In this installment of our “injury of the week” series we’re going to be talking about posterior tib strains. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system so that you’ll have a “sample treatment session”.

What is the posterior tibialis and where is it?

The posterior tib is one of those muscles that mistakenly gets lumped into the “calf”. Yes, it’s located in that area, but the problem with that belief is that the posterior tib doesn’t function like the overlying gastroc and soleus muscles.

Above we have the superficial calf muscles. You’ve got your gastroc and soleus which move down the leg to join together and form the achilles tendon. They have one function- to flex the ankle. The difference between these two is that the soleus does so while the knee is bent and the gastroc does so while the knee is straight.

The posterior tib on the other hand runs from the outer part of the lower leg down to the inside of the ankle. This means that not only does it flex the foot (like the gastroc and soleus), it also inverts it (points the foot in).

So how did I hurt it?

When it comes to the posterior tibialis the thing to remember is that this muscle is a stabilizer muscle. It helps the ankle and foot keep you upright when you hit uneven/loose terrain and it works as a pair with the peroneal muscles (which run down the outside of the calf).

The peroneals pull the foot out and the post tib pulls the foot in. Together they help to keep the foot level so that the ankle can move through it’s full range of motion and the big muscles of the calf and upper leg can propel you forward off of your big toe. This is important! If there is a limitation in the ankle (either the joint itself is tight or your calves are tight or your big toe doesn’t extend all of the way), this mechanism will not work. The only way to keep yourself moving forward is to rotate the foot in or out. The same goes for the other end of the leg chain- the hip. If you can’t extend your hip all of the way and push off using the glutes, you end up with a short stride that doesn’t give the ankle enough time to move through it’s motion. The body will compensate by rotating that leg so that you don’t fall over your own two feet. If your motion seems fine in the ankle and hip and you’re still getting this- time to look at your shoes. Too much/too little support can have the same effect!

In this picture you can see how the foot twists out and effectively twists the whole leg. When this happens the posterior tib gets loaded with every step and trying to shock absorb and then push off instead of the gastroc/soleus. The post tib is a skinny muscle compared to those two and it isn’t designed to handle that. Over time it will break down.

In this picture you can see how the foot twists in. Again, the whole leg twists to compensate for this. Here the posterior tibialis takes on the increased work load of shock absorbing and then trying to push off. Over time it can break down and get injured.

So what’s the take away from all of that? This is one of those injuries where you have two things to fix: 1) the injured muscle, and 2) the mechanism that caused it (tight ankle, tight calf, big toe, or tight hip). If you only fix the muscle, this will haunt you for a long, long time. Take the time to get to the root of the problem.

The inside of my calf hurts? NOW WHAT?

The first step is determining if it is truly a posterior tib injury or something else. Remember, the goal of this series is not to keep you away from your doctor so that you can self treat everything. It’s to teach you how to catch the early symptoms and take care of them before it becomes a full blown injury. That being said, post tib injuries can start as a gradual ache/pain during workouts or even after. It can also be one of those injuries where nothing is wrong until you sit down and stiffen up. Then all of the sudden- ouch!

Typical symptoms with post tib injuries include pain or tightness on the inside of the calf  in the middle of the shin bone (tibia). They can move all the way down the inside of the calf to the ankle, as well as, into the bottom of the foot. Symptoms are typically worse with activity and better with rest, and swelling can occur at the lower tendon (where it wraps around under the arch of the foot) if the inflammation is severe enough.

Here are some guidelines for when seeing a doc should be your top priority: 1) If you see any bruising and/or swelling, and 2) numbness/tingling along the outside of the leg (knee to foot). An injury to the post tib is a symptom of a bigger problem. Think of it like a link in the chain. Something stopped working and that chain got snapped due to the increased strain on it.

Be smart. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait months and even years before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:

• Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Post tib injuries respond well to hands on/massage work. If this is something that’s been around for a while, exercise alone won’t cut it as the whole leg has learned to compensate and multiple muscle groups will require attention.
• Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Not really. Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.

How to treat it.

 **download PDF with links, sets, reps, progressions, etc here**

( Click here for a walk through of how to use our PDF pages! )

Step 1- Traditional R.I.C.E. treatment:

When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage.

Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.

Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.

Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them or calf sleeves). In the case of a post tib injury, full compression socks (versus the calf sleeve where the foot is free) are best.

