Tag Archives: knee pain

Elite PT Newsletter May 2018 – Running Injuries Part 2 – Knee Pain

This month’s newsletter focus is on knee pain.  Things have been getting busier here with summer just around the corner and lots of runners prepping for races.

One thing we’ve definitely noticed with our runners is that prevention is key.  They’re coming in sooner, once they can tell something is not quite right, rather than waiting weeks or months for it to just go away on its own.  Because of that we’ve seen two trends:

1)  They are recovering much quicker than in the past
2)  They’re completing their races – most we’ve checked in on have run faster than in previous races.

So on that note let’s continue with our series on running injuries – this month focusing on knee injuries.

***Just a quick note for you non-runners out there – these injuries are very common in all sports and even in non-athletes so if you have knee pain you will still want to check this out!

The most common knee injuries in runners are:

1)  Patello Femoral Pain (front of the knee)
2)  Distal IT Band Syndrome, a.k.a. Runners Knee (outside of the knee)
3)  Patellar Tendinosis (just below the knee cap)

Last month we talked about improving mobility and stability of the foot and ankle – which will also help to relieve strain on the knee joints so if you have knee pain go back and read that article here:  http://www.elitepttc.com/elite-pt-newsletter-april-2018-common-running-injuries-part-i-foot-and-ankle/

This month I want to focus on a couple of the muscles that are notorious for causing knee pain, and what you can do about them. Check out the pictures below:

Rectus Femoris Trigger Points and Pain Referral Pattern

RF Trigger Point Knee Pain

Vastus Lateralis Trigger Points and Pain Referral Pattern
 

VL Trigger Points Knee Pain
The ‘X’ is the location of common trigger points (tight irritable bands of muscle) and the reddened area is that trigger point’s pain referral pattern.  From the pictures you can see how irritation within the big quadricep muscles can cause pain all the way down to the knee.

The quadricep group frequently gets overworked with running which can cause these hyper-irritable bands of tissue in the first place.  As a result the muscle tissues feel tighter and become less flexible.  This creates a vicious cycle over time and ultimately these tissues can refer pain down to the front or side of the knee mimicking the conditions I listed above.

Luckily these trigger points are usually easy to identify and treat with manual therapy techniques such as Graston Technique and Dry Needling.  Following up with corrective exercises can ensure that these irritable areas don’t flare back up after being treated.  On top of that, most of our clients can manage this in the future doing their own soft tissue work using foam rollers and massage sticks, and warming up properly.

Check out the video below if you’d like to see how we dry needle and treat that outer thigh muscle:

***This video was originally created for physical therapists and posted on SportsRehabExpert.com so there is quite a bit of medical lingo but you’ll get the drift.  Be sure to check out how much better Lydia’s leg moves after the treatment. 

Last year one of our Kingsley athletes was diagnosed with IT Band Syndrome and was experiencing significant pain on the outside of the knee.  His knee had actually buckled on a number of occasions while trying to sprint.

He presented with almost identical range of motion at the hip as Lydia in the video above.  One treatment of dry needling followed by a couple corrective exercises and he was able to return to running the next day without pain.

I can’t guarantee it will always work that fast but sometimes it does (helps to be 16 too!)

SPECIAL OFFER – if you’ve been struggling with knee pain and you’re not sure what to do about it then give us a call for a free screening.  We can quickly identify the cause of the problem and guide you down the right treatment path.  231 421-5805.

Until next time…

Joe Heiler PT
Joe@elitepttc.com
231 421-5805

Elite PT January Newsletter – Therapist Spotlight: Kristy Ockert

Hi everyone

Hope you had a great Christmas and New Years.

2017 was a great year for us at Elite Physical Therapy and hopefully 2018 will be more of the same.  It’s a blessing for us to be able to work closely with clients like yourself.  We really love getting to know our clients and helping them to achieve their rehabilitation and training goals.  It’s awesome to be able to do something you love for a living, and hopefully it shows!

