Jumper's knee, discussion and summary of the causes...

Time for a sports subject again… This post is about pain in the patella tendon, usually known as Jumper’s knee, but the correct medical term is actually Patella tendinitis.

Some background information;

Jumper’s knee is an overuse injury that is common in the sport of volleyball, but also in basketball.

The etiology (reason) for the injury is still not completely analyzed/researched or understood enough, so the reason is not yet known. Earlier studies have shown risk factors like jump height, mobility, age, gender, a high load of game exposure and a lot of jumping.

During last year I did a literature review in a sports medicine course, the purpose of that study was to present the latest evidence within biomechanical risk factors for the development of jumper’s knee. I thought I would try to share the result.

So, what are biomechanical risk factors?

Biomechanics is the science of such a simple thing as how two joint surfaces moving in relation to each other, but it’s also as complex as how the body is used as a whole, and the forces it’s subjected to. Biomechanical risk factors would then be movements in the joints that can cause damage.

Knowledge I want to share with you;

I looked into new research in the subject of jump and landing technique with advanced analysis and descriptions of the forces on the joints and tendons, angles of the feet, knees, hips and back. It was really interesting to read, though it took some time to get into the subject. It’s not so easy to analyze research, as the result is so dependent on the method; is it reliable and are the statistical methods right? When reading research you HAVE TO understand this type of analysis, as there are so much research with interesting and amazing results, but unfortunately they’re not reliable.

In a lot of studies I found that many used analysis of a two legged landing after a jump down from an elevated position. A lot of people would think; yes, why not? It’s the landing they’re interested in analyzing. OK, yes, but the force and the landing technique is totally different depending on how the jump is done, and very seldom athletes land with the force directed strictly downward after a jump as the jump normally isn't directed only straight up. This makes these studies unreliable as to the outcome and explanations for jumper’s knee, since the landing isn’t specific for the sport.

The athletes used for the research were mixed, but mostly volleyball and basketball players, athlete’s with previous history of jumper’s knee, athlete’s suffering from jumper’s knee at the time for the study, and usually a control group with no history of knee injuries.

I found some real interesting results, and not only of the landing, but also when it comes to the take off for a jump, and some other findings...

The result show;

• Range of motion in the ankle for dorsiflexion is very important
• Increased velocity of flexion of the hip and back in landing
• Increased velocity of loading for the quadriceps muscle in the deceleration phase in the countermovement motion preceding a jump
• The angle of the knee and ankle (lesser degree of plantarflexion) in initial ground-foot contact in the landing
• The flexibility of the Quadriceps, tighter muscle means greater risk
• The anatomical position of the feet in standing, neutral position meant smaller risk for jumper’s knee.

Conclusion; Several biomechanical factors in the landing technique and mobility of the joints and anatomical position of the feet affect the load on the patellar tendon and predispose jumper’s knee. 
So to avoid the problem, work against all of these risk factors. Work on jumping and landing technique with the youngsters, work on the mobility in the ankles and the muscles and so on. As usual; there are no shortcuts!

Video: see the movie here.

Landing with plantar flexed foot compared to lesser cushioning and lesser degree of flexion
Long vs short landing

Velocity of flexion of the hips and core in the landing

Countermovement phase in the stop-jump

Please have in mind that when the research was done, they used highly advanced technique to be able to follow the movements and measure exact angles, so it is difficult for the eye to see, but I did my best to try to show it on the video.

Pictures:

Range of motion (ROM) knee over foot

Normal ROM in the ankle; the knee is passed the foot

Stiff ROM in the ankle, the knee can't pass the foot

Foot position

Normal foot position

Foot position with sunken foot arches (inversion)

Research articles for the review

How to start training after a period of physical inactivity

As promised in my last post, I will try to give some general information about how to plan when changing your lifestyle into a more active or, or if you're planning to increase your level of physical activity significantly.

But keep in mind, that when talking to a Personal Trainer (PT) about your training plan, the PT really has to ask about your history when it comes to injuries, otherwise the exercises aren't adapt to your body, and you might even be training it into more problems. A serious PT always knows or makes sure to know what weaknesses or weak spots the client has.