Step 2- Kinesiology taping:

By now you’ve probably seen athletes covered in all kinds of colored tape. Some of you have probably even tried it out. Make sure to read the application instructions first! This stuff should last 3+ days, not fall off in an hour. That means you need to prep the skin so that it is hair free and clean.

1) Posterior tib application. Click here.

2) Foot application. Click here. Why the foot? It’s common to have pain down on the foot at the tendon with a post tib injury. This application also helps to support the mid-arch of the foot and evenly distribute the weight. Apply this application first, and then the one above!

Step 3 – Getting mobility back

The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a post tib injury isn’t about no pain, no gain. Don’t overdo it in an attempt to speed up your recovery.

1) R.I.C.E. + gentle stretching. There should be no pain with stretching.

2) Begin using the foam roller to work around the injury first. The goal here is to start getting slack into the post tib without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll the muscles around the area of pain -> stretch -> RICE. (** Remember- with post tib injuries you need to fix two things: 1) the muscle injury itself and 2) the muscles/restrictions that led to the injury. Fix just one and the other will be back to stir up problems again.)

3) Begin using the foam roller over the painful area to tolerance. The order should be foam roll the muscle around the injury-> over the injury -> stretch -> RICE.

4) As the tendon/muscle heals, we can really start to go after the muscles using the deeper cross friction and trigger point techniques.

5) Lastly, to really loosen up the post tib, we’re going to add muscle mobilizations as well as joint mobilizations at the hip and down at the ankle. The order should be foam roll around the injury -> over the injury -> cross friction/trigger point -> mobilizations -> stretch -> RICE.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

Step 4- Strengthening

We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.

What you’ll need: 1) resistance band/tubing. This is easy to find in any sporting good store these days. You can probably even get it in walmart or target.

Optional equipment: a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20.

Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.

Level One

Level Two

Level Three

To help put it all together, I’ve also created a PDF you can download to walk you through what a “treatment session” would look like. In it you will find everything you need including links to the videos and posts. Click here.

Hope that helps, and fire away with any questions in the comments.

 

References

1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.

5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.

6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.

 

 

While I’m working on the next injury post, I wanted to take some time to stop and really explain the PDF/treatment plans that you are finding in our “injury of the week” posts. With five different parts to the treatment plan and varying “levels” in terms of exercise, I admit, it can get a little confusing. Hang in there!  As I’m going to show you in this post, everything you need is right there in the PDF. I’m also going to answer the most popular question I get asked- x hurts, but….can I still train?

By now most of you have seen our standard PDF sheets. It has everything you need right on there. The blog posts walk you through everything in further detail, but this is designed to be your go to resource. So what should you be doing with this sheet?

STEP ONE:

Start with the first box!

This box is important to make sure you’re even looking at the right thing. Most of the injuries we are dealing with on the ATA site are in areas where there can be a few different things going on. That’s why we’ve included a picture to help you see where it would actually hurt. For example, in the sheet above- that blue tape is where your piriformis muscle actually is.

We then go on to describe the symptoms you would feel, as well as, some other possible things it might be. The most important part of this box, however, is the need to see a doctorsection. As I’ve said all along, this site is not designed to keep you from your doctor. It’s to help educate you on when the doctor in question can help you or if you’re better off seeing a different specialist.

** If you’re looking at this sheet and you have some of the symptoms listed in the see a doctor section…….please take it seriously. I’m pretty lenient when it comes to stopping training (as my patients and athletes will tell you), so if I’m saying that certain symptoms are a red flag, it’s for a reason. These symptoms are at a minimum a sign of something bigger going on than a muscle injury. Ignoring the red flags and pushing through will delay you’re recovery and potentially sideline you for a lot longer than you’d like.

STEP TWO:

The next box is your map through the column of treatments on the right. Along the top you will see the five different self treatments available on the ATA site. The chart itself moves left to right based on what your symptoms are. So for example, in the sample chart above, you’re still having discomfort walking. That puts you firmly in the top row. Following the chart you will start with self massage and moving right across the chart, do everything marked with a yes. As your symptoms improve you will move down the chart. This will change the focus from increasing mobility to restoring strength and muscle balance.

STEP THREE:

On the right hand side of the page are the individual treatment sections. In each box you will find the directions as well as the links you will need. Keep in mind, there is a learning curve to these treatments. Each of those links will take you to a post that will have pictures/videos and full instructions. Take the time to read them. Once you learn the spots you should be looking for etc, the treatments get easier, but you’ll need to learn them first.

