Knee injuries are quite common among athletes and active adults and one of the leading issues I deal with daily in the clinic. When years of wear and tear take a toll on your knees, you need to turn to strategies to relieve pain. Whether a sharp pain or dull ache, knee pain is a common complaint of nearly two-thirds of active adults. Exercising can strengthen your muscles and protect your knees without exposing them to pain, because your knees require the right balance of flexibility, stability, and care to stay healthy.
Licensed physical therapist, Matt Midkiff, director of our Mesa-Gilbert clinic, is an expert in all things knee pain, specializing in ACL repair and reconstruction. He has created the following videos to address and relieve knee pain.
Here are some additional tips to avoid future knee damage and pain during exercise and everyday activities:
- Maintain a healthy weight: Being overweight causes considerable strain on your knees. One extra pound of body weight puts an extra five pounds of force on your knee joints. Additionally, if you don’t strengthen the other muscles around your knee, it can cause instability and extra pressure. To prevent these types of problems, eat a healthy diet, get regular exercise, and focus on strengthening your quadriceps, hamstrings, and core muscles.
- Don’t ignore abnormal pain: A little knee pain is usually nothing to be concerned about and can typically be cured with some rest and recovery. But if the pain lingers or gets worse, don’t ignore it. This could indicate a more severe problem, and you may start overcompensating in other areas (your back, thighs, feet, etc.), which could lead to other injuries. Instead of ignoring the pain or hoping it goes away, see a doctor or physical therapist to diagnose the problem and get a treatment plan correctly.
- Let your muscles rest to prevent overuse: Disregarding muscle soreness can be just as dangerous as ignoring the pain. Soreness is a sign that your muscles are growing and rebuilding. After a challenging workout or activity, give yourself a chance to recover for a day or two before exercising again. Stretching also helps muscles heal faster, so be sure to take a few extra minutes before or after your workout to warm up or cool down.
- Get a physical therapist’s or trainer’s help with strengthening and agility: ACL tears (the ligament on the outside of your knee) are among the most common knee injuries due to your knees’ natural instability. Physical therapists and neuromuscular trainers can teach you how to improve your strength, agility, and performance to avoid ACL tears and other knee injuries. If you’ve already experienced a knee injury, seeing a physical therapist can help you recover quicker, regain strength, and return to regular activity as soon as possible.
It’s easy to take our knees for granted, but having an injury can be debilitating, frustrating, and painful. Becoming aware of the dangers and learning better habits now can help you be mindful and avoid problems later. For more advice on how to avoid injuries or to get more information on knee pain treatment in Phoenix, schedule your appointment with Matt Foothills Sports Rehab Physical Therapy.
Can virtual reality and dual tasking be part of your ACL rehabilitation? Yes, your ACL and other rehabs can incorporate virtual reality activities at all phases of the rehabilitation process as well as dual-task activities in order to be more successful.
Okay, here’s a couple of quick definitions:
- Virtual Reality Exercises: Doing any exercise with those cool VR glasses on that either makes your eyes see one thing in the glasses while you do something else or, has you follow a game while doing an exercise.
- Dual Tasking: You do an exercise while your brain is asked to do something else at the same time. For example, do a squat while you count backward by 5, name as many state capitals as possible, or have a ball thrown at you that you have to catch.
Injuries, such as ACL injuries often occur due to sensory-motor dysfunction.
We play sports in complex environments that have mental distractors that create great cognitive demand. Reviewing video analysis of ACL injuries there is a neuromuscular breakdown and a cognitive overload where the body is not able to adapt to the position and speed of loading. It becomes clear that there are pre-habilitation and rehabilitation programs that need to be better by increasing cognitive demand. We can even argue that by not increasing the cognitive demand with activity, we set patients up for failure. Once they are thrown back into a visually complex environment with their sport, they have not been trained to deal with it, and are therefore at risk for re-injury.
We realize that one of the growing areas of current and future research to improve our body’s function is cognitive research.
