With the recent push for getting everybody moving, for some, Health Screening, Exercise Testing, Exercise Prescription as well as Fitness Programming are all areas where professional guidance may be necessary. The knowledge and experience of multiple Healthcare and Fitness Professionals combined provides a holistic approach for a lifetime of optimal health and well-being.
It is a bit shocking when I realize I have been teaching fitness since 1975 right out of high school. I started teaching basic dance aerobics, which were the first version of high/low aerobics by Jacki Sorensen. I taught my first class with a vinyl 45 record album on a record player which was a long way from today’s Pandora, iPod or iPhone.
Throughout his life my father, Leonard DeVito, was very physically active and competitive. Had his mentor not suggested pharmacy school he would have chosen coaching. He played competitive basketball as an adult, golfed at every opportunity as a ten handicap, took yoga, worked out and accepted every invitation to alumni vs. current student sporting events.
The foot is where movement begins, requiring mobility to perform simple functional movements. The knee however, requires stability with daily movements, but more importantly, dynamic sport movements such as soccer or football. In this article, we will review the anatomy of the knee, common injuries of the knee, functional assessments and training strategies to work with clients with previous injuries.
Basic anatomy of the knee
Let’s look at the anatomy of the knee.. The joint is vulnerable when it comes to injury, because of the mechanical demands placed upon it and the reliance for soft tissue to support the knee. There are two primary joints within the knee, the tibiofemoral joint and the patellofemoral joint.
a. Tibiofemoral joint: Is a hinge joint that permits some rotation between the distal end of the femur and proximal end of tibia. The joint capsule surrounds the femoral condyles and tibial plateaus and provides stability to the knee by the medial collateral ligament(MCL) and the lateral collateral ligament (LCL).
b. Patellofemoral joint: Is formed by the patella(knee bone) that glides in the trochlear groove of the femur. The height of the lateral femoral condyle helps prevent lateral subluxation, while soft tissue surrounds the joint to increase stability. This is seen in figure 3.
Primary structures within the knee joint: ligaments and mensici
Several ligaments described below provide stability at the knee joint.
a. Collateral ligaments: The two primary supporting ligaments are the medial collateral ligament (MCL), which is along the inside of the knee. The MCL is a thinner and weaker ligament biomechanically, making it more susceptible to injury more often injured per the research. While the lateral collateral ligament(LCL) is along the outside or lateral aspect of the knee providing lateral knee stability.
b. Anterior cruciate ligament(ACL): is the most commonly injured knee ligament and is taut during knee extension. It originates more proximally on the femoral side than the posterolateral (PL) bundle. It inserts anteromedially(front and to inner side) on the tibia. The ACL limits and controls forward translation of tibia on the femur and limits tibial rotation.
c. Menisci: the menisci are fibro cartilaginous discs located on the articular surface of the tibia along the medial and lateral tibial plateaus. The outer portion of the meniscus(lateral meniscus)is oval shaped (O) and thick. Attaching at the anterior and posterior horns via coronary ligaments.
Vascularity: The middle third and inner third of both menisci are relative avascular. The medial meniscus is more C-shaped, and thinner in structure. Both menisci receive nutrition through synovial diffusion and from blood supply to the horns of the menisci.
Function of the menisci: The menisci provide shock absorption, joint lubrication and stabilization.
Common injuries and causes
There are several common injuries that affect the knee. The most common are patella femoral syndrome(PFS), osteoarthritis(O.A.) and anterior cruciate ligament(ACL) injuries.
In this next section, we will review each condition providing a deeper understanding of each.
a. Patellofemoral syndrome
Pathophysiology/sign and symptoms: PFS is a condition where the patella does not translate biomechanically in the trochlear groove between the femoral condyles. Here the patella is positioned in either a tilt, glide or rotation accompanied by diffuse, achiness in the front of the knee.
Contributing Factors(Evidence Based Research): Several studies have shown that decreased flexibility of quadriceps and hip flexors(Lankhorst et al. 2012 & Meira et al. 2011) contribute to PFS. Decreased hip abductor strength has been shown a significant factor seen in multiple studies as contributing to PFS (Khayambashi, H., et al. 2012, Meira et al, (2011), Bolgla et al. (2008),Cichanowski et al. (2007), and Robinson et al. (2007).
