When Do We Begin to Save Our Joints? More Musings from my footstool

This post is dedicated to Lynne.

     Just saw Lynne several days ago. Lynne brought up the age old question at her young age of 59 "do I stop running now to save my knees for the future?" Her knees have some X-ray and MRI findings of wear and tear. Lynne has never had any pain. She did have an episode of knee swelling and sought medical advice. Age old probably sage advice is to stop running since it is the most stressful of her activities on her knees.Lynne is high level triathlete. Yet is it the best advice for Lynne? Does running chew up your knees and hips and ankles silently until you wake up one day and can not walk? What do we know about the Nutritional Theory of cartilage health? What protects joints? What breaks them down? So many questions to be individualized for each of us. 

     My bias for recommending to Lynne to keep running comes from 5 factors. #1 Joint Cartilage is feed from pressure created in the joint from activity (nutritional theory of cartilage health). #2 Pain is our friend and will normally tell us way before severe damage is created that we must start limiting certain activities. #3 Sports Medicine for podiatrists evolved from being able to get injured knee patients to run pain free when the medical establishment was telling them to stop running forever, and I come from that time period of the mid 1970s.. #4 I personally want to keep exercising until I am 100 and I will continue to find ways to exercise (my last 3 orthopedic injuries found me at odds with surgeons wanting to cut, and I was able to successfully rehab each one, and am back playing full court basketball painfree). #5 When you break away from generalizations like stopping running to avoid knee wear and tear, you must own your knee more directly and do positive things daily for it. 

     So, Lynne had been running for 40 years, never had knee pain, did get swelling and her images showed classic wear and tear of a 59 year old. She did not have the knee joints of a 90 year old, so all the running she has done has not been bad for her knees. There was a famous study from Sweden or Norway (way up there) in the 1970s. Twelve 90 year olds who had died had there hip joints examined. All 12 never had hip pain. 6 of the 12 were very active their whole lives. 6 of the 12 were very inactive their whole lives. Guess who had the hip joint cartilage of 20 year olds--yes, the active group. The 6 individuals who had been inactive had hip joints of 90 years old (and not a day older). This study helped secure the global recognition that the cartilage in our joints needed pressure to drive the synovial fluid into the cartilage (a form of forced feeding). 

     Lynne stopped running to save her knees, but may be actually speeding their demise. Lynne can sure be smarter and try not to run down hill frequently where the force that your knee must absorb is up to 10 times body weight. And Lynne can get her knees strong with daily quad sets, straight leg raises, and short arc quad leg presses. Since most of her problem with wear and tear is behind the knee cap, and the load on the knee cap increases dramatically over a 45 degree knee bend, Lynne should do her activities and exercises in a 0 to 45 degree flexion range. Running is perfect for that, some parts of biking may not be. Let pain be your guide.  Lynne should ice her knees with swelling or pain after activities, she should wear a knee brace (I love the Bauerfiend GenuTrain for this problem) when she runs to see if it helps. She could also learn the many ways of taping her knee like McConnell Taping. She should take glucosamine daily. And lastly, Lynne should listen to her body and get back out there, and not listen to general rules that may not apply to her. And as Sue Sylvester on Glee says: And that is how I C it!

Do You See The Knee Alignment Problem On The Left Side???

This patient presents with bilateral bowlegs.  You can see in this photo that the left leg has more of a Bowing  at the knee joint.  This produces a compression force on the inside of the knee and a stretching on the outside of the knee.  If this patient presents with inside or medial knee pain, you must be concerned with medial compression syndrome.  Orthotic devices which oversupinate  the foot, can produce this effect even in a normal patient.  Due to the stretching of the outside or lateral side of the knee, ilio–tibial band syndrome is quite common.

Basics of Gait Evaluation: Knees

When I first started working at Saint Francis Memorial Hospital in San Francisco in 1981, I joined their already prestigious Center For Sports Medicine. I was the first podiatrist in an MD clinic. Patients were coming from near and far for treatment of their knee injuries. The renowned orthopedist Dr James Garrick called on my biomechanics expertise (I was just off a Biomechanics Fellowship) time and time again to help with his knee patients. I always found it funny, yet exciting, that I would spend some days never looking at a foot problem.

When you watch gait and observe knee function, use the following checklist:

Is the knee moving a normal amount?

      Or is it too Stiff?
      Or is the motion Excessive?  

 Is the rotation of the knee placing it in the center of the leg?

     Or is the rotation too internal?
     Or is the rotation/position too external?


Are there structural issues to be concerned about?

    Is there genu valgum (knock knees)?
    Is there genu varum (bow legs)?

Are there very damaging forces at the knee?

    Is there hyperextension of the knee?
    Is there varus thrust of the knee?
    Is there valgus collapse of the knee?

Hamstring Stretch: Various Positions can be Key to Flexibility

Hamstrings tightness is very common to athletes. Stretching of the hamstrings is one of the 3 most important lower extremity stretches that should be done both before (to prevent injury) and after (to gain flexibility and relax muscles) exercise. The other 2 muscle/tendon groups crucial to stretch are achilles and quadriceps. Various posts will be dedicated to each variation of stretch. I feel most stretching articles are too overwhelming with 5 plus exercises. I would rather you understand one well, before proceeding further.

The photo above shows the basic lower hamstring stretch getting the muscle/tendon loose around the back of the knee. The patients are told to place their heel on an elevated surface, like a chair or bench, where they feel no tension placing it there. The knee should be held straight and the toes straight upwards. The patient should not attempt to touch their toes which places too much stress on the back. It is emphasized to the patient to lean forward over the leg being stretched feeling the bend at the hip joint, not the back. Imagine the back as completely straight. Lean forward over the leg until you feel tension behind the knee. It is very important since you are standing on one leg to feel very stable. Be near a wall or table that you can hold on with your arms if needed to gain stability.

           Once you feel a great stretch, hold the stretch for 30 to 60 seconds (I love 8 deep breathes to get oxygen into the stretch. With every exhale, go slightly deeper  into the stretch). There should never be pain with stretching either during or after. Pain during stretching will always mean 2 hours later you are tighter than when you started. Pain after stretching means you stretched too hard and next time stretch easier. Please read the separate post on Generalizations of Stretching.

When stretching both legs, I like to alternate sides. The three stretch variations for the lower hamstring is all based on the big toe position. Let us discuss the right side, and I will leave it up to you to do the opposite for the left side. With the big toe at 12 o'clock, lean forward over the leg until you feel the pull of the hamstring behind the knee. Hold this painfree stretch for 30 to 60 seconds, or 8 deep breathes. Then do the left side. The second stretch for the right side is with the big toe at/near 9 o'clock. This gets a greater stretch on the medial hamstrings (semi-tendinosis and semi-membranosis). Then do the left side. The third stretch for the left side is with the big toe near 3 o'clock. This gets a greater stretch on the lateral hamstrings (biceps femoris).

You may be very surprised that one of the three stretches gets the sore muscle/tendon better than the other two. If so, do one more stretch to this variation for 8 more deep breathes, or go back it that stretch alone several times a day. Soon I will have a post on Upper Hamstring Stretching (the apparent mystery stretch to 99% of my patients whom have never heard of it).