"Kneecap Training"

[HillSlugger]

Over course of the summer (triathlon training) I developed discomfort in my left knee, above the patella. When I saw a knee specialist he said that I had tendonitis of the quadriceps tendon. When rest and antiinflammatories did not clear it up I went back. This time he told me I had too much knee flexibility and he sent me for PT to strengthen the knee. The diagnosis was "bilateral patellofem pain and quad tendonitis". At my first PT session today the therapist told me that my kneecaps were too loose and that they weren't tracking straight; both are deflected outward and the left one also has a bit of twist to it. So, for treatment she taped my kneecaps into the proper position and then started exercising my quads to this new alignment. We started with 8 minutes on the elliptical, then leg presses, "thigh push-outs", "thigh pull-ins", quad extensions, and electrostimulation. I'm supposed to wear the tape 2 days on, one day off, and do PT twice a week (Tuesdays and Fridays).

Can one or more of our lovely PTs tell me if all this makes sense? How long should I expect it to be before I start noticing definite improvement? Which part of this is making my lower back hurt?

Thanks, Nicole

[Zen]

Which part of this is making my lower back hurt?

Do you mean the exercises are making your back hurt or did you already have back pain accompanied by knee pain?

[HillSlugger]

Do you mean the exercises are making your back hurt or did you already have back pain accompanied by knee pain?

My lower back aches since PT this afternoon (my knees and thighs are quite tired and achy).

[Wahine]

MD - I understand where your PT is going with this but it may not be the right way for you to start. Make sure that when you see the PT you give very clear feedback about how you felt after the session. Eg: my back started to hurt an hour later and didn't stop hurting until I took advil a few hours after that. Be as specific as you can. If you are specific the PT will take this info and use it to mold a program that works for you. If they're any good they will. If you are not specific, it may come across as whining (not that it should but unfortunately sometimes PTs can be presumptuous and I hate to say it but especially if you're a little bigger and they think that you're not used to exercise). I personally prefer to start people on a stretching progam for the hips first and maybe with some strengthening of the inner thigh isometrically before I start in on leg presses, thigh push outs or knee extensions. In fact I never give knee extensions as an exercise for patellofemoral pain. I also like to add some deep tissue massage to release the lateral quad/thigh.

I really like taping techniques for this type of problem.

Here's how I might approach this with your PT. Poke around your quad and outer thigh area and see if you can find some knots. Point these out to your PT and politely ask if they think that deep tissue massage might help that. As for the hip stretches, I would say something like, "My hips seem really tight, could this be contributing to the problem. Would it help for me to stretch them?"

I'm laying this out in this way because some PTs feel threatened when a patient comes in and suggests a different approach. I don't personally think that there is anything wrong with this and I appreciate it when my patients put their thoughts out there, regardless of if it's positive or negative. But I am confident in myself and my work. Someone not as confident will not react well and instead of keeping a nice understanding repore and taking action to adapt a program as needed, they may start to rationalize why the treatment may not be going well by finding blame elsewhere.

Please realize that I'm not saying the treatment they have started with is bad. It may be very appropriate. I just think that you need to give some feedback and ask about some other options. It could be that your PT is planning to add these things in that I have suggested, they just couldn't get to it today.

Finally, your back pain may have something to do with your knee pain and if it persists it should be evaluated by the PT.

Knott will likely add some foot stuff to this.

[KnottedYet]

Knott will likely add some foot stuff to this.

Oh, yeahhhhhhhhh...

It's all because you have compensated hindfoot varus and probably forefoot also, and so over-pronate.
(seriously, ask your PT if insoles like Superfeet would help your knees)

Wahine said it all!

[HillSlugger]

Oh, yeahhhhhhhhh...

It's all because you have compensated hindfoot varus and probably forefoot also, and so over-pronate.
(seriously, ask your PT if insoles like Superfeet would help your knees)

Wahine said it all!