Other factors include prolonged wearing of high heels, muscle imbalances(quadriceps>hamstrings).
b. Osteoarthritis(OA) of the knee
Pathophysiology/sign and symptoms: A degenerative process of varied etiology, which includes mechanical changes within the joint as seen in figure 4.
Risk Factors: Excessive weight born on hip joint, muscle imbalance, repetitive stressors.
Sign and symptoms: Pain in the a.m. described as “achy” that decreases as the day progresses, pain with weight bearing or walking, difficulty squatting, and lateral thigh discomfort.
c. Anterior cruciate ligament injuries
In the last several years, there has been more news about the incidence of ACL injuries. The incidence rate is greatest between the ages of 16 and 18 years. Female athletes are 3-9x more likely to sustain an ACL injury then male athletes. This results in at least 200,000 ACL reconstructions are performed each year in the United States, with estimated direct costs of $3 billion (in U.S. dollars) annually (Frobell, R., et al 2010).
Pathophysiology/Mechanism of Injury: The knee is struck while in hyperextension, forcing tibia anterior(forward)on the femur, as seen in figure 5. The ACL can also be injured with same mechanism of injury with combined with medial rotation of the lower extremity(LE). This creates instability and a direct disconnect the nervous system to the musculoskeletal system because of the “lack of control” within the knee joint.
One great test to assess a client’s movement pattern, is the squat. The squat is a classic fundamental primal movement that someone typically performs almost on a daily basis. With this test, you can observe how the client’s ankle, knee, hip and back moves compared to normal movement patterns. This is seen in the figure below.
Another simple assessment is an in place lunge, which examines one’s control through the entire kinematic chain. The lunge is another fundamental primal movement. The lunge is a dynamic movement that is typically performed during daily activities (stooping down to pick something up) or as part of an athletic movement.
This test examines ankle control, knee control and pelvic movement in the sagittal plane. Lastly, a diagonal traveling forward lunge looks at the ability of the client to control ankle, knee, hip, and pelvic movement in both the sagittal and frontal planes. This is not only a functional movement, but very effective for sport specific clients.
Training strategies and programming for knee injuries
With any injury, the most important thing to remember is the type of injury, healing time and prior level of function of the client.
a. Patellofemoral syndrome
Recommendations for training: Continued stretching of tight hip flexors, ITB, and hamstrings is fundamental. Client should be taught initially static core strengthening exercises, and then progressed to dynamic core strengthening as appropriate. Client would also benefit from education on shoes with respect to type that are most effective for them, and to cross train utilizing, such as hiking, yoga, pilates, and swimming. Lastly, to alter running surfaces(if client runs) and educating the client about changing their shoes every 500 miles or 6 months for maximum stability and control.
b. Osteoarthritis of knee (O.A.)
Recommendations for training: Aqua therapy has been shown in the research to significantly reduce pain, improved physical function, strength, and quality of life (Hinman, Rana S., et al 2007), stretching ITB, hip flexors, quadriceps and hamstrings, strengthening weaker hip abductors(glute medias/minimus). Strengthening specifically hip abductors in various studies when compared to general strengthening resulted in s significant reduction in knee pain, objective change in functional outcome tests, physical function and daily activities (Bennell,K.L., et al. 2010 & Hernández-Molina, G et al. 2008). Core strengthening shoulder also is an integral part of the training program.
c. ACL injury(Anterior cruciate ligament injury)
Recommendations for training: should focus on hamstring strengthening. Strengthening the hamstrings biomechancally transfers the load from the front of the knee to the back, thereby decreasing the stress to the ACL. Neuromuscular training as seen in figure 9, is very effective. It challenges the connection between the nervous and musculoskeletal system requiring the client to stabilize the entire kinematic chain. Research has shown neuromuscular training reduces ACL injuries (HUBSCHER, M. 2010 & Griffin LY, et al., 2006). Core strengthening should be multidirectional in nature as seen in figure 10.
