If You Want Buns Of Steel ....

Ok I admit, that was a heading to get you to read this post. But seriously, I had a patient who was referred to our clinic by a GP across the road.  He hurt his groin while doing Brazilian jiu-jitsu 2 months ago and had not gotten better. He said his previous physiotherapist just got him to do clam shell exercises and it did not help at all. 

Want to know the best exercise for packing the biggest punch for the gluteal area? Let me share the results of the following study by Collings et al (2023).

Their study compared and ranked gluteal muscle forces in 8 hip focused exercises performed without and with external resistance, i.e. dumbbells or loaded barbell.

This 8 hip focused exercises in the study were single leg (S/L) squat, S/L Romanian deadlift (RDL), split squat, S/L hip thrust, banded side step, hip hike, side plank and side lying leg raise. The exercises were performed with and without weights for 12 reps max (RM)  and measured by electromyography (EMG). 

Analysis of muscle forces were limited to gluteus maximus (pictured above), medius and minimus (below). The results show that varying demands were placed on the individual gluteal muscles. Peak gluteal muscle forces significantly increased when all exercises were performed with weights compared with body weight alone. 

R gluteus medius and minimus

This is the first study to investigate a wide range of hip focused exercises that also includes isometric hip and hip abduction exercises. Clam shell exercises which you already know from my earlier  blog post is not great at activating gluteus medius and was not even included in this study. The S/L RDL and side plank  produced the highest peak gluteus medius and minimus muscle forces. 

Side plank

This is what I found most interesting. I was surprised that this variation of the side plank (pictured above) really targeted the gluteus medius and minimus too. It will be a good choice for physiotherapists to teach their patients this since no equipment is needed. Patients can easily do it at home or during on field/ court training.

Single leg RDL

We already know that the S/L RDL (pictured above) is good for  hamstrings strengthening. Done with weights, the S/L RDL activated high gluteus minimus force (100 percent observed) while gluteus maximus (98 percent) and gluteus medius (84 percent). S/L RDL is the go to exercise if you need to target all 3 gluteal muscles simultaneously along with the hamstrings.

To sum up, for the gluteus maximus, the split squat, S/L RDL and S/L hip thrust are the exercises that you want to do if that is what you want to train. The S/L RDL and side plank  produced the highest peak gluteus medius and minimus muscle forces. Those who are injured may start by doing the lower tier exercises and/ or reduce load (pictured above). You may want to remember this if your goal is to prevent injury, as part of rehabilitation or for performance.

Reference

Collings TJ, Bourne MN, Barrett RS et al (2023). Gluteal Muscle Forces During Hip-Focused Injury Prevention And Rehabilitation Exercises. Med Sci Sp Ex. 55(4): 650-660. DOI: 10.1249/MSS.0000000000003091

It's The Hip Not The Knee

My patient came with anterior (or front) knee pain yesterday. She had been to see another physiotherapist who said she needed to strengthen her quadriceps muscle. Who says physios can't prescribe exercises compared to strength and conditioning coaches? 

Pardon the link - it seems that almost every single patient that comes to our clinic (after seeing another physiotherapist) had been given exercises to do during the treatment session itself. Maybe that's why the general public thinks all a physiotherapist does is teach exercises.

In our clinics, we may give an exercise or two to our patients near the end of the session, for them to do at home. However, we do not make our patients do any exercises DURING the treatment session. We treat them, mostly using our hands. We do treatment that the patients cannot do themselves, while they are in the clinic. 

Anyway back to my patient with knee pain who was asked to strengthen her quads. I've written a few times since 2009 that treating (or strengthening the hip) is much more important than strengthening the knee (quadriceps). Well, here is further proof.

In this systematic review referenced below, researchers studied data from 14 suitable studies (out of 119) that were found between 1994 and September 2019. Results from all 14 studies demonstrated that strengthening the hip 2-4 times a week (for 3-8 weeks) effectively relieved pain and improved knee function compared to quadriceps stengthening and no exercise. This lasted for up to 12 months post intervention.

The researchers recommended that hip muscle strengthening be a standard clinical practice while treating patients with anterior knee pain. So if the physiotherapist that you're seeing gets you to do quadriceps strengthening for your anterior knee pain, you need to tell them that hip strengthening is superior to quadriceps exercise. Please note that hip strengthening does not mean clam shell exercises.