STEP FOUR:

So what isn’t on this page that you want to know? Typically the first question I get asked when people are looking at these treatment sheets is how often should I be doing this stuff? Let’s break it down a little first.

In a typical treatment session, I have you do your mobility work first. Mobility trumps all, however, in the case of an acute injury, it’s going to be limited by any pain/discomfort you get. That’s why we use progressions like around the injury first, then over the injury. You only go as far as you can until there’s pain. Then you stop. Depending on your injury and how far you get this might mean all of the foam roller work and tennis ball mobilizations or it might mean just easy foam rolling work. Let the injury decide, not you. The next step after the mobility work is stretching. We want to build on what you just loosened up by stretching it out.

Once the self massage, mobilizations and stretching are done, I add the kinesiology tape. This is to help support the area and maintain the gains that you are making with the mobility work. After the tape, it’s time to do the strength exercises. Again the exercises are arranged in levels. The first level does not actually impact the injury. As you progress through the levels you challenge the injured area itself. Use the protocol chart on the bottom left of the PDF page to see what level you should be on based on your symptoms.

So I still haven’t actually answered the question about how often you should be doing this have I?

• Mobility work (self massage and mobilizations) = every day. If you can swing it, shoot for twice a day. Use common sense here though. If the area is tender or sore during that second session, skip it until the next day. Whenever you get the chance, ice after 10 minutes (once the pains 100% gone, you can stop icing).
• Stretching = as often as possible. Even if you only get in one 20 second rep of each stretch, that’s fine. Keep it pain free, and stay after it. Ideally we’re looking for 3-5x/day with the stretches. Stay pain free!
• Strengthening = once a day for levels 1 and 2. As you get into level 3, you can start backing this off to 3x/week.

The next question I get asked is “what about my training?”. More often than not, the first question I get is not- what do I do to get this better? It’s what can I do while I get this better? To answer this question, I put together a chart that will help you grade the severity of your injury based on your symptoms, make appropriate training modifications, and determine what course of action is best in terms of medical treatment. Think of it like a giant thermometer. The higher up you move on the chart, the more important action is and the more likely your training and racing will take a hit.

***I can’t stress this enough- use common sense when using this chart. This is not all encompassing and it is not designed to keep you from your healthcare team. If you are experiencing symptoms like numbness/tingling, swelling, scary dark/purple bruising,inability to stand/weight bear, lift your arm over your head, etc please call your Doctor.***

Hope that clears up some of the common questions in using the site and our injury of the week posts!

While I’m working on the next injury post, I wanted to take some time to stop and really explain the PDF/treatment plans that you are finding in our “injury of the week” posts. With five different parts to the treatment plan and varying “levels” in terms of exercise, I admit, it can get a little confusing. Hang in there!  As I’m going to show you in this post, everything you need is right there in the PDF. I’m also going to answer the most popular question I get asked- x hurts, but….can I still train?

By now most of you have seen our standard PDF sheets. It has everything you need right on there. The blog posts walk you through everything in further detail, but this is designed to be your go to resource. So what should you be doing with this sheet?

STEP ONE:

Start with the first box!

This box is important to make sure you’re even looking at the right thing. Most of the injuries we are dealing with on the ATA site are in areas where there can be a few different things going on. That’s why we’ve included a picture to help you see where it would actually hurt. For example, in the sheet above- that blue tape is where your piriformis muscle actually is.

We then go on to describe the symptoms you would feel, as well as, some other possible things it might be. The most important part of this box, however, is the need to see a doctor section. As I’ve said all along, this site is not designed to keep you from your doctor. It’s to help educate you on when the doctor in question can help you or if you’re better off seeing a different specialist.

** If you’re looking at this sheet and you have some of the symptoms listed in the see a doctor section…….please take it seriously. I’m pretty lenient when it comes to stopping training (as my patients and athletes will tell you), so if I’m saying that certain symptoms are a red flag, it’s for a reason. These symptoms are at a minimum a sign of something bigger going on than a muscle injury. Ignoring the red flags and pushing through will delay you’re recovery and potentially sideline you for a lot longer than you’d like.

