As trainers we see a lot of knee pain. In this blog we are going to discuss anterior knee pain, as this seems to be cropping up recently in practice and is a more difficult one to treat. Trainers tend to be good when dealing with medial and lateral knee pain as the causative factors are more straight forward. Anterior knee pain is slightly more complex and can cause a few heads scratching in the gym.
AKP is usually associated with weakness of the vasti and hip muscles (Cichanowski et al. 2007). IT band tightness is usually associated with knee pain if it is acting as a stabiliser due to hip weakness in the frontal plane due to glute med and glute weakness. In this case shortened fascial connections with the distal IT band and lateral patella retincaculum could alter patella tracking (Page 2001).
There tends to be motor control deficit in clients with AKP, usually seeing a reversal in the normal firing order between the VM and VL with the VL firing earlier (Voight and Wieder. 1991). A typical corrective strategy is to strengthen the VM with isolation exercises to address the muscle firing balance.
EMG evidence does not support support the idea that strengthening the VM vs VL in a attempt to improve patella tracking and control in relation to the patella groove (Kettunen et al. 2007).
Other research (Tyler et al. 2006) showes that it maybe more effective to trat AKP by strengthening the muscles that control the patella directly is not as effective in reducing AKP as improving the strength and flexibility of the hip.
This provides some great guidance for trainers who deal with stubborn AKP as well as another route to pursue. Practically then it is worth screening the pelvis for dysfunction as well as the knee for imbalances which brings us back to the old fall safe 'one should assess the joints above and below the site of dysfunction'.
John
Tuesday, 26 April 2011
Sunday, 3 April 2011
Hamstring tightness....is it the hamstring?
Hi All! This is IMF Performance Training's first blog post, we hope you find it impartial, useful and just as importantly, you feel we are not trying to sell you anything! Our soul mission is to cut out the rubbish and deal with the useful. We do not pretend to know all the answers but will provide posts that are based both on research and experience.This is a open debate so please throw your pennie worth in, as constructive feed back is great.
As a athlete, trainer or coach you will not need to spend long on the track or in the gym to notice that there is ALOT of hamstring tightness. Due to the high number of hamstring strains and 'gym talk' around it, it is worth having a chat around the subject to clear up the uncertainties.
Firstly it would seem that we look at the hamstring flexibility in the wrong way, perhaps our PT books were a little dated? or the body building world influenced our anatomy bias too much? Firstly we must stop thinking of the hamstrings in isolation as a muscle, can they be tight on their own? Maybe maybe not..however it is impossible to isolate them, so unless you are working with a cadaver forget about it. There are a number of structures before you get to the hamstring that you should assess first before concluding that the muscle is 'tight'. What might look like hamstring tightness usually isn't! Sound complicated? It is! However we can go through step by step.
What we need to think of is what movement the do the the hamstrings restrict? What is your end goal that you are trying to achieve? Really what I am saying here is we should be more concerned about the joint range of motion at the hip rather than the length of the muscle its self. Generally the muscle is not tight, it is the connective tissue, lack or correct movement patterning, neural tension and restrictions in the supporting fascia that restrict the movement.
The standard 'text book' checks you would normally do to look for basic movement at the hip are as follows:
Active Leg Raise
Lumbo-Pelvic Rhythm
Squat Pattern
However, typically I hear people say that 'i just cant get rid of my hamstring tightness' and I cant ever pass those tests above, my first response to that is how often do you stretch? Mostly the answer I find out is..not nearly enough! So to start with i would look here! We all know how to stretch the hamstrings so i am not going to teach you suck eggs. However, what if you have a client or athlete that stretches every day, or you just keep plugging at it as a trainer and it doesn't clear up? This is frustrating and it is likely that there is a restriction some where else in the body causing the muscles to remain tight, this is known as 'hypertonicity'. There are a number of factors that could lead to the hamstrings 'holding on', i have listed some of them out as a check list below for you to have a think about:
- Is the sciatic nerve tight? - If it is the muscles will remain tonic to protect it.
- Is there piriformis tightness? - If so, the pelvis maybe rotated adding stress on the hamstrings. Also the sacrotuberous ligament maybe impinged.
- Is there adequate t spine mobility - If not the lumbar spine will become too mobile to make up for it and the hip will be forced to try to stabilise the lumbar region. Also the lack of rotation at the t spine will place more rotational forces at the hip.
- Are the glutes strong? If not the hamstrings will be overstressed in helping hip extension and forming trigger points.
- Is the hip flexor group tonic? if so the glutes will be inhibited placing excess stress on the hamstrings and causing trigger point formations in the hamstrings.
