Hip Pain - Impingement ?
Kelowna Manual Therapy Centre Blog
Knee pain is a common complaint at Kelowna Manual Therapy Centre. This article deals with knee pain that gradually increases, rather than knee pain that is caused by an acute injury. Treating knee pain must involve taking a thorough history as well as physical examination. A Thorough history-taking and physical examination will help determine whether the knee pain is the primary problem or the ‘victim’. In other words, a manual therapist will look for the root of the problem. The knee pain can be the source of the problem, or caused by problems in the lower back, pelvis, hip and/or foot and ankle.
Commonly, non-acute knee pain is brought about by about by stresses transferred from other areas. For example, tightness and weakness around the hip can cause a lack of control and an increased angulation of the knee with bending. This is termed “Valgus collapse”. This is one of the most common causes of knee pain seen with ‘overuse’ injuries.
PIC: Poor knee control as a result of hip muscle tightness and/or weakness
Another example is tightness in the calf muscles or stiffness in the ankle joint will put an increase in stress on the knee by causing an increase in twisting forces on the knee. Excessive pronation can also contribute to increased knee stress.
Manual Physical Therapy treatment will use a combination of manipulation, mobilization, IMS dry needling, soft tissue work, stretching and strengthening to help restore normal mechanics. Orthotics can be used if it is determined that increased foot pronation is contributing to the knee pain. A specific therapeutic exercise program will be taught to reinforce correct movement patterns.
The therapeutic rehabilitation program will follow one or more of the following principles:
- Correct knee, lumbar, pelvis, and hip alignment with exercises. This involves good control of the ankle, knee, hip, pelvis and lumbar spine with movement. Movement patterns that mimic the activities that were painful are focused on as part of the rehabilitation. Rehabilitation exercises must be kept pain free.
- Initially, exercises will be used to minimize ‘sheer’ stress on the knee. If the knee remains centered over the foot rather than allowed to move forward this will reduce stress on the knee. As the exercise program progresses increased loading will be used. There are a varieity of methods used to increase that load i.e. moving from both legs to one leg, adding weight, adding speed, adding unstable surfaces, etc.
- An emphasis on eccentric (muscle and tendons working and lengthening) exercises are used for sports that require this type of loading i.e. downhill trail running. Eccentric exercises are useful to prevent and treat knee tendinopathy.
- Attention to the type of activities and training previously discussed here.
OVERUSE INJURY PREVENTION AND RECOVERY FOR RUNNING ATHLETES
Overuse injuries are common in recreational and elite running athletes training for endurance events.
Overuse injuries take two forms, which often overlap. The first is simple overuse where an athlete has increased their training or has a sudden change in training to a level that has over stressed the tissue. Treatment is to identify the stressful event(s); decrease the inflammation and provide rest to the injured area.
The more common overuse injury is when the painful injured tissue can no longer handle the demands placed upon it. This requires a more in depth assessment to determine what the causes of the injury are. Quite commonly the injured area is the ‘victim’of stiffness, lack of mobility and/or control while another place in the body is actually the ‘culprit’. For example, if a runner is complaining of knee pain (the victim), ‘the culprit’might be a lack of hip mobility and strength which has put extra stress on the knee. All the intrinsic and extrinsic factors need to be examined.
|Intrinsic Factors||Extrinsic Factors|
|Biomechanical exam of joint mobility||Training Methods|
|Bony structure: Spine and limbs||Shoes, Orthotics|
|Muscles Activation /Strength|
|Body Awareness / Balance|
|Posture, Running Style|
Ideas for injury Prevention and Recovery:
A dynamic warm-up. Gradually increasing the pace and intensity of the warm up is important, especially with higher intensity exercise. Static stretching before activity has been shown to be detrimental to performance. There is also evidence that activities such as strength and balance exercises incorporated into a workout can prevent injuries.
An active recovery or cool down is very important after hard workouts to help flush out lactic acid. It should consist of 15-20 minutes of gentle movement.
Differentiate muscles soreness from injury soreness:
Delayed onset muscle soreness is common a day or two after a strenuous session. There is no harm done in continuing to exercise. Joint soreness is an indication that the joint itself has been stressed and requires more rest. Signs would include swelling or a ‘puffy’joint and tenderness. If body parts continue to ache or are painful longer than 1-2 weeks they should be assessed.