STEP TWO:

The next box is your map through the column of treatments on the right. Along the top you will see the five different self treatments available on the ATA site. The chart itself moves left to right based on what your symptoms are. So for example, in the sample chart above, you’re still having discomfort walking. That puts you firmly in the top row. Following the chart you will start with self massage and moving right across the chart, do everything marked with a yes. As your symptoms improve you will move down the chart. This will change the focus from increasing mobility to restoring strength and muscle balance.

STEP THREE:

On the right hand side of the page are the individual treatment sections. In each box you will find the directions as well as the links you will need. Keep in mind, there is a learning curve to these treatments. Each of those links will take you to a post that will have pictures/videos and full instructions. Take the time to read them. Once you learn the spots you should be looking for etc, the treatments get easier, but you’ll need to learn them first.

STEP FOUR:

So what isn’t on this page that you want to know? Typically the first question I get asked when people are looking at these treatment sheets is how often should I be doing this stuff? Let’s break it down a little first.

In a typical treatment session, I have you do your mobility work first. Mobility trumps all, however, in the case of an acute injury, it’s going to be limited by any pain/discomfort you get. That’s why we use progressions like around the injury first, then over the injury. You only go as far as you can until there’s pain. Then you stop. Depending on your injury and how far you get this might mean all of the foam roller work and tennis ball mobilizations or it might mean just easy foam rolling work. Let the injury decide, not you. The next step after the mobility work is stretching. We want to build on what you just loosened up by stretching it out.

Once the self massage, mobilizations and stretching are done, I add the kinesiology tape. This is to help support the area and maintain the gains that you are making with the mobility work. After the tape, it’s time to do the strength exercises. Again the exercises are arranged in levels. The first level does not actually impact the injury. As you progress through the levels you challenge the injured area itself. Use the protocol chart on the bottom left of the PDF page to see what level you should be on based on your symptoms.

So I still haven’t actually answered the question about how often you should be doing this have I? 🙂

• Mobility work (self massage and mobilizations) = every day. If you can swing it, shoot for twice a day. Use common sense here though. If the area is tender or sore during that second session, skip it until the next day. Whenever you get the chance, ice after 10 minutes (once the pains 100% gone, you can stop icing).
• Stretching = as often as possible. Even if you only get in one 20 second rep of each stretch, that’s fine. Keep it pain free, and stay after it. Ideally we’re looking for 3-5x/day with the stretches. Stay pain free!
• Strengthening = once a day for levels 1 and 2. As you get into level 3, you can start backing this off to 3x/week.

The next question I get asked is “what about my training?”. More often than not, the first question I get is not- what do I do to get this better? It’s what can I do while I get this better? To answer this question, I put together a chart that will help you grade the severity of your injury based on your symptoms, make appropriate training modifications, and determine what course of action is best in terms of medical treatment. Think of it like a giant thermometer. The higher up you move on the chart, the more important action is and the more likely your training and racing will take a hit.

***I can’t stress this enough- use common sense when using this chart. This is not all encompassing and it is not designed to keep you from your healthcare team. If you are experiencing symptoms like numbness/tingling, swelling, scary dark/purple bruising,inability to stand/weight bear, lift your arm over your head, etc please call your Doctor.***

Hope that clears up some of the common questions in using the site and our injury of the week posts!

In this weeks installment of our “injury of the week” series we’re going to be talking about quad strains. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system.

The front of my thigh (quad) hurts. Why?

If you’re involved in sports, this one is bound to get you sooner or later. The worst part? It’s typically a sign of the quad getting cooked by trying to compensate for something else. The good news, however, is that if you take the time to fix the injured muscle and correct whats going on in the rest of the chain, you can keep this one away for a long time.

So what are some ways that it can happen?

• In normal propulsion (walking, running, etc), the leg works by absorbing the shock of weight-bearing and then continues to carry us forward all the way to push off. This requires all of the muscle groups in the leg to work together. The quads carry us from that first touch of the foot all the way to full weight bearing. From there, hamstrings and glutes take over to push us forward through the hip.
• The above sounds easy right? I think most of assume that we do that with every step we take. The reality is that most of us don’t. Our muscles stiffen up from the work load and slowly we start to lose that ability to fully extend our hip and push off properly. The same goes for the cycling. The glutes are a big part of the pedal stroke and give the quads time to relax and regroup before it’s their turn again.
• If you never get to the glutes biking, running, swimming, etc then quads never get to relax 100%. They’re always on essentially.
• “Always on” = injury at some point.

