Anatomy of an Injury – Ankles and Knees
Last week we discussed the three various types of injuries: Mechanical, Chemical and Mental. If you haven’t read the article, please click here so that you have a full understanding of how injuries occur and how these strength & flexibility exercises will help keep you healthy and performing at an optimum level.
Throughout this Anatomy of an Injury Series, we will be looking at injuries associated with the various joints in the body. But before we discuss injuries, let’s take a look a brief look at the anatomy associated with the lower body.
Joints in the Lower Body
As expressed by Dr. Sovndal, MD, the three major joints of the lower body are the hip (which will be discussed extensively in the next article), knee and ankle. The hip can move in six different directions while the knee moves in two directions (extension –straightening the knee & flexion – bending of the knee). The ankle is more complex than the knee because it can dorsiflex (lift your foot up), plantar flex (point your foot down), inversion (roll the foot inward) & eversion (roll the foot outward). With each of these joints, there are multiple ligaments that create stability and endure high levels of load.
The ankle (as all joints) is comprised of muscles in front and back of the lower leg. The muscles on the front of the lower leg are responsible for “lifting” your toes. The muscles on the back of the lower leg are responsible for you to get up on your toes. Frequently a weak muscle group leads to pre-mature fatigue and improper sport specific biomechanics (which in turn leads to less than optimum performance). The strength & flexibility of your Achilles tendon plays an instrumental role in preventing injuries.
The knee needs to be viewed as a combination of three bones: the femur (thigh), the tibia (shin bone) and the patella (kneecap). There are four muscles on the front of your femur (Rectus femoris, Vastus intermedius, Vastus medialis & Vastus lateralis) which are responsible for straightening your lower leg. There are three muscles on the back of your femur (Biceps femoris, Semimembranosus & Semitendinosus) which are responsible for bending your lower leg. The knee has numerous ligaments that create strength & stability: medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL).
Common Ankle Pains & Solutions
According to Dr. Silverman, here are the four most common foot & ankle injuries associated with athletics: Ankle Sprains, Achilles Tendon Rupture, Plantar Fasciitis & Stress Fractures.
By far the most common sports related ankle injury is the ankle sprain. Sprains are caused by stretching and/or tearing of the ligaments around the ankle joints. More than 50% of ankle sprains leave patients with residual symptoms. While you can accommodate for the ankle injury, activity levels are affected, especially cutting and twisting motions required for most sports.
Ankle Sprain Treatment: RICE-rest, ice, compression & elevation
Achilles Tendon Rupture
Even with great conditioning, Achilles tendons can rupture seemingly without warning. Sometimes tendons undergo silent degradation. After at least 50% of the tendon degenerates, it will suddenly pop with a loading force. A rupture causes a sharp pain in the back of the leg. Surgical repair of this tendon permits a more rapid and likely return to pre-injury functional levels, but like every surgery, it carries risk. Non-surgical casting treatment can heal the tendon as well but, strength is diminished in some studies and re-rupture rates are higher.
Achilles Tendon Rupture Treatment: nonsurgical treatment of an Achilles tendon rupture is accomplished by casting or bracing the Achilles tendon for several months. The foot starts in a pointed position, which helps bring the torn ends of the tendon together, and over time the foot is gradually brought upwards. Most often the ankle is immobilized for a total of 8 to 10 weeks, and then motion and strengthening exercises are started. Aqua walking and jogging are two low impact modalities you can implement without significant set backs.
Plantar Fasciitis is characterized by pain in the bottom of the foot. It is an overuse injury to the tough band of tissue connecting the heel to the toes. The degenerative tearing of the tissue on the bottom of the heel hurts when weight is applied. Plantar fasciitis generally hurts with the first steps in the morning and after getting out of a chair during the day. The problem that is most often overlooked with plantar fasciitis is the nerve compression on the inside of the heel. Plantar fasciitis will resolve in over 90% of cases with adequate rest to the tissue.
Plantar Fasciitis Treatment: massage work in the calves; ice therapy to reduce swelling, rolling the bottom of the feet with a lacrosse ball prior to exercise; foam rolling the calves prior to exercise; pick up a hand towel with your toes.
Stress fractures are overuse injuries to the bone. They are caused by repeated physical activity in an abnormally shaped foot, abnormal muscle / tendon length, or in abnormal bone biology. Sometimes it is from too much forced activity. We find this in athletic programs without adequate rest and in the military. Too tight of a calf muscle can cause all sorts of overload injuries. In Minnesota we commonly have a Vitamin D deficiency because of inadequate exposure to sunlight. It slows bone turnover and can delay healing of stress fractures in any bone. The best treatment begins with defining which problems caused the stress fracture (biomechanical and/or biologic), and then addressing each one individually. Getting the fracture to heal is worthless if the true cause is not discovered. The problem will just recur.
Stress Fracture Treatment: ice therapy to control swelling; elevate your foot above your heart; nonsteroidal anti-inflammatory medicine like ibuprofen, avoid excessive load bearing weight & exercise – replace with non-load bearing exercises such as swimming or cycling.