For years in rehabilitation after a major injury, many of the exercises that have been done in traditional rehabilitation are boring, and not mentally engaging. Recent research on brain activity during simple, learned exercise shows that once an exercise becomes easy, our brains pretty much turn off. There is some activity in the motor and visual areas of the brain, but very little. This results in ultimately less carry over to real-life activity. However, when the same simple task is done while in a virtual reality world or with dual tasking, the brain is firing all over the place. That motor activity is tied to a large amount of brain input and visual focus is taken off the injured limb, even as it continues to have to work to do the exercise. This improves what we call neuroplasticity, where we increase neural efficiency and increase neural support cells to help the body create improved neuromuscular programs with activities. Pretty cool, and kind of sounds like the real world and sport activity.
Even cooler is what was found when two groups of post-op anterior cruciate ligament reconstruction (ACL) patients were tested on their neuromuscular control (ability to control their knee, hip, and ankle as they squat) after a step-down task.
The group that trained with VR during the step-down task significantly improved their neuromuscular control relative to the non-VR group. In other words, by using virtual reality to engage more of their brain during exercise, when virtual reality was taken away and both groups did the same exercise, the group that engaged more of their brain during the rehabilitation exercise was more successful performing it after training. They had significantly improved more limb control than the non-VR group.
What does this tell us?
It shows us a patient’s brain gets bored doing a simple, unchallenging activity that only causes them to use the vision and motor centers of the brain. Virtual Reality or dual-tasking with exercise stimulates far more of the brain with even simple tasks that then make them more successful with complex, sport and life-like tasks. These results and the contribution of the brain to rehabilitation are seen in significant research by Grooms, Diekfuss, Lepley, Rausch, Kim, Monfort and many others when you explore the current literature.
This further shows us…
that in the rehabilitation of complex surgical cases like an anterior cruciate ligament reconstruction, the body craves neurological input to the new ACL and the surrounding muscles. That ACL needs all the help it can get from muscles that are actively engaged and from neuromuscular programs that are developed early in the rehabilitation process. This then can be carried over to later phases of rehabilitation when we are asking the athlete and patient to do dynamic activities such as their sport with balls and people flying around them, while still safely controlling what their knee is doing during the activity.
Virtual reality integration with exercise can be implemented by a skilled practitioner in a comprehensive rehab program that is done safely at the right point of rehab. This can begin the first-week post-op in order to stimulate improvements in neuromuscular control over those not using VR with the same exercises.
Learn more and schedule a free pain assessment with a Foothills clinic near you to #GetYourMoveBack.
We often ask ourselves, ‘can we do more for our patients?’ We introduced blood flow restrictive (BFR) therapy a couple weeks ago to respond, “Yes,” to that question. After reviewing the research and talking with athletes and clinics using BFR throughout the country, it was a treatment that we felt we had to bring to our clinics.
We have a passion for rehabilitating athletes and have helped countless athletes recover from ankle and knee injuries. Many of those athletes are females who struggle to regain muscle size and density after injury and particularly after surgery. If you are recovering from a knee or ankle injury this blog will explain why and how BFR will help you get back to the game you love.
Female athletes are more likely to get injured
Female athletes are 2 to 8 times more likely to suffer non-contact anterior cruciate ligament knee injuries in running and cutting sports such as soccer, basketball, volleyball, and gymnastics. The same mechanism of injury can also result in meniscal tears or a medial collateral ligament tear. Often these injuries become surgical cases.
The surgical advancements and recovery on all levels over the last 30 years are amazing: athletes whose careers would have been over after an ACL tear are now are able to return to a high level after surgery. However, while the procedures are less invasive and cleaner, there are still massive challenges in the rehabilitation process.
Muscle loss occurs after an injury or surgery
One of the greatest challenges after an injury or surgery is regaining muscle size and strength. While this is challenging for males recovering from injury and surgery, females have a greater challenge.
Healthy males naturally have high levels of muscle-building testosterone and growth hormone to restore muscle size compared to the female body that has less of both. Compared to men, women have more of a challenge when trying to regain muscle function after injury or surgery.
After surgery, it takes about three days of disuse to begin losing muscle size. The muscle shuts down because it is really ticked off that the knee just went through a surgical process or injury. It is very typical to look down at one’s thigh muscles (quadriceps and hamstrings) within just a few short days after surgery and ask, “where did my muscles go?” or “is that my leg?’
Myostatin inhibits muscle growth
Why does your leg quickly lose muscle? Like I said, the body is unhappy with what it has had to go through. Consequently, it produces a hormone called myostatin that inhibits protein synthesis. The pesky myostatin tells the body not to rebuild muscle and promotes scar tissue around the muscle to limit the growth.