Please also note that this present review included  randomized clinical trials that also got their subjects to do both hip plus quadriceps strengthening exercises over just the quadriceps alone. All except one study showed that hip and quadriceps strengthening exercises over just quadriceps alone. There were no no hip plus quadriceps strengthening versus hip exercises alone study done.

Perhaps a combination of hip-quadriceps strengthening may be a more effective strategy in the treatment of anterior knee pain? We can certainly try that in our clinic before more studies are done. It would depend on what we find to be weak at your objective examination ;)

Reference

Alammari A, Spence N, Narayan A et al (2022). Effect Of Hip Abductors And Lateral Rotators' Muscle Strengthening On Pain And Functional Outcome In Adult Patients With Patellofemoral Pain : A Systematic Review And Meta-analysis. J baxk Muscl Rehab. Pre-press. pp 1-26. DOI: 10.3233/BMR-220.

** For those of you wondering, there were no standardized protocol for hip and knee exercises in the various studies. The common hip exercise protocol included hip abduction against an elastic band while standing and with weights in a side-lying position coupled with hip lateral rotation against an elastic band while seated and hip extension (3 sets of 10 repetitions). 

Conversely, quadriceps strenthening in all studies generally involved weight bearing and non weight bearing exercises such as closed kinetic chain exercises, seated knee extension, leg press, squatting and stretching of hamstrings and quadriceps (3 sets of 10 repetitions). 

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

Teaching Kinesio Taping @Pilatique In Malaysia

Group picture

The last time I taught in Malaysia at the very same location was back in November 2013. Now that's a fairly long time ago.

So it was really nice coming back to a familiar venue to teach Day 1 and 2 of the Kinesio Taping Assessments, Fundamental Concepts and Techniques (formerly known as KT 1 and 2) here at Pilatique.

Day 1

I'm friends with Steven and Melissa (they are Pilatique's owners) and I couldn't turn them down when they asked to come and teach in KL, Malaysia. Most of the participants were from Malaysia although we had three students hailing from Mauritius.

Day 2 of the course went much quicker as usual as we went through more practical applications such the association of Gluteus Medius and contralateral pelvic drop (or CPD), how a rotated pelvis would affect the shoulder blade and implications of the hip flexors and foot drop.

Here are some pictures from the past two days.

Clarissa having a go

All the boys listening

Watching the ladies

A big thank you to Steven and Melissa for having me over to teach. You guys organize the best courses here in Malaysia. The pleasure is all mine.

Also grateful to Mary Leou as well for coming to get me and sending me back after each day's teaching.

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

Clam Shell Exercises?

Clam shell exercises?

My patient came in complaining of knee pain after running. She had seen another physiotherapist who after treating her knee, prescribed clam shell exercises for her to do as well. But she still had knee pain after running and climbing stairs despite doing them regularly.

How many of you have been asked to do clam shell exercises to make your Gluteus Medius (or hip) muscles stronger? If you have, maybe you need not bother any more.

Latest research (Moore et al, 2019) shows that clam shell exercises do not activate your Gluteus Medius as much as you think.

Right Gluteus Medius muscle

The Gluteus Medius muscle is very important for female runners, especially if they have knee pain. You can treat their knees but their pain will not go away until you have addressed the weakness  in their Gluteus Medius muscle.

View from the back, Left Gluteus Medius

In that small study, three sets of six common lower limb exercises were performed by ten healthy adults after a short warm up. They did single leg squats, single leg bridging, hip abduction (lifting) in side lying, clam shell exercise in side lying, running man exercise (simulates running motion of running one leg at a time) and resisted hip abduction-extension exercise.

The participants had electromyography or EMG electrodes to measure muscle activity attached to all three parts of the Gluteus Medius muscle (in front, middle and posterior).

Results showed that clam shell exercises were not effective in activating any part of the Gluteus Medius muscle. Highest levels of overall activity were seen in the single leg squat, single leg bridging and the resisted hip abuction-extension exercise.

Other than the knee, you need to know that weakness in your Gluteus Medius can also contribute to pain or problems in your Achilles. Make sure you are doing the strengthening correctly.

Reference

Moore D, Pizzari T et al (2019). Rehabiliation Exercises For The Gluteus Medius Muscle Segments: An Electromyography Study. J Sp Rehab. DOI: 10.1123/jsr.2018-0340.

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.