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PrintRunners: ITB Syndrome and the “Stiff” Pelvis
Recurrent Hamsting injuries?
Footballers and sprinters- you must be wondering what your doing wrong? What is causing you to have recurrent problems with your hamstring?
Now as with any injury, you should always consult your GP and or physiotherapist before commencing any new exercise…
So a big mistake when rehabilitating the hamstring is the lack of eccentric work… people tend to stretch and concentrically strengthen muscles which does not protect the hamstring when it is under the most strain. Eccentric contraction involves contracting a muscle in a lengthened position- in the case of the hamstring this would be from knee flexion through to knee extension. This differs to concentric muscle activity where muscles are both contracted and shortened at the same time, this would be the equivalent of performing a hamstring curl
Nordic hamstring exercises are found to be quite useful in strengthening the hamstring muscle
Look out on MCR for a detailed hamstring rehabilitation programme in the coming weeks
Pilates and Physiotherapy
What is Pilates?
Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.
Background
Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.
Clinical Pilates vs Pilates
Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.
In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.
Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery.
The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.
Peripheral injuries
When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries.
Spinal Injuries
Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.
In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.
Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.
In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.
If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt.
The benefits of Pilates
• General fitness and body awareness greater strength and muscle tone
• Improved flexibility
• A flatter stomach
• Improved efficiency of the respiratory, lymphatic and circulatory systems
• Better posture and awareness
• Less incidence of back pain
• Increased joint mobility
• Lower stress level
Which clients would benefit from Pilates?
• Males and females
• Pregnant: Pre and post natal
• Athletes and dancers
• Amputee and stroke rehabilitation clients
• Elderly
• Children 12 years-old +
Clinical pilates therefore targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.
If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!
PFPS- Knee pain: Cause and solution!
If you notice a gradual dull aching sensation in the knee with intermittent sharp pain especially with negotiating stairs, along with crepitus in the knee when you bend and straighten the knee, you may be suffering from Patella Femoral Pain Syndrome (PFPS).
PFPS which used to be known as Chondro-Malacia Patella (CMP) , Anterior Knee Pain and Runners’ Knee are all very similar conditions. These conditions and symptoms can occur due to a varying degree of wear and tear (degeneration) of the cartilage behind the knee cap, also known as the patella femoral joint.
What are the main contributing factors?
Three main factors attributed to cause increased degeneration of this cartilage are:
1. Muscle tightness:
The quadricep muscles and the Ilio Tibial Band (ITB) tend to be tight in people with PFPS. If the quadricep muscles are tight, it has a tendency to pull the knee cap much closer to the thigh bone. This increase in pressure leads to grinding of the knee cap against the thigh bone causing the degeneration of cartilage.
The ITB has attachments to the outer side of the knee cap via a connective tissue known as the lateral retinaculum. The knee cap tends to sit comfortably in a congruent position within the thigh bone. However when the ITB is tight it pulls the knee cap in an outward direction shifting the knee cap away from, and out of its natural groove.
This slight shift or tilt increases the pressure or loading behind the knee cap leading to degeneration of cartilage and pain.
2. Muscle Strength:
Imagine jumping and landing on a straight knee compared to a bent knee. There is definitely more impact that goes through the knee in the first instance because your muscles are not helping to absorb the impact whereas a bent knee allows the muscles to contract and dampen the impact on the joint.
Similarly if the quadriceps, are not strong enough, your knee joints takes the slack with every step that you walk, run, or stairs that you climb.
The knee joint in this situation will be grinding excessively as muscles are not effectively stabilising the joint and supporting a person’s body weight.
3. Biomechanical faults:
Flat feet (poor arches), knocked knees, knee cap position (rotation/ tilt) and increased Q angle are all factors that result in an imbalance of muscles around the knee joint and mal-alignment of the knee cap, that may accelerate the degeneration of the cartilage in the patellafemoral joint.
So what can you do to solve your knee pain?
Treatment for PFPS would entail stretching exercises for the quadricep muscles and ITB and strengthening exercises for the muscles around the knee joint in particular the quadriceps. In addition getting appropriate footwear to support the arches of your feet or considering customised orthotics to correct your biomechanical faults would also be strongly recommended. If your keen athlete, or struggling with pain, you may even want to consider a knee support for symptoms reduction and control.
Knee Support for PFPS
A knee support helps by externally pulling the knee cap back into the groove so that it can sit nicely within it. As mentioned in a previous article on " Do you need a Knee Support?", the mal-alignment increases the wear and tear to the cartilages. In this article, I will highlight two basic types of knee support that are suitable for such a condition.
The first type is the sock-like knee support that wraps around the knee joint works by compressing the knee cap against the joint. But wait, wouldn’t that increase the pressure behind the knee cap? Not really, it allows for the knee cap to sit in a more congruent position, spreading the pressure over a wider surface area and hence decreasing the pressure.
The second one suitable for PFPS is the knee support with a open window does not give the compressive force. It works by pulling the knee cap inwards to counter the pull from the ITB. This will again allow the knee cap to sit nicely in the groove, without the compressive pressure.
Do you need a Knee Support?
The following assessment form will aid you in making a better decision. In the following few articles, I will also give some interesting information which will help you decide what kind of knee guards will help for the common knee pain or injury.
Heard about ACL. What about PCL?