A gradual increase in training is necessary. A 10% increase seems to be a good rule of thumb. Remember that while it is important to gradually increase training volume and intensity, adequate recovery allows the body to build up stronger. High intensity training requires around 36-48 hours of recovery before another high intensity session should be undertaken. A good guideline is, the higher the intensity of the session is, the longer that recovery should be. Knowing your body is key for any athlete, i.e. knowing when to push and when to rest.
A stride rate 180-200 strides per minute for runners has been shown to reduce injuries as there is less impact per stride. Simply count the number of steps (each time one foot touches the ground) over 10 seconds aim for 15-16 steps.
Runners should consider a soft landing (mid foot/forefoot strike), with a slight lean forward at the ankle, while keeping a tall chest. A running gait assessment which involves running while being videotaped for analysis by the Pedorthotists at Okaped can be very useful. Other running coaches can be used for ongoing technique correction.
An in-depth review of modern footwear is beyond the scope of this article. It is best to visit a local shop like Fresh Air Experience who have trained staff to help you determine the best running shoe style for your foot type. Orthotics can be very helpful, either custom or over the counter. Again, these are best recommended by professionals such as Okaped. If Orthotics are being considered, foot taping , which simulates an orthotic, can be very helpful to to determine if orthotics will help.
A strong stable core i.e. abdominal, back and hip muscles, provide a good base to stabilize, propel and transfer energy. This allows an athlete to maintain good form and technique even when fatigued.
Adequate flexibility is necessary for the demands placed on the individual i.e. hip mobility for runners. This is probably more important as we age. Static stretching should not be performed prior to a work out,. Dynamic movements and a good warm up are better. Static stretching prior to a work out has been shown to be detrimental to performance. Static stretching (20-30 second hold) should be performed only after a workout.
Correct strength training has been shown to help prevent injuries in sport. You can also consider eccentric strength training as this has been shown to improve flexibility and strength in certain muscles groups.
Deal with old injuries in the off-season that lingered during or after your competitive season. With an increased training load they will most likely reappear.
There is some research that ongoing sleep deprivation, longer than 1-2 nights, interferes with our hormonal balance that regulates recovery.
A great resource is the coach.ca website. It has a sport nutrition section. Eating properly is important on a routine basis and a post workout combination of carbohydrates and protein is critical for recovery.
Compression socks have become quite popular with some claims of improved athletic performance. Scientific evidence suggests that they can assist with post-exercise lactate acid clearance and decreasing swelling.
Cold baths have become popular and are theorized to reduce the inflammation that has occurred with a strenuous workout. Cold water may help recovery and can be used for around 10 minutes. It is not necessary to have an ice bath. Cold water of 24°Celsius is okay. Contrast baths of cold and warm water may also be beneficial though not very practical. This involves a 1 minute cold (10-15°celsius) then 1 minute warm (37-40°celsius) for 7 cycles. Anecdotally submerging the legs into the lake post run can also be of benefit. None of these cold baths are enjoyable and take a lot of mental toughness!
Have a physiotherapy assessment, either to deal with nagging injuries or prevent an overuse injury from occurring. The Kelowna Manual Therapy physiotherapist will examine the above mentioned extrinsic and intrinsic factors (Table 1), and work with you to help establish a treatment plan.
This is a brand new video demonstrating how to apply an arch taping technique called 'low dye'. This taping technique is great for supporting the arch of the foot to relieve a lot of painful conditions including plantar fasciitis, tendinitis, tendinopathy, achilles pain and even knee pain. I also use it as a trial to see if orthotic therapy would be of benefit. The taping is quite simple, with practice, and is something I teach patients to do themselves.
Osgoode-Schlatters - How can physical therapy help?
Osgoode-Schlatters is a fairly common condition affecting the tibial tubercle (the bump about 2” below the knee cap). The condition is more common in boys than girls during large growth spurts. The tibial tubercle is the site where the patellar tendon attaches to the tibial bone. The patellar tendon is part of the quadriceps muscle group. The tibial tubercle is also the site of a growth plate. So, during times of growth, the bone is softer and the tubercle becomes painful and often is enlarged as the patellar tendon pulls on the bone during activity.
The pain is typically worse with running and jumping activities and eases with rest. The diagnosis is made from both the history and clinical examination. X-rays are typically not helpful as they won’t provide any help in establishing the diagnosis.
Physical Therapy management will include:
- A thorough clinical examination determining any biomechanical dysfunctions that will put extra stress on the knee. Muscle tightness, poor muscle control and altered biomechanics can all put extra stress on the knee.
- Advice on specific therapeutic exercises for stretching and strengthening.
