running injuries Archives - Praxis Physiotherapy

Capping kneecap pain – Your guide to Anterior Knee Pain (Patellofemoral Pain Syndrome)

by Stephen Timms | Jul 11, 2023 | Knee, Return to Sport, Running Injuries

Patellofemoral Pain Syndrome (PFPS) is a common condition that affects the knee joint, particularly the area where the kneecap (patella) meets the thigh bone (femur). It is a prevalent issue among athletes, active individuals, and people with certain anatomical factors. In this Praxis What You Preach article, we will explore PFPS, its causes, symptoms, and available treatment options, shedding light on how physiotherapy can effectively manage and alleviate this condition.

What is PFPS?

Patellofemoral Pain Syndrome, also known as runner’s knee or anterior knee pain, occurs when the patella fails to glide smoothly over the femoral groove during knee movement. This causes irritation and inflammation in the patellofemoral joint, specifically the underlying bone, leading to pain, discomfort, loss of function and even swelling. PFPS can be triggered by multiple factors, such as overuse, muscle imbalances, poor biomechanics, weak hip and thigh muscles, improper footwear, and previous knee injuries. Essentially though it is the kneecap joints’ in ability to tolerate the load of the activities being undertaken.

Symptoms and Diagnosis

Common symptoms of PFPS include pain around or behind the patella, especially during activities that involve knee squatting, lunging, bending, climbing / descending stairs, or sitting for extended periods with knees bent (commonly called movie goers knee). These typically can occur when workloads have increased with activities such as running, cycling or weightlifting. Patients may also experience swelling, grinding or even stabbing sensations, and occasionally a feeling of knee instability. A physiotherapist will perform a comprehensive evaluation, considering the patient’s medical history, conducting a physical examination, and possibly using imaging tests, to accurately diagnose PFPS and rule out other potential causes of knee pain.

Treatment and Management

Physiotherapy plays a crucial role in managing and treating PFPS. The primary goal of physiotherapy is to exclude differential diagnoses, alleviate pain, improve knee function, manage aggravating workloads and prevent the recurrence of symptoms. Treatment plans are tailored after a comprehensive history taking and examination to the individual’s specific needs and should include the following components:

Pain Management: Initially, pain and inflammation may be managed through ice therapy, massage, stretching and non-steroidal anti-inflammatory drugs (NSAIDs).
Strengthening Exercises: Targeted exercises aim to strengthen the hip, thigh, and trunk muscles, which can help correct muscle imbalances and improve knee alignment and load tolerance.

Stretching and Flexibility: Stretching exercises can help improve flexibility in the muscles surrounding the knee joint, reducing strain on the patellofemoral joint.
Biomechanical Analysis: A physiotherapist may evaluate the patient’s movement patterns during functional activities such as jumping and running to identify any obvious faulty mechanics that contribute to PFPS. Corrective techniques, gait retraining may be employed.
Activity Modification and Rehabilitation: A gradual return to activities while maintaining a balance between rest and exercise is important to ensure proper healing and prevent re-injury.
Taping: taping has been shown to acutely help reduce symptoms by aiding in the improvement of kneecap tracking through the femoral trochlea (groove where the kneecap runs)

Prevention Strategies

To prevent the onset or recurrence of PFPS, individuals can incorporate the following strategies:

Regular strength and conditioning exercises to maintain muscle balance and strength of the lower limbs and trunk musculature.
Proper warm-up and cool-down routines before and after physical activities.
Gradual progression of activity levels and intensities to avoid overuse injuries.
Being aware of the early signs and symptoms and addressing them promptly.

Is my knee pain osteoarthritis?

In short, No. Patellofemoral Pain Syndrome (PFPS) is not the same as Patellofemoral Joint (PFJ) Osteoarthritis (OA). While both conditions involve the patellofemoral joint, they are distinct entities with different causes and characteristics. As mentioned, PFPS primarily involves pain and dysfunction in the patellofemoral joint, often caused by factors such as overuse, muscle imbalances, or poor biomechanics. It is commonly seen in younger athletes and active individuals. PFPS is characterized by pain around or behind the patella, especially during activities that involve knee bending or loading such as running.