If you break a bone in your leg and are casted or are in a knee brace and not able to put the same amount of weight on your leg then your myostatin levels are running wild.
BFR stops myostatin and promotes muscle growth
Well, shoot, how do we stop myostatin and start the muscle building process? The only two ways that research has shown to inhibit myostatin are:
- High-intensity training (HIT) with heavy weight.
- Blood flow restricted (BFR) training with 30% of your one-repetition maximum weight.
Now you see why we needed to bring BFR training to our patients and athletes. Our rehabbing athletes initially can’t do HIT but they can do BFR. BFR training decreases the anti-muscle building hormone myostatin and increases the muscle building growth hormone. This is a double win to rebuild muscle after surgery and injury.
The results are just what the female athlete needs after knee surgery. The research is already excellent and more research continues to take place. A current clinical trial is studying the impacts of BFR on females recovering from ACL reconstruction.
BFR is a great addition to our toolbox
We have enjoyed helping many athletes return to the sports they love. Many of these have been female. But, some cases are really tough, especially when an athlete struggles to regain muscle mass. Because we care for our patients and strive to help them return to their sports, we are always looking for ways we can help. Our past results have been excellent, but I am excited to add another tool to incorporate into our rehabilitation toolbox, so we provide even better results moving forward.
Please reach out to us at our Gilbert-Mesa location at 480-505-8140 for more information on how BFR can benefit your ankle or knee injury therapy program. If the Gilbert-Mesa location isn’t convenient, we have many other locations to receive a personalized therapy program.
I treat too many athletes with hip injuries that require them to miss practice time from their sport or give them pain with activities. I refer to hip injuries as “the new knee,” as knee injuries get most of the attention but hip injuries are becoming as prevalent.
Types of hip injuries range from strains of the hip muscles to surgical cases. An athlete could miss up to 6 weeks of practice for a simple strain, or in the worst-case scenario, may require surgery to fix the damaged hip joint and be sidelined for 6-9 months. For those with minor hip injuries, the quickest way to get back on the field is through physical therapy for hip pain. Examples of the more serious injuries are muscle and bone avulsions, hip labral tears, and changes in bone structure.
The majority of hip injuries I see happen either early in the season when a player’s body is adapting to the stresses of the sport, or late in the season when fatigue and overuse becomes a significant factor. A young player who has recently gone through a growth spurt, and who is getting used to their new body, is easily susceptible to these injuries. Gaining balance in mobility and stability from the feet to the shoulders is important to keep hips healthy.
The hip is centered in the middle of the body so what happens above and below it contribute to its success. The key to hip injury prevention is to get all of your muscles working together to help the hip. Like the shoulder, the hip is a ball and socket joint that allows for a wide range of motion. The hip is the center of how an athlete moves. The muscles at the hip, as well as above, and below all share an important role in athletic performance.
The goal of hip injury prevention is to create balance in the hip musculature among all local muscle groups. To further avoid injury, a combination of strength, flexibility, stability, endurance, and overall body control is required. An imbalance of muscle dominance or tightness can put you at risk of injury, especially when an athlete exceeds their own performance envelope. It’s important that an athlete takes the time to widen their performance envelope by working all of the muscles of the chain during training.
Stretching and Strengthening to Avoid Hip Injury
A good way to start improving hip mobility is by integrating exercises that place emphasis on movement and stability. These include yoga, dynamic stretching, and somestatic stretches. Strengthening exercises, including lunging and squatting, are also a great way to improve hip mobility.
We often joke that we are making the world better and stronger, one butt muscle at a time. A joke yes, but very true of how important hip and torso strength is for an aspiring athlete. As hip muscles are critical to body movement, they must be strong through full range of motion. Some athletes are very strong in one direction, but weak in another, which can put them at risk of injury. It’s also important to train with single leg motions so that the dominant leg doesn’t have to compensate for the weaker one.
We like to use different matrix exercises where the athletes lunge, squat, hop, and deadlift to improve strength and flexibility. This activates the athlete’s hip muscles so they can be ready for whatever their coaches throw at them. It’s important to build through repetition from controlled motions to explosive motions where the hip musculature and joints can be under high stress.
