Common Injuries and How to manage them.

Patella femoral syndrome, Achillies tendonitis, Illiotibial band syndrome (ITBS)

(This section is a guide to self treatment of common running problems. Off course your first step is to visit your running friendly GP and maybe a physiotherapist to determine a treatment course).

A common cause of Anterior Knee Pain.

What is patella femoral syndrome?

This term is used to describe pain around the patella(kneecap). The patella femoral joint is the joint between the femur (thigh bone) and the patella. The biomechanics of this joint are important to consider when explaining patella femoral pain syndrome. The patella sits in a groove on the femur (the trochlear groove). As the knee moves the patella glides across the front of the knee in this shallow groove. The patella moves up and down, tilts and rotates and there are therefore various points of contact between the patella and the femur.

The movement or tracking of the patella during movement of the knee requires a precisely timed, specific pattern of muscle contraction to ensure optimum movement of the patella through the trochlear groove. Improper patella tracking is thought to be one of the causes of patella femoral pain syndrome as are misdirected mechanical forces on the joint.

Maltracking of the patella occurs when the patella no longer remains centred in the trochlear groove, and develops an abnormal set of biomechanics resulting in increased pressure on the patellar articular (joint) surface. This causes abnormalities within the articular cartilage, chronic inflammation and pain.

What factors contribute to patella femoral syndrome?

There are a number of factors that predispose an individua lto patella femoral syndrome and these can be considered as causes that need to be addressed:

1. Abnormal biomechanics

1. Excessive pronation. Femoral anteversion – this is an internal rotation of the femur (thigh bone) and presents with the patellae (kneecaps) pointing inwards at each other. Increased Q angle – Q angle is the angle between the line of pull of the quadriceps muscles and the line of the patella tendon. Women often have wider hips than men and therefore their femurs (thigh bones) come to the patellae at a greater angle. This increases Q angle and can increase the chance that the patella is not properly aligned. Small patellae, which are highly positioned.

2. Muscle Imbalance

Tightness of the lateral structures of the patella femoral joint (as explained below). Weakness of the quadriceps muscles particularly the vastus medialis obliquus muscle (as explained below). Tightness of the calf and hamstring muscles. The stabilizing forces on the patella femoral joint are shownbelow:

The lateral (outside) stabilzing structures of the patella femoral joint are stronger than the medial (inner) structures so any imbalances in force will tend to cause the patella to move laterally (sideways) and this is abnormal (it usually goes up and down not side to side) Tightness of the lateral strustures and weakness of the medial structures particularly the (VMO) vastusmedialis obliquus will cause the patella to move more laterally in this way. This means it no longer tracks in the femoral groove and this causes discomfort.

Symptoms:

Pain around the patella, which may be non-specific.
Pain aggravated by; running (especially downhill), stairs or any weight-bearing activity requiring repeated knee flexion (bending).
Pain after prolonged periods of sitting.
May experience clicking of the knee or crepitus (grinding) under the patella.
May have tenderness on palpation of the patella.
May have some swelling.

Treatment:

Rest from aggravating activities.
ICE therapy – apply ice to the knee for 10 – 15mins 2 – 3 times daily. Wrap the ice in a damp cloth and check the skin regularly.
Use non-steroidal anti-inflammatory drugs (eg. Ibuprofen). Always consult your General Practitioner / Pharmacist for dosages etc…
Quadriceps strengthening exercises – particularly focused on the vastus medialis obliquus muscle. One such exercise is detailed below:

Step downs:

Stand with one leg on a step. The foot of the leg on the stepshould be turned slightly outward. Gently squat down, ensuring that your knee is aligned over the 2ndtoe of the foot on the step. Push backup again and repeat. This exercise should be done in pain free range and as the muscle may fatigue quickly should be done in small numbers regularly through the day. Repeat on both legs.

Stretching of the lateral structures.

Stretch 1:

In sitting, with your legs outstraight in front, cross the leg to be stretched over the other, bending at the knee so that the foot moves towards the opposite hip. Pull the knee of the leg to be stretched towards the opposite shoulder using the opposite arm.

Stretching of the hamstrings, calfs and quadriceps. Massage Therapy – To release tightness in the lateral structures. Get someone to use their forearm and apply pressure to the outside of the thigh starting at the knee and sliding slowly towards the hip. You may also try using a rolling pin (or rumble roller) to self-treat. Strengthening of the gluteal muscles to control rotation at the hip. Ensure appropriate footwear. You may require motion control shoes or orthotics to control over pronation. Consult a Chartered physiotherapist who may use other forms of treatment including taping of the patella and electrotherapy. They will also be able to give you further more specific strengthening exercises and other advice. On full recovery from patella femoral pain syndrome you can decrease the risk of re-occurence by

A gradual increase in training intensity.
Continuing appropriate stretches.
Ensuring an adequate strengthening programme as part of your training to include specific work for the quadriceps and gluteals.

Ensuring footwear remains correct.

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What is Achilles Tendonitis?

Achilles tendonitis is one of the most common overuse injuries in runners. The Achilles tendon is the large tendon at the back of the ankle joint which connects the calf muscles (gastrocnemius and soleus) to the back of the heel bone (calcaneus). If the tendon is placed under too much stress it can become tight and inflamed. This inflammation is known as Achilles tendonitis.

