Friday, January 17, 2014

Why Hips Don't Lie: Thoughts On Knee/IT Band Pain

Being an obsessed runner who loves running as much as possible, you can imagine how many people ask me if I'm worried about my knees.  Knees knees knees.  That's all people think about.

I used to respond with, "Oh, I'm a minimalist runner!  I run on my forefoot and midfoot and will thus never have knee pain!!"  I have moved past that stage, realizing that a little support and cushioning go a long away, especially when I pronate/evert like crazy.  Which led to a nagging peroneal injury.  Not that I think pronation control is the cure all.  That's for another post.

The point is, I'm back in traditional shoes (Brooks Adrenaline/Brooks Ghost) at the moment for my normal training.  It feels easy to maintain my form with a decent midfoot strike, but I know I'm a heelstriker.  So we'll call it a midfoot/heel strike because I switch between the two depending on my fatigue level or how paranoid I'm being about my form.  Another follow up post will be about footstrike and why it's not as big a deal as we think.  So I started to worry about my knees.  Yet they didn't hurt.  My quads got wrecked after my half marathon last week at the Southern California Half Marathon where I took second in 1:11:11.  That's 5:26 pace.  That's the longest I've ever raced and the only training I did for that was a couple 10-11 mile tempos runs pacing a friend of mine the month before.  That and my crazy high mileage from college(+110 miles per week).  So here I am thinking that I'm putting myself at risk.  One of the main reasons I got interested in physical therapy was long term injury prevention so I can run until the end of my days (whenever that happens to be).

But wait.....

Those of you who know me well know I struggled with constant IT band issues during the beginning of my competitive running career.  When I started competing my senior year of high school, I made it only briefly into each season of cross country and track before I succumbed to Iliotibial band syndrome (once on each side).  This continued into my freshman year of college, where again I was injured during cross country and  two weeks before the 10,000m NWC championship in track.  That 10k was a horrible race.

So finally I took things into my own hands and started researching what the hell was going on.

And here's what I found:

The IT Band is a thick band of fascia attached to the Tensor Fascia Latae and the Glute muscles.  You may hear DPTs and others talk about how the population has weak glutes because we spend so much time sitting.  Well, it's kinda true.  So what happens when those glutes aren't firing?  The Tensor Fascia Latae takes over.  And that muscle is tiny.  So eventually it fatigues, then the IT Band gets tight as hell and pulls on its attachment at the knee.  Then BOOM.  IT Band syndrome.

So how do you fix it?  By strengthening your glutes!!  Particularly your glute medius!  Which is responsible for much of the lateral stabilization of the hip and knee.  It's a hip abductor, so it's one of the muscles that prevents the knee from going inwards during standing or running!

I'll refer you to another DPT, Dr. David McHenry from PACE in Portland, Oregon for the best exercises on that.  The clamshells, reverse clamshells and Jane Fondas demonstrated here:

http://www.therapeuticassociates.com/sports-medicine/stability-routine/

are awesome.  Go check those exercises out.

Once I started doing those, I stopped having any IT band problems.  I've even stopped doing my special exercises for a week just to test it and then it comes back.  So obviously I need to keep doing them.

Back to knee pain!

I've never had any.

Being a heelstriker/midfoot striker made me wonder why I hadn't, because it's such a stereotypical thing to have happen.  The only thing I could think of was the fact that my core exercises have so much to do with strengthening my hips (another post coming up on why "core" doesn't just mean abs).  So I began to look into this.

Article after article seems to point to the fact that various types of knee pain may come from weak glutes.  I would guess that it has to do with how the knee is tracking through the gait cycle (ie does it stay in a neutral straight position or is it subject to valgus/varum forces, going inward or outward?) or maybe that the individual is using their quads primarily for propulsion rather than their glutes!  The quadriceps muscle attaches right below the knee on the upper Tibia (tibial tuberosity).

