Now, some ground rules!
Knee pain can sometimes seem very simple. I mean, it’s mostly just a modified hinge joint, right? I would beg to differ. So, here’s a quick guide on a select few of the common knee pain presentations we encounter weekly at Roar Physio;
As it is hopefully becoming apparent, there is a huge amount of diagnostic variance in knee pain. When you combine this with the enormous variety between individuals, it begins to become increasingly difficult to make generalisations about all types of anterior knee pain.
This isn’t to say that there are not factors that most of the above types of knee pain will have in common though. As such, you can apply most of these considerations and exercise advice to a variety of pain presentations and disorders, but it certainly won’t be a perfect fit.
Here are some key considerations when you have anterior knee pain;
One of the key questions that all clients at Roar Physiotherapy will be asked is about their training history and current training loads. This provides pivotal information as to what may be the primary pain driver and at times guides a rehabilitation plan and program.
Increasing training intensity/volume/frequency/ modality will push you up and beyond your current physical capability. In the right dose, this leads to supercompensation, adaptation and building resilience – the good stuff!
When we push the boundary further, we move outside our ‘envelope of function’ and this can result in pain and dysfunction. This is demonstrated in the following image.
In summary, when increasing your training, be smart and understand that this comes with risk and reward – it’s up to you or your coach to decide the balance!
To learn more about training load and its impact on training and injury, check out these previous blog posts, HERE and HERE.
More often than not, knee-pain sufferers tend to not find every activity painful, but rather a select few. There are some broad patterns I have observed in practice;
These can also be present in combination with one another. Accurately identifying the category, or categories, you fall in to can enable effective training modification, whilst recovering.
It can be broadly considered that adaptation occurs between the balance of fitness and fatigue. We develop fitness over time through training; depletion of energy; and recovery. This process is known as supercompensation (as illustrated in the diagram below).
If we interrupt the recovery process prematurely (prior to achieving supercompensation), then we accumulate fatigue, instead of positive adaptation.
Essential components for recovery are time, diet and sleep.
In fact, one study found that adolescent athletes who sleep, on average, less than eight hours have 1.7 times greater risk of being injured than those who sleep longer than eight hours.
By interfering with our sleep and recovery time, we potentially steer ourselves to developing pain. To learn more about sleep and its impact on training and injury, check out a previous blog post, HERE.
Furthermore, our mood & stress levels have been shown to be associated with the development/resolution of anterior knee pain. In one study, an individual’s beliefs surrounding their pain and activity levels were the strongest predictor of recovery from their knee pain.
So, when things don’t tend to make sense in regard to training itself, step back and consider how you have been recovering and what your stress has been like in recent times. This can start to build a clearer picture of why knee pain may have developed in the first place and what needs to be considered for optimal recovery.
Times they need a changin’..?
Ok, now we’ve established WHY you’re probably in pain, but what do we do about it?
Firstly, don’t freak out! Remember, pain is normal and is UNDOUBTABLY going to happen sometime in your training career.
If we look back to ‘Consideration Two,’ try to figure out what your sensitising features are;
The easiest method to begin managing this is to regress the aggravating activity. Perhaps for you this means reducing the weight, volume or depth of the movement. This is the option we promote most at Roar Physio and tends to be the most effective, whilst still keeping you very active.
If this doesn’t achieve our goal of pain reduction or functional improvement, then removing the aggravating activity should be considered. Seems like a no-brainer. The awesome thing about CrossFit is how ‘constantly varied’ it is. Take advantage of that and take a break from the one or two activities that’s are causing you pain for a week. It won’t kill you!
After implementing the above considerations and relevant activity modifications, there is usually a role for exercise rehabilitation to get you back into optimal function.
Here are a few favourites from Roar Physiotherapy to assist you in getting back to it!
Spanish Squats are very useful for warming up tendon-related pain and to practice a more ‘hip-dominant’ style squat, which reduces anterior knee force.
CrossFit is massively bilateral, until it’s not… Just ask the recent Games Day 2019 competitors how their 100 pistols for time went!
