A runner’s ability to avoid and manage injury will determine his or her fitness on race day. To help local runners reach their goals, Physical Therapists Rob Naber and Jenny Warner from Physical Therapy of Los Gatos, and Dr. John Kao from the SOAR Medical Clinic teamed up in May to deliver a running injury prevention and treatment seminar to 150 members of the San Jose Fit marathon training club.

Already several weeks into their training program, the San Jose Fit runners were engaged and attentive as Rob Naber presented information on avoiding and managing injuries. The runners received information on pronation and supination, walking and running biomechanics, and some corrective exercises that Physical Therapists prescribe to address specific problems.

Dr. Kao’s presentation provided information about the causes of injuries, specific training errors to avoid, and detailed medical descriptions of several kinds of running injuries. He also explained the injury first-aid “PRICEMM” protocol, which calls for Protection, Rest, Ice, Compression, Elevation, Medications, and other treatment Modalities.

The presenters offered these key take-away messages to the San Jose Fit runners:

• Avoiding injury is the key to running success
• Most injuries result from overtraining
• Do not increase training mileage or duration by more that 10% per week
• Complement your running training with specific stretching and strengthening exercises
• If you have an injury, use cross-training activities to continue your fitness training
• Use a heart rate monitor to maximize the benefit from your cross training efforts

Dr. Kao recommended contacting a physician whenever any of these circumstances arise:

• Pain is localized to the bone or joint
• Joint motion is accompanied by catching, popping or locking
• Pain cannot be controlled by the recommended dose of over-the-counter anti-inflammatory medication such as ibuprofen
• The problem persists for more than two weeks
• You are worried or concerned about your symptoms

Dr. Kao noted that individuals can make the most of any medical visit by coming prepared with accurate information about their injuries and symptoms. Dr. Kao can be reached by contacting his assistant Wendy at (408) 247-4900 x1214.

The seminar presenters thank Sports Basement for the use of their Sunnyvale store conference facility for the San Jose Fit seminar.

Education, screening and specialized training can turn back the rising incidence of ACL (anterior cruciate ligament) injuries in young female athletes. That’s why Physical Therapy of Los Gatos is pleased to announce the new community information web site Los Gatos ACL. There, you’ll find information on the ACL, ACL injury, prevention, rehabilitation, and our Sportsmetrics™ -certified screening program for identifying individual athletes at greatest risk of injury.

The screening program is a free service for the Los Gatos community provided by Physical Therapy of Los Gatos. Donations for participating in the program go directly toward athletic team fund-raising goals.

For more information, visit www.losgatosacl.com.

Therapeutic exercise is a hallmark of physical therapy. Among many benefits, therapeutic exercise can restore correct strength ratios between muscles, increase functional capacity, and improve coordination.

When prescribing therapeutic exercise, the physical therapist must consider the entire sequence of neuromuscular events that allows the patient to perform their daily activities and sports. This sequence can be thought of as a chain composed of three elements: proximal (closest to the spine) stability, distal (away from the spine) motion, and finally, the desired fine motor skill.

While this sequence of neuromuscular events accompanies all deliberate human motion, it is perhaps most readily illustrated by the action of throwing a dart. The motion requires a firm basis of proximal support and slight rotation around the spine, distal motion performed by muscles of the chest, shoulder, and upper and lower arm, and fine motor skill as the fingers take control of the dart’s release. The controlled, simultaneous engagement of all three elements is what enables the competitor to hit the target’s triple ring.

In Pilates-speak, the deep muscles of the trunk that provide proximal stability are called the “core,” and the ability to move one’s limbs and carry out skilled tasks while holding the trunk steady is called “dissociation.” Strength and control over these deep muscles of your trunk provide the stable base required to perform tasks such as kicking a soccer ball or swinging a golf club.

