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This is the third post in the knee pain series.  Part 1 started with a quick anatomy overview of the knee.  I then moved on to the most common type of knee pain- lateral knee pain.  Anterior knee pain is the second most common knee injury I see in the clinic.  As the image below demonstrates, anterior knee pain (in red) can include the area above or below the kneecap, under the kneecap, or any combination of these.  Medial knee pain (in green) is usually the inner edge of the knee and can be a little above or below the actual joint line.

anterior knee pain

sites of medial & anterior knee pain

This is where internet diagnosing becomes more problematic.  So let me start by saying that what follows is most appropriate for runners who have not had an “event” like falling, tripping, hitting your knee etc. that resulted in immediate knee pain with swelling and/or bruising.  Additionally, if your knee has a painful click, pop, locking sensation, feeling of instability, or other feeling that’s “not right” – you should go to have your knee looked at by a physical therapist or other knee specialist.  Those symptoms are the signs of something more significant like a meniscus or ligament injury.  Knees that pop, click etc. without pain are typically not something to be concerned about.

Whenever someone describes knee pain located above or around their kneecap, I immediately become suspicious of this person’s quad flexibility.  A tight quad will lead to improper patella tracking and eventually pain.  When the subject of patella tracking issues come up, it’s common to hear medical professionals recommend strengthening the vastus medialis oblique (VMO) muscle.  This is outdated information.  Unfortunately, there are still websites and people that give this advice.  While you won’t hurt anything or make the problem worse by doing these exercises, there are more effective strategies to correct this type of knee pain.

The first thing I have people do is work on stretching their quads.  By that I mean REALLY stretching their quads- not just grabbing their foot and bending their knee for a few seconds.  I recommend the following “lunge stretch”.  It focuses on the quads and hip flexors.  There are two versions to this stretch.  If you’re not very flexible, start with the left image.  Once you begin noticing some improvements, you can try the more advanced version on the right.

  • Begin by kneeling on a knee-friendly surface next to something that can be used as upper body support, preferably something on both sides
  • The opposite leg goes forward in a lunge position, arms/hands holding on to a stable surface allows your lower body to relax more
  • Keeping your head up, torso upright and hips facing forward, slowly move your hips forward and down until you feel a stretch along the front of your thigh of the kneeling leg
  • HERE IS THE IMPORTANT PART!  Hold this stretched position for 30-45 seconds.  Yes, it seems like forever.
  • Repeat other side then alternate back and forth three times each side
  • To make the stretch more intense, grab your foot or shoe and slowly bring your foot up toward your hip

 

Shortly after stretching has been incorporated into a person’s daily routine, the next step is to begin strengthening the running specific muscles.  Again, refer to Knee Pain Part 2 for descriptions of these exercises.  The above stretch, combined with hip and hamstring strengthening has helped many people.  If this stretch does not seem to help within a couple weeks of consistent effort, seek help from a medical professional.  As always, please send any questions along to me if anything is unclear.  Good luck!!

***This blog is intended for information purposes only.  It is not intended to diagnose or treat any injury.  Please consult with your doctor or physical therapist if you have any knee pain and prior to beginning any exercises or treatment plan on yourself or others.

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On Sunday, I ran in the first annual Sleepy Hollow Mountain Race.  This race is the first of six in the USATF New England Mountain Running Series, with other races in Vermont, Massachusetts and New Hampshire.

S.H. Mtn Race

The race was co-organized by 2011 U.S. and World Mountain Running Champion Kasie Enman and held in her back yard (literally) on the trails of the Sleepy Hollow Inn and X-C Ski Center.

With the preceding two weeks of wet weather here in VT, it was expected that the 10K course would be on the muddy side… and muddy it was!!  There were sections of ankle deep mud and saturated meadows that looked dry until you ran through them.  There were also sections of runner friendly single track and wide grassy trails.  Oh, and hills.  There were a few hills to run up, and down.  After all, it is part of a mountain series.