If you have cleared all of the above and the hip still does not have adequate range of motion, then it is worth having a look into restrictions up and down the whole of the superficial back line. The superficial back line is a myofascial meridian that connects the toes to the back of the head via fascial connections. It would be worth employing a manual therapist to assess this for you however, in my experience take a look at the following if you have the expertise.
- Does the plantar fascia allow adequate ankle mobility?
- Does the calf allow adequate ankle mobility?
- Is the soleus tender?
- Is the hamstring tender?
- Is there tension in the posterior thigh fascia?
- Is there restrictions in the thoraco-lumbar fascia?
In summary, lets not try to focus too much on the hamstrings themselves. Lets look at what could be causing the hamstrings to 'hold' on. Think about multi-planer hip mobility, and the connective tissue that can restrict the movement you are trying to create ie ALR or LPR, this should lead to the answer! Remember, be objective and consistent in your testing.
Hit me back with responses!
John Scriven MSc, ASCC
Biomechanics Coach
IMF Performance Training
http://www.i-movefreely.com/
As a athlete, trainer or coach you will not need to spend long on the track or in the gym to notice that there is ALOT of hamstring tightness. Due to the high number of hamstring strains and 'gym talk' around it, it is worth having a chat around the subject to clear up the uncertainties.
Firstly it would seem that we look at the hamstring flexibility in the wrong way, perhaps our PT books were a little dated? or the body building world influenced our anatomy bias too much? Firstly we must stop thinking of the hamstrings in isolation as a muscle, can they be tight on their own? Maybe maybe not..however it is impossible to isolate them, so unless you are working with a cadaver forget about it. There are a number of structures before you get to the hamstring that you should assess first before concluding that the muscle is 'tight'. What might look like hamstring tightness usually isn't! Sound complicated? It is! However we can go through step by step.
What we need to think of is what movement the do the the hamstrings restrict? What is your end goal that you are trying to achieve? Really what I am saying here is we should be more concerned about the joint range of motion at the hip rather than the length of the muscle its self. Generally the muscle is not tight, it is the connective tissue, lack or correct movement patterning, neural tension and restrictions in the supporting fascia that restrict the movement.
The standard 'text book' checks you would normally do to look for basic movement at the hip are as follows:
Active Leg Raise
Lumbo-Pelvic Rhythm
Squat Pattern
However, typically I hear people say that 'i just cant get rid of my hamstring tightness' and I cant ever pass those tests above, my first response to that is how often do you stretch? Mostly the answer I find out is..not nearly enough! So to start with i would look here! We all know how to stretch the hamstrings so i am not going to teach you suck eggs. However, what if you have a client or athlete that stretches every day, or you just keep plugging at it as a trainer and it doesn't clear up? This is frustrating and it is likely that there is a restriction some where else in the body causing the muscles to remain tight, this is known as 'hypertonicity'. There are a number of factors that could lead to the hamstrings 'holding on', i have listed some of them out as a check list below for you to have a think about:
- Is the sciatic nerve tight? - If it is the muscles will remain tonic to protect it.
- Is there piriformis tightness? - If so, the pelvis maybe rotated adding stress on the hamstrings. Also the sacrotuberous ligament maybe impinged.
- Is there adequate t spine mobility - If not the lumbar spine will become too mobile to make up for it and the hip will be forced to try to stabilise the lumbar region. Also the lack of rotation at the t spine will place more rotational forces at the hip.
- Are the glutes strong? If not the hamstrings will be overstressed in helping hip extension and forming trigger points.
- Is the hip flexor group tonic? if so the glutes will be inhibited placing excess stress on the hamstrings and causing trigger point formations in the hamstrings.
If you have cleared all of the above and the hip still does not have adequate range of motion, then it is worth having a look into restrictions up and down the whole of the superficial back line. The superficial back line is a myofascial meridian that connects the toes to the back of the head via fascial connections. It would be worth employing a manual therapist to assess this for you however, in my experience take a look at the following if you have the expertise.
- Does the plantar fascia allow adequate ankle mobility?
- Does the calf allow adequate ankle mobility?
- Is the soleus tender?
- Is the hamstring tender?
- Is there tension in the posterior thigh fascia?
- Is there restrictions in the thoraco-lumbar fascia?
In summary, lets not try to focus too much on the hamstrings themselves. Lets look at what could be causing the hamstrings to 'hold' on. Think about multi-planer hip mobility, and the connective tissue that can restrict the movement you are trying to create ie ALR or LPR, this should lead to the answer! Remember, be objective and consistent in your testing.
Hit me back with responses!
John Scriven MSc, ASCC
Biomechanics Coach
IMF Performance Training
http://www.i-movefreely.com/
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