Whenever I see a quad injury in the clinic I like to look at a few things:

• What’s their range of motion (ROM) look like. Does the hip move all the way? The foot/ankle? Can they straighten their knee all the way? If there are restrictions (and with quad strains there ALWAYS are)… is it muscular or is the joint locked up.
• What does their strength look like. Are they strong through the core meaning that the pelvis is level during activity or does it fall forward pinching the top of the quad and hip flexors? Do they have the strength to get to and fully fire the glutes or do they get stuck along the way?
• Is it equipment related. Are they in the right shoes for their foot or are they listening to running buddies and ads about the latest minimal shoe/racing flat. Same goes for cycling shoes and bike set up. Is it a setup that is honest about your flexibility/strength/fitness or is it strictly looking at maximum speed. Equipment choices always have a way of catching up to you and everything starts from the ground up. How your foot handles that first impact largely determines how the rest of the leg will handle it. If you’re ankle is blocked or your arch caves in, the knee will have to compensate (either by moving in/out or not straightening all the way). Whatever it does, by the time you get to the hip that stride/pedal stroke is going to look very different than it should.
• What’s their work setup like. Is this someone stuck at a desk or in a car commuting for 8+ hours a day? If yes, what’s their at home maintenance/mobility plan look like to counteract it?

As you can see, there are lots of things to consider with quad strains and even the knee in general. This is an area of the body that is literally stuck in the middle of the “leg chain”. If this is the part that breaks down, you better be looking at the other two ends of the chain! (***note: this is referring to gradual onset/overuse injuries, not acute trauma where you caught your foot in a pothole or fell or got tackled, etc etc. If you’re in that camp? hint hint- see your doc. )

note #2. If you’re symptoms are closer to the knee cap, be sure to check out our post on patellofemoral syndrome as well (PFS).

How to treat it.

**download PDF with links, sets, reps, progressions, etc here**

Step 1- Traditional R.I.C.E. treatment:

When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage when working to heal an injury!

Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.

Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.

Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them). You can also use a store brought ace wrap to accomplish this. Start the wrap below the injury using good tension on the bandage and move up above the injury. This will help keep swelling from moving down the leg.

Elevation: This is critical in the early days following acute injury where swelling may be present. In the case of an ankle injury for example, elevate the leg so that it is above chest level. This can be accomplished by laying down and propping for your foot up on the arm of the couch with pillows.

 

Step 2- Kinesiology taping:

For quad strains, we have some options in terms of tape applications. There are some that work up on the muscle itself and others that work on the knee cap. That being said, this is one of those injuries where you can absolutely use both. Tape the muscle and scoop up the knee cap with the U-strip and see how that feels. If you’re symptoms are up higher near the hip- add in the hipflexor and muscle application.

 

1) Quad strain application – Click here

2) U-Strip- Click here (you want the first video in this link! )

3) Hip flexor application. Click here.

Step 3- Getting mobility back:

The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a muscle sprain/strain isn’t about no pain, no gain. The muscle needs to heal! Don’t overdo it in an attempt to speed up your recovery.

1) R.I.C.E. + gentle stretching. There should be no pain with stretching. .

2) Begin using the foam roller AROUND the injured area. The goal here is to start getting slack into the muscle without aggravating the injury itself. No tennis ball work or mobilizations. The order should be foam roll around injury -> stretch -> RICE.

3) Begin using the foam roller over the injured area to tolerance. The order should be foam roll around injury-> over injury -> stretch -> RICE.

4) Begin using the tennis ball for mobilizations. The order should be foam roll around injury -> over injury -> active/joint mobilizations -> stretch -> RICE.

5) Begin using the tennis ball for cross friction + trigger point. These are the deepest of the soft tissue techniques so you want to save them for last to target specific adhesions and restrictions. Consider this your fine tuning step.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

Here’s what it looks like for a quad strain. Use the guidelines above.

Step 4: Strengthening

We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.

What you’ll need: 1) ankle weights or 2) resistance band/tubing. Both are easy to find in any sporting good store these days or walmart/target.

Optional equipment: 1) a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20. 2) Suspension trainer. I’m a big believer in these because it takes up zero space in my house and is an easy/inexpensive way to add a dynamic component to my strength training. Prices range anywhere from $30-200. Click here to see some of the options out there.

Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.

Level One

Level Two

Level Three

Hope that helps, and fire away with any questions in the comments section!

 

References

1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.

5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.

6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.

 

In this weeks installment of our “injury of the week” series we’re going to be talking about patellofemoral syndrome or PFS. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system.

What is PFS?? (aka Runners Knee)
This would refer to pain that is around the knee cap (usually on the inside just below it and on the outside just above it). In addition to pain, other symptoms include swelling, clicking, popping and creaking. PFS comes on gradually over time and is worse after rest (sitting for long periods of time and then standing up for example). During activity, symptoms typically start out as an ache/tightness and worsen as exercise continues. Another classic example is pain/creaking/clicking going up and down stairs.

Traditionally, there are two main types of PFS:

1) Symptoms due to abnormalities in the bone. This would include different shapes in the knee cap itself or the groove that it rests in on the femur (long thigh bone). Due to the differences in bony surfaces, inflammation and breakdown of the bone can occur.

2) Symptoms due to muscular restrictions and imbalances. This would include symptoms caused by tight muscles pulling the knee cap out of its normal groove. It also includes symptoms caused by tight muscles pulling the knee cap down tight over the bone so that it grinds or catches, causing inflammation and over time breakdown of the bone.

For this blog post, we’ll be focusing on PFS that is the result of muscular restrictions and imbalances. Proper diagnosis and detection of bony abnormalities is best left to evaluation by your health care team. That being said, if you are experiencing knee pain in conjunction with buckling, locking and painful clicking, it is strongly recommended that you schedule an appointment with your orthopedic for a full workup.

Why does Runners Knee occur??

During normal walking and running, your leg must accept the weight of your body during initial contact with the ground. This impact is absorbed and then transmitted up the leg as you move your body weight fully onto the leg (also known as mid-stance). This momentum is then used to propel the body forward during heel and toe off so that your other leg (which has been swinging forward) can repeat the process all over again as it comes into contact with the ground.

Sound confusing?? Here’s a different way to look at it and the muscles that are involved:

Phase 1) Shock absorption as the foot lands and the leg then straightens to support the full weight of the body = Quads

Phase 2) Moving the body forward over the weight bearing leg = Hamstrings + Glutes

Phase 3) Final push-off = Calf + Big Toe

If there are any hitches or restrictions in the muscles that provide this sequence, other muscles must compensate to maintain forward motion. Essentially, this is what causes “runners knee”. If forward propulsion is interrupted or shortened either at the ankle or knee, the result is a shortened stride that uses the hamstrings and adductors to pull through (instead of the larger glute muscles that are supposed to do the job) and the quads for everything else. With this increased load on the quads (now they have to shock absorb and push off), it is very common for the increased strain on the muscle to affect the knee cap, causing pain and irritation as it gets pulled from it’s normal bony groove.

Here’s a visual of what I mean:

The picture above represents the final phase of push off. The hip is fully extended, the knee is straight, the ankle is pointing down and the big toe is extended. From this point, the ankle fully points down as the calf engages, the knee bends, and the leg can begin it’s swing (typically the force of push off causes the knee to bend enough that the heel comes up towards your butt….this is a major difference between elite level and beginning runners).

To get into this position requires three things:

1) The mobility to straighten your knee all the way. That means flexible hamstrings and inner adductors.

This is what normal knee extension looks like. If you can’t get there, you can’t fully contract your quad muscles, which means they don’t ever fully relax. No relaxing means increased load on the tendon and muscles above it. Remember our saying: if you can’t move it, you can’t use it. This is key if you are plagued by knee pain.

2) Good mobility in your ankle and hip. Unfortunately the knee is stuck in the middle and it can get pretty beat up through no fault of it’s own. This means that you need to be able to extend your hip all the way.

It also means that you can fully dorsiflex your ankle.

Lastly, it means that you’re big toe moves all the way. To truly get the most power from push off, full toe extension is required. If unable to bend your big toe back all of the way, heel off will be limited and the stride shortened. This is often the case with arthritis and bunions.

So what do you really need to take away from all of that??

PFS (the functional kind versus the mechanical kind!) is an injury that happens because of 1) mobility restrictions and 2) strength. You need to fix both components to get rid of it and keep it away for good.

Differential Diagnosis (How do I know if it’s PFS or something else entirely???)