I will divide my guidelines into two parts:
1. For people who haven't been physically active except for maybe walking a bit each day.
2. For people who's been a little active; for example walking, taking the bike to work every now and then, joining a game once a month, or doing some bodyweight training twice a month.

Nr 1...
... Haven't trained the last couple of years, and maybe wasn't that much of an athlete before that either. How does this person start over with physical activity?
The best way is to make sure you have 8-12 weeks of a transition phase. During this phase you train twice a week with the aim of getting your body used to loading, and really just strengthening the tissue. This means that even though you feel that the training is easy after 3 weeks, do not increase the weight of intensity, as the increase of strength you feel is merely the nervous system getting better at corresponding with the muscles and coordinating them. What you could do instead is to add another set. So for example if you start with 2x12/exercise (2 sets of 12 repetitions in each set per exercise), you do 3x12/exercise instead.

What exercises should you do? Well, If you are totally new to this, most people start working out in machines, because they are safe. But if you have a good PT, it would be better for your body to work with functional movements instead.
When you're only training two times a week, you can do whole body exercises, or just use machines for the different parts of the body both times, but maybe change the exercise even though it's still the same body part (if you train more than twice a week, it's better to split the program so the different muscles get enough recovery time).
After 8-12 weeks, that is when you start to increase the load and go for 3x10/exercise. You can also add another day of training per week, progressively up to 4 times/week during a period of 8 weeks.

Nr 2...
... Has done a little bit of training every now and then, probably because of the bad conscience telling this person to do at least something... ;) Which means that once a month or so, this person does something other than walking or biking; for example goes out for a run, or does some bodyweight exercises.
The main difference compared to the example above is that this person can add some aerobic training in the beginning. Although the strength part is still only twice a week with the same plan as above, but add some easy aerobic training as well, for example using the rower, bike, crosstrainer, treadmill and so on, and maybe even switching between these conditioning machines every 5-10 min once a week.

About what weights to start with; make sure that you at the end of the set feel tired in the muscles, but are still able to do at least 5 more repetitions. That's a good weight to start with.

It's very difficult to give specific advice (obviously) when the information isn't to a specific client. Which means the information above is very general, but hopefully it'll give you some idea about how soft the start really needs to be.

However, if you want to start running, then that's a completely different matter, and needs a completely different approach. I will leave that topic for another post in the future.

Stay well!
Sunny regards from Doha!
Shirin
With special guest appearance from Sophia Bassemir (physiotherapist), Stuttgart, Germany

Training with a Personal Trainer? What do you know about his/her knowledge?

As a physical therapist, I am very pleased that most people in the west (and foremost in Sweden) are taking their training seriously, changing their lifestyle, and spend more time on physical activity to improve their health status. However, we should not forget that there are still very many people who with low physical activity level, but that is not the topic for this post. It was training, and in particular exercise with PT (Personal Trainer).

The background to the topic of this post is that a friend after a long period wanted to get started with exercise. He therefore bought a gym membership, and made an appointment with a PT for help to reach his goals. A few days after the meeting with the PT, my friend wanted to discuss how the meeting went and what information he had received. My reaction was; that will never work, you'll just end up with a lot of injuries!
Maybe not the most humble reaction, but the fact remains; going from no physical activity in the form of regular exercise over a period of about 2 years, to train 5 times / week of which 3 workouts are full body exercises and 2 workouts consist of interval training is far from a realistic and manageable start.
This is partly due to the purely physiological side; the body will eventually break due to the high amount of load and lack of recovery. Instead of enjoying regular exercise; you'd spend the time on rehab instead. But there is also a psychological angle to this; behavior change is difficult enough without the extreme load of this start.

So what do I as a physiotherapist have to say about this. There are actually several things I would like to discuss concerning this topic. Let's start from the beginning ...
Who is the typical person to seek help from a PT? In my experience, it's usually people that during a certain period in their lives haven't had time or for other reasons, couldn't maintain a physically active lifestyle - often for several years. This may be due to an emphasis on career, having small children, and so on. Therefore, I conclude that PT costumers probably consist mostly of 30-40 year olds, who want to get their body fit again. And the goals are often set quite high; a person who's barely done more than a few push-ups before want to be able to do pull-ups and chins (both men and women), or run half and full marathons. The goals are sometimes disproportionate to the person's training history.

