Friday, 22 March 2013

Knee Injuries.

Knee Injuries

Let’s take a snapshot of each common injury and discuss them individually and then look ways of preventing them.

Cartilage (Meniscus) injury 
Found in your knee fixed to the top of the shin bone (tibia), the cartilage helps to stabilise the knee and help with cushioning when you land. They are commonly damaged in field sports when you are twisting and turning, but runners are prone to this too as they step off a curb or slip doing cross country for example. Typically your knee will buckle and then swell. Sometimes your knee locks and becomes difficult to move and bear weight through it. In these cases Rest, Ice, Compression and Elevation (R.I.C.E) can be helpful. A compressive knee sleeve at this point can be helpful when you are trying to minimise the swelling. Do see a Sports Injury Therapist or Sports Injury Doctor so a decision can be made as to whether conservative measures (R.I.C.E and exercises) will be enough to resolve the problem or whether surgery is indicated. It’s usually worth taking some time to try and get the swelling down and the knee stronger, even if surgery is going to be necessary, as it will heal better after the surgery if the knee is in better shape first.

Anterior Cruciate Ligament (ACL) injury 
This is one of a pair of ligaments in the knee, the other less well known ligament being the Posterior Cruciate Ligament (PCL). They attach from your thigh bone (femur) to your tibia and cross over in the knee and provide stability. They can do this physically by virtue of their attachments, but also by sending your brain useful information about the types of loads going through your knee via strain gauges (proprioceptors) as you move. This enables your brain to reflexly decide how much muscle force is required to control the knee during the task or sport you are performing. When your ACL gets injured these strain gauges switch off and so the knee becomes unstable as your brain doesn’t know how much load is going through the knee and so how much to activate the muscles. When you tear your ACL your knee can become swollen and painful in a similar way to that of a cartilage tear and feel very unstable.

Sometimes surgery isn’t necessary and if it’s not a bad tear, a good rehab programme by a specialist therapist is sufficient to allow a return to sport. You can find that knee bracing is helpful in particular phases of your recovery, so it’s worth discussing this with your therapist. Exercise like the ones in figs 1 and 2 can be very helpful at teaching your muscles to start to engage again. To help this further and to encourage the strain gauges in your knee to fire up again, standing on one leg with your eyes closed is very effective. This type of exercise with your eyes closed means that your eyes cannot help you make balance corrections and you have to rely on your strain gauges if your balance is to improve. Variations on this exercise theme can progressively improve your knee’s ability to provide the right information to your brain at the right time, to improve your balance and stability. Make sure you’re near something you can hold on to for safety reasons in case your balance needs working on!

If it comes down to it though, ACL surgery is now getting so good that it is not as scary a thought as it was 10 years ago.

A Plica is a fold of the synovial membrane, which is the inner lining of your knee joint. These folds are normal structures which develop while you are in the womb. They are often asymptomatic in most people but sometimes, usually following a minor injury such as a direct blow on the knee, the Plica becomes inflamed and scarred and can click as it slides across the surfaces of the joint. Running can then cause your knee to become painful and inflamed. The pain is usually on the inside of your knee around the knee cap (patella), but it can be on the outside too. Your knee can often click and become stiff and painful when held in the same position for prolonged periods, as with sitting. A knee support called an infra-patella brace can help to take the pressure off the tendon while it is healing and when you start to exercise again. Therapy can help this by massaging the thickened area of scarring, as can exercise, but sometimes surgery is required. This injury can be quite difficult to diagnose so make sure you’re specialist comes recommended. Exercises in fig 1 and 2 will help with a Plica and combine well with the massage to minimise the risk of surgery.

There are times though when these injuries do not present in the extreme way described above. Often these structures will become damaged gradually over time due to particular external forces, for example, incorrect shoes or faulty biomechanics (muscle imbalances, leg length discrepancies, tight calves etc). The affects our biomechanics have on our body and the vicious circle of injury and pain it can cause is one of the main reasons knee pain can be recurrent.

A rotated pelvis for example can go unnoticed for many years until the compensations start to cause problems. This abnormal pelvic position often causes one leg to appear longer or shorter and the body must compensate for this. Typically one way it compensates is to overly pronate the foot of the longer leg to try and shorten it, another way is to bend the knee more.

Unfortunately both of these options will increase the load on the knee. If the foot over pronates, it will likely cause the leg to internally rotate excessively and if this is a quick movement, knee problems are exaggerated. This rotation force (torque) will often be absorbed at the knee, which can result in pain. Alternatively if the knee bends too much during mid-stance phase as you run, this can de-stabilise the knee and it will naturally want to rotate inwards. If this is combined with an already over pronating foot, the problem is often exaggerated. Both of these situations are likely to result in knee pain.