One of the main reasons that PFS (especially when the cause is muscular versus bony) is challenging to treat is because there are multiple things pain around the knee cap might be (these are also known as differential diagnoses).

This picture is where typical PFS symptoms are. Inside the knee cap and outside/above it.

To help differentiate, here are some other possible things that could be going on with your knee.

#1 Quadriceps Tendonitis- This refers to the area directly above the knee cap where the quad muscles become tendon at the top of the knee cap. Very common for this area to get injured due to acute trauma and also due to repetitive overuse. With this injury, pain is directly on the tendon and the tendon itself may be tender or swollen.

#2 Patellar Tendonitis- As the common quad tendon crosses the knee joint, the knee cap actually sits inside of it. The tendon that then connects the knee cap to the lower leg bone (the tibia) is called the patellar tendon. Like the quad tendon, it is a very common area to get injured due to acute trauma and also due to repetitive overuse. With this injury the pain is directly on the tendon and the tendon itself may be tender or swollen.

#3 ITB (Iliotibial Band or IT band)-

One of the easiest ways to differentiate PFS from ITB is to look at where it is. The ITB runs down the outside of the knee and inserts onto the fibular head (little lower leg bone on the outside of the leg). If your symptoms are at the level of the knee cap but are behind it looking from the side, it is more likely that your problem is ITB related versus PFS.

My knee hurts. Now what?

First things first. Like we’ve said all along. This site is not designed to keep you from your doctor and healthcare team. It’s designed to teach you the things that you can do at home to help alleviate symptoms and prevent them from becoming a full blown injury. That being said, if you have any of the following, time to see your doctor. Visible swelling. Bruising around the knee cap. Buckling/giving out of the knee. Numbness/tingling anywhere in the leg. If you aren’t making any progress? See your doctor.

Be smart when self treating at home. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait weeks and even months before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:

• Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Typically with this kind of injury, the whole leg will benefit from getting dug out.
• Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Nope! Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.

How to treat it.

**download PDF with links, sets, reps, progressions, etc here**

Step 1- Traditional R.I.C.E. treatment:

When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage when working to heal an injury!

Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.

Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.

Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them). You can also use a store brought ace wrap to accomplish this. Start the wrap below the injury using good tension on the bandage and move up above the injury. This will help keep swelling from moving down the leg.

Elevation: This is critical in the early days following acute injury where swelling may be present. In the case of an ankle injury for example, elevate the leg so that it is above chest level. This can be accomplished by laying down and propping for your foot up on the arm of the couch with pillows.

Step 2- Kinesiology taping:

For PFS, there are two tape applications to test out.  Both essentially scoop up the lower part of the patella to help it move through it’s normal path. Try both. One may feel better than the other.

 

1) U-Strip- Click here (you want the first video in this link! )

2) Chondromalacia tape application. Click here.

Step 3- Getting mobility back:

The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a muscle sprain/strain isn’t about no pain, no gain. The muscle needs to heal! Don’t overdo it in an attempt to speed up your recovery.

1) R.I.C.E. + gentle stretching. There should be no pain with stretching. .

2) Begin using the foam roller AROUND the injured area. The goal here is to start getting slack into the muscle without aggravating the injury itself. No tennis ball work or mobilizations. The order should be foam roll around injury -> stretch -> RICE.

3) Begin using the foam roller over the injured area to tolerance. The order should be foam roll around injury-> over injury -> stretch -> RICE.

4) Begin using the tennis ball for mobilizations. The order should be foam roll around injury -> over injury -> active/joint mobilizations -> stretch -> RICE.

5) Begin using the tennis ball for cross friction + trigger point. These are the deepest of the soft tissue techniques so you want to save them for last to target specific adhesions and restrictions. Consider this your fine tuning step.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

Here’s what it looks like for the PFS. Use the guidelines above.

Step 4: Strengthening

We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.

What you’ll need: 1) ankle weights or 2) resistance band/tubing. Both are easy to find in any sporting good store these days or walmart/target.

Optional equipment: 1) a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20. 2) Suspension trainer. I’m a big believer in these because it takes up zero space in my house and is an easy/inexpensive way to add a dynamic component to my strength training. Prices range anywhere from $30-200. Click here to see some of the options out there.

Video’s for each level are here. Please note, in the PDF download (above) you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.

Level One

 

Level Two

Level Three