What is normally the status of people with low physical activity level?
I'll generalize a bit for simplicity, but we can surely agree that it usually means;

• some measure of overweight,
• weakness in muscles, tendons, ligaments, etc,
• imbalance of muscle groups,
• reduced stability of the trunk and joints (weakness of the stabilizing muscles),
• reduced coordination,
• and stiffness in muscles and joints.

How should the start of a more physically active life look like? This is the first challenge. Everybody want results right away, but obviously our bodies don't work that way. If we go ahead and try that, there's no way to avoid overload injuries. A slow start which means habituation of the body, building strength, durability, stability and mobility is the correct way.

Certainly, the PT feels pressure to deliver results, but sometimes I ask my self the question; does the PT have the knowledge to be able to lead the customer on the right path? Including explaining the training plan and what to expect.
I was pleasantly surprised when I saw people working out with PT:s on Muscle Beach in Los Angeles. The PT where really working with their clients in responsible way; focusing on mobility and stability, taking care of the client, teaching them how to use their body and coordinating it.
No customer should be satisfied with training that leads to injury; although I sometimes find that people generally take getting injuries for granted because they train hard, and are even a little proud of these - because then it means they're training hard. Crazy!

There are many very talented PT's and fitness coaches, but you have to find them. Have you checked what background the PT has? What education he/she has? How many years of experience?
In Sweden, for instance, it wasn't until the end of 2012 that discussions about who's qualified to call them selfes a personal trainer. Before that anyone could, but now there are some rules about the education level a PT has to have. But still there are different education levels on the course, some are just 11-12 days, and some are more serious and are even college level educations. Make sure you know what you are paying for!

Obviously, experience, years in the industry and further education play an important role in choosing a personal trainer. But my advice to you as a paying costumer is asking about the personal trainer's education, experience, and always put the well being of your body first. If the plan sounds too good to be true, then it probably is...

YOU are responsible for your body, no one else. And you want your body to be healthy for many wonderful training years to come!

Listen to your body, and good luck!

PS. In a couple of days I will post a short text on how the start of training could look like... 

Just given childbirth? Exercises for new moms!

A close friend had her first child recently, and took the opportunity to ask if I could advise her on exercises she could start with. The midwife had told her that she could start training lightly, but my friend felt a little unsure of what exercises that could fit in the beginning. So, I chose this topic for my next post ...

The information from midwives is that postpartum women should take it easy and let their body heal first few weeks when it comes to exercise, but start pelvic floor exercises as soon as possible after birth, and taking walks from the second week. To do abdominal exercises like sit-ups should be avoided for a few weeks, both because of diastase between the large abdominal muscle Rectus Abdominis two parts (separated abdominal muscles; Diastasis recti), and to avoid increased abdominal pressure in a situation where they are still struggling to get the strength of the pelvic floor back. With caesarean section it's even more important to avoid sit-ups as it takes 6-8 weeks for the tissue to heal properly.

If you are suffering from Diastasis recti, you should hold off on all the exercises for the trunk until you get the green light from a midwife or physiotherapist about the exercises you are allowed to do, in order to avoid aggravating the healing of connective tissue.

Whether your child is born vaginally or by cesarean section, the starting exercises I would give a new mother are the same. However, a woman who underwent cesarean should wait a few weeks longer with certain exercises, as it can stress the wound, but you have to be aware that various exercises could tug at the wound for up to 10-12 weeks in varying degrees. It will be my general advice that you can start with the first supine exercises 2-3 weeks after birth. Use the time before to focus on training the pelvic floor, as it is important to get good function, and you do not want to miss the recovery window in the beginning. Later you can take the opportunity to combine training the pelvic floor and core, as this provides a more efficient muscle training in these muscles.

The exercises I have chosen are effective for trunk stability and posture, without stressing the body with sit-ups. Midwives provide information that you can start with crunches (which is like a little mini sit-up) as soon as it feels good. It's really the only exercise I did not film, as I feel I want to be careful to prescribe that exercise in general to all.
Obviously, one can develop these exercises and program endlessly, but 8-12 weeks postpartum, you should normally gradually get back to your regular workout, if you feel restored.

