qualified PT or specialist. Happy running everyone!

David Kwon, PT, DPT, CSCS