The View from Sports Center

Will Knee Pain Cost Rafael Nadal $1 Million?

He failed to win the 2009 French Open, the first time in four years, because of knee pain and knee pain may keep him from defending his Wimbledon title later this month.

It could cost him $1,200,000.

Rafael Nadal is considered as one of the most athletic and fit tennis players in the world. Yet, he his doctors say he has tendonitis in both knees that has plagued him for many, many months.

How does such a fit person end up with tendonitis and why does he still have it?

I doubt Rafael has tendonitis (and that may not be what his doctors actually said but what the media chose to report). Tendonitis is an acute inflammation of the tendon. Considering that Rafael has had knee pain since at least the end of 2008, he more likely has tendonosis. Now, you may think I'm just being picky or hyper about word choice but the two conditions are treated very differently.

Tendonosis does not respond to the usual anti-inflammatory procedures used for tendonitis like ice, non-steroidal anti-inflammatory drugs or other modalities aimed at reducing inflammation. Tendonosis is a focal weakness in the tendon from very small tears that have not fully healed. Why you hurt is still not completely understood but some research suggests that the pain comes from the stress applied to this weakened area as well as certain chemicals that ooze out of the injured tendon into surrounding tissue activating pain receptors.

Tendonosis of the knee usually involves the patellar tendon. This tendon is exceptionally strong so to tear it, even at the microscopic level, you have to use a lot of force. How this happens is most often from a combination of biomechanical abnormalities and high force levels with a large volume of activity and inadequate rest.

Tennis, certainly played at Rafael's level, is a game that creates a lot of force on the knees from sliding, lunging, sprinting, stopping, turning for hours at a time. And Rafael has been very active over the past year. Consider what he has accomplished:

• his fourth French Open title.
• his first Wimbledon title in a match considered the greatest ever.
• an Olympic gold medal.
• a Davis Cup.
• a first Australian Open title.
• several Masters titles.
• a 33-match unbeaten run on clay. 
• became the number one player in the world.
• played 14 matches in three weeks to win clay titles in Monte Carlo, Barcelona and Rome.

And, for at least some of this work, he was already injured. So, he has two ingredients for chronic tendonosis: high force levels with large volume of activity and inadequate rest (in fact, Rafael complained about the tournament calendar being too busy back in May 2009).

As for the other factor, biomechanical abnormlaties, only Rafael, his doctors, trainers, and therapists know anything about that. Typically, the biomechanical abnormalities are usually two things: weakness of the external rotators of the hip and a tendency for the arch of the foot to collapse to the floor. These two events lead to an increase in load on the patellar tendon from a twisting effect on the leg.

So, how does he heal his injured tendon? A treatment that shows a lot of promise for tendonosis is Platelet Rich Plasma injection (and in Austin, here) or PRP. Your blood contains growth factors, chemical agents that encourage tissue to heal. PRP is a process that extracts these growth factors from your blood and then injects them back into the injured tissue at a super concentrated level. But, from the people I've spoken to who have had this procedure done, it's not exactly a smooth ride. It still takes several months for the tissue to heal and in that time, you often experience spikes in your symptoms. So, just about the time you think all is well, your symptoms return sometimes with a little more bite. The end result can be very good though when combined with the appropriate forms of exercise.

If Rafael has tendonosis and he's just now starting his rehab, I think his chances of being 100% at Wimbledon are slim (and he's said that if he's not 100%, he won't play). In his case, tendonosis may come at a very high price.

DK

You can comment on any post by clicking "COMMENTS" at the end of the article. Share your opinions and ideas!

**

For the latest on MY TRAINING ROUTINES, click here .

**

New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed. Or sign up to get email updates in the box at the top left hand corner of my blog and then share this blog with your friends.

**

Did you know I have another blog? If you enjoy the science and art of getting and staying fit, you might enjoy Exercise:ology.

**

Do you have a copy of my new book, "The Little Book of Sparks"? You can read a sample and order it here.

Question From A Reader: Dislocating Patella

I gave a technically detailed answer to a question from a reader about her struggle with a chronically dislocating patella. You can read it here.

DK

News: Weak Hip Muscles Associated With Running Injuries

More evidence that when your knee hurts, the problem isn't always just your knee.
Read the article here.

DK

Number One Myth of Knee Rehab: Update

Sometimes conversations go well. Sometimes they go down the toilet faster than the 2008 stock market.

A couple of years ago, a new surgeon had joined the practice of an orthopedist whom I had known all of my career. He wanted me to meet his new partner. So, we had lunch.

Our discussion turned technical when my longtime orthopedic friend asked me to explain my position on VMO (Vastus Medialis Oblique) strengthening for patellofemoral pain- one of the four muscles of the quadriceps muscle group - to his new partner. He said, "I think you'll find Doug's ideas very enlightening. He's helped me and my patients for years." So, I did. Who knew such an innocent subject as a muscle could cause such a riff.

The new surgeon said, "Well, everyone knows that you do VMO strengthening for patellofemoral pain. I can't believe you don't do this!"