Our goal is to keep athletes healthy, and to get them back in the action as soon as possible after injury. Remember, sports by nature can lead to overuse, and the hip muscles are usually at the center of this issue. An athlete must train to build hip strength and flexibility to avoid injury and to realize their full potential. Stop by Foothills Sports Medicine to learn how physical therapy for hip pain can help you get back to the activities you love.
Female athletes suffer a disproportionate number of knee injuries in running and cutting sports compared to their male counterparts of the same age. The medical community has done considerable research on the reasons for this increase of knee injuries in females, and whether the number can be reduced. Knee injuries in female athletes range from slight sprains and bone contusions to more severe anterior cruciate ligament (ACL) injuries and meniscal tears, which often require surgery. These types of injuries can cause over a year of missed time from competitive play, and significant expense through the surgical and rehabilitation process.
Knee injuries can be divided into two categories: contact and non-contact injuries. In contact injuries, the impact of a collision results in the injury. This type of injury is often inevitable based on the force of the collision, and the difference between male and female athletes is often negligible. However, non-contact injuries tell a different story. These injuries occur when the athlete hurts their knee without being contacted by another athlete. It has been found that females are four to eight times more susceptible to sustain non-contact knee injuries than males.
Why the disparity? Research divides the risk of athlete’s injury into two factors—intrinsic and extrinsic. Intrinsic factors are essentially a person’s genetics. As it relates to knee injury risk, these factors would include the athlete’s Q-angle (hip to knee angle), their hormonal cycle, and foot-type. Extrinsic factors are external things an athlete could change in order to become more or less successful. Females tend to put more stress on the ligaments of their knee rather than rely on the supporting musculature which is also weaker than the males.
Intrinsic factors are inherent to a person and are difficult to change or alter. For example, females have a wider hip to knee ratio, on average, than males. This increased angle may put the knee in a more compromising position when jumping, landing, or pivoting. Also, ample research has been done on the hormonal cycle of females and its correlation to knee injuries. It is intuitive that when a female athlete produces more of the hormone relaxin, there is an increase in joint laxity and a decrease in joint stability. This decrease in joint stability may put the knee more at risk to exceed its limit, causing injury. A flatter foot has been shown to aid in driving the knee more inward when squatting and landing. So, to combat this problem, the use of an over the counter orthotic device may help decrease that inward acceleration of the foot and knee which causes injury.
Female athletes have four common components in the mechanism of non-contact knee injuries. Females tend to land with their knees pointed inward, with a straighter knee, with their weight mostly or all on one foot, or with their trunk tilted outside of their center of mass. These mechanisms are controlled by the extrinsic factors of the female athletes themselves. After puberty, females typically gain increased strength in their quadriceps in the front of their legs at a disproportionate rate to the strength of their hamstrings and glute muscles in the back of their legs. This disparity in strength is accentuated by the hamstrings and glutes firing later than the quadriceps during jumping and landing movements. The combination of weaker muscles and delayed firing causes the knee to be pulled forward and inward, putting it at risk for injury.
Women usually rely more on their ligaments to stabilize the knee rather than the supporting muscles. This can lead to the knee being thrown backward into hyperextension and an injury to the ACL and/or menisci. Females also tend to be more one-legged dominant than males, with one leg stronger than the other. All of these factors are magnified by their tendency to land in a position with knees facing inward and rotating while being in a straighter position. This is attributed to having less spatial awareness (compared to males) of where their trunk is in space, causing body weight to be unequally distributed over the lower body.
After puberty, males typically gain more power and strength that is proportionate to their size. This helps control their bigger and longer body. Females, without extra training, tend to have a greater fat to muscle ratio without an increase in strength and power to control their longer body. This compounds with the other risk factors to jeopardize female athlete knee health. With less trunk control, disproportionate muscle strength, and the mechanical inclination to land in a compromising position, it is much more likely for a female athlete to sustain a knee injury.
What can we do?
Females in the at-risk category of 12-22 years of age have been shown to benefit greatly from training to correct these factors. Training programs have been found to be up to 80% successful in reducing non-contact ACL injuries. Some injuries are inevitable, but with proper training, the injury rate is significantly reduced. The focus of this type of training is to improve the female athlete’s ability, technique, strength, and balance, the extrinsic factors that greatly reduce knee injury.
If you would like to learn more about how to prevent or treat knee injuries contact Foothills Sports Medicine, your Phoenix physical therapy experts, for more details!