Uphill Start

Uphill Start

The race started with a climb for the first 9/10 of a mile to the highest point.  To make things interesting, there was a special prize (VT Maple Syrup of course) for the first man and woman to reach the top of the first climb.  The entire second mile was downhill.  This is where we encountered some of the first serious mud of the day.  Mile three sent us back up hill rather abruptly for the longest climb of the course.  Just over a mile long, the second climb continued with the muddy-trail motif.  Mile four sent us back down hill, this time on some drier terrain.  Mile five offered a little more single track, less mud and less climbing.  Mile 6 was all down hill again along a wide soft grassy road that let you enjoy the run instead of deciding where and where not to step.

Choosing an aggressive soled shoe for this course was very important.  I decided to wear my Inov-8 Oroc 340’s because of the giant lugs on the bottom and because I converted my Talon 212’s into road shoes by shaving the lugs off them.  I noticed that the Inov-8 Talon 212 was a popular choice for this race, as was the Roclite 295. As a Physical Therapist, I really like the Inov-8 brand.  I think they have a great philosophy and design.  I was curious to see what other styles of Inov-8 were at this race.  Here’s what I found.

X-Talon 190

X-Talon 190

Roclite 295

Roclite 295

Terafly 303

Terafly 303

F-Lite 230

F-Lite 230

Oroc 340

Oroc 340

I noticed that even Scott Mason, the race photographer had Roclites on.

Race Photographer Scott Mason

The race photographer – Scott Mason

There were 136 runners at this years race and ZERO injuries that required medical attention!!  Overall it was a great day!!

Kasie

Kasie

A much deserved rest

IT band syndrome and IT band friction syndrome are two common diagnoses that mean the same thing for lateral knee pain.  I know first hand how painful and annoying this type of knee pain can be.  Years ago, I was on a run two days before a big race when I started feeling a slight pain along the outside of my left knee.  I figured it would go away.  But within five minutes it had progressed to a very sharp pain, like a knife was being jabbed into the outside of my knee every time my foot hit the ground.  I had to stop and walk home.  Over the next two days, my knee felt tight & sore and stairs remained painful to walk down.  After a few days of rest I tried running again but the pain returned, this time more quickly.  A trip to the knee doc and an MRI only intensified my frustration.  He said there was nothing showing up in the MRI.  And his advice – my blood pressure still goes up even thinking about this –  ”I don’t see anything wrong with your knee.  Maybe you just shouldn’t run so much.  Do you like biking?”  WHAT!!!!!?????  Are you kidding me!?  I couldn’t believe THAT was his answer.  Fortunately, I was half way through the Physical Therapy program and eventually figured out that I had IT band syndrome.  So I’m always very excited when I can prevent other people from having that same frustrating experience.

Like I said in part 1, there are always exceptions to types of knee pain.  Not everyone will have the exact same intensity of pain that I had.  Also, there are other causes of lateral knee pain (see disclaimer below).  But for runners who haven’t fallen or had some other traumatic knee injury, IT band syndrome is usually the problem.  Below is an explanation, beginning with a self-assessment to help you better understand what’s going on.

Start by standing in front of a mirror with shorts on so you can see our knees.  Stand relaxed and look at your kneecaps.  Do you see one or both oriented somewhat inward instead of straight ahead?  In an extreme case, a person might even notice their knees are closer together than their feet. Next, you’re going to tighten your glutes, AKA: squeeze your butt muscles (not with your hands, I actually had a guy do that once) – watch what your knees do – they’ll slightly rotate laterally to the point where your knee caps are now facing more forward.  Tighten and relax your glutes a few times and you’ll see your knees rotating in and out.  As you’re tightening your glutes you’re externally rotating your hip, which directly affects your knee orientation.  If your knees face inward when you stand relaxed, then the hip external rotator muscles that should be maintaining the alignment of your hips have become weakened.  This leads to knee pain.  So when you need your muscles to support your hips in the proper position while running (which is much more demanding than standing), they eventually fatigue to the point where they can no longer do their job.  This is why your knee pain doesn’t set in until you’ve run a few miles.  Over time, the distance you could run would lessen, stairs would become more painful and eventually you’d have knee pain all the time.