Here at Physical Therapy of Los Gatos we draw from a wide a variety of exercises to help our patients coordinate, strengthen, and engage this three-part chain. Visitors to our clinic might recognize our use of movements from yoga, Swiss ball exercises, elastic band resistance exercises — even pull ups and hands stands. They might also recognize mat-based and equipment-based Pilates exercises. As a form of exercise, Pilates expands the clinical repertoire of physical therapy with a diverse range of exercises, performed in multiple planes and positions.

Pilates for Neuromuscular Retraining
Full recovery from injury proceeds through overlapping stages. Therapy to bring about full recovery must be coordinated with these stages. Initially, a patient may need to unlearn inefficient movement patterns that allowed the injury to occur in the first place. The Pilates Reformer offers an effective exercise platform where this unlearning can occur, and old patterns of movement can be replaced by ones that properly engage the proximal to distal to fine motor skill sequence. The Reformer enforces correct exercise motion and helps the therapist and patient isolate and train the deep muscles of the trunk required for proximal stability.

On the Pilates Reformer, neuromuscular re-training exercises can be performed in kneeling, supine, prone, or side-lying positions. This allows the therapist to prescribe some unusual exercises, such as supine “jumping” and rowing while kneeling. Patients and therapists have found that neuromuscular retraining to correct injury-causing patterns of movement proceeds more rapidly in these unfamiliar exercise positions, where gravity pulls the body along different axes and the usual proprioceptive cues are absent. As training proceeds, the therapist can progress the patient to exercise postures needed for his or her sports and activities to fully restore endurance, power and agility.

Pilates for Correct and Calibrated Strengthening
At Physical Therapy of Los Gatos we design individualized treatment programs that coordinate the timing and intensity of therapeutic exercise with each patient’s condition and functional capabilities. Injured tissues such as bones and ligaments must be allowed to heal, but incremental loading (progressive resistance training to increase strength) along correct axes is required to bring about full maturation of healing tissue. If exercise is delayed or inadequate, the muscles around the injured site become weaker and atrophy, slowing down the recovery process. Pilates helps close the gap between bed rest and full recovery by providing a variety of exercises that can be performed over a wide range of functional abilities.

In the case of a basketball player recovering from knee arthroscopy, the mechanics of jumping can be practiced in a supine position on the horizontal carriage of the Pilates Reformer. In addition to providing the neuromuscular training benefits described above, the Reformer in this case allows the therapist to initiate incremental loading of the affected knee without subjecting injured tissues to the full forces of gravity. In this type of therapeutic exercise, the Reformer is unlike a traditional leg-press apparatus because the patient’s position during the Reformer exercise simulates the relative head, torso, and leg alignment of regular upright jumping. With Pilates, the physical therapist can prescribe low-intensity jumping exercise in early treatment, and increase the intensity as recovery progresses. This enables the patient to recover upright jump capability and return to competition sooner.

Pilates for Full Recoveries
To us, “full recovery” does not simply mean returning the patient to his or her previous activities in order to be injured again. We are unique in our analytical approach into the causes of each patient’s susceptibility to injury. Our definition of full recovery includes identifying and strengthening weak muscles that allowed the injury to occur in the first place, and achieving neuromuscular control consistent with injury prevention. Ideas such as “dissociation” and “core” in Pilates helps isolate and train muscles responsible for preventing injury.

The Spring 2006 West Valley College Sports Medicine Symposium was held May 5th. The symposium was organized by John Kao MD for an audience consisting of physical therapists, athletic trainers, and physicians. The purpose of the Sports Medicine Symposia series is to continue improving the standard of orthopedic medicine here in the Bay Area by providing orthopedic professionals an opportunity to share their knowledge with one another and with other medical practitioners. This year’s spring symposium focused on current challenges of treating the lower extremities.

The following local professionals gave presentations:

• John T. Kao, M.D.

• Grady L. Jeter, M.D.

• Robert S. Nishime, M.D.

• Thomas Elardo, D.P.M.