Symptoms:

Pain along the Achilles tendon which is usually worse on exercise. Some runners find they have pain at the beginning and end of a training session with a period of decreased pain in the middle.
Swelling and redness over the Achilles tendon. A small lump of scar tissue may also be palpable.
A creaking may be felt around the tendon on moving the foot or pressing the tendon. This is scar tissue rubbing against the tendon.
Limited ankle flexibility / stiffness of the tendon especially in the morning.

Causes:

Inflexibility (tightness) of the calf muscles (gastrocnemius and soleus).
Weakness or fatigue of the calf muscles.
Over pronation (turning inwards of the foot on impact).
Number of years running.
Recent change in footwear or inappropriate running shoes.
Recent increase in training activity (mileage, speed, intensity or an increase in hill work).
Change of running surface / running on uneven ground.
Limited movement at the ankle joint (dorsiflexion).

Treatment:

Rest – avoiding painful aggravating activities.
Use ice wrapped in a damp cloth and apply to the Achilles for 10 – 15mins. This is especially useful after exercise.
Take non-steroidal anti-inflammatory drugs (eg. Ibuprofen.). Consult your pharmacist / General Practitioner for advise/ dosage.
A heel raise can be used initially (in both shoes) to reduce the load on the tendon. This should only be used in the acute stages.
Ensure correct shoes.
Self massage – massage in small semi-circles away from the lump on the Achilles in all directions.

Stretching of the gastrocnemius and soleus muscles as below:

Stretch 1 – Gastrocnemius Muscle

Stand with one leg in front of the other and hands against a wall. Make sure that both feet are pointing forwards and that your heels remain on the floor. Lean in to the wall until you feel a gentle stretch down the back of your calf. Hold for 30 secs.. Repeat on both legs.

Stretch 2 – Soleus muscle

Stand with one foot in front of the other and the toes of the front foot against a wall. Bend your front knee until it touches the wall, hold for 30 seconds. If this is too easy and you do not feel a stretch make it more difficult by gradually moving the front foot away from the wall so you have to bend the knee further. This should increase the stretch.

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What is Iliotibial Band Syndrome?

The Iliotibial band is a connective tissue band that runs down the lateral aspect (outside) of the thigh. It is a continuation of the tendinous partof the tensor fascia lata muscle and provides its attachment to bone.

In summary, the Iliotibial band runs down the outside of the leg between the top part of the hip and the upper tibia (shin bone).

Iliotibial band syndrome occurs due to friction between the iliotibial band and the underlying lateral femoral epicondyle, which is a bony prominence of the thigh bone at the knee joint. As the knee is bent and straightened repetitively the iliotibial band moves backwards and forwards over this bony prominence. Problems can occur with this mechanism and may lead to iliotibial band syndrome.

Symptoms:

An ache over the outside of the knee usually after running for roughly the same time / distance on each run.
Pain may disappear soon after running.
Tenderness on the outside of the knee joint when palpated.
Local inflammation is occasionally present around the outside of the knee.
As the condition progresses there may be a sharp stinging pain, or burning on the outside of the knee.

Pain is likely to be aggravated by:

Running over a certain distance / time.
Running down hills.
Running on cambered surfaces.
Walking up / down stairs.

Common Causes:

A significant / sudden increase in training intensity.
Increased training on hills, uneven or cambered ground.
Excessive foot pronation (turning inwards of the foot on impact).
Incorrect or worn shoes.
Tightness of the iliotibial band.
Bow legs or knees which turn inwards.
A leg length discrepancy.
A lateral tilt of the pelvis.

Treatment:

Reduce training load and intensity so running remains ‘pain free’.
Apply ice to the knee (10mins approx every 2-3 hours). Wrap the ice pack in a damp cloth.
Use non-steroidal anti-inflammatory drugs (eg. Ibuprofen) regularly for 5-7 days. Consult your pharmacist or General Practitioner for recommended dose.
Massage therapy to decrease tightness of the iliotibial band. Get someone to use their forearm and apply pressure to the outside of the thigh starting at the knee and sliding slowly towards the hip. You can also try using a rolling pin to self-treat.
Gentle stretching of the iliotibial band approx 3 times daily, holding stretches for 30 seconds.

Stretch 1:

In sitting, with your legs straight out in front, cross the affected leg over the other. Bend the affected leg at the knee so that the foot moves towards the opposite hip. Pull the affected knee towards the opposite shoulder using the opposite arm.

Stretch 2:

In standing, with both knees straight, cross the affected leg behind the other. Bend the upper body away from the affected leg whilst sticking out the hip on the affected side.

Ensure appropriate footwear. You may require motion control shoes or orthotics to control over pronation. Gait analysis can be used to determine this.
Avoid excessive downhill running or running on cambered surfaces.
If running on a track alternate between running clockwise and anti-clockwise.
On full recovery from iliotibial band syndrome decrease the risk of reoccurrence by the following preventative measures:
Gradually increase training intensity.
Continue iliotibial band stretches regularly.
Ensure footwear remains correct.
Ensure adequate strengthening of the gluteals, quadriceps, hamstrings and calfs within your training program.
Avoid excessive downhill running or running on cambered surfaces.
Ensure adequate rest within your training programme.