To which I replied in my best Spockian way, "Well, you can't. It doesn't have a separate nerve supply. You have to train all of the muscles and if you're going to do that, you might as well be weight bearing."

I'm not sure there's a color of red that could describe the hue on his face right then.

He's a surgeon. I thought he knew the anatomy. He didn't or I guess he hadn't stopped to think it through. He said, "Nice meeting you," with the emotion of a piece of steel and got up and walked out. No handshake either.

If you want to kill a relationship, point out the other person's shortcoming and serve it up with a few razor-edge words.

I looked at my orthopedist friend and said, "I guess he won't be sending any people our way."

"Well, he'll figure it out. You're right. Don't worry about it," he replied.

Back in 2005, I wrote about this and caused a ruckus. People with knee pain, especially patellofemoral pain, are often told by clinicians to strengthen their VMO to improve the alignment and tracking of the patella (a Structuralist view). By improving where the patella sits and travels, knee pain will improve - so the theory goes. The exercises for this selective strengthening are typically quad sets, limited range of motion knee extensions with or without the addition of electrical stimulation. But, since the VMO doesn't have its own nerve supply, you can't isolate the muscle from the rest of the quadriceps.

But, this isn't just my opinion. Cerny examined this in 1995 and found no difference between the VMO activity and the rest of the quadriceps for a variety of common exercises used to target the VMO.*

And now, a new study reports:

 "A large number of PFPS patients can experience significant improvements in pain, function and Quality of Life, at least in the short term, with quadriceps femoris rehabilitation, with or without emphasis on selective activation of the VMO component." **

For those of you with knee pain, this means that working on your entire leg strength is preferred to attempting to isolate the VMO. Why? Because the knee serves at the pleasure of the hip and ankle. It's stuck in between and needs to learn to work in harmony. And people with knee pain will almost always have weakness of the hip on the same side as the knee pain which means that the hip will have trouble directing and controlling motion at the knee ***. So, to get everyone to play together, the hip, knee, and ankle, you have to train on your feet (even if you have to reduce the effect of gravity).

DK

* Cerny, K. (1995). "Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome." Phys Ther 75(8): 672-83.
** Syme, G., P. Rowe, et al. (2009). "Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening." Man Ther 14(3): 252-63.
*** Boling, M. C., D. A. Padua, et al. (2009). "Concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain." J Athl Train 44(1): 7-13.

Why Do I Hurt Under My Kneecap?

For such a small bone, the patella (kneecap) seems to cause a lot of problems.

Pain under the patella (or around it) carries many names: patellofemoral pain syndrome, retropatellar pain syndrome, runner's knee, jumper's  knee, chondromalacia patella among others. And it also carries frustration for both clinicians and patients.

For decades, patella pain has been explained and treated by Structuralism - a school of thought that believes the genesis of musculoskeletal complaints is from one or more biomechanical abnormalities. For patella pain, the biomechanical abnormalities include a laterally tracking patella, weak medial quadriceps, tight hamstrings, tight iliotibial band, tight calf muscles, weak or tight hip rotator muscles and over pronation of the foot. A Structuralist view would then be to set the mechanics "right" and symptoms would subside.

But, there's a problem with this view. No one has perfect biomechanics. Most people do not train muscles, work on flexibility, for example, enough to alter or maintain a biomechanical homeostasis and they don't know their biometrics (strength, flexibility, motion, power, balance, etc.) well enough or at all to direct their training toward any specific deficit. So, most people go through life with a variety of "abnormalities" and are just fine until one day (or over a series of days) something happens and suddenly pain appears under the kneecap.

The reason a person hurts under the kneecap is because the force applied to tissue(s) is greater than what the tissue can withstand. There are two primary sources of retro-patellar pain from tissue over load: sub-chondral bone and synoivum. I'll cover sub-chondral bone today (there are sources of pain outside the knee that can create knee pain but that's another day).

The over load can occur from a high force, blunt trauma such as a fall on the knee or a lower load, sustained force such as sitting in a three hour movie with your knees bent to ninety degrees. Function occurs across a certain range of loads or a "physiologic zone". When you move too far outside this zone, past the edge of your physiologic function, you often develop symptoms. The cartilage under the patella serves as a force attenuator. It slows the transmission of loads into the underlying bone much like the bumper on your car protects the frame from collision. When the cartilage is too soft, the force travels into the bone at a higher rate. Whether the overload is from blunt trauma of a fall or the sustained overload of a movie, the bone under the cartilage of the patella may experience force greater than its ability to manage it and the result is you hurt (cartilage has no nerve endings so it can't be a pain generator). In fact, there is actually an increase in metabolic activity in the bone similar to a stress fracture with resultant swelling. The increase in pressure activates pain nerve fibers.*

When you get up from the movie for example, your knee may hurt for a period of time then go away. So, from a Structuralist perspective, does that mean your biomechanics improved? No. It means that your tissues were able to return to a state of biochemcial equilibrium. The time for this to occur varies depending on how "fit" your tissues are, how far over your physiologic edge you were pushed and what you chose to do following the movie (move around or walk next door and sit through a meal with your knees bent to ninety degrees again).