On the other hand, PFJ OA refers to the degeneration and wearing down of the cartilage within the patellofemoral joint. This condition typically occurs in older individuals and is more common in those with a history of knee injuries or conditions such as patellar instability. The primary symptom of patellofemoral joint osteoarthritis is joint pain, stiffness, and swelling, which worsen over time. This pain can be at rest.

While both conditions can cause knee pain and affect the patellofemoral joint, the underlying mechanisms and treatment approaches differ. Physiotherapy plays a crucial role in managing both conditions, but the specific treatment plans and exercises may vary based on the individual’s diagnosis, symptoms, and physical examination findings.

In summary, Patellofemoral Pain Syndrome is a common knee condition that can significantly impact an individual’s daily activities. With a comprehensive physiotherapy approach involving pain management, strengthening exercises, and biomechanical analysis, PFPS can be effectively managed and treated, allowing individuals to regain pain-free movement and engage in their desired activities. If your knee cap pain prevents you from doing the things you want to do, book in with of our expert Praxis team members to discuss getting you back to function!

Until next time,

Praxis What You Preach

Team Praxis

Hamstring Strain Injuries: Lessons from Personal Experience and the Latest Research

by Stephen Timms | May 29, 2023 | Gym and Strength, Return to Sport, Running Injuries

Recently, in an effort to keep the ballooning effects of the all-you-can-eat buffet at bay during my Cricket Australia Indian tour, I ramped up my high-intensity running load. Things were going splendidly — four days of high-intensity running under my belt — until day five, when 90% of the way through a very intense interval session, I tore my hamstring.

I felt the tell-tale sensation so many of my patients describe: a sharp tearing and retraction sensation in my outer thigh while sprinting. I had to pull up immediately and iced the injury straight away. You’ll be happy to hear that I’ve since fully recovered. No longer ‘gun shy’ at my top speeds (which, admittedly, are not that fast!), my strength has vastly improved, and I’m back running at full capacity.

Having treated countless hamstring injuries through my long involvement in recreational, semi-elite, and elite sport — especially with Cricket Australia teams and the Aspley Hornets NEAFL squad — this experience gave me even deeper appreciation for how tricky these injuries can be. Hamstring strains are one of the most common injuries in running athletes, responsible for significant downtime and lost performance. Hamstring injuries have remained the most prevalent injury in professional AFL for the past 21 consecutive seasons (Orchard et al., 2013), with the average 2012 injury costing clubs over $40,000 per player!

Understanding Hamstring Injury Mechanisms

Most hamstring tears occur during the late-swing phase of running, where the hamstring undergoes rapid lengthening while producing high forces (Danielsson et al., 2020). Key risk factors include:

High eccentric loading demands.
Poor neuromuscular control.
Muscle imbalances (particularly hamstrings vs quadriceps).
Fatigue — as evidenced by my own injury, occurring late in a demanding session!

Importantly, the long head of biceps femoris is the most commonly injured muscle, partly due to its higher proportion of fast-twitch fibers and its anatomical position under stretch during running (Martin et al., 2022).

Fatigue, poor trunk/pelvic control, and sudden spikes in high-speed running are emerging as significant contributors to hamstring strain risk, particularly in field and court sports (Martin et al., 2022).

Preventing Hamstring Injuries

The good news is, hamstring injuries can often be prevented with smart training. Strengthening the hamstrings through eccentric exercises like Nordic hamstring curls and single-leg Romanian deadlifts has been shown to reduce injury rates significantly (Al Attar et al., 2017; Martin et al., 2022).

Effective prevention programs should also include:

Agility and trunk stabilization exercises — not just strength work (Martin et al., 2022).
Warm-up routines with dynamic stretching and sport-specific drills.
Monitoring high-speed running loads to avoid sudden spikes in intensity.

Addressing muscle imbalances is key too. Maintaining a healthy strength ratio between the quadriceps and hamstrings — and ensuring good trunk and gluteal control — promotes optimal biomechanics and reduces injury risk (Martin et al., 2022).

Recovering Well After a Hamstring Injury

A proper recovery should include:

Early management: Controlling swelling and pain with ice and appropriate activity modification.
Progressive eccentric strengthening: Integrated carefully to build resilience.
Functional rehabilitation: Sprinting drills, agility work, and sport-specific movements are crucial before returning to full play (Martin et al., 2022).