Side view of the knee

Side view of the knee

What’s causing my knee pain if the problem is in my hip?  The IT band starts at the hip as a wide tendon where it attaches to the hip bone (Ilium), the glutes and a small muscle called the tensor facia lata (TFL).  It runs down the outside of your thigh to just below the knee, attaching to the tibia.  This is why it’s called the “IT band.”  It connects the ilium to the tibia.  As the IT band approaches the knee, it rubs against the lateral condyle of the femur (see small image).  I like to use the car front-end alignment analogy to explain this:  If the alignment is off in a car, the tires wear more quickly.  The problem is not the tires, it’s the parts that align the tires.  In our knees, the IT band pain is the same as the worn tires, just a symptom of the root problem.

IT Band

IT Band

How is this related to running?  Think of your knees as simple hinge joints, similar to a door hinge.  They can only go forward and back.  Our kneecaps point in the direction that the hinge is facing.  So if you’re running forward you want your knees to flex straight forward and back, not at an angle.  If your knee is rotated inward, the friction of the IT band on the lateral condyle is greater and things become irritated, especially during repetitive movements like running.  When you see runner’s with their feet kicking out to the sides when they push off, you’re seeing the poor biomechanics of hip internal rotation in action.  They probably have painful knees.

How did this muscle weakness happen?  The short answer is sitting.  When we sit for hours at a time, the muscles are not active.  The use-it-or-lose-it philosophy rings very true here.  Over time, the muscles become more accustomed to being at rest and lose their strength.  I’ve noticed a trend when I talk to people about this subject.  The knee pain usually starts after about 5-6 years of working at a desk job.  Unfortunately, you can count graduate school as a sit-down job.  Incidentally, sit-stand work stations are becoming more popular and I strongly encourage people to consider those if they’re stuck behind a desk work.

How do I fix it?  The permanent fix is to re-strengthen the hip external rotators.  I’ll describe a few exercises below.  In the mean time, there are a couple of things to try that might give some temporary relief.

You can never go wrong with putting ice on the painful area.  This will help decrease any swelling and pain.

Many people try using a foam roller on their IT bands.  That works, but it can be quite uncomfortable and not everyone has positive results.  In the clinic, I do a manual technique called the IT band release.  The closest thing I can describe that a person can do on their own legs is to work up and down the outside of your leg (4-5 times) pressing down and twisting, similar to how you’d open a medication bottle.  You do this WITHOUT any massage cream or lotion.  The idea is to get the layers of fascia, muscle and connective tissue to move independently of each other under the skin. It will feel like a dull ache as you apply pressure.  You can have another person do this for you as you lay on your side, just be careful because your leg will be very sensitive the first few times.  If done correctly, when you stand up and walk around after, your knees should feel lighter and easier to move.  This usually carries over to running.

Exercises: A person will benefit from any exercise that involves hip extension.  I encourage people to avoid machines and do functional exercises.  Functional exercises are more dynamic, require balance and often include the core.  That being said, some functional exercises will be too advanced for someone with significant hip imbalances.  Below are some good basic exercises to start off with.

Standing hip Extension:  Start with a thera-band or cable machine passed under your foot and the handle or loop around your heel.  Stand tall with knees slightly bent.  Without tipping forward or bending your knee, extend your leg backward 1-2 feet (don’t strain to achieve more movement).  Hold for 1 second and SLOWLY return to start.  Try to stay balanced on one foot the entire time as you do 12-15 repetitions.  You should feel your low back, glutes and hamstrings working.  Repeat other side.  Alternate sides, doing 2-3 sets each side.