- Knee taping. If this provides significant relief a patellar tendon strap can be prescribed.
- Orthotics and/or proper running shoes can also help if there is an increase in pronation (excessive foot flattening).
- Advice on activity modification.
The good news is that the condition is self-limiting, i.e. when the knee is sore it is best to reduce activity. The soreness will increase when there is a large growth spurt and will disappear in between growth spurts and will entirely disappear once growing is completed. Often there will be a prominent bump that remains at the tibial tubercle into adulthood.
Heel pain is a common condition. Pain in the arch of the foot, where it meets the bottom of the heel, is most commonly diagnosed as Plantar Fasciitis.
Typically the pain is worse with the first few steps in the morning or after prolonged sitting. The pain maybe worsened with running or prolonged walking. The pain can be, but is not always, reduced with light activity. The heel pain typically comes on gradually and progressively. On examination there is local tenderness on the bottom of the heel bone towards the arch. The tenderness may extend into the arch itself.
Common causes of heel pain can be due to the bony structure and/ or alignment of the foot, ankle, lower limb and spine. A flattened arch can put excessive strain on the plantar fasciitis. Commonly, there are muscle imbalances around the ankle and lower limb. Work and/or training factors should be considered such as prolonged standing, a sudden increase in activity, etc. Commonly there is a lack of mobility in the joints of the ankle and muscle tightness around the ankle.
Manual Physiotherapy treatment of plantar fasciitis is multifactorial:
- Improve the joint mechanics and improve muscular flexibility around the foot and ankle. This is done through hands-on joint and soft tissue mobilization/manipulation.
- Check for other underlying biomechanical faults in the leg and spine. Check for altered mobility of the nerves and soft tissue in the leg and spine.
- Unload the plantar fasciitis with sports tape or a temporary orthotic. Typically the relief felt is significant with a reduction of pain almost immediately. Taping the plantar fasciitis is also helpful in determining if a referral for orthotics is necessary. With correct taping a 50% improvement in pain with taping is expected before recommending custom orthotics.
- Assist the healing through use of physiotherapeutic modalities like ice, electrical stimulation and ultrasound.
- Provide an exercise program to improve mobility and strength around the foot and ankle. An exercise program would also address any other muscle imbalances around the spine or leg.
- Educate to reduce strain on the plantar fasciitis through change in footwear, work habits, as well as training factors.
- Another treatment option with more ‘stubborn’ cases is IMS dry needling of the foot, calf and spine muscles.
If the plantar fascia does not respond to physiotherapy treatment, a night splint, which keeps the foot held at a 90° angle all night can be used. Another option is to see your family doctor to discuss the use of medication or a local cortisone injection.
A recent study in the New England Journal of Medicine compared physical therapy to arthroscopic surgery for knee meniscal tears and early osteoarthritis.
The study was randomized with 351 participants divided into a surgery group and a physical therapy group. To be eligible for the study the participants had to have signs of a meniscal tear that included: clicking localized knee pain, giving way and catching.
The physical therapy group attended therapy 1-2 x per week for 6 weeks.
The treatment consisted of manual therapy, specific therapeutic exercises, cardiovascular conditioning and modalities such as ice and electrical stimulation.
The authors concluded that patients with a meniscal tear and evidence of mild to moderate osteoarthritis that were assigned to the arthroscopic surgery group (with postoperative physical therapy) and physical therapy group both had very similar improvements in function and pain.
Within the physical therapy group 70% percent of the patients had a successful outcome.
However, 30% of patients assigned to the physical therapy group went on to have surgery within the first 6 months (as they did not meet the study’s criteria for success). It is important to note that the patients in the physical therapy group, who did not improve enough, who then went on to have surgery, had as good a final outcome with those that had surgery immediately.
It is important to remember that this study was performed in the U.S. where surgery can be performed immediately, whereas in Canada there typically is a longer wait. So considering this study’s results and our wait times in Canada, if you have a meniscal tear get to physical therapy. Maybe you won’t even need surgery!
Trochanteric bursitis has become a catch all term for any pain on the outside of the hip.
A bursae is a fluid filled balloon that works to reduce friction between a bone and the overlying soft tissue.</h4>
A trochanteric bursitis presents with pain on the outside of the hip at the bony prominence below the pelvic crest, the pain may also radiate down the outside of the thigh.
The trochanteric bursitis is a symptom.