Interestingly, studies show athletes who follow programs that include eccentric training and trunk stability work have lower reinjury rates than those who just focus on basic strength and stretching (de Visser et al., 2012; Martin et al., 2022).

Return-to-play decisions should be made carefully. Factors like strength symmetry, absence of pain, and readiness for high-speed running should all be considered to reduce the risk of reinjury, which can be as high as 30% otherwise (Martin et al., 2022).

Final Thoughts

Even as a physio, my personal hamstring tear was a stark reminder that fatigue, progressive loading, and structured rehab are vital ingredients for both prevention and recovery. Whether you’re a weekend warrior, a professional cricketer, or just trying to beat the buffet, hamstring health is crucial.

If you’d like help strengthening your hamstrings, managing an existing injury, or optimising your running and performance, feel free to reach out. I (and my hamstrings) would be happy to help!

Till next time, Praxis what you Preach!

Backed by evidence. Trusted by athletes. Here for every body.

References

Al Attar, W.S.A., et al. (2017). The effectiveness of injury prevention programs in reducing the incidence of hamstring injuries in soccer players: a systematic review and meta-analysis. Journal of Physiotherapy, 63(1), 11–17.
Danielsson, B., et al. (2020). Mechanisms of hamstring strain injury: current concepts. Sports Medicine, 50(4), 669–682.
Martin, R.L., et al. (2022). Hamstring strain injury in athletes: Clinical Practice Guidelines. Journal of Orthopaedic & Sports Physical Therapy, 52(3), CPG1–CPG44.
Orchard, J.W., et al. (2013). AFL Injury Report 2012.

Why lifting is your missing endurance link: A guide for long distance runners (Part 1)

by Stephen Timms | Aug 10, 2018 | Uncategorized

You have the shoes, the GPS watch, training schedule and alarm set for 5am. You are dedicated and that race is right around the corner. Whether it is your first 5km or your 50th marathon, the thrill of crossing the finish line drives us all. Whilst you may know your average km split time like the back of your hand, do you know how strong your lunges or deadlifts are? If you haven’t stepped foot in a gym recently, then research suggests you could be missing out on a host of positive effects on your running. There has been a whole host of research in this area so deciphering the literature can be a difficult task. Thankfully, a recent paper by Blagrove et al [1] has done much of the hard work for us. The paper entitled Effects of Strength Training on the Physiological Determinants of Middle- and Long-Distance Running Performance: A Systematic Review aimed to provide a comprehensive critical commentary on the current literature that has examined the effects of strength training modalities on the physiological determinants and performance of middle and long-distance runners. They also offered recommendations for best practice which you can read about in the Part 2 blog post.

Running is a surprisingly complex task and as such there are many factors that affect performance. Physiological, biomechanical, psychological, environmental, and tactical factors all inter play to result in determining the average runner from the elite. With respect to physiological markers of performance, maximal oxygen uptake (known as VO2max), running economy, and the sustainable percentage of VO2max go a long way to determining performance [2]. In fact, these three elements can predict performance with up to 95% accuracy in well trained runners. The difference between VO2max in the elite running population however is surprisingly marginal. On the contrary, running efficiency displays a high degree of inter-individual variability and thus a potential area to better discriminate between runners and their respective performance [3]. Defined as the oxygen or energy cost of sustaining a given sub-maximal running velocity, running efficiency is underpinned by a variety of anthropometric, physiological, biomechanical, and neuromuscular factors [4]. More specifically to the purpose of this article, force generation and stretch–shortening cycles are the neuromuscular factors that are the most relevant. Whilst force production of a muscle is a straight forward concept, the stretch shortening cycles may not be. Stretch shortening cycles describe the pre-stretch and recoil action of a muscle and tendon unit that occurs in a dynamic action just as jumping. Think of the stretch shortening cycle like a spring whereby energy is stored and released within the spring, or in real terms, the musculo-tendinous unit. To produce higher forces, the more motor units (muscle) are required [5]. There is a strong correlation between the cross-sectional area of a muscle and its ability to produced force. Several other factors are involved, but for the most part, a larger muscle will produce more force than a smaller muscle. However, force production becomes more difficult when activities are dynamic. This is because there is a reduction in force produced per motor unit due to the faster shortening velocity involved in the stretch shortening cycle [5]. In general, strength training activities can positively affect both muscle force as well as improve the stretch-shortening cycle through several different adaptations including muscular and neural changes [6, 7]. Hypertrophy is the term to describe an increase in muscle size. It is the cyclical process whereby muscle cells are exposed to repeated bouts of exercise causing micro damage to the muscle cells. Micro damage causes an inflammatory response and it is the pain you feel for the next 48hrs after a bout of exercise (also called delayed onset muscle soreness or DOMS for short). It is also the stimulus for the body to mitigate future damage by repairing the damaged tissue and adding more muscle cells. This is what is commonly known as the super compensation cycle. Hypertrophy is aided by rest, dietary protein, certain hormones (e.g testosterone) and has a very strong genetic component as well [7].