Yes, I overpronate. I have motion control running shoes. Still, I had ankle issues after I started running and now use custom orthotics in my running shoes. I have Superfeet in most of my sneakers and shoes.

Could you please explain "compensated hindfoot varus and probably forefoot also"?

Many thanks!

[HillSlugger]

MD - I understand where your PT is going with this but it may not be the right way for you to start. Make sure that when you see the PT you give very clear feedback about how you felt after the session. Eg: my back started to hurt an hour later and didn't stop hurting until I took advil a few hours after that. Be as specific as you can. If you are specific the PT will take this info and use it to mold a program that works for you. If they're any good they will. If you are not specific, it may come across as whining (not that it should but unfortunately sometimes PTs can be presumptuous and I hate to say it but especially if you're a little bigger and they think that you're not used to exercise). I personally prefer to start people on a stretching progam for the hips first and maybe with some strengthening of the inner thigh isometrically before I start in on leg presses, thigh push outs or knee extensions. In fact I never give knee extensions as an exercise for patellofemoral pain. I also like to add some deep tissue massage to release the lateral quad/thigh.

I really like taping techniques for this type of problem.

Here's how I might approach this with your PT. Poke around your quad and outer thigh area and see if you can find some knots. Point these out to your PT and politely ask if they think that deep tissue massage might help that. As for the hip stretches, I would say something like, "My hips seem really tight, could this be contributing to the problem. Would it help for me to stretch them?"

I'm laying this out in this way because some PTs feel threatened when a patient comes in and suggests a different approach. I don't personally think that there is anything wrong with this and I appreciate it when my patients put their thoughts out there, regardless of if it's positive or negative. But I am confident in myself and my work. Someone not as confident will not react well and instead of keeping a nice understanding repore and taking action to adapt a program as needed, they may start to rationalize why the treatment may not be going well by finding blame elsewhere.

Please realize that I'm not saying the treatment they have started with is bad. It may be very appropriate. I just think that you need to give some feedback and ask about some other options. It could be that your PT is planning to add these things in that I have suggested, they just couldn't get to it today.

Finally, your back pain may have something to do with your knee pain and if it persists it should be evaluated by the PT.

Knott will likely add some foot stuff to this.

This is my first experience with PT so I don't yet know how it's all supposed to work in regards to the decision making. Thanks for you comments and suggestions.

The PT knows I'm a triathlete (she seemed quite impressed); she even commented on how "cut" I am (maybe she was coming on to me ). Do you think she may have taken this into account when she chose my exercises? I see her again tomorrow, but then switch to early AM sessions next week with someone else. Just wondering if different PT might do things differently and how much control I need to take.

[KnottedYet]

Every PT does things a bit differently. (for example, I *always* fixate on feet and posture first) But, every PT knows their own habits and knows how to branch off from there; and every PT is going to adjust what they have you doing based on how your bod responds.

Lots of feedback to the PT is always good. Lots of questions are good. I love it when my patients come in saying, "Hey, I looked this up on the internet; how does such-and-such apply to me?" "Why am I doing this exercise, and how does it help my problem?"

Here's one of my favorite quotes: (I have it hanging at my desk)
"No physical therapist can possibly match the work of an educated patient."

If you think of your PT as education sessions rather than work-out sessions you will get even more out of the whole process. The more you can learn, the better you will be able to manage your muscles and joints both now and later.

[OakLeaf]

Hi, new here... I had to reply because I experienced this exact issue years ago. This is probably too obvious an answer, but have you tried shorter crankarms? By my height and frame size I "should" be fine with 167.5s, but I have patellofemoral issues on the bike unless I use 165mm cranks. (Anyone here want a brand new 170mm Shimano 105 triple?) Plus, it really helps smooth out my spin.

I've never had a complete professional bike fitting, but it might be in order for you, since it doesn't sound like your PT has a whole lot of experience in bicycling body mechanics. Obviously seat height, cleat placement and cleat rotation will directly affect your knees, but it's possible that what seems right to you isn't actually what's best for your knees.