Common Knee Pains & Solutions
Jumper’s Knee Cause
Also known as patellar tendinitis, it is found most common in athletes that implement too much volume & intensity of bounding & jumping into their training programs along with speed and agility sports like basketball, football, soccer, etc.
The most common cause of pain is the micro trauma tears of the patellar tendon below the kneecap. This tissue can be injured by direct trauma, poor flexibility, muscle weakness, strength imbalances or miss alignment of the patella, causing it to pull to one side and create friction and as a result swelling.
Jumper’s Knee Symptoms
Pain below the patella on the tendon is usually associated with this condition. Because this condition is often misdiagnosed, the most accurate assessment is to press directly on the patella tendon just below the knee cap, if it is sore to the touch, you have patellar tendinitis. Additional symptoms include dull ache after exercise, stiffness in the morning and physical signs of the tendon thickening.
4 Stages of Patella Tendinitis
Stage 1: pain only after activity which doesn’t affect biomechanical function
Stage 2: pain early during exercise, but decreases during a warm up, and returns after activity; little to no performance effects
Stage 3: pain remains beyond your warm up and even throughout the entire duration; difficult to maintain normal performance levels
Stage 4: Complete tearing of the tendon requiring surgery, rehab and rest
Jumpers Knee Treatment
If symptoms are related to activity, you should modify it or reduce it until they are resolved. Occasional local quarter steroid injections into the written Maybe helpful to. If nonoperative treatment fails, surgical options may be necessary
Chondromalacia of the Patella
Underneath your patella (kneecap) you have a layer of cartilage (Note: the thickest cartilage in the body) designed to let the knee cap glide over the end of the femur & serves as a shock absorber of exercise.
Cause of Chondromalacia
Besides the typical overuse issues (too much volume and/or intensity), there are three consistent causes of Chondromalacia:
1) Muscle imbalance: a combination of tight quad (front of thighs) muscles & muscle weakness on the muscle found on the inside of the four quad muscles (Vastus Medialius) allowing the patella to pull to the outside of the patella groove (because of strong quad muscles on the outside of the quads). This leads to friction, damage to the cartilage along with inflammation and tenderness.
2) Poor alignment of the kneecap: due to genetic disposition, the patella tends to sit too high or low in the patella groove. Usually this situation isn’t recognized until adolescence.
3) Biomechanical issues associated with your feet: when your feet fall inward (pronation), this creates torque at the knee joint putting excessive stress on the cartilage of the knee making it more prone to tears, inflammation and tenderness.
– Tenderness is more of a dull ache rather an acute (sharp) pain
– Painful to walk down stairs
– Early morning stiffness
– Stiffness after sitting for a long time without movement & stretching
– Grinding (crepitus) when extending the lower leg
– Swelling around the kneecap
– Tenderness when the patella is pressed on
– Strength Training: eliminate muscular imbalances (see below) to improve how the patella slides in the patella groove
– Improve your range of motion by reducing the tension within the muscles
– Avoid knee straps – they only mask the true source of pain
– Anti-inflammatory medicine – only before bed, consume non-steroidal anti-inflammatories (NSAID’s) such as ibuprofen
– Implement the PRICE methodology: Protect, Rest, Ice, Compression & Elevation to reduce pain & inflammation
– Check your shoes for excessive wear; this causes your feet to “fall off of the shoe”
The Iliotibial Band (ITB) is a thick band of fibrous tissue that runs down the outside of your leg from your pelvis to your knee. Pain is felt on the lateral (outside) of your knee cap on the bony process known as the lateral epicondyle of the knee; frequently the pain radiates up the thigh. A bursa (a small fluid filled sac) sits between the ITB and the bone to allow smooth, gliding movements. However if there is too much friction, tenderness & inflammation becomes associated with the bending and extension of the lower leg.
ITB Syndrome Causes
Muscle Tightness: Tightness in the quadriceps & overdevelopment of the lateral quad muscle (Vastus lateralis) increases the friction on the ITB attachment at the lateral epicondyle of the knee
Muscle Weakness: Weakness in the buttock muscles (glutes) puts more strain on the Iliotibial Band, increasing your chances of developing Iliotibial Band Syndrome
Flat Feet: If you have flat feet (dropped foot arches) it slightly changes the angle of the lower leg, putting more friction through the Iliotibial Band
Excessive long distance or hill running: Overuse can also lead to Iliotibial band syndrome due to repetitive friction. Hill running puts even more tension through the ITB
Running on a sloped surface: Lots of running surfaces eg roads and running tracks are slightly banked. The foot position on the lower leg causes the Iliotibial band to be stretched
Sudden increase in training volume: adding too much volume in a short period of time
Leg Length Discrepancy: If one leg is slightly shorter than the other it puts more strain on the Iliotibial Band
Bow legs: The curved nature of bow legs means there is a bigger than normal space between the knees
Lateral Knee Pain: pain is felt over the lateral (outer side) of the knee, especially when the heel strikes the ground. The pain intensifies when going down stairs. Pain is also felt when straighten the knee
Swelling: at the pain site from inflammation or thickening of the IT Band
Popping & Snapping: when bending or extending your lower leg
ITB Short Term Treatment – reduce inflammation
Rest: It is important to give the ITB time to heal so aggravating activities should be avoided. The simple rule is if it hurts (regarding activity & exercise) simple stop!