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Neural adaptation tends to be one of the earliest changes and accounts for most of the strength increases observed in the initial stages of all strength training [8]. Those who are exposed to repeated bouts of resistance training generate significant strength gains with minimal hypertrophy early in the process. The body achieves this via synchronous activation (the ability to recruit more muscle cells in a simultaneous fashion) and reduction in neural inhibition (a natural response of the central nervous system to feedback signals arising from the muscle) [9]. Inhibition allows muscle to avoid overworking and potentially damaging itself due to unaccustomed load. This response is rapid as it utilises the nerve and muscle cells already present. These adaptations are in direct contrast to the untrained muscle in which atrophy (muscle wastage) and reduced neural drive are typical. What this all boils down to is that following a period of strength training there is an increase in absolute motor unit recruitment resulting in a lower relative intensity of that muscle unit to deliver the same outcome as previous. If the bouts are habitual and frequent enough, muscle cells hypertrophy and become larger, increasing their ability to generate force. As a result, the trained muscle will be able to recruit a higher threshold of larger motor units. Combine all of this with an enhanced stretch shortening cycle and you have some excellent adaptations to improve running efficiency.

With respect to the dosage, the Blagrove paper suggested, a strength training intervention, lasting 6–20 weeks, added to the training program of a distance runner appears to enhance running efficiency by 2–8%. In real terms, an improvement in running efficiency of this magnitude should theoretically allow a runner to operate at a lower relative intensity and thus improve training and/or race performance. Improvements were observed in moderately-trained, well-trained and highly-trained participants, suggesting runners of any training status can benefit from strength training. For the particulars of the dosage, exercise selection and periodisation, check out Part 2 blog post.

Until next time, continue to Praxis What You Preach…

Prevent. Prepare. Perform.

References:

RC. Blagrove, G Howatson, PR. Hayes. Effects of Strength Training on the Physiological Determinants of Middle- and Long-Distance Running Performance: A Systematic Review, Sports Med. 2018; 48(5):1117-1149
McLaughlin JE, Howley ET, Bassett DR Jr, et al. Test of the classic model for predicting endurance running performance. Med Sci Sports Exerc. 2010;42(5):991–7
Morgan DW, Craib M. Physiological aspects of running economy. Med Sci Sports Exerc. 1992;24(4):456–61.
Saunders PU, Pyne DB, Telford RD, Hawley JA. Factors affecting running economy in trained distance runners. Sports Med. 2004;34(7):465–85.
Barnes KR, Kilding AE. Running economy: measurement, norms, and determining factors. Sports Med. 2015;1(1):8–15
Denadai BS, de Aguiar RA, de Lima LC, et al. Explosive training and heavy weight training are effective for improving running economy in endurance athletes: a systematic review and meta-analysis. Sports Med. 2017;47(3):545–54
Schoenfeld BJ, Ogborn D, Krieger JW. Effects of resistance training frequency on measures of muscle hypertrophy: a systematic review and meta-analysis. Sports Med. 2016;46(11):1689–97
Aagaard P , Simonsen EB , Magnusson SP , Andersen JL , Dyhre-Poulsen P. .Enhanced motoneuron activation as effect of heavy-resistance strength training in man.Med Sci Sports Exerc 29: S23-1997.
Aagaard, P., E. B. Simonsen, J. L. Andersen, S. P. Magnusson, J. Halkjær-Kristensen, and P. DyhrePoulsen. Neural inhibition during maximal eccentric and concentric quadriceps contraction: effects of resistance training. J Appl Physiol 89: 2249–2257, 2000