The goal of manual physical therapy is to both decrease the pain and determine the underlying cause of the bursitis. Determining the factors that have contributed to the bursitis is critical for a good outcome. A manual physical therapist would like not only at the mechanics of the hip but the sacroiliac joint, lumbar spine and lower leg.
Some common causes of bursitis are:
- Differences in leg length
- Early osteoarthritis of the hip
- Low back or sacroiliac dysfunction (i.e. ‘stuck’ or stiff joints)
- Lumbar nerve irritation (especially the 5th lumbar nerve)
- Habitual posture (sleeping position, standing and sitting posture)
- Overuse i.e. starting or increasing running intensity or mileage
Treatment may include manual therapy (joint manipulation, joint mobilization, soft tissue mobilization), IMS dry needling, stretching, strengthening, posture correction, education on reducing stress on the hip, ultrasound and electrotherapy.
A home exercise program is taught which will include exercises for range of motion, stretching and strengthening.
Tendinopathy has replaced the term tendinitis to reflect the latest research on the source of the tendon pain.
The term tendinitis refers to pain from inflammation.
Current research on tendon health demonstrates that instead of inflammation the tendon has micro tears with evidence of poor tissue healing. A good analogy is that the painful tendon breaks down and is much like the end of a frayed rope. If the tendon continues to be strained the breakdown of tissue and pain continues. Often the tendon becomes thickened around the area of strain as the body creates an increase in the quantity of tendon rather than quality.
Achilles Tendinopathy is common in both elite and recreational athletes.
The most common type of Tendinopathy is a midtendon, i.e. about 1” or so above the attachment to the heel bone. Less common is an insertional Tendinopathy, which is pain at the Achilles attachment into the heel bone. The site of pain can be swollen and thickened or normal in appearance. The pain can be brought on with activity or only become painful after activity.
The goal of manual physical therapy is to decrease the stress on the Achilles while promoting healing.
Reducing stress involves a careful biomechanical assessment of the foot, ankle, knee, hip, pelvis and lumbar spine looking for areas that would increase the stress on the Achilles. The problem areas are addressed by a combination of manipulation, mobilization, stretching, therapeutic exercise, and modalities such as electrical stimulation and taping.
Proper footwear, a heel lift, night splint and possibly orthotics can also be helpful. Often a ‘low dye’ foot (which supports the arch) tape is used to determine if orthotics would be helpful.
A therapeutic exercise program consisting of an eccentric loading program is critical to promote healing.
The eccentric loading program has been well researched and demonstrates good success in both reducing pain and improving function. The key components of the program are heel drops on a stair with the knee bent and knee straight. The program is done in 3 sets of 15 repetitions, twice daily 7 days a week. The program can take up to 3 months. The eccentric loading promotes the tendon to produce better quality tendon cells and promote healing and reducing pain. It is also suggested that some discomfort while doing the exercise program is normal. It is best to check with your physiotherapist about the correct exercise dosage and technique.
A video of correct technique can be seen below:
Great experiences can be had up on the ski hill. Yet, for too many people, the thrills end in spills and the dream day on the slopes is marred by a knee injury.
Knee injuries are common in skiers and snowboarders because the knee is highly vulnerable due to the very nature of how our legs are attached to the skis or boards. The foot and ankle is locked in the ski/board. So if there is a fall and the ski bindings do not release, as they should, it is the knee joint that suffers as a result. Likewise on a snowboard, the bindings do not release and therefore as you tumble down a slope your body is at the mercy to how you and your board fall as a unit.
A vast majority of injuries on the slopes involve knee injuries.
Most injuries will heal with the help of knee support/braces and physiotherapy treatment. The very worst scenario is a injury that will require surgery. The three most common ski/boarding injuries are meniscus tears, tears to the anterior cruciate ligament (ACL), and tears to the medial collateral ligament (MCL). There are varying degrees of injury to these structures from sprains to complete tears. If this should happen, a knee brace can be of great benefit to help alleviate further sports injury. Custom braces can be used to support an already injured knee to allow you to continue your ski season, but they can also be used to prevent injury, much like a helmet can help prevent concussions.
A strong core along with strong quadriceps and hamstrings are also good ways to help protect your knees too. Prior to a full day of skiing or boarding it is important to get a good warm-up at the start of your day. This can be as easy as a green or blue run where you do a lot of turns to get the blood pumping in your legs. Also take the time to stretch the long muscles in your legs, hips as well as your back.
A very simple but effective common sense tip is to always avoid skiing or boarding when you are tired as evidence shows accidents are much more common at the end of the day. So wise up and keep your knees safe on the slopes this year!