Run for Life: Part 3

Welcome back for the conclusion of Run for Life!

Injury #3: Patellofemoral pain syndrome (PFPS)

There can be many different causes for knee pain, but one of the biggest culprits is overall faulty mechanics. In the vast majority of cases we find a significant lack of hip and trunk strength and stability as well as faulty foot mechanics, which cause more stress to be placed on the knee surfaces between the patella (knee cap) and your femur (long leg bone). Generally runners will feel pain under or around the knee cap with either a sharp or achy sensation during or after running. If these mechanics are not corrected, the cartilage behind the kneecap will eventually wear away causing even more pain and dysfunction with movement. 

Self-treatment: Trunk, hip and foot strengthening and stabilization activities as well as making sure that all of the above have the appropriate mobility are key to decreasing stress on the knee joint. Single leg activities are great and there are so many varieties available starting with balancing on one leg and progressing to single leg squats and single leg RDLs. Making sure your hamstrings, calves, quads and IT bands are at their proper length and mobility is key to creating optimal lower extremity mechanics while running.

For a runner with general knee pain we once again put them through the Runner’s Screening Exam and as an example, we find limited ankle mobility. We will then treat/improve that ankle mobility which commonly improves the entire movement pattern of the leg thereby decreasing strain on the knee and eliminating that runner’s knee pain. Again in conjunction with correcting spinal and leg mechanics in our sessions, we provide the runner with a comprehensive home exercise program for them to continue using for the prevention of re-injury in the future.

So what if these self-treatments don’t work? If your injury continues to the point where you can’t run without pain or worse, you’re starting to walk differently because of pain you may need to seek out the help of a movement professional. Find someone who will perform a comprehensive assessment of all the pieces of this puzzle to determine the cause(s) of your pain. Once you have a baseline you will be able to begin a targeted and intensive rehabilitation program to eliminate your pain and keep you running.

Who are these health professionals you ask? Some examples include physical therapists, orthopaedic physicians, podiatrists and athletic trainers. I am a bit biased of course, but a physical therapist should be at the top of your list especially one who has a running and/or competitive athletics background in treating runners.

Also, footwear is a critical component a runner needs to look at if they are having pain when running. A great resource is your local running store where the employees will be able to determine which shoe is best for you based on your body type, foot type, training regimen, etc. Our friends at Potomac River Running www.potomacriverrunning.com have in-store treadmills where they have their patrons run for a few minutes to determine which shoe will be the best fit. These stores are also great resources for finding running clubs, training programs, additional running equipment you may need and to meet other runners who share your passion for the sport.

Overall, the key point is to use self-treatments when appropriate after incurring a running-related injury, but to know when it is outside of your knowledge and to seek professional help. Make sure the professional you seek out has the most appropriate education/background for your injury, who takes the time to get to know you individually and doesn’t just give you the “typical protocol” they give to everyone else. We are all unique in our anatomy, running mechanics, motivation and discipline when it comes to running so find someone who is going to tailor the treatment to you and ultimately a person whom you trust and enjoy being around.

"If you run, you are a runner. It doesn't matter how fast or how far. It doesn't matter if today is your first day or if you've been running for twenty years. There is no test to pass, no license to earn, no membership card to get. You just run." –John Bingham

As the phoenix rises from the ashes, so too will RGIII!

Hyperbole maybe. Let's be honest; millions of people, professional athletes included, have had this procedure, had excellent physical therapy and returned to nearly, if not completely, 100%. However, Robert Griffin III holds a special place in the hearts and minds of everyone in the Metro DC area and for many in and around professional football.

 

I was recently asked to contribute to a piece on Robert Griffin III regarding his ACL reconstruction, his expected course of rehabilitation and the likely prognosis for a full recovery. I was happy to help a dear friend of mine and a friend of SPARK Physiotherapy, Fairfax Hackley with his weekly segment on WTOP (103.5FM).

 

Here is a link to the piece that was aired on Monday, 1/14/13 at 2:20PM on 'Hack's Best Body Report': RGIII ACL recovery from WTOP with Fairfax Hackley

 

The  main question asked was 'what's in store for RGIII with regard to the specifics of the surgery and his recovery'. One of the most important details here is the type of graft being used to repair his knee. For this surgery, they chose to use a patellar tendon-bone graft (PTB) which has some advantages over other grafts. 