Free Screening Day

We’ll be hosting another free screening day coming up in February (date to be announced soon).  This is an annual service we’ve started providing to the following:

  • All past physical therapy clients
  • All present clients who have another problem currently not being treated
  • All loved ones, family, friends, neighbors and co-workers of our past and present patients

If you are having pain or problems with day to day activities such as walking, standing, sitting for long periods, going up or down steps, getting in and out of the car, sleeping or driving, then this is an excellent opportunity to see one of our world-class therapists, find out the cause of your problem, and get some treatment ideas.

I’ll be sending out an email soon with more information on how you can take advantage of this free offer.

Therapist Spotlight – Kristy Ockert MSPT

Kristy Ockert began working at Elite Physical Therapy 2 years ago and overall has been practicing since 2002 in the outpatient setting. She earned her Bachelor’s degree in Kinesiology with a specialization in Health Promotion from Michigan State University and her Master of Science in Physical Therapy degree from the University of Colorado Health Sciences Center. Kristy is a Certified Kinesio Taping Practioner (CKTP) and enjoys treating a wide variety of patient populations including post-operative, athletes, and patients with spinal dysfunctions.

She has enjoyed furthering her education with a Pilates specialization and various manual techniques including Graston Technique, Functional Dry Needling, Muscle Energy Technique (MET), Muscle Release Technique (MRT) and Myofascial Release (MFR). Kristy is passionate about providing one on one care to her patients and taking into account all pieces of their individual health puzzle for restoring optimal wellness and return to function.

Q & A:

What got you interested in physical therapy as a career?

It’s a long story!  When I was younger, I wanted to become a teacher, like my mom.  As I got into high school, I knew I wanted to be a doctor – either a pediatrician or sports medicine physician so I could focus on optimizing health for kids and athletes.

My first glimpse of PT was as a patient when I was injured during my high school senior year softball season.  I had a great PT and PTA work with me, but I didn’t think much of it until my senior year of college at MSU.  I decided that I did not want to go to medical school any longer and was looking for a new career path.

After some research and lots of deliberation, I changed my major from Human Biology to Kinesiology, which is the study of human movement.  I finally loved my classes – movement throughout the lifespan, biomechanics, adaptive movement, etc.  It all seemed to fall into place after that.  I got in touch with my former PTA and asked if I could interview her for a class assignment.  It turned into shadowing and weekly volunteering in a small outpatient clinic.  I was hooked!  If I were to become a physical therapist, I could work in the health care field with people of all ages and teach them about how to optimize their movement for improved quality of life.

Over the past couple years you’ve become certified in Graston Technique and dry needling.  Any other techniques you really like to use?

I also enjoy being a Certified Kinesiotaping Practitioner.  Whether it is to help with swelling, bruising, or scar tissue, working on retraining a muscle with proper activation or even unloading an injured area, Kinesiotape has so many uses.

What are your favorite things about being a PT?

I enjoy working with closely with people whether it’s younger athletes, weekend warriors, middle aged or even geriatric patients interested in remaining active.  If there are a few exercises, hands on techniques, and instruction in daily modifications that can make someone’s life more functional and optimize their movement, I’m happy!  I love seeing the changes that people go through from the start to finish of therapy.

Outside of working at Elite, what kinds of things do you and family enjoy?

I enjoy spending time with my husband of 16 years, Ken, and our three kids Carter (14), Peyton (11), and Emma (8).  We love watching movies, going to the beach, bowling and skiing as a family.  I also have a love-hate relationship with winter running, so I’m going to try snowshoeing with my running buddies this year for our longer distances to gear up for the 2018 racing season!

Kristy Ockert
 

 

 

 

 

 

Testimonial

Thank you, thank you, thank you!! After 5 years of physical therapy at numerous other locations, false diagnosis and lack of improvement, MRI’s that showed nothing, Kristy and Lydia correctly diagnosed the problem with my daughters knee and have fixed the problem! You have got her active again with little to no pain. You have brought a smile to her face and to her parents face as well! Thank you for getting her back to healthy! 5 stars isn’t enough! – M.R. Ludington

Sore Knees???
Pain site does not always equal pain source!

Just because your knee hurts doesn’t necessarily mean that the problem lies only with that knee.  You’ve got numerous joints above and below that must move correctly to take the pressure off the knees.

