Can A Bit Of Tape Rotate Leg Bones?

Unlike others in the picture above who are skeptical and think that leg bones cannot be rotated with "a bit of tape" in 2022,  I remain open to finding out how to treat our patients with knee pain. 

Just because I cannot ride a unicycle does not mean others cannot. Similarly if the author above cannot rotate his / her patient's leg with "a bit of tape" does not mean others can't.

We do see many patients in our clinics presenting with knee pain. Even though we have very good results treating these cases, I am always on the look out on how to get these patients with knee pain better quicker. Especially those who run.

In our clinics, we almost never tape the patient's knee, especially if the cause of their knee pain is coming from elsewhere. In fact, we do not even use rigid sports tape when we do tape the patient's knee.

Using Kinesio tape compared to using rigid sports tapes to do McConnell taping, (first published in 'Physiotherapy' journal in 1986 by Australian physiotherapist Jenny McConnell) definitely produces a superior result.  

So I was really intrigued when I saw a paper that investigated the effects of using rigid sports tape for tibial internal rotation taping (IRT) and external rotation taping (ERT) done on subjects with patellofemoral pain syndrome (knee pain) during three functional tests. During double leg squat, single leg squat and maximum isometric thigh muscle contraction.

Internal rotation taping

The researchers found that compared to no taping, both IRT and ERT significantly reduced pain during the three tests, especially for those with higher pain levels initially.

External rotation taping

ERT was found to be more effective than IRT. Why? The authors did not provide any suggestions. My thoughts are that when you externally rotate your tibial (shin bone), you can activate your gluteus medius better. Remember, one of our most popular posts shows that the cause of patients' knee pain is usually coming from the hip.

To see if the two taping techniques work, let me try the ERT and IRT techniques on my colleagues in our clinics first before I unleash them on our patients. Bear in mind we still want to treat the cause of the problem and not just the pain itself.

Reference

Deng F, Adams R, Pranata A et al (2022). Tibial Internal And External Rotation Taping For Improving Pain In Patients With Patellofemoral Pain Syndrome. J Sci Med Sp. DOI: 10/1016/jsams.202204.003

*thanks to Byron and Megan for helping me with the photos

PS Sim Finishes 200 Miles Race

Picture from PS Sim

Yes, you read correctly, PS Sim is the first and only finisher (male or female) so far in the 2021 Singapore 200 Miles Ultramarathon held from 6-9 August by Running Guild. She finished in an amazing 76 hours and 41 minutes!!

She came to see me last Thursday (5/8/21) for one last tune up as she had some knee pain. After treating her, she asked if I could do some taping for her. Since the cause of her knee pain was coming from her hip, I taped her left hip (instead of her left knee) and she was pain free through out the run. Have a look at the whatsapp message she sent me yesterday below.

She even offered to write me a testimonial for the Kinesio taping that I did for her. For all the naysayers who do not believe  that Kinesio taping works, the proof is in the pudding - or rather in PS Sim's legs! 

Now, I have nothing against all the published articles that say Kinesio taping does not work. And there are many healthcare professionals who do not believe in it. However, if the researchers have never learnt to do the actual Kinesio taping correctly, or used different brands/ types of tape, then I would humbly suggest that their research methodology may be flawed. 

Similarly, if I never learnt for example, Alexander technique, and I try it on my patients and end up with poor results, surely it is then unfair for me to say it does not work.

Anyway this post is not about Kinesio taping, this post is to congratulate PS Sim on a run super well done on Singapore's 56th National day! 

She has next set her sights on completing the last mountain she needs to summit before she scales the highest peaks on all 7 continents in Antarctica this coming December. After Team Singapore's outing at the recent Tokyo Olympics, there were calls for the private sector to step up and support sports in Singapore. We have always done that and we will continue to do so. Sports Solutions will be wishing her all the best and supporting her.

She has next set her sights on completing the last mountain she needs to summit before she scales the highest peaks on all 7 continents in Antarctica this coming December. After Team Singapore's outing at the recent Tokyo Olympics, there were calls for the private sector to step up and support sports in Singapore. We have always done that and we will continue to do so. Sports Solutions will be wishing her all the best and supporting her.

No Need To Stretch Or Foam Roll Your ITB?

You are a runner and you haven't been able to run more than 2 km before a sharp pain in your outer knee reduces your run to a hobble. Resting, icing and changing your running shoes made no difference. The sports doctor you saw just diagnosed you with the dreaded Iliotibial Band Syndrome (ITBS). He tells you that you need to stretch your Iliotibial band (ITB) and use a foam roller.

Sounds familiar? Well, this latest published paper on the ITB by Paul Giesler (2020) challenges common treatment approaches of stretching and massaging the ITB. Basically, he says that you do not want to stretch or foam roll your ITB.