In the picture on the left, left trunk rotation involves the internal/external obliques, atissimus withdorsi, and right glute medius and minimus muscles to stabilize, as the left glute medius and minimus to stabilize. With the yellow cord applied from the back, this engages the abs primarily to stabilize (from the front) accompanied by the obliques to stabilize, which the low back extensor muscles contract to prevent being pulled backwards. It is important to include dynamic training focusing on hamstrings, glute medius, maximus. Closed chain strengthening (CKC) exercises, such as diagonal forward and diagonal reverse lunges are not only functional, but replicate many common sports as soccer, football and basketball accordingly.
Contrainidications/Precautions: Avoid leg extension exercises completely this causes an anterior translation(shearing) of the tibia on the femur/stressing the graft. Therefore, the exercise is contraindicated. *Biomechanically, shearing stress on the ACL is greatest from 30 degrees of knee flexion to full extension.
Recommendations for training: American Academy of Orthopedic Surgeons (AAOS) Guidelines Post Therapy:
• Continuation of closed kinetic chain exercises(ie. reverse lunges, diagonal lunges,
forward lunge with medicine ball trunk rotation)
• 3 ½ months light jogging begins
• 4 months running begins
• 4 months introduction of plyometrics
• Surgical reconstruction typically sidelines athlete for 6-9 months and once cleared by physician can return to sport activities.
The knee is a dynamic joint that is comprised of a multitude of ligaments, tendons,
connective tissue, muscles that synergistically initiate and correct movement, and
stabilize when an unstable environment. Understanding the anatomy, biomechanics
and weak links of the knee, common injuries and evidenced based training strategies, should provide you with the insight to better understand and work with clients with these kind of injuries more confidently.
Written by Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS.
Chris is the CEO of Pinnacle Training & Consulting Systems (PTCS). A continuing education company, that provides educational material in the forms of home study courses, live seminars, DVDs, webinars, articles and min books teaching in-depth, the foundation science, functional assessments and practical application behind Human Movement, that is evidenced based. Chris is both a dynamic physical therapist with 14 years experience, and a personal trainer with 17 years experience, with advanced training, has created over 10 courses, is an experienced international fitness presenter, writes for various websites and international publications, consults and teaches seminars on human movement. For more information, please visit www.pinnacle-tcs.com.
Bennell, K.L., et al., 2010, ‘Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomized controlled trial,’ Journal of Osteoarthritis and Cartilage, vol. 18, issue 5, pp. 621-628.
Bolgla, L, et al., 2008, ‘Hip Strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome,’ JOSPT, vol. 38, pp. 12-18.
Cicanowski, H et al., 2007, ‘Hip strength in collegiate female athletes with patellofemoral pain,’ Medicine Science Sports Exercise, vol. 39, pp. 1227-1232.
Frobell, R., et al 2010, ‘A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears,’ New England Journal of Medicine, vol. 363, issue 4, pp. 331-341.
Griffin LY, et al., 2006, ‘Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II Meeting, January 2005, American Journal Sports Medicine, vol. 234, pp. 1512-1532.
Hernández-Molina, G., et al., 2008, ‘Effect of therapeutic exercise for hip osteoarthritis pain: Results of a meta-analysis,’ Journal of Arthritis Care & Research, vol. 59, issue 9, pp. 1221–1228.
Hinman, Rana S., et al 2007, ‘ Aquatic Physical Therapy for Hip and Knee Osteoarthritis: Results of a Single-Blind Randomized Controlled Trial,’ Journal of Physical Therapy, vol. 87, no. 1, pp. 32-43.
HU ̈ BSCHER, M., et al., 2010, ‘Neuromuscular Training for Sports Injury Prevention: A Systematic Review,’ American College of Sports Medicine, pp. 413-421.
Khayambashi, H., et al., 2012, ‘The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial, ‘Journal of Orthopedic Physical Therapy, vol. 42, no. 1, pp. 22-29.
Landry SC, et al., 2007, ‘Neuromuscular and lower limb biomechanical differences exist between male and female elite adolescent soccer players during an unanticipated side-cut maneuver,’ American Journal of Sports Medicine, vol. 3, pp. 1888–1900.
Lankhorst, N, et al, 2012, ‘Risk Factors for Patellofemoral Syndrome: A Systematic Review,’ JOSPT, vol. 42, No. 2, pp. 81-90.