I'm not suggesting though that biomechanics are not important to address. Weakness of the hip external rotators. for example, allows the femur to rotate inward and create focal loading points under the kneecap. But, failure to also address the tissues at risk (in this case both cartilage and bone under the patella) often results in a short term resolution of pain with long term recidivism.

Haing once been a Structuralist, I understand its allure. You can sometimes see the biomechanical deviations, feel them, test them and the urge to direct all of your attention to the mechanical variants is exceptionally strong. Sometimes, it works. Most of the time, it doesn't.

DK

Dye SF, Chew MH: The use of scintigraphy to detect increased osseous metabolic activity about the knee. J Bone Joint Surg 75A:1388–1406, 1993

**

For the latest on MY TRAINING ROUTINES, click here .

**

New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed. Or sign up to get email updates in the box at the top left hand corner of my blog and then share this blog with your friends.

**

Do you have a copy of my new book, "The Little Book of Sparks"? You can read a sample and order it here.

Question from a reader: MCL Tear and What To Do?

This takes less than 8 minutes to read. If you have an MCL injury, you'll find it very worthwhile.

I recently received an email from a reader, Nancy, (the email is below my answer with personal information removed) who was struggling with a few things after tearing her Medial Collateral Ligament (MCL) in her knee. I boiled them down to these:

• If something hurts, should you stop?
• Should I push my self to get my motion back or not?
• Do you use a different process for strengthening the leg when you've had an MCL tear?

Here are my thoughts on this.

This breaks down into a few parts: anatomy, biomechanics, and tissue healing. I'm giving a few suggestions, basics; not a comprehensive list of all of the things I would do. That's a book and I doubt any of you want to read a book today in this post. But, there's enough information here to get you on the path to recovery and to understand how these three components fit together.

Ligament is a tough, fibrous tissue with very little give or elasticity in it. It's job is to connect bone to bone and keep joints from moving more than they should. The MCL is tightest when the knee is straight which is why, usually after a Grade III tear, you end up in a brace that really doesn't let your knee move much. Also, I'm usually concerned about joint surface damage after an MCL tear because the force that it takes to tear the MCL is fairly large, what's called a high energy transfer, and that force just went through the knee. Sometimes people escape without any obvious damage but it's on my list of things to watch for. A bone bruise is another common injury with an MCL tear and you may not see that on MRI; probably wouldn't. You probably would need a bone scan to pick that up but, a bone bruise will reduce weight bearing ability and interfere with the rate of progression functionally as will damage to the articular surface.

The first part of tissue healing is a mad dash for real estate. New cells, scar, scramble around looking for a place to land. Some of these cells will land where they're supposed to, somewhere in the ligament or attached to the torn ends, and some won't. Some scar may end up on the medial meniscus or other "normal" tissue in the region. This can create trouble when you try to bend your knee later because the scar tugs on the meniscus and other tissue and it would prefer to be left alone. Result is - you hurt.

So, for the first eight weeks, roughly, scar tissue forms tethering the torn ends of the ligament and does its best to tie them together but without some guidance, which usually comes from the stress of load and motion, the result is mixed. What you have at eight weeks is sort of like a repaired bridge without all the struts and slats and bolts and some of the slats are going in the wrong direction. But. at least you have a bridge.

After the first healing phase, and there's some disagreement about the time but eight weeks is typical, is when the remodeling begins. This is when you start knocking the boards around, adding some more, shoring it up, making the bridge drivable. It may not be a very pretty bridge when you're done but if you do things right, you can drive a tank over it.

Exercise plays a crucial role in the remodeling phase and it's not just exercise at or for your knee. The knee serves at the pleasure of the hip and ankle. It goes where they go. Injuries to the knee and the subsequent decline in activity, causes atrophy of the quadriceps muscles and reflexively dials down the strength of the hip muscles. Unfortunately, much of rehab following a MCL injury is focused on muscle strengthening, of course that is important, but the tissue that needs the most help is the ligament.

Ligaments will heal best by applying controlled stress with a functional focus. The MCL does two main things for your knee: keeps the medial or inside part of the knee from opening up too (and it does this in all angles of knee flexion) and keeps the tibia from rotating too much. After about four months of work, the MCL will be close to 85% of normal strength but it takes almost a year for it to reach 100% and it's the type of movements that you use that influence the rebuilding of that strength.

Getting Your Motion Back (If something hurts, should you stop and should I push my self to get my motion back or not?)