Attachments of ITB at L knee

I've written about the ITB before in a few different posts. Except for Daniel Liberman and Carolyn Eng's study, most other articles seem to suggest that the ITB causes pain via a 'friction syndrome'. This is thought to be due to the ITB rubbing to and fro over Gerdy's tubercle on the outer shin bone while running due to hip weakness. 

Treatment is normally targeted at stretching the ITB (to reduce friction). Doctors will often suggest a steroid injection to reduce 'inflammation' (in the bursa) on the outer knee.  Giesler (2020) however,  suggested that ITB pathology is more likely to involve compression of sensitive structures beneath the ITB rather than friction.

also know as Iliotibial tract (ITT)

Since the ITB is a really broad, strong and complex structure with many attachments (picture above) along the hip, thigh and around the knee, it can provide stability for both the hip and knee. Like I wrote before, the ITB is actually thought to function like our Achilles tendon. To store and release energy like a spring. Therefore you cannot and would not want to stretch a spring. A coiled spring can release energy much better than a spring that is stretched out.

From Carolyn Eng's running simulation 

Hence the need to treat the cause of the problem rather than just treating the pain over the outer knee. Hip strength and control thus thought to be key in causing ITBS, especially weakness in hip increased hip adduction (dropping of the hip inwards) during loading. 

Runner on L has increased hip adduction

In runners/ patients with excessive hip adduction while running, progressive rehab and addressing potential causes should be adapted for individual runners, especially while running downhill and during longer runs. I've written on this topic specifically, you can read that article here.

So treatment should be to calm the symptoms (knee pain) and treat the cause. We don't get you to stretch your ITB or use the foam roller in our clinics, come see us if you want to run pain free.

The Paul Geisler (2020) article is free, click on the link under references if you want to read it.

References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Eng CM, Arnold AS, Liberman DE et al (2015). The Capacity Of The Human Iliotibal Band To Store Elastic Energy During Running. J Biomech. pii: S0021-9290 (15) 00354-1. DOI:10.1016/j.jbiomech.2015.06.017.

Geisler PR (2020). Iliotibial Band Pathology: Synthesizing The Available Evidence For Clinical Progress. J Ath Trg. DOI: 10.4085/JAT0548-19

Is Your Running Style Causing Your Running Injury?

How's my running gait?

I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.

Picture A- Injured runner with CPD and right hip adduction 

Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.

Contralateral pelvic drop

CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.

Injured runner (L) heel striking, forward trunk lean vs normal

Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

My Patient Was Told Her Knee Alignment was "Off"

Have a look

My patient came in complaining of pain in both her knees after running. She had been to another physiotherapist who told her that her "kneecap alignment was off". He proceeded to give her some strengthening exercises for her quadriceps and asked to return for another session. He checked on her exercises and did some ultrasound and "electric current" therapy.

After the two sessions, she didn't get any better doing the quadriceps exercises and was referred by her friend to see me. I told her that all of us have highly variable alignment in our knees and she shouldn't worry too much about what the other physiotherapist told her.

Yes, just in case some other healthcare professional tells you the same, there is a very good article published on this topic. In fact the article is a systematic review, which means a search aided by computer for all randomized and clinically controlled trials. When it comes to quality, there is none higher than a systematic review or meta-analysis.

The systematic review concluded that healthy knees have a highly variable alignment, although this may be due to variables when doing x-rays/ MRI scans, measuring techniques and the people studied.

The exact role of knee joint alignment in development of knee pain/ symptoms remains unclear.

So we should not be telling patients that their knee joint alignment is in any way abnormal at all, not if we do not even know what normal alignment is.


Reference

Hochreiter B, Hess S et al (2019). Healthy Knees Have A Highly Variable Patellofemoral Alignment: A Systematic Review. Knee Surg Sp Trauma Arthr. pp 1-9. DOI: 10.1007/s00167-019-05587-z.

Is this knee's alignment abnormal?

I know some of you will be asking what did I do to make my patient better? After assessing the knee joint, I usually make sure there is no hip dysfunction or shortening in the calf muscles. In this particular patient's case I started with her Superficial Back Line (SBL) and her Spiral Line.

Superficial Back Line

Since she runs, I made sure I checked her running style/ technique too.

Spiral Line

Can Your Calf Muscle Cause Your Knee To Hurt?

Now that's some very defined soleus muscles

Really? You must be wondering how and why after looking at the title of this week's post. Well, my last patient today had knee pain caused by her soleus (or calf) muscle. She had recently been doing a lot of step ups in her gym classes and her knee pain started soon after.

Runners' knee or patellofemoral joint pain (pain under the kneecap) is very common in runners. I've written before about how this may be due to heel striking, heavy landing and hip dysfunction.