Meira, E., et al., 2011, ‘Influence of the Hip on Patients With Patellofemoral Pain Syndrome,’ Sports Health, vol. 3, issue 5, pp. 455–465.
Prins, 2009,’ Females with patellofemoral pain syndrome have weak hip muscles: a systematic review, Australian Journal of Physiotherapy, vol. 55, issue 1, pp. 9-15.
Robinsion, R et al., 2007, ‘Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome,’ JOSPT, vol. 37, pp. 232-238
You may have read Jaclyn’s recent post outlining her thoughts on the television show The Biggest Loser. Here, she follows up and outlines simple steps you can take to become the ‘biggest winner’ the healthy way, not relying on short term rapid weight loss to reach your goals.
Research demonstrates that rapid weight loss programs are not recommended nor do they support any correlation to long-term success. Follow some of these simple steps to maximize your chances for success in achieving your “healthy lifestyle goals.”
STEP 1: Assess your Readiness for Change
Embarking on something that you are not ready to do could be harmful because an unsuccessful program could impair your self-esteem and dampen future efforts to achieve your healthy lifestyle goals. Before setting any short or long-term goals, it is recommended to take some time to reflect on your reasons for wanting to set these goals and initiate this journey.
STEP 2: Realize you are an individual
Just as with success, we define what “healthy” means to us. This is an individual aspiration and although our loved one’s can help to motivate us to want to make changes, we ultimately need to aspire to our own picture of “healthy” in order for us to stick with new lifestyle changes. Define what healthy means to you!
STEP 3: Eat real food
Evaluate where you can make minor changes in your dietary intake. Increase fruits, vegetables and water and decrease your intake of sugar and processed food. Eat close to the earth and prepare as much food as possible on your own. But be realistic – don’t expect perfection! You can start by making small nutritional changes that have a big impact on your health! And remember….FIBER is your FRIEND!
Always remember that a calorie is not just a calorie. Contrary to what we were taught in school many years ago, it is not just as simple as calories in, calories out. Many different factors make up the quality of the calories you take in (or expend). To determine what the best foods are for YOU, it is best to contact a Registered Dietitian or qualified healthcare professional.
STEP 5: Exercise
Choose an activity you enjoy and get some professional advice on the right activities for you and how to do them safely. It should challenge your muscles so you get stronger, but exercise should not hurt. No Pain No Gain does NOT pertain to YOU if exercise is done properly.
STEP 6: Focus on progress
Rid yourself of the All IN or All OUT mentality. Rather than telling yourself “I need to lose X pounds” set small goals toward better health and be proud of your accomplishments in the process. Many times if we set a goal and don’t achieve it, we can give up all together thinking that if we don’t make it to the summit of the mountain, than what’s the point. You still made progress – reward yourself for that and get up tomorrow and do it again. If you fall into old habits, don’t beat yourself up – tomorrow is another day.
STEP 7: Simple Strategies
Switch from drinking soda to seltzer water. Keep raw nuts, carrots and high fiber foods readily available for snacking. Take a therapeutic walk every day. When you’re stronger and ready for something new, challenge yourself a little more with things like roller skating, indoor rock climbing, or setting a goal for a summer hike. If you fall into old habits, don’t beat yourself up – tomorrow is another day.
Everyone has different health goals, and the way we approach them is not a one-size-fits-all process. It’s about more than just numbers on a scale. It’s also about your energy, how you feel, and so many other factors. Health is a journey, and we are all on it together, but in different places. When we understand that, and support ourselves and each other, we all win. And THAT is the message I want my son, and all of America, to hear.
Jaclyn Chadbourne, MA is a Clinical Exercise Physiologist and Co-Owner of the Medically Oriented Gym (M.O.G.) in South Portland, Maine. With a passion for sustainable healthy living and desire to advocate for patient-centered care, Jaclyn works to help the M.O.G. support community resources for all special populations and to implement and oversee clinical protocols. Read more from the MOG on their website, themoggroup.com/blog
Sunday morning 9 am…..My eyes are focused on the snow in my driveway as I step onto my treadmill that sits in my garage….my ears filled with the sounds of the song “Afterlife” by Switchfoot. I slowly move the treadmill from 4.0 to 6.0 mph – my feet move faster – my breathing begins to increase – and I focus….It was in this moment that I realized I’m beginning the ascent from base camp to my new summit.