If you've had your leg in a brace for four to eight weeks, your knee is not going to like it when you try to bend it but you have to get your motion back to be functional. Many years ago, I would force the issue and be much too aggressive. These tissues are nudged into changing their length; not pushed. Physiologic pain is not necessarily bad for you. Physiologic pain is what you feel when you tug, twist or squeeze tissue. Remember that the healed ligament is shorter than normal and you'll need to gradually lengthen it. Ligament responds best to a low load, long duration stimulus to alter its length. This is why I use the Total Gym so much (a Pilates Reformer may work in the early stages of remodeling too). I can use a low load, 20-30% of body weight, and ask you to perform a bilateral squat. You squat until you feel some pain, hold the position for about 30 seconds, and repeat. Over and over. I set a timer for 15 minutes. Do a set then move on to the next drill then come back and do another set. I often would use at least three sets and sometimes up to five.

You can also use more conventional techniques such as gently pulling your foot toward your (lie prone, use a sheet around your foot, hold onto the other ends and pull your foot) head. Again, you want to hurt a little. Hold the stretch for 30 seconds and release. Repeat this for about 15 minutes, take a break and go again.

You're not going to gain a lot of motion in a hurry though. Dense connective tissue changes slowly so expect about 10 degrees a month on average. Normal motion of the knee is about 130 degrees of motion. So, if when you start the process, you have 80 degrees, it may take five months to get the remaining motion back. Often what happens is you'll gain 20 or 30 degrees in a few weeks and then hit a very slow cycle of improvement. The temptation is to then push harder. Don't do it. Nudge your tissues. You'll have a healthier knee when you're done.

How do you know when you've pushed enough or too much? My definition of an injury is this: a transfer of energy that disrupts cellular processes leading to a decline in physical function. Pain is not an injury. If you lose motion, your muscles won't fire properly, you start limping, and these types of symptoms last for more than 72 hours, then you've injured your self. Otherwise, I usually press on (and I emphasize usually here because in most cases there's a fair amount of coaching that takes place to reduce inherent fear).

Getting Your Function Back (Do you use a different process for strengthening the leg when you've had an MCL tear?)

The short answer is yes. As part of the remodeling process, I apply stress to the ligament and usually use a Total Gym (it also is part of getting your motion back). You lie on your side on the Total Gym (injured limb up) at a low level - Level 3 or 4. Now, perform a single leg squat through the range of motion your knee permits. The force of gravity applies a gentle gapping stress to the inside of your knee which your injured ligament restrains. Since the MCL restrains this gapping through all degrees of flexion, this drill stresses the ligament in exactly the way it's used. It gets stronger as a result of this stress. You can work on your motion (described above) as well.

As soon as possible, you want to be up on your feet stressing your leg through various functional movements. In our facility, we have tools that can alter the effect of gravity so we can perform movements such as a squat and reach across your body (the rotation stresses a different part of your ligament) that you might not be able to perform under full body weight conditions. We also use a treadmill with body weight support to allow you to walk sideways (great medial stress), backward, forward, high step, foot over foot. The idea is to blend function into the remodeling phase. You could use a pool and walk in about chest deep water. The buoyancy of the water will protect the weak tissues and the resistance will add some stress.

Balance and coordination drills become important since ligaments have receptors in them that tell your brain where your knee is at any give moment. A simple drill to challenge balance and stress the rotational element of the knee is to stand on the injured leg only and hold a weighted ball in both hands with the arms straight (something that weighs 2 to 4 lbs). Now, turn your body side to side. This creates perturbation and your foot, knee, and hip react to it. Sometimes all you need is just the weight of your arms. This may hurt some. If you're concerned about it, go back to the definition of an injury and then decide if this drill is too hard or not.

Getting Your Strength Back (Do you use a different process for strengthening the leg when you've had an MCL tear?)

None of this recovery is linear. While you're working on your motion, you should also be working on waking your muscles up. Conventional techniques such as isometrics (quad sets, glute sets, straight leg raises, etc.) work well but are not strength building drills. Their purpose is to get the muscle to fire properly then you have to begin stressing the muscles as functionally as possible. A great way to get the hips and quads to work together is to perform a plank drill. This forces your muscles to work at a reactive level bypassing the conscious part of your brain.

The muscle fiber that seems the most difficult to recruit is the fast twitch fiber and it just happens to be the most important. You'll activate fast twitch under either of two conditions: speed or high loads. If you haven't had joint surface damage, you can load your knee in a pain free arc using a resistance that causes high levels of fatigue within 8-10 repetitions. My preference is a squatting type of drill; not a knee extension drill. This will begin recruiting fast twitch fiber. If you've had joint surface damage, you can do this eventually, but you have to go through a joint conditioning program first. You can perform squats either on a Total Gym or something comparable, a Reformer, or even upright if your able to move through the range and control the movement pattern. The key is to use enough load that your muscles start running out of gas in about 10 repetitions but that you could do 2 more. Stop when you hit 10 but could do 12. Rest one minute. Repeat this three times.

So, those are the basics. I hope this helps. And, just to make sure I've answered the top three questions:

• If something hurts, should you stop? No. As you stress the tissue and lengthen it, you'll hurt. But, it should be a physiologic type of pain (hurts at the time and not longer than 72 hours).
  