One of the prime examples (or prime offenders) is the ankle joint.  A stiff ankle will negatively affect your walking and running stride, ability to squat down, walk up/down stairs, balance, and more.

The client from the testimonial above was a great example of this.  Resolving her ankle mobility limitations went a long way toward making her knees feel better.

Check our the link below for a short article/video on how we assess and solve the problem of ankle mobility:  http://www.elitepttc.com/ankle-mobility-update/

This is exactly the kind of thing our free screening day is for!

Til next month

Joe Heiler PT

ACL Injury Prevention 101

ACL injuries (anterior cruciate ligament) have been an epidemic in sports but even more so in women’s athletics.  Females are 3-4x more likely to tear their ACL than men.  A few of the main reasons are:

– poor mobility/flexibility
– insufficient strength levels
– improper jumping and cutting mechanics

ACL Injuries

Poor Landing Mechanics!

At our ACL Injury Prevention clinic you will learn the fundamentals of strength training, flexibilty, speed and agility, and jump training to become a better athlete while also decreasing the risk of devasting ACL injuries.  See our recent blog posts for more information on ACL injuries and examples of how we teach landing mechanics.

Athletes will work in small groups with our expert staff addressing each of these problem areas. They will also learn drills and exercises that can be done at home or within school training programs to continue to develop athletically.

Come ready to work and learn!

Cost is $10 per athlete

Who:  Middle and High School Female Athletes

Where:  Elite Physical Therapy and Sports Performance – 4177 Village Park Dr. Suite B Traverse City (next to Wuerfel Park)

When – February 11th 10am – noon

What to bring:  athletic attire, water bottle, and your energy!

Space is limited to 24 athletes so sign up today!

Bonus:  we’ll be offering a free movement screening session to attendees who would like to participate.  Screening consists of the Functional Movement Screen (FMS), Y Balance test, plus jump and hop testing.  Exercise programs are then individually developed based on these test results.  Those interested can schedule their free screening by calling us at 231 421-5805.

UPDATE: The clinic was a big success and we definitely plan on doing it again. Here is what some attendees thought about the clinic:

“It was a lot of fun and I learned a lot of new exercises” – A.R.

“I never realized how hard it would be to do some of these exercises. Or that my right leg was a lot stronger than my left leg” – A.H.

“The girls had a good time. It was really eye opening to see some good athletes struggle with controlling their landings. Thanks for doing this” – J.W. Parent.

We can also set up an ACL injury prevention clinic for your team. If you are interested just give me a call at 231 421-5805 or email Joe@elitepttc.com.

ACL Injuries and Prevention

ACL injuries (anterior cruciate ligament) have been an epidemic in sports but even more so in women’s athletics.  Females are 3-4x more likely to tear their ACL than men.  There are several proposed theories on why this is so but for the purposes of this article and what we address here at Elite Physical Therapy we will discuss the following:

  • Poor movement quality
  • Strength deficits
  • Landing mechanics

I’ll go more in depth in subsequent articles but for now here are the basics:

Poor movement quality

There are just certain joints in our bodies that need to be very mobile in order to get us through our daily activities and especially sporting activities like running, jumping, and cutting.  Don’t get me wrong – all of our joints need to move through their full range of motion for us to be efficient movers.  Some just need to be emphasized a bit more because of their tendency to become stiff while other areas of our body need a bit more stability/motor control.  Check out the picture below to get an idea of how this works – it’s called the Joint – by – Joint theory.

Alternating sequence of mobility - stability through the entire body

Alternating sequence of mobility – stability through the entire body

It’s a very simplified way of looking at things but it does often work out this way.  The knee joint needs to have a great deal of stability in all directions to prevent injury.  If the ankle and hip joints above and below are moving well then the knee joint will more likely stay within it’s accepted range of motion during athletic movements.  If the ankle and/or hip are stiff then the knee may just have to go outside of it’s normal boundries to land from a jump or decelerate while cutting.  This is where things can go south in a hurry!

Strength deficits

There is plenty of research out there in the medical and physical therapy journals showing that strength deficits can lead to knee injuries, and in particular ACL tears. Years ago the main concern was the ration of strength between the quadriceps and hamstrings, which if it was below a certain level it could inhibit an athletes ability to decelerate correctly leading to injury.

