Archive for April 1st, 2008

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I just want to show you here a very nice and relaxing way to stretch the iliotibial band. It is a little more effective than some of the standing, weight-bearing positions that you often see. Although it does require that the person think ahead and not think that they are going to do it right before the hop on the track or head out in the neighborhood. Another good way to stretch hamstrings is just to lie up against a wall. We encourage people to maintain these positions for 15-30 seconds and practice some relaxation breathing. You can do the hamstring stretch bilaterally as well as unilaterally. Much better than having an assisted hamstring stretch.

What I want to show you here is really the rationale for why therapists choose to do the kind of knee exercises that they do. Here we are talking about open and closed kinetic chain. The leg press, which is the dark line here, is a closed kinetic chain. As you can see, what happens with patellofemoral joint compression, as you move from extension to more flexion – here, almost 90 degrees – you get a steady increase in patellar compressive forces. On the other hand, if you are talking about seated leg extension, which is an open kinetic chain exercise, what happens there is just the opposite and as you move from complete extension to flexion you actually get a decrease in patellar compressive forces. They meet here in the middle, somewhere between 40-50 degrees. So when we are choosing knee strengthening exercises for someone who is experiencing pain on up and down stairs, or up and down grades or in squatting and knee bending, the guidelines for clinical choices are to try to decrease pain that comes from patellar compression and to try to strengthen the quadriceps so it is not inhibited by pain. Some of the things that we do in that case are functional strengthening. You see we call it a wall-slide or a squat. In this case the person would do it only to about 45 degrees and many people will tell you that if they try to go lower than that, that’s when they start to have knee pain. So we try to strengthen functionally in this position. Once they are doing well with that we might go to one-legged activity, put them on a Bapp’s board. But still you don’t want to go past – as long as they are in pain – you don’t want to go past that point of knee flexion pain. Another example here. Bob and I keep trying to turn her the other way, however this really is correct. This is closed kinetic chain on a leg press and once again, you would try to encourage her not to do deep knee-bending but to stay at the other end of the range. We will follow her monthly for a period of months, trying to monitor her to make sure that she is making progress and check back in with us.
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Probably what we are seeing here, and what our bottom line would be is that people with fairly good lower extremities very often start to have a problem when the increase in activity or demand outstrips the conditioning of the neuromusculature and they need time to back off a little bit and get in condition and get in shape for what they are doing.

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We also need to do the activity modification to give her time to get better and stronger. We are suggesting that she modify her training until her symptoms actually resolve. To move to three times a week, only one long run a week, and to be sure to include a pre-run stretch. We also are talking about five minutes of a walking warm-up for a musculoskeletal warm-up in her active muscles and also to choose run/walk intervals so that she doesn’t get into the pain cycle. We are also suggesting to her, anecdotally I might add, that she look for places that she can run and consider alternating right and left sides on the pitched running surface. People often do this as a way to use the surface to actually supinate the foot for most of the gait cycle. And people tell you that it’s effective for them. Also we will try to educate her so that she can develop some good self-management skills to replace her competitive athletic collegiate mind set of “no pain, no gain.” We are going to do quad strengthening with this person and we know that quadriceps strengthening in patellofemoral pain is quite effective. They pretty much consistently show improvements in pain and function. Anything that interferes with complete extension of the knee does diminish the effectiveness of knee-strengthening exercises so things like an extensor lag, patellar shift, knee flexion contracture, or even very slight knee effusion definitely will get in the way of your efforts to strengthen the quadriceps. We are not exactly sure why strengthening the quadriceps works so consistently when so many people have different reasons for pain. Some of the speculations are that may actually alter the location of the patellar contact. You may actually redistribute the pressure of the patella, or that you are actually producing improved proprioception and neuromuscular control of knee activities.
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The exercise program we are suggesting for her is: daily and pre-run stretches for the tight muscles, and three times a week strength training for her quadriceps, hamstrings and hip abductors – which we also found to be weak. It will be important for this person who is training for a fairly rigorous event that we help her develop a training regimen that will stimulate the quadriceps and the hamstrings to over 70% of their maximal voluntary contraction and keep up with her improvement. We need to get to that level of a stimulus before we know that we are recruiting fibers and we will get a new training adaptation then. So quad sets, isometrics are probably not going to be adequate for what this person needs. We will try to instruct her in a home or gym program and provide monthly follow-up.

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