Over the past 15 years I have successfully summitted many mountains – metaphorical of course. Unlike MOG’s very own Bill McCormick, I have yet to actually climb a mountain like Everest or Rainier. But I have overcome many obstacles – I have felt the desire to quit – I have been challenged by unfavorable conditions – and I have persevered. At the age of 21, I successfully completed my first marathon – the Maine Marathon, all while completing my senior year of collegiate soccer. I was competitive, driven and trained like a madwoman. It was one of the most gratifying times in my life… second of course to marrying my husband and starting our family.
In my mind I have always felt that unless I get back to that place, than what is the point of my exercise? If I was not training for something, I lost my focus. Those of you that have had children know how that can affect your body in so many ways. It has been years since I have felt like myself physically – constantly challenged by the changes that have occurred from carrying my children.
At this very moment, it is not envisioning crossing the finish line at the marathon that pushes me to continue running on the treadmill. It is the face of my 5 year old son who comes around the corner and smiles at me with his sneakers on and asks me “Mom! Are you almost done so I can exercise!?” It is the vision of all of our MOG members who inspire us in their daily dedication to walking through our doors and changing their lives. It is the passion that every one of my co-workers embodies in our daily quest to have a positive impact on one person’s life.
We all have mountains to climb within a day, a week or a year. Today I found clarity at my base camp as I stepped onto my treadmill and hit start. I could not be more excited about beginning one of the most important climbs of my life. Today, in this moment, I exercise for me and for my family. I am a better mom when I exercise. I am a better wife when I exercise. I am a happier person when I exercise. It is not easy. The days are filled with the endless pursuit to make it through my massive to do list – but alas, I realize that mountain I will never summit. But it does not matter for I am dedicated as I write this today that I will summit this mountain I call exercise one day at a time – and realize that each day I climb will get easier and more exciting. I will be invigorated to challenge myself in ways I never thought I could – and then peacefully descent into my life with confidence and a renewed sense of self because of the one thing that will always make me better……Exercise.
Jaclyn Chadbourne, MA is a Clinical Exercise Physiologist and Co-Owner of the Medically Oriented Gym (M.O.G.) in South Portland, Maine. With a passion for sustainable healthy living and desire to advocate for patient-centered care, Jaclyn works to help the M.O.G. support community resources for all special populations and to implement and oversee clinical protocols.
Why exactly is “Exercise” considered medicine? Exercise has a difficult task of competing with the 5 seconds it takes to consume a pill, versus the 30 minutes it takes to gain health benefits from exercise. However, since the development of the Exercise Is Medicine Organization, there has been great momentum in the area of implementing exercise prescription as the first line of treatment for patient’s when appropriate.
I have always had a love-hate relationship with exercise.
And while I know that it is very important for my health, it is more challenging for me, because of my medical condition, and I don’t enjoy it.
I was born with cystic fibrosis, a fatal genetic lung disease that makes breathing very difficult and causes excessive coughing.
My doctors have always told me that exercise will help strengthen my lungs and will literally help extend my life, but every time I’ve tried to work out, I have been unsuccessful. When my health began to decline a few years ago, I decided that it was time to commit to a work out regimen.
I was very excited when I found Lisa because she specializes in working with people with chronic illnesses. Lisa studied my condition and planned out strategic workouts to ensure that our time together is most effective for my health. She is patient with me but also pushes me to work harder and do more than I ever thought I could.
After working out with Lisa for only two months, I saw dramatic improvements in my health. My lungs went from 96% to 104% as shown in my Pulmonary Lung Function Test. My doctor was thrilled to say the least.
I still have a long way to go, but I am already feeling better- I have more energy and feel stronger. I have finally found an exercise regimen that I can stick to. I am so grateful to Lisa for devoting her time and energy to helping and teaching me.
I know that our work together will result in a longer and healthier life for me, despite my illness.” -Stacy Motenko, 26, with Cystic Fibrosis