Popliteus Is The Problem, Not Baker's Cyst

Back of L leg

I had a patient who came to our clinic this past week complaining of pain in the back of her knee. She looked at her symptoms online and thought she had a Baker's cyst. One look at it and I told her not a chance of it being a Baker's cyst.

After examining her knee carefully, I told her it was her popliteus muscle bothering her.

Here's some background information about my patient. She was about 13 months post ACL (anterior cruciate ligament) surgery, back to weight training, running and training two to three times a week for netball.

Now, as far as I remember, every single patient who've undergone an ACL reconstruction I've treated have had a problem with their popliteus muscle at some point or other.

The popliteus muscle is triangular in shape sitting at the back of the knee. It starts on the lateral femoral condyle (posterior, outer part) of the femur (thigh bone) and the lateral meniscus. It then runs down and across the back of the knee joint to finish on the posteromedial (inner) part of the tibial (shin bone).

R popliteus

The muscle limits excessive internal and external tibial rotation. It helps straighten your knee from full extension by rotating the tibial internally. It also "pulls" the lateral meniscus out of the way during knee bending to prevent too much compressive forces from the femur of the tibial so you don't tear your lateral meniscus.

The poplitues muscle is very seldom the main cause of the problem. There is usually a problem with other stabilizing strutcures in that posterior lateral corner of the knee. It is often hurt because of compensating mechanisms related to that. Such has hip rotator weakness that transmits excessive forces towards the knee. Also, hamstring weakness with hip, knee pivoting movements, which are extremely common in netball.

Consider that most ACL reconstructions for patients now are done usually using the hamstring grafts so the hamstring is consistently weaker thus causing the injury/ strain to the popilteus muscle.

Treating the poplitues muscle for my patient was the easy part. I got her pain free at the end of the session. Ensuring the pain does not come back is trickier.

She needed to address the weakness in her hip stabilizers and hamstrings to prevent the problem from coming back. And that will take some effort on her part.

11th Floss Band Course

What a coincidence. Physio Solutions turned eleven earlier this week and at the end of the same week I'm teaching the 11th Floss Band course. Good things come in pairs I suppose.

My Saturday usually starts with an early bike ride. I'm usually out of the house before six in the morning and get back in time to start work in our clinic by 10:30 am. I see patients til 1:30 pm so I have about 30 mins to get ready.

Drenched this morning

Thanks to Danny and Amy who have already set up the chairs, projector etc I hook up my laptop to get my presentation ready before I try to eat and drink a little before I start teaching at 2 pm.

Fortunately, the course got up fine today. Despite my early start, I wasn't too tired and was still able to answer the questions that came my way. We had a mix of trainers, physiotherapy students, massage therapists, cross fitters and a couple of physiotherapists attending today.

3D image of skin, fascia and muscle from my slides

We went through the anatomy and function of fascia, Pain Gate Theory etc so the participants can explain how the Floss Bands work.

Too tight says Si Rui

A big thank you to Danny, Amy and Jane who came later for helping to get the clinic ready for the course and also for helping tidy up after. Please contact them at Sanctband Singapore for the next Floss Band course and if you need to get the Floss bands.

Thank you to the participants who came too. Hope everyone found the course useful.

Don't Force The Teenage Athletes

I read with interest a recent New York Times article about Katelyn Tuohy. A female teenage track phenom with the headline "America's Next Great Running Hope, and One of the Cruelest Twist in Youth Sports."

Although Katelyn had already won titles and set records at sophomore (15-16 years old) level, the article made the point that many previous high school phenoms fail to live up to their early promise because of changes to their physique. The article pointed out that this seems to be a cruel twist in youth sports as girls turn into women.

The article mentioned that it was nearly impossible to predict an elite girl's future success in distance running because the female body changes so much as they continue to grow. Other than a good lung capacity, long distance races require great body weight to strength ratio. The teenage girls are skinny in their early years. Then as they mature and and grow, they may not develop the strength to move their bigger bodies  as quickly.

It's not surprising then that many girls end up with eating disorders, body related issues and end up getting injured. Off the top of my head, I can think of so many teenage athletes I've treated over the years that ended up going down that same path.

Many of the young athletes couldn't understand that it was perfectly normal to have the ups and downs (in their performances) they experience as their bodies change. Girls tend to put on more fat to prepare the body for reproduction. Good if we want to maintain our population, but not good if you're an elite athlete looking to improve your performance.

I had a former classmate PTL in primary school. He won the "Individual Champion" title in our school's track and field meet after winning 100, 200 m and the shot putt (plus the 4 x 100 relay too). That streak started in Primary Four (while he was ten) til Primary 6 (there was no meet from Primary One to Three).

We went to the same Secondary school and he won the 100, 200, 400 m and 110 m hurdles to emerge "Individual Champion" again in Secondary One and Two.

While in Secondary Three (they finally had longer events in track and field), PTL won the first 3 events and finished runners up for the 110 m hurdles event. We shared the "Individual Champion"  title after I won the 1500, 3000 m, 2000 m steeplechase and was 2nd for the 800 m. (Luckily for me, they gave out 2 trophies).

By the time we were in Secondary Four, I won all my four events while PTL didn't win any of his individual events. I ended winning our school's only individual medal at the National School's meet later that year while PTL ran the relays and never competed again after that.

Looking back now I know PTL reached puberty and had his growth spurt earlier than us in Primary school and was physically superior to everyone else. That's how he won all the events earlier. When the rest of us "caught up" hitting puberty later he didn't have that advantage anymore.

Perhaps PTL, having been raised on victories from young, could not comprehend or accept defeat. Early victories may have paved the way for defeat and giving up eventually.

