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.
Today we will discuss a subject dear to my heart and dearer to my muscles, joints and tendons.Loading.
I started this chat a few weeks ago on the Roar Physiotherapy Facebook page and on the Roar Physiotherapy YouTube Channel. Check that out here.
Something I have come to realise over the past three years is the dire importance of loading. Load can be considered any form of activity applied to the body. It could also be defined as what makes or breaks an athlete.
I want to go through some of the basics around load monitoring today in order to help all who are reading, stay injury free (that assumes someone other than me is reading this though – a dangerous thought indeed…).
So first we need to know a few things;
The two types of load are internal and external load. Internal loads are measures such as our heart rate or rating of perceived exertion (also known as RPE; table of RPE below). Whereas, external load is the distance, weight, or intensity of activities.
The other critical element of load monitoring is the individualised effect of training. For example;
Asking both myself, a poor runner at the best of times, and an Olympic level runner to run a 400m in under one minute. This will have vastly different response (one being death and the other a casual run), despite being the exact same distance (external load).
Furthermore, humans are complex, emotional creatures. You’re not likely to train as well after your goldfish just died and you’re an emotional mess (why did you have to leave me Goldy?) as compared to when you’re fresh, rested and stress-free.
Now we are all on the same page, let’s get stuck into some numbers! Yay… Good thing it’s simple.
For internal load, the easiest method is to multiple the session RPE by the session duration. So, it will look something like;
Sessions RPE (5/10) x minutes (60)
5 x 60 = 300 arbitrary units (AU)
The units are purely arbitrary, meaning they’re just a way for us to measure and compare week to week.
For external load, it is a little more straightforward in that it’s just what you have done for your session.
Example; 10 x 70m sprints = 700m
Or, conversely if you have access to it, GPS is a reliable and accurate way to measure things like distance and heart which you can use immediately.
To illustrate this, here is an example for a training week of mine, working out my internal load.
In this short example, we can see the type of training, the minutes, RPE and internal load, respectively. In this way, we can see the weekly total and compare this week to week in order to accurately measure our workload and subsequently calculate our injury risk!
This write-up provides you with the basics of load monitoring. I hope it has begun to get you thinking about how you train.
The next part of this topic will examine how we can use Acute to Chronic work ratios to establish how to remain injury free and maximise performance!
Gabbett, T. J. (2016). The training—injury prevention paradox: should athletes be training smarter and harder?. British journal of sports medicine, 50(5), 273-280.
Following on with the theme of loading (check out the previous blog post, here and the video here), I wanted to discuss how loading can impact on injury rates. Brace yourself for some factual healing, Dr Marvin Gay style. Work by Tim Gabbet (Professional Man Crush alert), has paved the way for these results, thus all credit to him.
Essentially, his work across many team sports found that the higher your workload, either external or internal (refer to my previous articles if you want more information on what those terms mean), the higher your likelihood of sustaining a soft-tissue injury. Bummer.
Though all is not as it seems, which we will get to later.
Somewhat surprisingly, the external load and our internal loads are strongly correlated. So, if you’re continually feeling like junk after training, take notice, you may be pushing toward overtraining syndrome.
Something I spend a considerable amount of time discussing with the athletes I manage, is how to modify their weekly load to minimise injury risk.
Gabbett’s research resulted in a piece of startling information; Players who exceeded their weekly load threshold were 70 TIMES MORE LIKELY to test positive for a soft-tissue injury!
Furthermore, previous research has shown that 40% of soft tissue injuries were associated with a rapid change in weekly training load.
Getting back to the exception to higher training.
Take a look at this graph – we can see the steepest part of the ‘pre-season’ curve represents what we’ve been talking about; higher load has a higher likelihood of injury. However, if we look at the top of the is curve we can see it almost flattens out. This means, if we safely and effectively build fitness (the positive adaptations of training) we can then progress to much higher loads with a minimal increase in likelihood of injury! In short this means, if we can build resilience to training it becomes protective and preventative for injury! This is the whole reason for a pre-season
The result from all of this is;
Train Harder AND Smarter.
I just got tingles…
Though seemingly simple, it takes care and patience to achieve. It means you must become educated on training loads, apply this information regularly and then make informed decisions on training daily. This is how you reduce injuries.
“The problem is not with training per se, but more likely the inappropriate training that is being prescribed”.
If you require any further information, or are looking to understand your training loads and how to prevent injury better, please don’t hesitate to contact me or comment below!
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 email@example.com or get in touch via Facebook @roarphysiotherapy or Instagram @roar_physio.
Roar Principal Physiotherapist
Part two of our exposé into everything hamstrings leads us to the deep, dark and depressing topic of hamstring injuries.
If you haven’t read or watched the previous posts, find them here (this link contains about 5 different pieces which are hamstring related) and here.
As for now – ONWARD!
The Quadrant of Doom is a theory that I stumbled across a little while back which nicely summarised what I had been thinking for a long while. Hamstring injuries are far more common when you have short AND weak muscles. In fact, you’re almost 10 TIMES more likely to get injured than if your muscles are long and strong.
The important thing to note here is the ‘and’. If you spend all of your time stretching to prevent injury, you are wasting your time – Period! If you truly want to prevent hamstring injuries, you must step into the ‘House of Iron and Gainz’ to achieve your goals.
I often get asked ‘Is there an optimal way to train your hamstrings?’. All secrets (which are freely accessible through a literature search…) will be revealed in part three!