Standing Hip Extension

Standing Hip Extension

Hamstring curl on a ball:  Lay on your back with heels on an exercise ball and arms out to the side for balance.  Lift your hips up so your body is in a straight line through your knees, hips and shoulders.  Bend your knees and roll the ball toward you with your feet until your knees are bent to about 90 degrees.  Keep your knees, hips and shoulders aligned the entire time.  At this point, you may feel like most of your weight is on your shoulders and upper back.  SLOWLY straighten your knees returning to the start position.  Repeat 12 times, 2-3 sets.  If you have trouble lifting your hips all the way, raise them as high as you can and avoid touching the floor when you straighten your knees.

Hamstring Curl On A Ball

Hamstring Curl On A Ball

Ball squat:  Place an exercise ball against a wall and lean against it with your low back.  Feet should be ~12-16 inches out in front of your hips.  Keeping your back straight and your weight on your heels, SLOWLY squat down as far as you’re comfortable, not letting your knees bend past 90 degrees.  If your knees go out beyond your toes, move your feet forward so knees are above the middle of your foot.  Push through your heels and straighten your knees.  Do not bend forward as you press up and do not let your knees quickly snap straight.  Repeat 12-15 times 2-3 sets.

Ball Squat

Ball Squat

Step Up:  A small weight (3-5#) is helpful in this exercise.  Start with the weight in your right hand and your right foot on a 5-8 inch step.  Step up on the right foot and simultaneously raise the weight straight up and lift your LEFT knee to hip height (as if a string was attached from your right elbow to your left knee).  Hold for 1 second.  Lower back down.  Repeat 12 times.  Switch the weight to left hand, place your left foot on the step and repeat.  Alternate sides for 2-3 sets.

Step Up

Step Up

In the next knee pain post I’ll be talking about anterior knee pain.  The type of pain that feels like it’s under your knee cap or just above or below the knee.

Have you experienced this type of knee pain? Has this post been helpful? Feel free to ask specific questions in the comment area!

Please let me know if any of the exercise descriptions are unclear and I’ll try to fix it.

***This blog is intended for information purposes only.  It is not intended to diagnose or treat any injury.  Please consult with your doctor or physical therapist if you have any knee pain.  Please consult your doctor or physical therapist prior to starting any exercises or treatment plan on yourself or others.

This was my third year running the Boston Marathon, and the second year of very unique weather conditions.  Last year we had a tail wind that would help Geoffrey Mutai run the fastest marathon ever.  This year, the intense heat would slow even the elite runners, to a winning time of 2:12:40.  With the exception of 2007, when rain and a relentless 30 mph head wind slowed the winner to 2:14:13, a winning Boston time hasn’t been over 2:12 since 1985.

Being a glass-half-full type of person, I’ve been reflecting back on the high points of the day.

  • My pre-race routine went exactly as I planned.  (With the exception of the bus I was on taking a wrong turn.  I hear stories every year of lost busses and this year I was on one.  Fortunately, we got back on the right path within 15 minutes.)
  • I felt like I ate and drank exactly what I should have before the race.
  • I walked to the starting line feeling surprisingly calm and confident.
  • At 9:50 I still didn’t think the heat was too bad.

I entered my corral and immediately made my way over to the left edge where things appeared to be less chaotic (I always start on the edges in big races).  I realized that I was directly in front of the route where the elite runners make their way to the start!  Just as I realized this, they came out from the church with Mutai leading the crowd.  I was impressed with the reverence the other elites showed him.  No one would walk in front of or next to Mutai.  With a smile, Mutai humbly encouraged the others to go ahead, but they insisted he lead the way to the start.  That was nice to see.

Shortly after, the gun fired and we were heading down hill.  It took me a few minutes to really get my head focused.  Something finally clicked and the realization of “you’re running the Boston marathon” sunk in.  I assessed my pace and thought about how I wanted to run these first downhill miles.

  • About 2 miles into the race I saw that I was about to pass Joan Benoit-Samuelson!  I said “Hi Joanie!” as I went by, and she wished me good luck.
  • I passed Dick and Rick Hoyt around 8 miles and said hello to them.
  • My plan to go out a little more reserved was going very well.  I hit the half at 1:21:45.
  • I made it up the first couple Newton hills without any trouble.

