Move Well, Live Well Newsletter June 15, 2016 Volume 4, Number 6 In This Issue: Lateral Knee Pain in Runners: The Role of the Biceps Femoris The Role of 2D Video Running Analysis in Determining the Cause of Running Injury The Importance of Pelvic Floor Exercises Postpartum Balancing Hip Flexor Strength & Muscle Length for Efficient Running Sign up for the Sapphire PT enewsletter at sapphirept.com Links to Related Sites: SapphirePhysicalTherapy.blogspot.com www.runnersedgemt.com www.momentumat.com www.irunfar.com Lateral Knee Pain in Runners: The Role of the Biceps Femoris The summer calendar is packed with races and runners are piling on the miles. Along with long runs and back-to-back workouts are running overuse injuries. Nearly 80% of runners sustain at least one overuse running injury per year. 1 This month s article will focus on the biceps femoris hamstring muscle. Biceps femoris tendinopathy (chronic inflammation and dysfunction of the tendon related to overuse) is a common, often misdiagnosed injury which plagues many runners. The biceps femoris is one of three hamstring muscles. The biceps femoris is the lateral hamstring muscle and is composed of a short head and long head. The long head originates at the ischial tuberosity of the pelvis whereas the short head originates along the posterior portion of the femur. The short and long heads of the biceps femoris insert on the lateral knee (fibular head) and lateral collateral ligament of the knee. The biceps femoris flexes the knee, assists with knee extension, and the short head also externally rotates the tibia. Excessive biceps femoris use and deceleration (eccentric 1 Van Gent RN, Siem D, van Middelkoop K, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. J Sports Med. 2007; 41:469-480.
www.ratpod.org www.apta.org Related Sites: www.runnersedgemt.com The Runners Edge: Missoula s hub for running gear, information, and races www.runwildmissoula.org Run Wild Missoula membership promotes running, training, and racing in Missoula www.momentumat.com Missoula s choice for core strengthening and ski conditioning. From beginners to elite athletes, Momentum classes will increase your strength and reduce your injury risk. Find us on Facebook: www.facebook.com/sapphirept For more information on the services provided by Sapphire Physical Therapy or to read more related articles, see our website or give us a call at 406-549-5283 contraction) while running may lead to overuse and inflammation at the origin or insertion. Repetitive irritation due to excessive running or compensatory movement patterns (over-striding, glut/core weakness, poor core stabilization leading to anterior pelvic tilt) may lead to chronic tendinosis. Over-activation of the biceps femoris during hip extension results in less than ideal foot strike placement due to external rotation of the tibia. Repetitive hamstring-dominant running increases the risk of overuse injuries in the foot, ankle, knee, and hip by increasing torsional forces at foot strike and during the stance phase of the running stride. Often misdiagnosed as iliotibial band friction syndrome, biceps femoris tendinosis must be treated through specific release techniques. The photo below demonstrates an effective dynamic release technique using a roll or ball beneath the distal biceps femoris while the subject slowly extends and flexes the knee. Following a period of manual therapy to release the hamstring, a glut, core, and eccentric hamstring strengthening program must be implemented for long-term symptoms resolution. Closed chain (weight bearing) double and single leg dynamic core, glut, and hip exercises must be included in an effective long-term hamstring strengthening program. Sign up for the Sapphire PT enewsletter at sapphirept.com Contact Us: (406) 549-5283 http://www.sapphirept.com Photo: Dynamic Release Biceps Femoris (http://bretbrookbush.com) A physical therapist skilled in both therapeutic exercise and manual therapy is the person to evaluate and treat the cause of the pain. Manual therapy is a clinical approach using skilled, specific hands-on techniques to evaluate and treat joint structures and soft tissue restrictions for the purpose of reducing pain, increasing range of motion, reducing soft tissue inflammation, relaxing muscle guarding,