 

RGIII did, in fact, undergo two separate procedures for this reconstruction. A PTB graft can be taken from a cadaver or from the patients own knee when it's appropriate. The PTB graft was harvested from RGIII's left knee and arthroscopically implanted into his R knee. If the right knee didn't previously have a PTB graft removed in 2009 when he first tore that ACL this surgery would only have been slightly less complicated.

 

Below is a great video that shows what this surgery looks like.

NOTE: the video depicts most of this without the skin and muscle in the way, but in fact, most of either procedures are done with minimal incisions and the entire ACL implantation is done through very small portals (.5-1.0 cm incisions) and small video cameras. 

 

 

Immediately after surgery, the main goal of the medical and physical therapy teams is to decrease any chance for infection and blood clots. No matter how young or in shape the patient, we are all susceptible to these problems if precautions are not taken. For the first week or two, blood clots are managed by gentle movement of the joint by RGIII and his physical therapist(s). He will use crutches to get around for the first week to 10 days and he'll wear an immobilizer brace that protects the surgery while he's moving around.

 

Once the initial phase of recovery is complete, at around the 2 week mark, the main focus of the rehab is to maximize the protection of the newly implanted graft. All movement will be highly controlled placing very little to no stress on the ACL. During this time the PT team will work with RGIII on exercises that will prevent weakening of his quadriceps, glutes and further decrease his swelling and inflammation.

 

The next phase of rehab, typically at 4-weeks post-op, will bring us to a stage where more care can be taken to regain range of motion muscular control over the knee, hip and foot. This is also the stage where RGIII will resume walking on his own even if it is with a slower pace but at least he'll be without the crutches or brace now. As long as his range of motion has continued to improve and the swelling has continued to decrease, the overall intensity of PT will start it's climb! Good times!!

 

As the physical therapy team approaches the 8-week mark, things get fun but they are still keeping a close eye on the intensity of movements that might place the new graft at risk. The bone that is attached to the ends of the PTB graft is fully attached to it's new place. BUT at roughly the 10-week mark, the actual tissue that the PTB graft is made of is undergoing a transformation that makes it quite a bit weaker even though he will be relatively pain free. Special care will be taken at this point to ensure everyone is on the same page about this!

 

Once we're at 12-weeks or so, we're mostly in the clear and the real fun can begin. PT becomes more about introducing plyometrics (jumping and bouncing exercises), introducing light running and intensifying his "closed-chain" training (movements like squatting, lunging, etc).

 

All told, recovery from this type of ACL reconstruction should take anywhere from 4-6 months. Everyone responds to surgery and treatment differently. RGIII has the best and brightest working with him every day to ensure he'll be back to terrorize defensive coordinators in NFC East for many years.

 

We at SPARK Physiotherapy wish him the best of luck for a full return to play.

 

 

 

Run for Life: Part 2

Welcome back to Run for Life: Part 2. We will continue with another common running injury…

Injury #2: Iliotibial band syndrome (a.k.a. IT band syndrome/ITBS)

This is another chronic inflammation issue where the IT band, which is the big band of connective tissue on the side of your leg, becomes irritated due to overuse and poor mechanics. Not only does it alter normal running mechanics, but commonly causes lateral/outside knee pain or hip pain because of strain at its attachment sites. Similar to treatment of plantar fasciitis, usually the IT band needs to be mobilized in order to break up any “sticky spots” that develop within the tissue as well as the muscle that attaches to it tensor fascia latae (TFL).

Self-treatment: A foam roll, tennis ball or lacrosse ball tends to be one of the best tools to aid in loosening the IT band. This is accomplished by lying on your affected leg on top of the foam roller/ball and then rolling up and down your leg, stopping at any tender points for a few extra seconds to break up the tissue. Hip strengthening and stabilizing exercises as well as proper ankle mobility needs to be part of a comprehensive rehabilitation program when it comes to IT band issues to restore normal mechanics of the leg.

If a person comes into our clinic presenting with IT band syndrome, we again put them through our Runner’s Screening Exam to assess their overall movement patterning. In our assessment, we usually find the IT band has restrictions, which may cause the leg to be pulled outward slightly due to the attachments of the IT band. As mentioned above, this is when outside knee pain may occur and overall running mechanics will likely be compromised. We recommend using the above self-treatment of tissue mobilization, but as physical therapists we can offer more efficient manual therapy to break up any tissue adhesions (“sticky spots”) in the IT band as well as specific techniques to develop proper movement patterns of the legs and spine when running.

The conclusion of Run for Life is coming up so don’t miss it!

"Running should be a lifelong activity. Approach it patiently and intelligently, and it will reward you for a long, long time." -Michael Sargent