It is often suggested that insoles (orthotics) can be helpful to reduce the pressure on the knees. Bear in mind that many causes of knee pain come from the pelvis and the biomechanical problems with your feet are often due to compensations for faulty hip or pelvic biomechanics. It is therefore important that before we start thinking about orthotics, we need to check out the hips and pelvis first. If not orthotics which could potentially be a good thing to help reduce the pressure on the knees, could likely aggravate it.

Managing these biomechanical issues is critical if your knee pain is to be managed and allow you to return to long term training and also to reduce the risk of recurrence. Please make sure you get these biomechanical issues checked by your local therapists as part of your rehab and conditioning programme.


I have noticed over recent weeks my knee has become sore under my knee cap. The band under it is very tender when I touch it and it gets worse either when I train or when I sit and watch TV. I’ve also noticed that the knee can be very stiff in the mornings too. What is it and what should I do?


It sounds like to you have damaged your patella tendon, it’s also known as patella tendinitis or Jumpers Knee. It usually occurs gradually if you over-practice jumping and landing type activities, but can also be caused when you up grade your training too quickly especially if it includes hill training or plyometrics.
Ice can help after a run, but longer term you will likely find that massage to the tendon can be very effective. If you find the tender spot and massage it most days for 2-3 mins, although tender at the time, the knee should feel looser and less painful afterwards. Over time this can have a positive effect on the knee. You often find that patella tendon straps help this too as they take the pressure off the tendon and allow it to heal. Many people also find that shock absorbing insoles help by minimizing the impact, especially if you run mainly on hard surfaces.
Last updated: 26-05-2012

Tuesday, 19 March 2013

The Role of the Transverse Abdominis in Low Back Pain

by Jason Ford 

What does Transverse Abdominis do?
The function of the TrA is to stabilize the pelvis and low back prior to movement of the body. It acts within a feedforward bilateral muscle activation rationale from spinal perturbations with everyday activities. Rehabilitation is typically aimed at restoring motor control of this key stabilizing muscle. Literature points to effective means of treating low back pain with trunk stabilization and strengthening of deep abdominal musculature to improve motor control1. 
Diane Lee gives a great description of how to activate the TrA through abdominal drawing-in maneuver (ADIM). However, how long does it take for someone to learn this and do you think they will really do this correctly and efficiently if they are pain?  It has been shown that teaching a patient to perform the ADIM maneuver can be time consuming and difficult.3

How effective is activating the Transversus Abdominis?
It has been shown that the TrA is activated after the deltoid (~50ms) with arm movement task studies with LBP patients.4 A recent study showed that during a volitional recruitment task for the TrA , induced pain was shown to attenuate the activity of the TrA.5  It has also been discovered that pain will alter a muscle’s role as an agonist or antagonist to control movement for protection through the pain adaptation model.6 This has also been demonstrated with many prior studies of reduced TrA muscle thickness with chronic LBP. In turn, the delay of TrA timing and optimal muscle activation is altered, potentially making exercises that activate it ineffective when pain is present.
If we abolish the pain, would motor control and activation of TrA resolve itself? There has not been any conclusive data to show that the spine is controlled less when the activation of TrA is changed and altered timing of the TrA leads to poor core stability. The feed-forward activation of TrA can be interpreted differently from a small study that showed 3 of 8 pain-free individuals did not have the feedforward responses in 70% of trials with bilateral arm tasks.7 Even prophylactically, the isolated muscle pattern in pain-free subjects is controversial.8 This goes to show further that low back pain is complex, multimodal and overall challenging to treat. 

Is a lack of strength or stability really the reason for the low back pain? 
Do we claim to 'stabilize' every patient?  A recent study stated that some patients are not unstable at all and showed that LBP patients actually have increased stability rather than decreased stability.9 Even if we feel a patient is unstable, how do we diagnose it as unstable?  Special tests to clarify this are inconclusive.  P/A force over specific segments of lumbar spine have been found to be useful to identify the segmental impairment.  However, will activating the TrA fix this? PPIVMs for extension & flexion have poor sensitivity values. A common test practiced is the prone instability test also giving poor diagnostic values.10  You might as well flip a coin to determine instability by the values. 

Some thoughts…
As musculoskeletal specialists, we have significant knowledge and a pertinent role in management of low back pain. We need to concentrate on teaching the patients how to control their symptoms independently.  To me, this means giving the patient tools to provide self-pain relief through therapeutic means.  Activating transverse abdominis stating it will give stability when everyday aches and pains arise just doesn’t seem feasible. The use of foam rolls, towel rolls or any other affordable methods can be very effective in not only giving relief, but obtaining joint motion and allowing an exercise program to be more advantageous.  If a treatment doesn't give someone relief or change, he or she will not be adherent to it, consecutively, returning to health care providers and starting the sequence again.
Since low back pain re-occurs in 70% of cases depending on source, we may not be challenging this problem appropriately. I think having the transversus abdominus as an active component in the treatment is somewhat useful but not conclusive.  Pain relieving exercises and education need to be the forefront of each program so muscle activation can be optimal.