Here's a couple examples:

Robinson and Nee (Robinson & Nee, 2007) examined female subjects with unilateral patellofemoral pain.  ALL of the subjects with patellofemoral pain tested positive for weak hip strength (it's a cross sectional study, so there were only 10 subjects w/ pain compared to 10 without.  So "ALL" is relative).  They looked at hip abduction, extension and external rotation.  All of these motions had strength impairments in those with knee pain.

Cichanowski, Schmitt, Johnson and Niemuth (Cichanowski, Schmitt, Johnson & Niemuth, 2007) analyzed   female collegiate athletes with unilateral knee pain in regards to hip strength.  They compared the subjects to themselves and found that the hip abductors and external rotators were much weaker on the injured side than the non-injured side.

I can keep spouting off more of these because they keep going on and on.  Just look up "Glutes" and "Patellofemoral Pain" and you'll find enough articles to last you until the end of days.

Like I mentioned early, my thoughts (as a student, not a dpt yet.  I have nothing to cite on this so take it with a grain of salt) on this are that patellofemoral pain can be due to instability of the knee and/or overuse of the quads instead of the glutes for propulsion during a running or walking gait.  I think excess lateral/medial movement of the knee puts pressure on all the tendons and ligaments surrounding and excess use of the quads puts pressure on their connection point just inferior to the patella.

Solution?  Strengthen your hip abductors with the stereotypical Physical Therapy exercises (Clamshells and lateral leg raises or Jane Fondas at minimum) and your hip extensors.  Why the hip extensors?  Ask any DPT, PT, strength and conditioning specialist, etc about the glute muscles and sports performance.  THEY'RE REALLY IMPORTANT!!  Why do you think elite sprinters have big butts?   But in most people they end up weak, and the quads take over for propulsion.  Which can (there will always be exceptions thanks to human variability) lead you down the path we've been talking about!

So Shakira had it right.  She just didn't realize that her song was applicable to injury prevention and rehab.

Now if hip strength/kinematics affects the knee joint, what about the other joints in that chain?  The human body is REALLY good at compensating for a weakness, even to the point of another injury.  Trust me.  It's what a majority of my job as a doctor of physical therapy will be involved in correcting.   I'm assuming you can guess that it may involve injuries in the ankle and the hip areas.  It probably involves attempting to get more propulsion from the calves (achilles injuries), foot (Plantar fascities), hamstrings (hamstring injuries) and more to compensate for those weak hip extensors.

So strengthen those hips.  They'll help you run faster and may protect you from various injuries.

If nothing else, the exercises will make your butt look better.  Think of it as a two for one deal.

Hope you enjoyed my first real blog post.

As always, my thoughts are my own unless cited.

Thanks for reading.

-Matt Klein, SPT

Citations:

Cichanowski, H., Schmitt, J., Johnson, R., & Niemuth.  (2007).  Hip Strength in Collegiate Female Athletes With Patellofemoral Pain.  Medicine & Science In Sports & Exercise.  39(8): 1227-1232

Robinson, R., Nee, R.  (2007).  Analysis of Hip Strength in Females Seeking Physical Therapy Treatmet for Unilateral Patellofemoral Pain Syndrome.  The Journal of Orthopedic Sports Physical Therapy, 37(5): 232-238

2 comments:

  1. Incredible appraisal right there. Like any problems, there are a lot of dimensions to a knee injury, so it is best that we give each of them a double take, to see if your assumptions remain consistent. That essay is a good way of going at it. Thanks for sharing! Kudos!

    Agnes Lawson @ MedWell Spine, OsteoArthritis & Neuropathy Center

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  2. As any runner worth his salt, I work out my glutes with sound exercises, diligently executed (daily clamshells, glute bridges, donkey kicks, pigeon). That said, I'm always up for new variations to break the routine, and wanted to look at that link in your blog entry. Unfortunately it has moved/ was removed. Do you happen to know where to find it or is it something like this?:
    http://www.jospt.org/doi/pdf/10.2519/jospt.2013.0501

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