Email Us: : john@sapphirept.com Rachael Herynk, DPT: rachael@sapphirept.com Jesse Dupre, DPT: jesse@sapphirept.com Holly Warner, DPT: holly@sapphirept.com Jennifer Dreiling: jennifer@sapphirept.com Find Us: Sapphire Physical Therapy 1705 Bow Street * Missoula, MT 59801 Map: improving stability through a joint, facilitating movement, and restoring function. 2 Remember, regular strength training and adequate recovery are the best defenses against injury as the greatest predictor of future running injury is a history of prior injury. john@sapphirept.com 1 Information on definition of manual therapy from American Academy of Orthopedic Manual Physical Therapy (AAOMPT). www.aaompt.org. Accessed November 26, 2011. 1 Information on definition of manual therapy from American Academy of Orthopedic Manual Physical Therapy (AAOMPT). www.aaompt.org. Accessed November 26, 2011. The Role of 2D Video Running Analysis in Determining the Cause of Running Injury Sapphire Physical Therapy will begin providing on-site 2D video running analysis in our new gait lab on June 23, 2016. Utilizing the Simi Aktisys system, runners will be able to receive real-time feedback from physical therapists as joint angles, foot strike, posture, and asymmetries are calculated via wireless LED markers (placed on key body landmarks) which communicate with the Simi computer software system. Two high-speed digital cameras and five LED markers track the running gait cycle via frontal, sagittal, and posterior views. Our Services: Orthopedic injuries Functional strengthening Pre and post-operative rehabilitation Core strengthening & conditioning programs Back and neck pain Running overuse injury and prevention Running video gait analysis Work related injuries Functional Capacity Evaluations Work Hardening & Functional Conditioning Programs The guesswork of gait analysis is now a thing of the past. A 2D running analysis allows our physical therapists to detect and quantify asymmetries and deviations from normative ranges for efficient running. The scope of physical therapy treatment and/or running form recommendations is based, therefore, on objective information obtained from the interactive running analysis. A recent study in the Journal of Orthopedic and Sports Physical Therapy (JOSPT) looked at the reliability of 2D qualitative video running analysis (Heiderscheit, et al. JOSPT DOI: 10.2519/jospt.2016.6280). The study suggested that qualitative 2D video analysis of running kinematics can be reliably performed in a clinical (physical therapy) setting with strong inter-rater (consistency between different evaluators) and intra-rater (consistency through repeated testing by a single evaluator) reliability for both healthy and injured runners. In conjunction with our new 2D video running analysis system, Sapphire PT will begin using a wireless electromyography (EMG)
Cycling injuries & biomechanical bike fitting Women s health All insurance accepted & billed Cash payment option system to provide real-time biofeedback for more accurate muscle recruitment for more efficient strength training. The beauty of a wireless EMG system lies in the fact that individuals learn to recruit muscles through a variety of verbal and visual cues. Incorporating EMG will objectively measure whether the athlete is truly using the proper muscle (weak, under-activated muscle), or continuing to compensate with the muscle(s) responsible for the asymmetry and/or injury. The entire Sapphire PT staff is excited to offer this new, innovative, cutting-edge technology to the Missoula Running Community. We are doing this for Missoula runners because the Missoula running community is the best!!! The Importance of Pelvic Floor Exercises Postpartum Rachael Herynk, DPT Just as seeking physical therapy after an injury is important to recovery, pelvic floor physical therapy can be helpful after pregnancy and delivery of a baby. In other countries like France, women attend la re-education perineale, or pelvic floor rehabilitation following birth. Pregnancy and delivery of baby causes stress to the pelvic floor, which may result in weakness. Weakness in the pelvic floor muscles may lead to incontinence. In fact, pelvic floor exercises started during pregnancy result in less incontinence and pain after delivery. But if you didn t do them during pregnancy, it s great to start doing them after delivery! It s important to perform pelvic floor exercises after
birth to improve or prevent urinary incontinence, or loss of urine with sneezing, coughing, laughing, running, and jumping. Recently published guidelines recommend Pelvic floor muscle therapy for persistent postpartum urinary or fecal incontinence. i Studies have shown that 87% of people can significantly reduce or eliminate incontinence with pelvic muscle exercises. ii, iii But pelvic floor exercises can be difficult to perform correctly. Several studies have shown that many women have difficulty performing these exercises without individual instruction. Aside from pelvic floor weakness and incontinence, some women experience low back pain, pelvic pain, or pain with intercourse and gynecological examination. Other women may have a diastasis recti, or separation of the abdominal muscles that may be contributing to abdominal pain or weakness. A physical therapist can assess for these issues and help with appropriate exercises, giving you the confidence that you are performing these exercises correctly and consistently. Please don t hesitate to call or email Rachael Herynk, DPT with any questions or concerns you may have. i Deffieux X et al. Postpartum pelvic floor muscle training and abdominal rehabilitation: Guidelines. J Gynecol Obstet Biol Reprod (Paris). 2015 Dec;44(10):1141-6. doi: 10.1016/j.jgyn.2015.09.023. Epub 2015 Oct 31.