• Should I push my self to get my motion back or not? Yes. You have to. Read the definition of an injury to determine if you pushed too much.
  
• Do you use a different process for strengthening the leg when you've had an MCL tear? Yes. Blend function into the remodeling phase.
  

DK

---

I am looking for someone who seems to have more practical experience and thinks beyond the realm of what 80% of the trained PTs out there know.

First my MCL tear was Grade III, the radiologist suspected it was complete and diffuse, tear was at the femoral origin.  The Medial retinaculum was not as well described but I understood it to be the most medial part of the retinaculum which follows the line of the MCL not the portion that merges with the rectus femoris tendon.  The patella was not dislocated.

At first I was eager to start PT 2 weeks after my injury because I could tell that the immobilization had allowed the ligament to reattach.  I was eager to get back muscle tone before I lost all of it. My orthopedist explained to me that would not be wise.  And I realized that although the MCL would slacken with knee flexion, the medial retinaculum (MR) would not.  So I continued to rest, try minimal flexion/extension heel slides and ice. I totally bought into the idea to not move into any pain. So even if that had been a good idea it is no longer and option.  I continued to rest and deal with the issues and sensations that occur as muscles atrophy.

Now at 5 weeks, I have the OK to start PT and find myself confused - do I try to increase my range of motion even if it causes pain?   I tried walking around, slight bending felt good without my brace but then ended up feeling at the end of the day like I had sprained my knee it hurt so much right at the MCL/MR where the original tear was.  So I figure I did too much, but then for the most part it didn't hurt when I was doing everything, it hurt later when at rest...

SO on one hand I would think - if movement causes pain then I should not do it.  But what I am told is that I need to work through that pain to get back range of motion.  Is that true?  When I read your blog on the typical exercise of trying to isolate muscles by pushing the back of the knee into a towel vs having all the muscles work in harmony you made sense.  I have also been thinking about your notes on ligament healing and how the ligament is supposed to be stronger than the muscle. I also understand that at USC they are doing research on ligament/tendon healing and that eccentric not concentric work is key.   Based on these thoughts does it  make sense to push through pain to get range of motion and strength in a muscle back does this really strengthen the ligament or does this force the ligament to become lax and rely on the muscle to do its work?  (The same way the global mobilizing muscles take over for the structural stabilizers?)  If this is true then would re-strengthening take a different tack?  Or would it be the same initially and then branch off...

What do you think, what would you advise? 

A Tip From a Hall of Famer

It's been three days since Cirque died and well, to be honest, I'm moving into the normal pace of life slowly. I didn't realize how much of him had been woven into me. Cirque has always been Elle's boy but over the last year, he and I spent a lot of time together. The energy level in our home is about 20% of what it usually is and I'm fairly sure that Spencer is sad. He is normally a very energetic, happy to see you, what's next kind of dog but since Tuesday, he's been very low key and just lies around. I've read that dogs grieve and from what I see in Spencer, I think it might be true. If anyone has any tips on how to help a grieving dog, I could use them.

So, in an effort to get back to a normal routine, below is an email I received recently from a Sports Center Hall of Fame member about a novel approach to taking care of his knees.

Well done Grasshopper!

---

Doug-

Regarding cycling…..as you’ve mentioned it: Here’s what I’ve done regularly since graduating. It sounds really simple but I’ve never heard anyone else mention it.

After a tough session on a stairmaster (with  backpack) or some other form of knee grinding exercise, I get on a stationary bike and I…..here’s the trick….I cycle backwards. For about 10-15 minutes. While I’m doing this, I’m consuming fluids and electrolytes which I lost during the earlier parts of my workout. It feels great. Once you get the hang of it and can do it smoothly, it truly is an ultra-low resistance, inertia fueled version of a tailgater. Granted, it is a limited range of motion and you don’t get the assistance which you get on an NK table, but it seems to work for me.

 When people at the gym point out that I’m cycling backwards, my stock reply is: :”Yeah…..Am I getting any younger?”.

 Maybe I am!

 Omar

**

For the latest on MY TRAINING ROUTINES, click here .

**

New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed. Or sign up to get email updates in the box at the top left hand corner of my blog and then share this blog with your friends.

**

Do you have a copy of my new book, "The Little Book of Sparks"? Here's what one reader had to say about it. "This was great reading. "The Little Book of Sparks" inspired me to live a healthier lifestyle. Each chapter in the book motivates me to do something daily to keep my mind and body healthy and active. This is a book that's entertaining, and filled with simple suggestions that when applied to our daily routines make a positive difference in our health and happiness - David."

You can read a sample and order it here.

More Motion and Less Load for Osteoarthritis

"So, why does this feel so good on my knees?"
"Why does this work?"
"What's happening in my knees when I do this?"