There is also some evidence where the length of the soleus muscle can influence patellofemoral joint pain (PFP). It has been suggested that in runners with PFP, there is a greater activation in the muscle compared to runners without knee pain (Piva et al, 2005).

See soleus after you cut away gastrocnemius

Your calf muscles consist of the more superficial gastrocnemius muscles and the deeper soleus muscle. If you peel off the gastrocnemius muscles, the soleus muscle lies underneath. Together they end as the Achilles tendon finishing at the heel bone (picture above).

The soleus muscle is largely thought to help with our posture as it is mostly made up of Type I slow twitch muscle fibres. The gastrocnemius muscle is made up of mainly Type II fast twitch fibres.

The fast twitch muscles of the gastrocnemius allows you to sprint. However, the gastrocnemius muscles tire easily.

The slow twitch soleus muscle is very important for your walking and running. Since they're more fatigue resistant, you use them a lot chalking up mileage whenever you run.

One of the main functions of the calf muscles is to absorb shock. If they're overused, they can't absorb shock well, your knee takes more of the load and you get knee pain.

A very simple way to take load off your soleus muscle is to take smaller steps when walking or running. Increasing your step rate, especially while running will ensure you're not over striding and heel striking. This reduces impact loading and lessens your chances of knee pain.

Reference

Piva SR, Goodnite EA et al (2005). Strength Around The Hip And Flexibility Of Soft Tissues In Individuals With And Without Patellofemoral Pain Syndrome. JOSPT. 35(2): 793-801. DOI: 10.2519/jospt.2005.35.12.793.

You Should Not Be Heel Striking

Picture by richseow from Flickr

In the picture above, you can see clearly the lead runner and a few others behind him heel striking whilst running. So is heel striking bad?

A group of Danish researchers studied runners who landed on their heels while running, The runners had a personal best time of 17 minutes or slower for 5 km.

In the study, the runners ran 1 km on a track with a force plate at three different speeds. 8 km/ hour (about 12 min/ mile), 11.79 km/ hour (8:20 pace) and 15.78 km/ hour (slightly over 6:00 pace).

The results showed that the total load on the front of the knee actually increases with slower running. This can cause or aggravate anterior (or front) knee pain, also commonly known as runner's knee.

Although the load on the runners' knees was higher on each stride during faster running, the runners took more strides to cover the same distance if they ran slower. As a result, the runners accumulated 80 per cent more load on the front of their knees when they ran at a slower pace.

The results explain why running more mileage (and heel striking) is linked to pain at the front of the knees. This also explains why runners with knee pain who switched to running with minimalist type shoes with the correct technique stopped having knee pain. Note that it has to be correct technique, otherwise the impact can be 7 times greater.

The authors suggest that if you are a heel striker with knee pain you may want to consider running shorter distances at a faster pace to limit the cumulative loads on your knees.

Well, better not heel strike when you run to avoid getting knee pain in the first place.

Reference

Petersen J, Sorensen H et al (2015). Cumulative Loads Increase At The Knee Joint With Slow-speed Running Compared to Faster Running: A Biomechanical Study. J Orth Sports Phy Ther. 45(4): 316-322. DOI: 10. 2519/jospt.2015.5469.

Ladies, Your Knee Pain May Be Coming From Your Hips

How many of you ladies have knee pain? Well, you may be interested in this then. I have seen quite a few women runners/ triathletes the last couple of weeks, both elite and recreational with knee pain in the clinic. And guess what? Majority of my patients knee pain came as a result of weakness in the hips. Yes, some of them do have contributing factors coming from the knee itself, but the main cause was the hip weakness. So the hip weakness basically led to knee pain.

Well, you do know that at Physio and Sports Solutions we are really good at treating the cause of your pain rather than just treating the pain itself. So besides treating the patients' knee pain, the main thing was to explain the rationale of the treatment plan to them and then teach them how to specifically strengthen the hip muscles.

The strange thing is I've actually noticed this trend quite a while earlier from treating previous patients. So I was really pleased to find an article that was published earlier this year that confirms what I thought.

The study had 19 female runners with knee pain and a separate control group of another 19 female runners as well without knee pain. The group of women with knee pain had greater average hip internal rotation range and reduced hip muscle strength compared to the other group.

The authors concluded that it is the abnormal hip mechanics and decrease strength levels rather than the difference in hip shape and structure of women (as compared to men) that caused their knee pain.

So ladies, if your knees are causing you grief while running, please come in and see us and we will treat the cause of it to prevent it from coming back. And then you can run, pain free of course.


Reference

Souza RB and Powers CM (2009). Predictors of Hip Internal Rotation during Running: An Evaluation of Hip Strength and Femoral Structure in Women With and Without Patellofemoral Pain. Am J Sp Med. 37(3):579-587.