When I've aggravated my knees doing other things, a simple stretch before I ride helps a lot. Just kneel on the floor (butt on my heels) for 1-2 minutes to stretch my quads and knee ligaments out.

I overpronate too, and this spring I started working the Chi Running program for correcting my body mechanics, which is doing wonders for me. Just being aware of which direction your toes are pointing when you walk or run - paying attention to how you're balancing your body weight on your feet - is more than most PTs will teach you.

Hoping you're healed up and back on the bike soon.

[HillSlugger]

Welcome! How are your knees now?

No, nothing is obvious to me Actually, it was obvious that I should do a full fitting and had one on Tuesday. We never spoke about crank length. Currently I'm riding 170's (105 triple). I should get the bike back this weekend, but don't expect to try spinning for a bit yet.

Yesterday afternoon my back pain started to subside and today I'm doing much better. I got to remove the tape this morning so my knee mobility is improved. I haven't been doing the sorts of things that typically aggravate my knees, but it's been a pretty good day. Hopefully I can get someone to listen to me on Tuesday and can start thinking positively about therapy.

[HillSlugger]

Today, before we started, I spoke with the therapist about my back pain after therapy and about stretching. She said that stretching was definitely in order, that tight muscles contribute to pulling my kneecaps out of alignment, and that stretching should also help my back.

Three sessions, three therapists, three ways of taping. Today my knees are taped lower down, directly over the kneecaps, and are restricting my flexibility less. Yea! As long as I stick to early morning sessions I should keep seeing the same therapist. I was sent home with stretching assignments.

Elliptical: 8min/0.56mi
Knee taping
Electrostim (russian): 15min
Hamstring stretching on foam roller: 2min
IT band stretching on foam roller: 2min each leg
Hamstring stretching with band: 30sec x3, each leg
Leg press: 20 x 78#
Thigh abduction: 20 x 68#
Thigh adduction: 20 x 68#
Leg extension: 20 x 78#
1 hour total time

[OakLeaf]

My knees are good now, thanks for asking. I haven't had a flareup in almost 10 years (touch wood). I wear PF straps for aerobics (stepping and lateral movements) but I'm weaning myself off them when I run. I don't use any straps or tape for cycling and it's fine. I do get a twinge now and then, just a little grindy feeling. Taking shark cartilage or glucosamine/chondroitin mostly prevents that.

The last time I went through PT for PF dysfunction, they had me doing straight leg raises with my leg rotated outward, to develop the vastus medialis. From what I've read, a weak VMO is implicated in a lot of women's kneecap tracking issues. The Chi Running method is definitely developing that muscle, too.

Hope you're starting to see some improvement.

[Wahine]

Elliptical: 8min/0.56mi
Knee taping
Electrostim (russian): 15min
Hamstring stretching on foam roller: 2min
IT band stretching on foam roller: 2min each leg
Hamstring stretching with band: 30sec x3, each leg
Leg press: 20 x 78#
Thigh abduction: 20 x 68#
Thigh adduction: 20 x 68#
Leg extension: 20 x 78#
1 hour total time

That sounds a little better. I'm glad you're stretching. I still wonder about the knee extensions tho.

[KnottedYet]

Yeah, I wonder about the knee extensions, too. Ask your PT to explain why they are doing "open kinetic chain" exs rather than all "closed kinetic chain"? (open chain, you aren't putting weight thru your feet. perhaps not an optimal situation with the quad/knee business.)

(and what's with the Russian stim? was that on your VMO? Are you unable to contract the muscle on your own?)

Very glad to hear you are stretching! And glad they put the McConnell tape in the right spot!

Straight leg raises with the leg rolled out a little are really fun, cuz you can FEEL and SEE the vastus medialis obliquus contract. Way cool. Hillslug, you might get a kick out of them, ask your PT to show you.

3 diff PTs in 3 visits is pretty interesting. It will be nice if you can keep the current one for the rest of your visits.

Edit: BTW, I really like ChiRunning.