Ice: Ice therapy can be used to help reduce inflammation, click here on how to make & use ice cups
Anti-inflammatories: ibuprofen before bed will help reduce the pain & inflammation
Change the Activity that Causes Pain: If your symptoms are aggravated by running, you might find that switching to activities like swimming or cycling allow you to keep exercising without aggravating the Iliotibial Band.
ITB Long Term Treatment of ITB Syndrome
Muscular Strength & Balance: strengthening your buttocks (glutes), quads (front of the thigh) and hamstrings (back of the thigh) improves how the hip and knee function which reduces the friction on the Iliotibial Band.
Improved Flexibility: foam rolling & isolated stretching of your quads, hamstrings and ITB also helps reduce the friction at the knee.
Massage: a qualified massage therapist will help you determine if your symptoms are a result of overdevelopment of your lateral quad (Vastus Lateralis), a myofasical issue (where your skin, muscles and connective tissue are literally sticking) or a lack of flexibility within your lower body muscles
Whether you are a runner or not, pain associated with the knee is frequently referred to as patella tendonitis or “runner’s knee” by physicians & therapists and is described as a non-arthritic pain under & around the kneecap.
Patella Tendinitis Cause
The exact cause of Patella Tendinitis is thought to be a problem in the way the patella (kneecap) moves within the patella groove found on the femur (thigh bone) at the front of the knee. It can glide, tilt and rotate, upwards, downwards and sideways in this groove.
There are a number of factors that stop the patella from moving properly in the groove, all of which increase the forces and friction going through the kneecap, causing knee pain:
Muscle weakness: Weakness in the muscles reduces the support around the knee causing more weight to go through the kneecap. Also, if the muscles on one side of the knee are weak while the muscles on the other side are too strong, the kneecap will shift slightly to one side in the groove.
Muscle Tightness: If the muscles around the kneecap are tight, they will pull the kneecap up slightly, and possibly slightly to the side, increasing knee cap pain and friction.
Biomechanics: An abnormal foot position, such as flat feet, causes the foot to roll inwards which alters the way the forces go through the knee.
Symptoms of Patella Tendinitis
Pain comes on gradually and typically increases with activity such as endurance activities (i.e. cycling, running), going up stairs, kneeling squatting & prolonged siting with the knee bent. Individuals complain of the knee joint giving way, locking and crepitus (i.e. grinding). Note: Swelling in the knee is not common, but when present may indicate another problem such as meniscal tears.
Treatment of Patella Tendinitis
– Ice, rest & elevation
– Foam rolling & isolated muscle stretching
– PNF Stretching (click here for a PNF stretch for your hamstrings)
– Strength training to balance the muscles (front to back, left to right, top to bottom) in the legs
– Avoid sitting for more than 30 minutes; at the bottom and top of every hour complete some dynamic movements
– Avoid anti-inflammatory medicine during the day; you want to “feel” if there is pain and needs more treatment. Consuming anti-inflammatory medicine during the day will mask the actual pain and give you false confidence that you are healed and you will resume load levels and volume that is not sustainable.
How to Reduce Inflammation & Joint Pain: Physically & Nutritionally
Ironically, in an attempt to improve our muscular strength & endurance with load bearing exercises (sport specific exercises, plyometrics & strength training) we often put more time and effort into the execution of load bearing and less time into the recovery process. The key is to monitor your exercise to ensure that you are not doing too much load or too much volume. Additionally, you need to ensure that your body is absorbing your volume & intensity of training (both sport specific and cross training). Below are some soft tissue strength & recovery exercises that you can incorporate into your weekly schedule.
Increasing omega-3 oils from fish, Alpha linoleic acid (ALA) found in flaxseed, walnuts, soy, pumpkin seeds and canola, and Omega-9 rich fats found in olive and sesame oils, avocados, vegetable oil, have been shown to reduce inflammation, mainly in joints and tendons. Gama linoleic acid (GLA) an omega six fat is also a precursor to the anti-inflammatory process; found in Evening Primrose, Blackcurrant and Barrage Oils.
Antioxidants, vitamins and Phytonutrients can also prevent free radical damage, the trigger for the inflammatory cascade of pain. Flavonoids are also powerful antioxidants, protecting collagen, reducing capillary permeability and fragility, and reducing chemicals and cells involved in pain. So substitute tofu in your main course or have a nutrient rich shake with Nutritionally Green’s Protein fuel as a snack. Green tea is also a great source of flavonoids, with 3 cups a day being the optimal dose.
As for herbs, Capsaicin from chili peppers may stimulate, then block pain fibers by depleting them of substance P, thought to be the main mediator of pain from the periphery.