These are commonly asked questions by people who first experience the wonder of Tailgaters. This is a very simple, seemingly too simple really, exercise performed on a special device called an NK Table. An NK Table is an very old tool in physical therapy dating back to the 1950s. It was invented as a strengthening device; one of the first knee extension machines. The machine has two adjustable bars or resistance arms on each side. The intent of these arms was to restrict the range of motion of the exercise and to change the magnitude of force within the arc of motion. But, I found that if you placed your legs on top of the resistance arms and used a very light weight, the machine could help you swing your legs - kind of like sitting on the tailgate of a pick up truck and swinging your legs in the air. Hence, the name Tailgater. The top image to the right is NOT how we use it; the bottom image is how we use it. Notice that the leg is on  of the resistance arm.

Tailgaters feel really good if you have osteoarthritis of the knee. In fact, we have some clients who just want to sit and swing their legs and if they had their way that's all they would do. So, it's natural to wonder why something so simple can be so helpful.

First of all, the idea that easy motion on arthritic joints is helpful is not new. In the 70's, Robert Salter, MD invented the Continuous Passive Motion (CPM) device which helped patients move their knees after surgery. He found in his research that injured joints healed faster and more completely if they were moved gently. Of course, at the time, his colleagues all thought he was nuts. They were placing people in casts thinking that injured joints had to be protected. Well, it turns out that both camps were right. Diseased or injured joints need motion but the load that accompanies that motion must be light - at least at first. Salter's machine drastically reduced the load on the joint while it moved the joint and not it's the gold standard for procedures like Knee Replacement and ACL Reconstruction.

In the 80's, I started studying the effects of exercise on joints and stumbled onto Salter's work (remember, no Internet then. It was all old school - go to the library!). I had been introduced to the NK Table at a hospital on one of my clinical rotations. So, what happened is like that commercial for Reese's Peanut Butter Cups where the two trucks collide, one chocolate and one peanut butter and bingo, you have the Reese's Peanut Butter Cup. Make the NK a CPM. Just change how you use the resistance arms. Make them assistance arms.

The science behind the light repetitive motion produced by a Tailgater exercise is this: light repetitive motion alters the secretion of a joint lubricant called hyaluronan*. This substance improves the fluid in your joint, makes it easier to move and it also binds water making your cartilage stiffer; more resistance to load. The result is that your knee feels better. It's not permanent though. You'll notice improvements almost immediately but you'll have to repeat the exercise frequently to reproduce the effect. Over time, you'll have to do less of it but most people would really rather do more; not less.

There are a few other ways to create light, repetitive motion in your knee:

• Use a skateboard. Sit down in a chair. Place your foot on the skateboard. Slide your foot back and forth.
• Use a furniture mover. These work best on carpeted surfaces. Do the same thing as with the skateboard.
• Use a rocking chair (yikes!). Yep. Rocking chairs create small, light motions in the hip, knee and spine. They really work.
• Swing your legs in water while sitting on the edge of a pool. For this to work, you have to swing your legs very slowly. Otherwise, you'll fatigue the muscles too fast.

People often ask if they can use cycling as a way to improve their joint health and the answer is, it depends. It depends on how much motion you have in your knee, how irritable your knee is, and how easily you can control the resistance on the bike. Cycling can create body weight or higher loads on your knee so it's usually not my first choice. But, it is an option. And, only on a stationary bike.

We suggest fifteen minutes per session and aim for three sessions per day. The key is to move slowly and feel very little fatigue in the muscles. The purpose is not to strengthen your muscles; it's to improve the fluid in your knee.

More motion; less load and your knees will feel better.

DK

*Ingram, K. R., A. K. Wann, et al. (2008). "Cyclic movement stimulates hyaluronan secretion into the synovial cavity of rabbit joints." J Physiol 586(6): 1715-29.

**

For the latest on PROJECT SKI: MY QUEST TO RETURN TO SNOW SKIING, click here .

**

New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed. Or sign up to get email updates in the box at the top left hand corner of my blog and then share this blog with your friends.

**

Do you have a copy of my new book, "The Little Book of Sparks"? Here's what one reader had to say about it. "This was great reading. "The Little Book of Sparks" inspired me to live a healthier lifestyle. Each chapter in the book motivates me to do something daily to keep my mind and body healthy and active. This is a book that's entertaining, and filled with simple suggestions that when applied to our daily routines make a positive difference in our health and happiness - David."

You can read a sample and order it here.

Do You Believe Aleve?

The full page color ad for Aleve suggested that if you wanted to be able to do the things you love and be free from joint pain, all you had to do was take Aleve. Just two pills will wipe away arthritis pain for a whole day. Life will be grand.

But, in very small print in the bottom left hand corner that no one who actually uses this stuff can read was a disclaimer: "Use as directed for minor arthritis pain."

So, what exactly is "minor" pain? And, if you have minor pain, why are you taking a pain reliever? The people I've met who take over-the-counter non-steroidal anti-inflammatory (NSAID) drugs regularly, like Aleve or Motrin or Advil, hurt doing things like walking, climbing stairs, or lifting a bag of groceries so much that they avoid the activity. That's not minor pain. Minor pain is a nuisance; annoying but it doesn't interfere with your function. It doesn't alter your movement. And, minor pain goes away on its own so you don't need any help from drugs.