Lately the focus has been more on the hips and muscles of the ‘core’ and how weakness or lack of control in those areas can contribute to injury.  I’ll get more into the ‘how’ and ‘why’ in another article but it is a reality that needs to be addressed.

At Elite Physical Therapy, we know that a comprehensive strength program must be implemented to assist in the prevention of ACL injuries.  Quality movement is critical for effective strength training as well.  Being able to combine these qualities is what we do best, and definitely one of my favorite things to talk about so more to come for sure!

Landing mechanics

It is also well documented that female athletes land and cut differently than the male athletes.  Women tend to land stiffer and higher than the men who typically land in deeper hip and knee flexion angles.  Stiffer and higher landings are more dangerous as far as the knee joint is concerned.

Strength and movement quality again play a large role in this.  Some athletes can’t even get into a good position to perform complex athletic movements.  Big problem!

Many don’t have the strength to get into the proper positions.  Another big problem.

As the athletic activities get faster, more complex, impose higher forces, etc it becomes more and more challenging to perform them using good technique.  Fortunately all of these qualities can be addressed through physical therapy and proper training techniques.

Check out the video below showing how we start teaching athletes to jump correctly using box jumps.  The nice thing about landing on a box is that you don’t really have to come all the way back down.  Much less strain on the knees and an easy way to work on jumping and landing technique.

I’ll be posted a new video every few days showing more of the progressions we use.  We will also be hosting some ACL prevention clinics in the near future so if you’d like to learn more and get some hands on assistance than please contact us.

Here is what we have coming up:

December 28th from 2 pm – 6 pm at Kingsley High School with the Northern Pride Sports Academy.  6th – 8th grade girls basketball skills camp.  We will be teaching a session on jumping progressions to improve athletic performance and reduce injury risk.

In February (date to be determined) we will be hosting an ACL Injury Prevention clinic here at Elite Physical Therapy and Sports Performance.  Topics will include mobility training, strength training, and jump training progressions. More on that to come as we continue to line up speakers and instructors.

For more information you can contact us at 231 421-5805.

Joe Heiler PT

Dry Needling for Hip and Knee Pain

At Elite Physical Therapy and Sports Performance we strive to find new and innovative ways to treat pain and get you moving again.  Dry needling has been one on my go-to treatments for the past 3 years now, and the method I’m going to show you today works wonders for hip and knee pain.

The Vastus Lateralis (VL) is one of the four muscles that make up your quadricep and is the most lateral.  Trigger points in this muscle will often refer pain to the lateral knee.  Check out the photo below of the VL and corresponding trigger point referral patterns.

Vastus Lateralis Trigger Points

Even without active trigger points, the VL is often in a state of high tone which can significantly limit hip mobility in certain directions.  With it’s attachment all along the IT band, it can also create greater stress on the knee joint through that IT band.

In the video you’ll see the limitations in our patients hip adduction (her knee should hit the table when I try to lower the leg across midline).  Her right hip does this easily.  This is a fairly standard PT test, known as the Ober test in most circles.  In the video you’ll see how dramatically dry needling the Vastus Lateralis with a few minutes of muscle stimulation can change her hip mobility.

Just a quick note on the video.  This was originally created for my SportsRehabExpert.com website which is read by other PT’s, Athletic Trainers, Chiropractors, etc.  Sorry for all the medical talk but you’ll get the idea with the huge change in range of motion following the dry needling treatment.

Here are some of the common diagnoses you’ll hear from your doctor that will respond well to dry needling:

  • IT Band Syndrome
  • Runner’s Knee (distal IT band syndrome)
  • Patello-Femoral Pain Syndrome/Patellar Mal-Tracking
  • Hip Bursitis

There are many other ‘diagnoses’ that can benefit from improved hip mobility but those above are what we would see most frequently.  For those that are needle-phobic, we can get similar results using Graston Technique and other manual therapy techniques, it’s just often not quite as dramatic.

There are also a number of specialized motor control and strengthening exercises that need to be used following this treatment to maintain this new mobility.  Just because she can move her hip now on the table doesn’t necessarily mean its going to move that well when she is standing, walking, or running.  Strength must also be established in that new range.