(Incase the video doesn't work, click here.)

When you exercise, it is important that you listen to your body and stick to what feels good!

Good luck, and congratulations to the parenthood
Shirin Zarur, physiotherapist

Muscle pain and imbalance in the shoulder

I got inspired to write this post after seeing an old friend a couple of days ago. He has a shoulder problem and it started some time ago, got better but came back. (For us physiotherapists this is a very common scenario.) He noticed that trigger point treatment of some of the rotator cuff muscles (joint stabilizing muscles in the shoulder) helped. However, when the pain came back – it was worse, now with more muscles involved and he had trouble lifting his arm as a result. This could very well be the symptom of a lot of different diagnosis.

So, what to do?

As I've explained before in the previous post, this could be a typical history of pain due to imbalance around the shoulder joint, and the shoulder joint is very dependent on the shoulder blade and it's function, as well as eventual shortness and/or stiffness of the pectoral muscles.

Now, if I treat the symptom of trigger points in one or two muscles, I still haven’t addressed the underlying problem and the pain will keep coming back. The incorrect movement pattern is still there, ruining the balance. 

Altered pressure, joint force and muscle work around the shoulder can give many secondary symptoms; various inflammations and irritations in rotator cuff tendons, bursitis, impingements, small partial ruptures etc. 

If the pain is due to imbalance, then a massage, acupuncture, trigger point treatments etc. can ease the symptom of pain, but you also need to work on your body (in this example the shoulder joint) and get it in balance again to get to the root of the problem.

Imbalance and altered movement patterns

The subject of imbalance and altered movement programs that affect the muscular chain is a fairly complicated subject, it took me at least six years working as a physiotherapist to fully comprehend it. I might try to take it on and explain this concept in a deeper manner later in another post. But this post is really just an introduction for the next post about shoulder pain, and maybe other posts there after, who knows… :)

Normally, muscle pain is a symptom, not a diagnosis of a primary injury or problem if it isn’t for example an acute rupture. Why? 
We are born with certain movement patterns that develop during the childhood years. These movement patterns control the way we move and keep our body in good balance. Balance between flexors and extensors, between small stabilizing muscles and bigger power- or force muscles, and keeping our posture in balance.

BUT, our daily lives with monotonous movements, sitting, standing still and so on, ruins our physical balance… We overwork some parts, and become weak in other; our joints are used biomechanically wrong, putting strain on ligaments, cartilage, discs and so on. Our movement patterns are changed and the muscles keep working in the wrong way as they’ve now become programmed to do as a part of a new movement pattern.

Overuse muscle pain can be primary if for instants I clean 20 windows in one day, but the acute overuse pain will be in the shoulder muscles overall, and will subside entirely in a few days. If you haven’t triggered the pain in such a manner, then the pain is more due to the imbalances.

I hope you're a little bit wiser on the differences between the pain that sneaks up on you and over time due to imbalance, and acute overuse pain.

Regards,
Shirin

How do I know if an injury is serious or not?

It's very rare to have a doctor or other health professionals to ask when you are out exercising, running, working out in a group and so on. How are we to know whether one has become injured enough to step off and put compression on the injury? 

The moment you feel that something happened, trust your instinct! Often one feels that something in the body is not as it should; you know that something’s happened in your body; and you should trust that feeling. Because it is usually an injury you need to take care of ... Sometimes you can even feel that something snapped, or hear it inside your body. This is not a good sign and you should definitely take care of that body part as instructed earlier in Acute Injuries.

Often we are so pumped up with endorphins when we’re working out, that we don’t feel the pain, and therefore you can’t trust that symptom. Many have unfortunately the tendency to pause a moment and try the injured area out and find that it's not so bad, it barely hurts, and decide to keep training ... But this is the worst thing you can do for the healing process of the injury; as the bleeding increases, and unfortunately the healing and recovery time will increase because of this. 

In other words ... Trust your instincts! 

I would appreciate any comments on the texts I've posted so far, good or bad, and suggestions for improvement, etc. And why not questions or ideas for new topics. What would you like to read about?

Good Luck!
Shirin Zarur