"Use as directed...." is one pill every 8-12 hours for no longer than 10 days. Few people I've met actually do that. Some have been taking NSAIDs for years. Here's what's really happening. People with joint pain hurt enough that they can't do the things they need to or want to so they turn to an over-the counter drug like Aleve because the advertising is non-stop, everywhere you go, in nearly every magazine, on radio stations, TV, and online. It's a massive onslaught of misinformation aimed directly at the heart of the unsuspecting and vulnerable. But you don't know that it's misleading because you don't know why you hurt nor do you know what drugs like Aleve actually are doing for you. You just trust the ad implicitly. Afterall, companies can't actually lie to you, right? They can't run a TV ad that misleads you, right? The government makes sure of that so it must be ok. Right. Where have you been living?

I don't believe Aleve. They're not being honest with us.

What's the truth about drugs like Aleve?

These drugs may relieve pain. The research on this is mixed. But, even if they do relieve joint pain you still haven't addressed why you had the pain in the first place and you're not one bit healthier or stronger or more capable of doing the very thing that forced you to pop a couple of pills to begin with. And in fact, there's some research that suggests you could make your self much worse. The joint may get weaker even as you feel better. Oh, and I forgot to mention the myriad of gastrointestinal side effects from it.

I'm not saying you should not take Aleve. If you have to, you have to. I have. If taking a drug like Aleve is the difference between you getting on a cycle or an elliptical machine and sitting on your butt, the upside of the exercise is greater than the potential downside of doing a bit too much because you feel better than you actually are. But, keep in mind that NSAIDs may make you feel like you're ready to run or play tennis or hit the gym but your body has a protective armor like the outside of an M & M. It seems pretty tough but tap on it and the whole thing caves in. So, proceed with caution.

I know many of you want to know what to do. I've written some articles (below) on dealing with joint pain. Maybe these will help.

• A New Supplement for Chronic Joint Pain
• How to Use Supplements to Rebuild Your Joints
• How to Cut Your Risk of Getting Osteoarthritis
• When Less is More
• Knee Pain in Wisconsin

In the meantime, this issue weighs on me. I think about it a lot, have dealt with it myself, have several friends who struggle with joint pain and I've decided to do something about it. Many of you have asked me to compile information rather than dig through a large website. So, here's what I'm doing: working on a book all about joint pain, injuries and how to deal with them and then adding more detailed information to Exercise:ology. As that happens, I'll let you know.

Onward....
DK

An Angry Iliotibial Band...What to Do

H

i Doug,

I stumbled upon your blog. Sitting here with a bag of frozen broccoli on an angry ITB. Ha. After a two year hiatus from running I have returned SLOWLY to walking, swimming and some running. My ITB flared up in the past and lay dormant all this time- waiting to reclaim its hold on any plans of race day glory. Im 37 years old and feel like the clock is ticking too fast.

 

I consider myself an expert on the vast blogs and internet approaches to treating ITB. I have done every "ITB...marathon training..physical therapy... running" web search. I have read it alllll. You are one of the FEW people I have read that touts the impracticality of stretching a brick. Your argument made alot of sense.

 

I found your take very interesting. Im 37, fit and interested in a conservative approach to learning HOW to address the ITB problem. I am overly flexible, and probably lack strength. I have had some success with PT- but everyone says stretch it, stretch it stretch it. I wound up with a nasty hip bursitis (which began my running hiatus).

 

My question is- I have read your entire blog looking for specifics on what path to take. I have correct shoes, run on soft paths, avoid hills. Beyond Rest, Ice and taking time off...do you advocate a foam roller or specific hip excercises? I live in Durham NC and cannot come see you in practice. Do you have any tips on HOW to treat ITB generally speaking. (I know you cannot treat people over internet). I just mean...do you suggest massage, roller or specific hip strengthening-all things equal.

Sorry if I rambled. I am a frustrated wanna be athlete.

Thank you, in advance, for any info you might share. I have to go the broccoli is starting to get mushy.

Sincerely,

J

---

A few years ago, I felt compelled to come up with answers that people could execute on their own and, as a result, created a great deal of internal conflict for my self and loss of sleep and who knows how effective the advice was. I understand this problem, ITB Syndrome, but I use certain tests to help clarify the nature of the it and certain tools to fix it. You, the reader, may or may not know how to do the tests or have access to the tools. I understand that might be frustrating to you but I'm trying to be as helpful as I can. I hope the information that follows helps you.

Treatment of ITB Syndrome: Fundamentals ( and this is the kind of topic I'll be covering in my new blog - I'll post this once it's up).

There are three main components: biomechanics, tissue injury, and attitude. What the reader has bumped into is that most approaches for this problem come at it from one of the components, usually biomechanical (orthotics, stretching, etc), and leave out the other two. So, if you actually have tissue damage in the ITB, which is entirely possible, and you correct the biomechanics, the tissue is still weak. So, when you resume loading it, as in running, symptoms return.