Hope that was helpful to see plus you get a bit of a glimpse at what we do here at Elite Physical Therapy and Sports Performance.

Big thanks to our Athletic Trainer, Lydia Case, for being our ‘patient’!

Vastus Medialis Obliquus Muscle (VMO) “Isolation” Exercises Fact or Myth?

At Elite Physical Therapy and Sports Performance we take pride in the fact the we are well ahead of the curve with out treatment techniques compared to the rest of the traditional PT world, but we also acknowledge that it is important to use evidence based treatment techniques.

Evidence based practice is the buzz word in PT circles but despite this strengthening/isolating the VMO continues to be utilized as a way to decrease knee pain and improve function.   PT’s and physicians alike continue to prescribe strengthening for the VMO muscle of the quadriceps group even though the research has proven this concept to be faulty and ineffective.

This short article was written by a couple PT friends of mine in New York (one of which is in the PT and Strength and Conditioning Halls of Fame!) showing once and for all that you can not isolate the VMO, nor should you bother trying when it comes to solving knee pain.

Enjoy!

Originally posted on SportsRehabExpert.com

Robert A. Panariello MS, PT, ATC, CSCS
Timothy J. Stump MS, PT, CSCS, USAW

Professional Physical Therapy
Professional Athletic Performance Center
New York, New York

Patellofemoral pathology is a fairly common condition observed in clinical setting. The treatment philosophy of some rehabilitation professionals to resolve this painful condition may include the prescription of exercises in the attempt to isolate the Vastus Medialis Obliquus muscle (VMO). Although this VMO exercise isolation “myth” has been negated at least 20 years ago (1, 2) it continues to presently endure.  During this attempt to isolate VMO activity, some designated exercises executed include but are not limited to the following:

  • Quad sets
  • Terminal open chain knee extension exercises
  • Straight leg raises (SLR) with external rotation of the lower extremity

These exercises may or may not be performed with the adjunct application of electric stimulation.

Although these exercises will enhance the strength of the quadriceps muscles, likely assisting in resolving the patient’s knee pathology, this is not due to isolation of the VMO. The case some clinicians formulate for the performance of SLR with external rotation is based on the false premise that by externally rotating the femur will result in further activation of the VMO.

The knee is a hinge joint and during the execution of a SLR, the force of gravity will act in a perpendicular manner between the knee and ground surface. The quadriceps mechanism will now be required to resist the resultant force attempting to flex the knee as this is the only contractile soft tissue structure that is capable of resisting that force.  The quadriceps mechanism like any other dynamic structure can only resist this external force via the neural activation of the muscle group.  The external rotation of the femur gives rise to the placement of stress on medial collateral ligament (MCL), a static stabilizer of the knee.  This treatment philosophy actually removes stress from the very muscle(s) the clinician is attempting to enhance.  As an example a patient with a diagnosis of polio, a condition affecting the anterior horn of the femoral nerve or a patient with a quadriceps tendon rupture can still perform a SLR when externally rotating their femur based on the static stabilizing properties of the MCL.  Therefore one may inquire why would a clinician who is attempting to activate and enhance the quadriceps muscle group perform the SLR exercise in external rotation.

The anatomy and neuroanatomy of the quadriceps muscle group

The quadriceps muscle group is comprised of the rectus femoris, vastus lateralis, vastus intermedius, and vastus medialis. The vastus medialis (VM) is located at the medial aspect of this muscle group and has been reported to consist of two separate components, the proximal vastus medialis longus (VML) and the distal vastus medialis obliquus (VMO) (4). The neuroanatomy of the quadriceps muscle complex reveals an innervation from the femoral nerve.  The femoral nerve is comprised of large motor units that innervate all four heads of the quadriceps without individual fine motor unit innervation of the separate muscle heads.  Therefore, since the VMO does not have a distinct and separate nerve innervation, it is not possible to “isolate” this muscle from the other quadriceps muscles via a specific exercise performance. The most beneficial way to enhance the VMO is to incorporate the same exercise philosophy used to improve any other muscle or muscle group, the application of unaccustomed stress. The application of unaccustomed yet safe levels of stress is simply known as the “overload principle”. This may be accomplished in two ways; expose the patient to higher levels of unaccustomed resistance or overload them by increasing the velocity of the movement. Both methods will result in a positive adaption of the entire quadriceps muscle group.