Hence, I will never ever push my kids to excel in sports or something they don't like. I was never pushed when I was a kid. The desire all came from within. However, if they're keen, I will definitely help, support and guide them if I can.

So parents, teachers, coaches and all of you who are involved with young athletes take note of what Kara Goucher said. "Talent never goes away. Once these women/ girls (or boys) adjust to a mature body, the talent can come through again. The obsession with labeling these girls as 'the next big thing' is part of the problem  .... Katelyn is very talented. She will grow and probably slow. But once she adjusts, if she still has the love, the talent will still be there."

Don't push the kids, support, guide and help them if they themselves wish to excel.

Here's a close up of my first Individual Champion trophy. Thanks to my brother who took the pictures for me.

Beach Running Anyone?

I have patients who get impact associated injuries like shin splints or stress fractures all the time. it's probably the most common running injury we see in our clinics along with knee pain.

Other than deep water running which has no impact, I often suggest going to the beach to get them running again.

Have you tried running on the beach? Research shows that running on sand requires 1.6 times more energy expenditure than running on a firm surface. Try it to believe it. Due to the change in technique you require as well as balancing on the sand, the stabilizing muscles in your hips, knees and ankle are working much harder.

Soft sand is particularly difficult while hard or packed sand (near the edge of the water) is definitely easier to run on. It definitely works different muscles (compared to running on the road) and it requires more focus so you don't sprain your ankle due to the uneven surface and constantly shifting ground.

In fact, while combating the "slip" element, range of motion of joint angles around the hip, knee and ankle were found to similar to running during faster speeds on firm ground (Binnie et al, 2013). That translates to a much higher heart rate, increasing your oxygen debt and blood lactate levels. Meaning you get fitter, stronger and faster quicker.

So incorporating sand running into your training can definitely help improve your race times.

Another article found that soft sandy surfaces reduced muscle soreness and fatigue (Binnie et al, 2014) due to almost four times less impact versus a firmer surface. Because of the softer surface, there's also less stress on our joints which can lessen impact and helps prevent injuries.

When running on firm ground, less of the elastic energy which is stored in our tendons is absorbed, so you don't have to work as hard. When running on sand, it absorbs the forces, meaning you have to generate more forces with your muscles to run.

Researchers found that there was almost four times less impact forces on soft sand compared to firm ground with every single foot strike. This is really good if you need to reduce load through the legs but still want to get in a hard workout when you run. 

Research also suggest that runners who ran on the beach (especially on soft dry sand found farther away from the water) had less muscle damage and inflammation compared to running on grass (Brown et al, 2017).

Due to where I stay, I hardly get to run barefoot on the beach. When I do, which is often during our family's holiday trips, I always start much slower than my usual runs. I also do not worry about the time or distance that I clock. In fact, I often do some short hard sprints (because of the lower impact) to get my heart rate up even higher.

Hearing the waves crash also helps to calm and clear my mind, which is a nice bonus.


References

Binnie MJ, Dawson B et al (2014). Effect Of Sand Versus Grass Training Surfaces During An 8-week Pre-season Conditioning Programme In Team Sport Athletes. Eur J Sp Sci. 32(14): 1001-1012. DOI: 10.1080/02640414.2013.879333.

Binnie MJ, Peeling P et al (2013). Effect Of Surface-specific Training On 20-m Sprint Performance On Sand And Grass Surfaces. J Strength Cond Research. 27(12): 3315-3520. DOI: 10.1519/JSC.0b013e31828f043f.

Brown H, Dawson B et al (2017). Sand Training: Exercise-induced Muscle Damage And Inflammatory Responses To Matched Intensity Exercise. Eur J Sp Sci. 17(6): 741-747. DOI: 10.1080/17461391.2017.1304998

Lejeune TM et al (1998). Mechanics And Energetics Of Human Locomotion On Sand. J Expt Biol. 201: 2071-2018.

"Collapsed" Arches And Tibialis Posterior Muscle Pain

I had a really interesting case involving a triathlete/ runner recently. She had terrible pain in her arches and couldn't even walk around barefoot at home. It had started after she increased her run training recently. The orthopaedic surgeon she consulted had prescribed two pairs (yes two, you read correctly) of orthotics. And he said if they failed she would require surgery. A soft pair for her training and a hard pair while she was wearing her work shoes for her "collapsed arches".

She was advised not to run but was given the green light to bike and swim. Unfortunately, both times she wore her soft orthotics for cycling (and not evening running) her arches hurt after only fifteen minutes and she had stop riding. Even after icing her foot after the ride, her foot still felt sore the next day.

Pretty high eh?

Upon further questioning, she told me she didn't use the orthotic  and was able to walk pain free for 2-3 hours a few days ago in her Havaianas flip flops (or slippers).

However, after she biked again yesterday morning for only ten minutes, the pain came straight back with a vengeance.

When I examined her, her foot was was fairly flat and she had no arches. Her pain was mostly on her navicular bone and it was very tender to touch. I took a quick look at her soft pair of orthotics and noticed that the medial (inner) side of the orthotic was highly built up.

I told my patient I thought it was probably the orthotic irritating her navicular bone since it flared up within such a short time of using it while riding her bike.

Here's how the Tibialis posterior irritates the navicular bone

Other than her navicular bone tenderness, her tibialis posterior muscle was sore upon palpation all the way up her shin. Yes, the tibialis posterior muscle is the very same muscle that causes the much dreaded shin splints in runners.

L tibialis posterior

To make the long story short, I treated her and she's back running happily with no pain. What did I do? I treated her lateral, spiral and superficial back line.

Spiral Line