• Make sure you really have ITB Syndrome and not degenerative joint disease / chondromalacia. Fluid from inside the joint can find its way under the the ITB which then increases the pressure between the ITB and the bursa. Other signs and symptoms of a joint problem include aching, stiffness, a sense of fullness in the knee or pain. You should also have a positive Noble's Test (pressure applied to the lateral condyle of your femur while flexing and extending it through 30 degrees of motion).
• Now for biomechanics...and why I cannot tell you precisely what to do but can give you guidelines.
  
  • People with ITB Syndrome tend to have a high medial arch of the foot and impaired control of the rear foot. Your orthotics should correct for that, if you have it, and not for the more common "flat foot" found in the general population.
  • Make sure you have adequate dorsiflexion of the ankle as inflexibility is associated with ITB Syndrome. If you lack motion, find out if it's from tightness or structural limitations (you'll need a therapist to help you).
  • Check your hip strength since weakness of the gluteus medius is common in ITB Syndrome. Stand on a step with one leg off the step allowing the hip to drop. Hike your hip up without rotating the pelvis right or left. You should be able to bring the top of the pelvis well above the horizonatal and be able to do this at least 10 times. Check both sides. Usually, the side with symptoms will fatigue sooner and / or you will not be able to keep the pelvis from rotating. I also use a digital muscle tester to test your hip strength using other motions which provides an exact measurement of your strength and I can compare this to both your other side as well as to a ratio of strength to body weight. Either case, your hip muscles are too weak and if so, you're not ready to run.
  • Check your single leg squat strength. Stand in front of a chair on one leg with the back of your leg just in front of the chair. Hold your other leg off the ground in front of you. Squat down until your knee reaches a 70 degree angle and then stand up. I use an adjustable table that limits the range of motion. Watch the pattern of motion of your leg. Your knee, as you look down on it, should travel in a reasonably straight line. If not, if it tends to wobble in and out, and you are unable to control it using your muscles, your hip muscles and leg muscles are weak. You should not run until you can squat up and down at least 30 times.
• Now to address the tissue injury (assuming there is one which in most cases is not an inflammatory disorder (as in tendonitis) but a tendonosis (and if you actually have a joint disorder, that's another story).
  • What to do here depends on how "irritable" your tissue is; how quickly you hurt. The treatment of tendonosis always involves discomfort. The exercise needs to stress the tissue. I usually use squats - single leg - at a load level that produces some discomfort in the leg between 20-30 repetitions and aim for 30 repetitions. I often use squats in supine (lying on your back) and in a sidelying position on a Total Gym since almost everyone I've seen with ITB Syndrome fails the hip and leg strength tests and has to exercise with less than full body weight. Perform 3 sets resting about 1 minute between the sets. This yields 180 repetitions of load and depending on your body weight, could be between 6000 and 10,000 lbs of load.
    
    • People often get anxious about pain during the exercise. Tendosois pain generally won't hang around long after the drill and the degree of pain should be mild to moderate.
  • As your leg gains strength, I usually add hopping on the Total Gym until you pass the hip and leg strength tests and then begin some limited hopping full body weight. The hoppin g prepares your leg for running.
  • I use sidelying hip abduction drills (some call these hip or leg lifts). While on your side with the bottom hip and knee bent, align the uppe leg such that it forms a straight line with your trunk. Lift the leg up and down like a pump handle keeping it straight. As you fatigue, your leg will want to drift forward. If you cannot keep the leg in the proper position, stop. This exercise will fatigue the hip muscles considerably.
  • I also use standing hip abduction drills. Standing on the symptomatic side, I attach a pulley to just above the ankle of the other leg. Now, bend the weight bearing knee about 20 degrees. This activates the hip muscles. Move the oppostie leg away from the body and then back. Repeat this 30 times, 3 sets with a minute of rest in between.
• Now to address inflexibility and pain...
  • I use a foam roller under the involved side. Lying on top of it, just roll your leg back and forth, up and down. It doesn't matter which pattern you use. It will likely hurt. If a tennis ball feels better, use it. This procedure often reduces pain and improves flexibility through reflexive relaxation of the hip muscles.
  • I use Capsaicin as a topical agent over the region of pain to reduce symptoms.
• As for attitude....
  • This is reflected in how well you pay attention to your symptoms and the choices you make. A very difficult thing to do, for just about everyone, is to accept your current state of abilities and work from that level. If you find your self refusing to give up running, for example, despite symptoms that force you to stop or cause you to modify your running for, you have an attitude problem. No amount of physical treatment will work in the presence of an attitude that runs on denial.

I hope this is helpful. I realize it's a lot of stuff (and it's not everything, that's a book). But, you asked :-)
DK

**
New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed. Or sign up to get email updates in the box at the top left hand corner of my blog and then share this blog with your friends.

**

Do you have a copy of my new book, "The Little Book of Sparks?" It's a great thing to have around when you need a little emotional boost. You can read a sample and order it here.