Since stress transpires throughout the kinetic chain of the lower extremity during the performance of ADL’s as well as athletic endeavors, the activities prescribed for patellofemoral pathology should also include exercises for both the hip and ankle. “Critical thinking” is a requirement for the approach to the patient’s optimal exercise selection and treatment design. The health care professional’s obligation to provide optimal treatment does not include the application of myths during the patient’s plan of care.

References

1. Cerny K “Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome”, Phys Ther (8):672-83, 1995
2. Malone T, Davies G, Walsh WM, “Muscular control of the patella” Clin Sports Med 21(3); 349-362, 2002.
3. Hubbard JK, Sampson HW, Elledge JR, “The Vastus Medialis Oblique Muscle and Its Relationship to Patellofemoral Joint Deterioration in Human Cadavers”, J Ortho Sports Phys Ther 28(6):384-391, 1998.
4. Weinstabl R, Scharf W, and Firbas W, “The extensor apparatus of the knee joint and its peripheral vasti: anatomic investigation and clinical relevance”, Surg and Radiological Anat  11(2): 17-22, 1989

Robert A. Panariello MS, PT, ATC, CSCS
Rob Panariello PicRob is a Founding Partner and Chief Clinical Officer with Professional Physical Therapy presently with 44 facilities in the New York and New Jersey Metro areas and the Professional Athletic Performance Center located in Garden City, New York. He has Bachelor Degrees in Physical Therapy and Physical Education/Athletic Training from Ithaca College in Ithaca, NY. He also holds his Master’s Degree in Exercise Physiology from Queens College in Queens, NY.

Rob has more than 30 years of experience in the related fields of Sports Physical Therapy, Athletic Training, and the Performance Training of Athletes. His experience includes the study of the Science of Strength and Conditioning of weightlifters and various sport athletes in Bulgaria, the former Soviet Union, and former East Germany. He previously held the positions as the Head Strength and Conditioning Coach at St. John’s University of New York (1986-1995), the World League of American Football NY/NJ Knights (1991), and the WUSA NY POWER Women’s Professional Soccer League (2001-2002). He continues to rehabilitate, athletic performance train, as well as serve as a consultant to many NFL, NBA, MLB, NHL, Collegiate and University teams, coaches, and players.

Rob has more than 60 peer reviewed Orthopedic and Sports Medicine Research, Sports Physical Therapy Research, and Strength and Conditioning Journal Articles and Book Chapter publications. He has also presented his research at the International World Confederation of Physical Therapy in Washington, D.C. He is nationally renowned and lectures throughout the country with regard to the related fields of Sports Physical Therapy and the Performance Training of Athletes.

Rob received the 2015 APTA Sports Physical Therapy Section Lynn Wallace Award for Excellence in Clinical Education, the prestigious National Strength and Conditioning Association’s Presidents Award in 1998 and was elected to the USA Strength and Conditioning Coaches Hall of Fame in 2003.

Tim StumpTimothy J. Stump is a partner with Professional Physical Therapy, and is also a founding partner with the Professional Athletic Performance Center. He  has more than 20 years of experience in the related fields of Orthopedic and Sports Physical Therapy, Strength & Conditioning, and Performance Training of Athletes of all levels of competition. Tim’s experience includes the successful participation as a nationally ranked competitive strength athlete in the sports of Powerlifting and Weightlifting from 1990-2010. He continues to actively participate in these sports as a coach and mentor to many athletes.

Tim has published several peer-reviewed original research articles and has presented his research at the APTA National Conference and at CSM. Tim was also awarded the Jacob & Valeria Langeloth Foundation research grant for studies on ACL functional outcomes while employed at the Hospital for Special Surgery. Tim was the 2012 recipient of Columbia University’s Award for “Leadership in Clinical Education” and co-chairs Professional’s Clinical Affiliation Program with over 64 school contracts providing PT, PTA, ATC and Exercise Physiology students with quality clinical affiliation experiences.