Have you ever hit your knee against the dashboard of your car coming to an emergency stop? Or fallen onto the ground on the front of your knees resulting in your knees fully bent backwards? Chances are you might end up with a tear in a major ligament in your knee without you knowing, the posterior cruciate ligament (PCL).
The posterior cruciate ligament or PCL , is a lesser known cousin of the anterior cruciate ligament (ACL) but of no less importance. It is one of the 4 key ligaments that stabilize your knee. Its primary functions are to prevent your tibia (shin bone) from sliding too far backwards and providing rotational stability to your knee.
How is PCL injured?
These are some common ways the PCL may be injured:
- Commonly known as the “dashboard injury”, it happens in car collisions where the shin hits the dashboard hard. The shin is forcefully pushed backwards when the knee is already in a bent position
- Falling onto the front of the knee where the tibial tuberosity (top part of the shin bone which protrudes out) hits the ground first, causing the shin bone to move backwards forcefully.
- Forceful pressure on the front of the shin while the knee is hyperextended (during a soccer game, a player’s knee is extended out during the end of a kick and received a hard tackle from the front of the shin)
How to know if you have injured your PCL?
If your knee is injured in the above few ways, there is a high chance you might have torn your PCL. The signs and symptoms for a PCL injury is similar to an ACL injury, i.e. swelling, pain, decreased mobility of the knee. However, the sensation of instability of the knee is not as common and pronounced as an ACL injury. If you do have sensation of instability, such as the knee giving way while turning or pivoting on it, surgical intervention might be necessary.
How is PCL injury diagnosed?
A major part of the diagnosis stems from you remembering as closely as possible how your injury occurred. A reliable test that your doctor or physiotherapist usually does is the posterior drawer test to test the integrity and laxity of the PCL. Further investigations such as X-Ray and MRI can help to confirm and assess the damage of the injury and reveal any other bony, ligament or cartilage injury.
Knock Knees – Can I reverse it? (Part 2)
In the previous entry for Knock Knees, we discuss about the different types of knock knees and the contributing factors of it. Now, we will talk about the problems of this condition and ways we could get rid of it.
The Problems of this condition
The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.
How do I get rid of it?
External aids:
1. Orthotics
The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.
2. Knee braces
These can help prompt correct alignment of the knee joint, but may create a degree of dependency.
3. Strengthening
A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.
4. Stretching
Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.
Knock Knees – Can I reverse it? (Part 1)
Knock knees is a phenomenon where it appears as though your knees are at an inwards angle in relation to your feet. Most kids under the age of 6 appear to have knock knees, but grow out of it as their body shape changes. An adult with knock knees may or may not have pain – mostly depending on the severity.
In this article, we would discuss on the different types of knock knees and the contributing factors that may develop with this condition.
When discussing the reasons for knock knees, structure of the bones and joints must be assessed. Structural reasons for knock knees are not normally reversible, unless surgery is indicated. When it comes to the strength, control and stiffness of muscles that control the alignment of the knee, a full assessment must take place so that a corrective program can be enforced.
Structural reasons:
Genu varum: … Not Reversible
A structural deformity of the knee joint, causing the lower leg to be angled inwards and the upper thigh to be angles outwards, causing a bowing effect.
Tibial valgus: … Not Reversible
This is a deformity of the tibia.The bone angles outward towards the end furthest from the knee joint.
Coxa Varum: … Not Reversible
A deformity of the femur; the angle between the head and shaft of the femur is more acute, making the shaft of the femur angle inwards.
Q angle: … Not Reversible
This is the angle between the line of the femur, and the line of the mid patella – tibial tuberosity. A larger Q angle will mean more biomechanical problems within the knee joint.
Poor strength of:
Hip external rotators: … Reversible
- Gemellus inferior & superior
- Obturator internus & externus
- Quadratus femoris
- Piriformis
- Gluteus maximus
- Gluteus medius posterior fibers
- Sartorius
Weakness in these muscles will cause the femur to internally rotate causing an increased ‘knock knee’ effect.
Hip abductors: … Reversible
- Gluteus medius
- Gluteus minimus
- Tensor fasciae latae
- Sartorius
Without the strength of these muscles, the femur is more likely to adduct, increasing the knock knee appearance.
Quadriceps: … Reversible
- Rectus femoris
- Vastus medialis, lateralis & intermedius
Asymmetry in the strength of this muscle group may result in misalignment of the knee joint, giving the appearance of knock knees. Generally it will be the inner most compartment of this muscle that is weak.
Hamstrings: … Reversible
- Biceps Femoris
- Semitendinosis
- Semimembranosis
Similar to the quadriceps, asymmetry in the strength of this muscle group i.e. inner most compartments (semitendinosis and semimembranosis) may lead to this appearance.
Poor control of:
Hip External rotators: … Reversible
Hip abductors: … Reversible
Lumbo/pelvic muscles: … Reversible
If these muscles are not controlled well because they have poor activation or endurance, they muscles will not be able to hold the knee joint in a correct alignment constantly. In other words, the muscles will get tired, and they will not be doing their job.
Stiffness in the:
Hip: … Reversible
Tight muscles in the hip region may limit the range of motion available. If the joint is not moving correctly, the required muscles will not be able to work to correctly align the knee joint.
Ankle Overpronation and Injuries video
Have you wondered why overpronation (rolling inward) of your ankles can cause injuries? Click on the video to find out more.