• Paul Christensen, DPT, OCS, ATC

• Rob Naber PT, OCS, ATC

• Ross Nakaji PT, OCS, ATC, CSCS

• Fabrice Rockich, DPT, OCS, CSCS

• Paul Starks, MA, ATC, PTA, CSCS

Physical Therapy of Los Gatos principal Rob Naber spoke about the evaluation and treatment of problems affecting the knee. Rob began by noting the value of recent knee research and the bearing of research findings on the practitioner’s approach to knee conditions and injuries:

“The knee is often the weakest link that defines and limits an athlete’s total competitive capacity. The knee is needed for speed, power and strength, but is also vulnerable to injury. A knee injury not only means missing practice or competition but may also lead to the loss of scholarship support and potential professional opportunities. Extensive research of the knee, and improved diagnostic, rehabilitation, and surgical methods have brought new hope to athletes and clinicians dealing with the challenges of the injured knee.”

– from Current Issues in Sports Medicine: The Knee presented by Rob Naber PT, OCS, ATC

One of the key takeaway messages from Rob’s presentation was the importance of quantifying the capability and condition of the knee while the joint is in motion. In the evaluation and treatment of anterior knee pain, for instance, measuring the concentric vs. eccentric torque capacities of the knee is critically important as a diagnostic aid and as a reliable indicator of treatment progress. In rehabilitation following surgical reconstruction of the anterior cruciate ligament, videographic analysis of lower extremity angles during landing and jumping provides data the therapist needs to design and carry out a course of treatment that brings about rapid restoration of function and corrects neuromuscular control deficiencies that would otherwise invite re-injury.

Using the links below, interested individuals can view visuals and handouts from Rob Naber’s presentation to the Spring 2006 West Valley College Sports Medicine Symposium. For more information about Physical Therapy of Los Gatos’ approach to the evaluation and treatment of knee problems, please call the clinic at (408) 358-6505.

Current Issues in Sports Medicine: The Knee (view presentation visuals)
Current Issues In Sports Medicine: The Knee (download text)

Jump Strength Training Program (download program description)

Jump Strength Training Glossary (download glossary)

Physical Therapy of Los Gatos principal Rob Naber spoke by invitation at the Western Occupational Health Conference 2005, held September 15 – 17 in Monterey, California. The annual conference is sponsored by the Western Occupational and Environmental Medicine Association, an educational and advisory organization that helps bring about and preserve legislation aimed at improving worker injury care. The organization is part of the influential American College of Occupational and Environmental Medicine.

As the only physical therapist invited to speak at the conference, Rob chose to present information on the diagnosis and treatment of knee and back maladies, which can result from on-the-job injuries and overuse.

Information on anterior knee pain has been previously published on this web site. Rob’s presentation on anterior knee pain to conference attendees contained additional clinical information of value to health care professionals involved in setting treatment guidelines for rehabilitation of work-related injuries.

Anterior Knee Pain: The Use of Eccentric Strength Exercise

presentation to the Western Occupational Health Conference 2005

Western Occupational Health Conference 2005: New Horizons in Occupational Medicine
Western Occupational and Environmental Medicine Association
American College of Occupational and Environmental Medicine

Anterior Knee Pain, also known as “runner’s knee,” is the second most common reason for joint pain related physical therapy office visits. Patients with anterior knee pain complain of a dull ache at the front of the knee that feels like it’s coming from behind the patella (kneecap). Patients feel pain most strongly after sitting for a long time with their knees bent, as in a long meeting or at the movies, and when walking downstairs or bending down into a crouching or squatting position. In almost all cases, anterior knee pain can be relieved temporarily by simply straightening the leg. Untreated anterior knee pain is often severe enough to limit knee function, requiring sufferers to discontinue sports activities, avoid stairs, and seek out seating that allows frequent full leg extension.

The exact cause of anterior knee pain is not known, and the condition is considered difficult to treat. Most interventions for anterior knee pain are based on one or the other of two popular theories: “chondromalacia” of the cartilage behind the patella, and “malalignment” between the patella and femur.