ii Sampselle C. 1990. Changes in pelvic muscle strength and stress urinary incontinence associated with childbirth. Journal of Obstetrics Gynecology Neonatal Nursing. (12):5:371-377. iii Urinary Incontinence guidelines Panel. Urinary Incontinence in Adults: Clinical Practice Guideline. AHCPR Pub, No. 92-0038. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, March 1996. Section on Women s Health, American Physical Therapy Association Continence Foundation of Australia, 2011 iv Fredericson M, Cookingham CL, et al. Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clin J Sport Med. 2000; 10(3): 169-175. Balancing Hip Flexor Strength & Muscle Length for Efficient Running
The importance of hip flexor strength for efficient running is often overlooked. Strength and cross training is often placed on quadriceps and hamstring. While research has shown a correlation between gluteus medius weakness and iliotibial band pain (Fredericson et al. iv ), the role of the hip flexor in preventing lower extremity running injuries is more obscure. The complexity of the relationship between the hip and pelvis while running deserves explanation. A delicate balance exists between the muscle length and muscle strength of the hip flexor muscle complex. When this balance is compromised, asymmetries develop which predisposes a runner to overuse injuries. Because each running stride results in a force 2.5 to 5 times greater than our body weight, subtle strength asymmetries may rapidly become an acute running injury. Common hip flexor-related compensatory injuries develop in the hamstrings, lower leg, iliotibial band, low back, and foot. In order to discuss the hip flexor complex in running mechanics, a brief anatomy lesson is necessary (see the following picture illustrating the hip flexor musculature). The primary hip flexor is the iliopsoas. Composed of the psoas and the iliacus, the iliopsoas connects the lumbar spine and pelvis with the femur of the leg. The tensor fasciae latae (TFL) muscle is a hip flexor located on the lateral surface of the pelvis and leg. The distal fibers become the iliotibial band which supports the lateral knee. The TFL often is overactive in the presence of gluteus medius weakness. The rectus femoris is a quadriceps muscle which aids in flexing the hip and straightening the knee. The rectus femoris is the antagonist or works in opposition to the hamstring. This is key point in understanding the impact of a tight or shortened rectus femoris muscle. The sartorius muscle originates on the anterior pelvis and runs diagonally to the medial knee. Tightness or overuse of the sartorius can lead to Pes Anserine tendonitis commonly referred to as runner s knee. So how does all the above anatomy relate to running efficiency and running injury treatment and prevention? It is actually quite simple. As your running mileage increases, your hip flexors (all four included) are strengthened. Hill training in general and trail running specifically leads to mega-strong hip flexors. In addition to strengthening, frequent muscle use with running often leads to a shortening of the hip flexors. Add to the equation the fact that most of us sit all day at work and the
result is an even tighter hip flexor muscle group. Strong and tight hip flexors and frequent sitting pull the pelvis forward (anterior tilt). As the antagonist to the rectus femoris, the hamstring muscles are placed on tension or stretch which predisposes the hamstrings to strain and overuse injury during activities such as running. Similarly, the forward tilt of the pelvis due to tight hip flexors increased compression in the lumbar spine and inhibits the lower abdominals in their attempt to stabilize our core. Addressing hip flexor dysfunction (tightness, overuse, weakness) is not as simple as hanging your leg off the edge of your bed and stretching. A series of active, dynamic stretching exercises aimed at isolating each of the four hip flexor muscles is an effective way to determine which part(s) of the hip flexor complex warrants attention. Manual therapy is an important diagnostic and treatment technique to determine the contribution the hip flexors in other sites of pain and to restore spine and hip joint mobility. Deep tissue mobilization, myofascial techniques, and dry needling are skilled treatment techniques which if applied correctly, can lead to tremendous results. So the next time you are pounding the pavement or bounding up Mount Jumbo, take a minute to appreciate the reciprocal, efficient work being done by your hip flexor and hip extensor muscle groups with each stride. An efficient, pain-free running stride begins with flexing the hip, but involves stability of the pelvis, lumbar spine, and hip agonist and antagonist muscles as well. Sapphire Physical Therapy www.sapphirept.com john@sapphirept.com 1 Fredericson M, Cookingham CL, et al. Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clin J Sport Med. 2000; 10(3): 169-175. www.sapphirept.com