As such, I think it’s important to regularly include and practice single leg movements. A simple regression/progression ladder may be;
For some knee-pain sufferers, training the gluteal muscle group has an effect on pain reduction and functional improvement. Have a go at this example of a banded glute !
I hope this has provided some assistance for anyone suffering from knee pain. As a long-term knee pain sufferer myself, I understand how difficult and frustrating it can be to be limited by a cranky knee.
To learn a little more about knee pain, HERE is a previous blog piece I have written on common sources of knee pain.
If anyone is struggling to get on top of their pain or regain their function and performance, get in touch with us on the details below and get a plan in place!
Phone: 0421 833 801
Milewski, M. D., Skaggs, D. L., Bishop, G. A., Pace, J. L., Ibrahim, D. A., Wren, T. A., & Barzdukas, A. (2014). Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. Journal of Pediatric Orthopaedics, 34(2), 129-133.
Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of rehabilitation medicine, 41(8), 604-612.
Piva, S. R., Fitzgerald, G. K., Irrgang, J. J., Fritz, J. M., Wisniewski, S., McGinty, G. T., … & Delitto, A. (2009). Associates of physical function and pain in patients with patellofemoral pain syndrome. Archives of physical medicine and rehabilitation, 90(2), 285-295.
Willy, R. W., & Meira, E. P. (2016). Current concepts in biomechanical interventions for patellofemoral pain. International Journal of Sports Physical Therapy, 11(6), 877.
The winter season is well and truly underway thus the busiest time of the year for field sports is upon us. Hand in hand with this comes soft-tissue injuries for the unlucky and unprepared. A significant proportion of these people will experience a hamstring injury (HSI). Check out our video for more info on Hamstring Injuries, here.
HSI’s can be as frustrating as they are common, with one study suggesting they represent 12-16% of injuries in all soccer players. The difficulty, however, arises in the recurrence of HSI with the same study suggesting 22% of those with HSI will have another within 2 months after the initial injury and 25% will re-injure the season after.
These numbers are huge and represent massive failings across a few areas:
Poor compliance/utilisation of the strength and conditioning during pre-season
Failed or poor rehabilitation post-injury
Possibly never doing either of the above!
So, how do these HSI occur in the first place and what is their mechanism?
Peak hamstring force occurs in the late swing phase (Figure 1 – panel 4 and 5, right leg) of the running gait cycle. This force increases as we increase our speed. This is where the majority of HSI occur due to the hamstring having to generate tension whilst lengthening to decelerate the knee.
Plenty of people who have experienced a HSI will tell you they did their warm-up or pre-season work. However, unless you are exposed to loads at high speed and intensity the hamstring will not be prepared. This is due to the hamstring muscles being relatively dormant during the walking or jogging gait cycle. Put simply, going for a jog does not condition your hamstrings enough for field sports. Period.
Knowing this, some canny researchers in Denmark decided to try implementing a hamstring strengthening protocol, known as the Nordic Hamstring Curl (Figure 2) and measure its impact on HSI in soccer players. This revealed some interesting results.
A reduction of 60% in new HSI and a reduction of 85% in recurrent HSI’s! Furthermore, another study reported the Nordic improved hamstring length as much as static stretching, plus all the extra strength gains.
I will add a third to this;
The reason for this is that the exercise mimics the role of the hamstring muscles during sprinting (lengthening whilst contracting) and thus can present a potential mechanism for re-injury if not introduced carefully by a professional.
A more recent paper has found that when combined with a lack of eccentric (lengthening) strength, a short Bicep Femoris long head (BFlh) increased the risk of a HSI. More specifically;
We know from previous research that a really effective way of improving muscle fascicle length is through incorporating eccentric exercises. So through incorporating eccentric exercises, such as the aforementioned Nordic, we are able to significantly reduce our injury risk due to targeting weakness and tightness! This is accurately summarised in Figure 3 (below).
Take home points:
I hope this brief overview provides some insight into why and how HSI occur and what to do in order to rehabilitate following injury. You can also use this general advice as a way to remain injury free!