The Female Athlete and Osteoporosis

The Female Athlete and Osteoporosis

  Osteoporosis occurs when there is improper bone formation and a decrease in bone mineral density. With this condition, bones become thin, porous, and brittle, which paves the way for stress fractures or broken bones With female athletes, it often comes as part of the Female Athlete Triad, which is a combination of disordered eating, amenorrhea (absence of a menstrual cycle), and osteoporosis. Osteoporosis develops as a result of the lack of estrogen production that accompanies amenorrhea -- a result of disordered eating (1). Competitive sports have has been shown to provide a common link in the development of eating disorders. Also, stress fractures are more common in female athletes with menstrual irregularities and/or low bone mineral density. This risk increases four-fold in amenorrheic females!
For these reasons, it’s especially important that female athletes combat osteoporosis through sound nutrition and exercise that increases bone mineral density. They should ensure that they are taking in adequate amounts of calcium, iron, vitamin D, and potassium which are normally found in fortified milk and other beverages. Further, exercise, although it cannot offset the negative effects of decreased estrogen production, and can’t build bone mineral density as a stand-alone intervention, should be used as a complement to a sound nutrition plan.
Exercises and activities that build bone mineral density are those that are mainly weight bearing, and strength based resistance training for those that participate in non-weight bearing activities such as swimming. For instance, running, hopping, and jumping are all bone density building activities. Bone building exercises include squats, lunges, pushups, seated shoulder presses, and pull-ups. 
For those who work with female athletes, prevention, recognition, and treatment must be a priority. Understanding how osteoporosis occurs, and how to prevent it, or intervene when necessary will prevent related complications for these athletes later in life. Healthy athletes are happy athletes.
National Academy of Sports Medicine.
Jason Ford.
Professional Sports Therapist.

Saturday, 2 March 2013

Orthotics and leg length discrepancy.

By Abbie Najjarine BSc (Pod) - QMU UK Dip Pod - NSW

Back pain is always interesting as there are so many causes of this problem. I want to keep it simple and address back pain and sacroiliac pain associated with leg length abnormality and how I treat the problem incorporating orthotics and other modalities.
Firstly leg length can be categorized into:
1. Structural – a difference in the long bone measurement of the leg and,
2. Functional - arising from a variety of causes which affect the biomechanics of the body.

When a patient presents with back pain I always start with the basics, and complete a full biomechanical assessment, which includes long bone measurement and a comparison of the amount of pronation/eversion and supination/ eversion at the foundation. The first thing to look for is whether the patient is presenting with bilateral or unilateral pronation. If it is UNILATERAL, I try to establish if the patient has:
a. suffered a trauma in which one plantar fascia may have ruptured or elongated more so than the other, consequently, creating a functional short leg.
b.tibialtorsionwithhipcompensation: such as tight psoas which will rotate the pelvis anteriorly, or tight piriformis ITB’s and Gluteals, as a compensation
for internal tibial torsion to correct the pigeon toed position. Both these compensations could either rotate the pelvis forward or backward creating functional leg length problems in the gait cycle.
If the patient has a long leg compensation in which the long leg drops down or pronates to level the pelvis, I then try to establish the true structural length and this can be verified using a CT scanogram (see Figure 1) for leg length or the normal x-ray film to check the leg length.
Figure 1: CT Scanogram
The longer leg will be predisposed to hip joint wear and tear and may lead to the patient requiring a hip replacement in the future. Therefore if a patient is asymmetrical, inform them about the consequences of not treating the condition. Some practitioners say the body will take up and compensate for the difference and why bother with a heel raise to level the pelvis? However, suggest to them that if they were sitting at a table that rocks side to side, would they place a wedge to stop the
rocking? Most will say YES! So if the rocking table annoys you, imagine how a leg length discrepancy of 3-4mm can upset the biomechanical structures.
If the patient is suffering from hip compensations they will need to be either referred to the appropriate Allied health practitioner to ‘loosen- up’ the pelvis and use stretching and strengthening exercises to correct the anomaly. At the same time prescribe orthotics to realign and correct the biomechanics. A combination of orthotic therapy and muscle stretching and strengthening will, in my experience, give the best treatment results.
If the patient presents with a structural deformity and it is not due to a recent trauma related imbalance, then the use of a heel raise on the structural short leg will be required. I recommend halving the leg length discrepancy measurement, and adding only that amount in the heel raise. Then this amount can be gradually increased, to limit initial discomfort and quicken patient compliance. Contraindication in this instance would be any fusing of the spine as this may cause the patient to be in more pain.
If you prescribe the patient orthotics and have NOT MEASURED leg length (when the patient does have a leg length discrepancy) the orthotic will invariably remove the normal body compensation of the ‘long leg pronation’. This jamming action will create problems with the SI joint and thelongleg mayalsocontributetothe development of a scoliosis, as stated in Blake & Ferguson, 1992.