Posts in knee pain
Reducing Knee Pain In Cyclists

Cycling is one of the most popular outdoor activities in Boulder.  Cyclists we encounter in our Boulder Physical Therapy practice most commonly complain of pain on the front of their knee or anterior knee pain.  Research shows 1 in 2 competitive cyclists have experienced this knee pain resulting in lost training and competitions in over half of those affected (Clarsen et al. 2010).  A cyclists exposure to the impact of poor pedaling biomechanics is amplified by the volume of their training.  It is not uncommon for a competitive cyclist to flex and extend their knee over 5 million times per year during their training sessions and competitions (Callaghan et al. 2005).  In addition to training errors, bike biomechanics remain one of the key sources of an athlete's knee pain.

Athletes who have excessive movement in their lower bodies both reduce their cycling economy and performance, as well as, increase their injury risk.  In particular, the movement of the knee toward or away from the frame increases stress across the knee especially during the power portion of the pedal cycle.  The suboptimal mechanics change the alignment of the knee and the ability of the leg muscles to import forces on the foot and pedal.  Commonly, bike fitters use shoe orthotics or wedges to modify the relationship between the foot, shoe, and pedal.

Research has shown a rigid cycling shoe is the most economical and efficient interface with the pedal allowing cyclists to pedal at a lower % of their VO2 max for a given work load compared to a softer shoe.   Research regarding orthoses or wedges on cycling alignment and mechanics are fewer in number.  The limited research shows these orthoses or wedges 5-10 degrees can temporarily impact mechanics but their long term efficacy as a tool remains to be limited (Fitzgibbon et al. 2016).  They are most likely to benefit those athletes with true structural alignment impairments in the leg.  

Conversely, many of our patients's symptoms improve quickly with Physical Therapy interventions to correct impairments such as limited range of motion and muscle imbalances in the leg.  Once these are addressed an athlete is better able to use cuing and movement retraining to improve static and dynamic alignment of the knee while cycling.  In summary, athletes need the capacity to control the knee position through strengthening then the appropriate retraining to use that strength in an optimal cycling pedal cadence.  


Arthroscopic Surgery for Knee Pain

Last year over 500,000 thousand arthroscopic knee surgeries (scopes) were performed in the Unites States making it one of the most common orthopedic surgical procedures.  In a previous post we highlighted some of the evidence behind this surgery showing it is not superior to a sham or placebo surgery for degenerative meniscal tears.  In addition, many literature reviews and analyses have shown the procedure offers little to benefit to patients with knee pain (Thorlund et al. BMJ. 2015).  

A recent article in the British Medical Journal compared Physical Therapy exercises to surgery for middle aged patients with degenerative medial meniscal tears (Kise et al. 2016).  The authors found no difference in self reported knee function at long term follow up, but reported greater strength and muscle performance in the exercise group.  Patients with knee pain are encouraged to utilize Physical Therapy over surgery for painful knee conditions.   

Does Running Cause Knee Osteoarthritis?

Knee arthritis is a common condition among older adults leading to increased knee pain and decreased participation in recreational and sporting activities.  A incorrect, but commonly held belief is exercise may lead to further arthritis or knee damage due to a "wear and tear" effect.  This outdated line of thought has been disproven by many research studies documenting a beneficial not harmful effect of exercise on both young and old knee joints.  Unfortunately, the myth of exercise causing knee arthritis remains especially in regards to sports including running.

A recent study by Lo and colleagues should finally put this myth to rest (Arthritis Care and Research 2016).  Authors studied over 2500 participants to retrospectively identify risk factors which were associated with the eventual development of knee arthritis.  Among these individuals, 30% had run at some time in their lives.  The authors reported no increased risk of knee arthritis among the running participants compared to their age matched peers.  They concluded that running does not appear to be detrimental to the knees.  

Risk Factors for Shin Splints and IT Band Pain

As we move towards the middle of summer many runners have experienced an increase in overuse injuries in their legs.  Unfortunately, these running injuries are common among athletes with the vast majority of runners reporting one injury over the last year of training.  Two of the most common injuries include shin splints (medial tibial stress syndrome) and IT band pain.  Both of these injuries can be successfully treated with Physical Therapy, but also may be prevented by modifying known risk factors for the conditions.  

A review article identified the known risk factors for the development of medial tibial stress syndrome in runners (Newman et al. J Sports Med. 2013).  Authors reported prior history of medial tibial stress syndrome, increased body mass index, increased pronation, orthotic use, and fewer years of running experience are all associated with increased risk of these symptoms.

A second review article documented the known risk factors for iliotibial band pain (IT band pain) in runners.  Aderem and colleagues reviewed the available literature on the development of IT band pain from 13 research studies (BMC Musculoskelet Disord. 2015).  They noted increased risk of IT band pain among runners with poor knee control at foot strike.  Increased movement of the knee is due to weakness and coordination in the hip musculature.  Overtime these abnormal movements create friction between the IT band and thigh bone at the knee.  Athletes are encouraged to work with a local Physical Therapist on gait retraining to improve knee control during running.  

Risk Factors for Knee Injuries in Adolescents and Teenagers

The knee is one of most commonly injured areas among our Boulder County student athletes.  Injuries range from the traumatic (ligament tears) to overuse (tendonitis) across a variety of indoor and outdoor sports.  Prior research has shown overuse injuries to be the most common knee injury affecting our student athletes but data regarding the risk factors for these two types of injuries has been limited.  

Recently a large study was conducted to document sports participation, injuries, and pain levels of over 1300 8-15 year old children (Junge et al. Med Sci Sp Ex. 2016).  The authors documented the frequency, severity, and type of knee injuries within this group in order to determine the risk factors associated with these injuries.  The authors reported 952 knee injuries (85% overuse) were sustained by the athletes in the study.  Participation in gymnastics was the greatest risk factor for traumatic knee injury.  

Within the overuse injury category female sex, prior knee injury, and a higher frequency of practices and games per week were associated with a higher risk of injury.  The majority of these overuse conditions were self limiting in nature and are successfully managed with conservative care including Physical Therapy.  To learn more on now to reduce your child's risk of knee injury contact your local Physical Therapist. 

Does Physical Activity Improve after a Total Knee or Hip Replacement?

Total knee and hip replacements are among the fastest growing surgeries in our country.  Physical Therapy remains the first line treatment for patients with knee and hip arthritis, but in patients with severe osteoarthritic pain and loss of function joint replacement remains a good surgical option.  In prior research among patients undergoing these procedures there is often a disconnect between subjective reporting of pain and function and the objective testing of a patient's function.  For example, a patient may report great outcomes and an ability to walk long distances without fatigue or pain, but objective testing in Physical Therapy often reveals residual endurance, strength, and balance impairments.  

In addition to severe pain, one of the most important indications for a total joint procedure is loss of function.   After the surgery patients are expected to increase their activity levels due to reduced pain, but new research is questioning this assumption.  A recent review article in the Journal of Orthopedic and Sports Physical Therapy examined if physical activity levels increased after these procedures (Arnold et al. 2016).  Authors reviewed the available data and found 8 studies of 373 patients who underwent a total joint replacement.  

These studies objectively tracked a patients physical activity levels up to 1 year after the procedure to see if levels had increased compared to pre operative levels.  The authors reported negligible improvements at 6 months and limited evidence to support increases in activity levels at 1 year.  At one year, patients with total joint replacements were significantly less active than their peers.  This study indicates the importance of post operative Physical Therapy to effectively improve strength, endurance, and balance allowing patients to resume an active lifestyle.