If you’ve suffered HSI in the past and are looking to bulletproof yourself for the winter season, contact Roar Physiotherapy in 0421 833 801 to get started on your specific hamstring strengthening protocol today!
O’Sullivan, K., McAuliffe, S., & DeBurca, N. (2012). The effects of eccentric training on lower limb flexibility: a systematic review. British journal of sports medicine, bjsports-2011.
Petersen, J., Thorborg, K., Nielsen, M. B., & Hölmich, P. (2010). Acute hamstring injuries in Danish elite football: a 12‐month prospective registration study among 374 players. Scandinavian journal of medicine & science in sports, 20(4), 588-592.
Petersen, J., Thorborg, K., Nielsen, M. B., Budtz-Jørgensen, E., & Hölmich, P. (2011). Preventive effect of eccentric training on acute hamstring injuries in men’s soccer a cluster-randomized controlled trial. The American journal of sports medicine, 39(11), 2296-2303.
Timmins, R. G., Bourne, M. N., Shield, A. J., Williams, M. D., Lorenzen, C., & Opar, D. A. (2016). Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. Br J Sports Med, 50(24), 1524-1535.
Now we know what the hamstrings are made of (here) and the principles of avoiding hamstring injury (here), we can move onto something heavily practical which you can sink your teeth into – The optimal hamstring rehab program, according to science.
These clever researchers have managed to assess some of the most common hamstrings exercises and from there, measure the activation of each hamstring muscle. They have therefore been able to determine which is the most targeted exercise for each hamstring muscle.
So, without further ado, what you need to know.
Low activation All exercises S > BFlh activation
To simplify this slightly, Bourne et al found that hip extension activities (e.g. RDL) preferentially activate the BFlh whereas knee flexion activities (e.g. Nordic HS Curl) preferentially recruit the semitendinosus.
These findings are vital to effective hamstring rehab as they allow a good clinician to provide a complete rehab program which targets the whole muscle group. This has the capacity to improve rehab outcomes as well as reduce reinjury when gym-based rehab programs are maintained in the long term. Furthermore, this information could be useful for those in the bodybuilding community who pursue a symmetrical and intentionally well-developed figure.
If there are any questions regarding this piece or the previous two, contact me on firstname.lastname@example.org or get in touch via Facebook @roarphysiotherapy or Instagram @roar_physio.
Roar Principal Physiotherapist
Hamstring injury rehab is a buzz topic in physiotherapy right now and rightfully so! Subsequently, I’ve been reading and listening to everything I can to provide to you a condensed version of what we know, so you can get better, faster!
Firstly, if you haven’t checked out the previous hamstring articles by Roar Physiotherapy, check them out, here and here. If reading isn’t your thing, I summarised it in a short video which can be found, here. These resources go through why we get hamstring injuries and the factors that can predict them.
To begin the conversation, let’s get into what we know about how the hamstrings are built, or their architecture. There are three hamstrings which can be divided roughly into medial and lateral groups. The medial hamstrings are made up of the semitendinosus and semimembranosus muscles and originate from the medial aspect of the ischial tuberosity (your sit bone) and insert to the medial shin bone. The lateral hamstrings are split into two heads of the biceps femoris muscle, being the long and short head. The long head starts in the same spot as the semitendinosus (medial sit bone) and the short head originates from a bony groove in the back of the femur called the linea aspera. These heads run down and insert in a few locations, but mainly to the fibular head and into the lateral collateral ligament (LCL).
The semitendinosus, semimembranosus and bicep femoris long head are all supplied by the tibial branch of the sciatic nerve. Interestingly, the short head is actually supplied by the common peroneal portion of the sciatic nerve. It remains to be seen if this could be a potential reason for so many bicep femoris muscle injuries, but is certainly an area to watch!
That was intense…
The reason it is important to understand the hamstring anatomy is because of the distinct differences in each muscle. Hamstring rehab and injury prevention should include MANY different exercises, rather than just one or two curls. This will be thoroughly explained in part three, plus all the exercises you NEED to know!