Considering the heat, I was very comfortable and happy with my pace.  Even if I backed off this pace a little, I’d still be well under 2:50.  Eighty degrees?  Whatever! …  To continue with the positive points of the day I‘ll have to skip over miles 19-25.  The heat finally hit me during those miles.  My legs wanted to go but my brain was saying “you’re walking now”.

high five at 40k

high five at 40k

  • I discovered that high-fiving the crowd really took my mind off how heavy and slow I was feeling.
  • From mile 25 to the finish I was able to pull it together enough to run the whole way.
  • The faster you run down Bolyston St., the louder the crowds cheer!

I crossed the finish line at 3:02:43.  Considering the fact that the heat even slowed the Kenyan runners, being 17 minutes off my goal time wasn’t that bad.  But the best was yet to come.

  • I could still walk!!
  • This year my preparation for the race was much more thorough and I got through the race without blisters, cramping, chaffing or heat exhaustion.
  • The post-race muscle soreness that followed has been very minimal!!  I consider that a huge success.

The first goal I had set for myself was to not let the course beat me.  Last year, I could barely walk or go down stairs for a full week.  My original time goal of sub 2:45, would have been about 40-45 minutes behind the winner of the race.  When all was said and done on Monday April 16 2012, my finishing time was 50 minutes behind the winner.  I’ll take it.   That’s one of the unique things about endurance sports.  Everyday people get the chance to compare their times directly with the best in the world, on the same day, on the same course, in the same conditions.  When will you get a chance to play in a tournament with Tiger Woods, or sprint against Usain Bolt, or swim in the lane next to Michael Phelps?  Probably never.  But if you sign up for the Boston Marathon, you’ll get a chance to race Geoffrey Mutai, Ryan Hall, Desiree Davilla, Joan Benoit-Samuelson, and probably the next big name in marathon racing.

The folks at the BAA have been monitoring the weather for Monday and sending updates regularly.  The latest report was not very uplifting…

“We are now making the recommendation that if you are not highly fit or if you have any underlying medical conditions (for example-cardiac disease, pulmonary disease or any of a number of medical problems), you should NOT run this race.

Inexperienced marathoners should not run.

Those who have only trained in a cooler climate and who may not be acclimated (for at least the last 10 days) to warm weather running conditions should also consider not running.
 
For those very fit athletes who decide to run, you should take significant precautions:

Run at a slower pace and maintain hydration.

You should frequently take breaks by walking instead of running.

This will not be a day to run a personal best.”

The high of the day is predicted to be 87, but not until 3pm.  The race starts at 10am and I hope to be done around 12:45.  I’m feeling very ready for this race so I’m still going for it!!

My number is 1095 this year.

I’m feeling ready for this race!  If all goes well I hope to be hitting the half around 1:19 and finishing under 2:45.

Only six more days to Boston!  All the work is done so it’s really a week of low mileage and REST.  See how I put “rest”  in bold and capitalized it?  That means it’s pretty important!  In the last week or two before a marathon, a lot of people fear they haven’t done enough, and they try to cram in more mileage and/or speed work to make up for it.  At this point it’s too late.  Trying to make up missed workouts will only keep you from recovering completely for the big race.  If you’ve done the work in the months leading up this point, have faith that the training will have made you stronger.  The lower mileage in these last weeks will give your muscles a chance to recover and rebuild so they can handle the marathon.   This is why listening to your body is important.  If you need the extra rest, take it.  That can mean more sleep, lower mileage or an additional day off.

Over the weekend, my plan was to run 12 miles for my last long run.  As I started out, my calves were a little tight and I was feeling fatigued overall.  I didn’t really feel like running.  When I feel like that, I usually give myself 15-20 minutes to warm up and then decide if I should cut the run short.  I felt better after a while but I did decide to stop around 8 miles.  This close to the marathon, I’d rather end a training run feeling like I could have done more.