Chondromalacia in the context of anterior knee pain refers to softening and degradation of cartilage behind the patella. Chondromalacia is so commonly considered the cause of anterior knee pain that the word is often used incorrectly as a synonym for anterior knee pain.

Cartilage behind the patella is thought to allow the patella and the end of the femur to slide smoothly relative to each other when the knee joint is in motion. Chondromalacia theory says that anterior knee pain occurs when the cartilage is softened or degraded. Chondromalacia is treated by surgery aimed at encouraging new cartilage to grow inside the knee joint or by separating intact cartilage from its original location and moving it to sites where the surgeon believes it will be more useful.

Surgery to correct chondromalacia has not been shown in rigorously designed, statistically valid studies to provide long-term relief from anterior knee pain. This lack of effect is consistent with what we know about joint cartilage: joint cartilage does not have nerve endings and can therefore not be a source of pain. The absence of pain receptors in knee cartilage was confirmed in an unusual experiment carried out on orthopedic surgeon Scott Dye, MD, who reported no sensation during direct probing, without anesthesia, of the cartilage behind his patella.

The presence or absence of chondromalacia does not predict whether someone does or does not have anterior knee pain. Many individuals with advanced chondromalacia do not have anterior knee pain, and many individuals with anterior knee pain do not have chondromalacia.

Malalignment theory proposes that the patella is somehow crooked or is located too far to one side or the other of the knee, causing excessive friction and pain. A number of therapies aimed at correcting malalignment have been developed, including:

• using tape applied to the skin to try to hold the patella in a “medial glide” position
• specific muscle training exercises aimed at changing the position of the patella
• “lateral release” surgery to change the position of the patella

None of the non-surgical treatments for patellar malalignment have been shown to change the position of the patella for any clinically meaningful duration of time. Therefore, it has been difficult to detect a statistical correlation between malalignment and anterior knee pain. In addition, none of the non-surgical or surgical treatments based on correcting malalignment have been shown statistically to provide long-term relief of anterior knee pain.

Like chondromalacia, patella alignment or malalignment does not predict whether an individual will experience anterior knee pain. Chondromalacia theory and malalignment theory are also similar in that they are both based on observations made when the knee is not moving.

At Physical Therapy of Los Gatos, we view the knee as a dynamic process, and we believe that anterior knee pain must be evaluated while the knee is in motion.

Our approach to understanding and treating anterior knee pain is influenced by the work of Bennet and Stauber, who in 1986 noticed that, in individuals with anterior knee pain, the amount of torque produced around the knee joint by the quadriceps muscles during dynamic, eccentric exercise (when the quadriceps muscles are lengthening to allow the knee to bend) was not normal in its distribution around the axis of rotation of knees affected by anterior knee pain. Contrary to the differences normally observed between eccentric and concentric muscle strength, torque measured around affected knees was less than torque measured around the same knees during concentric exercise. Bennet and Stauber also found that specific exercises could restore eccentric torque and torque distribution to normal, and when that was accomplished, anterior knee pain went away.

Analyzing the relative torque-producing capabilities of the quadriceps muscles during eccentric and concentric exercise is a critical aspect of our approach to evaluating patients with anterior knee pain. In our experience, re-defining the eccentric and concentric torque profiles of the quadriceps can be readily accomplished by a motivated patient using specific exercises that emphasize eccentric muscle strength. This approach provides long-term relief from anterior knee pain and allows our patients to return to sports and other activities requiring normal knee function.

Osteoarthritis is a degenerative joint disease marked by joint inflammation and deterioration. Osteoarthritis is common: according to the Arthritis Foundation, nearly 21 million Americans, or 7% of the US population, are affected by osteoarthritis. The incidence of osteoarthritis goes up sharply with age.

Considering its prevalence, you probably already know someone who has been diagnosed with osteoarthritis. If that person is a competitive or recreational runner, one might expect to hear others say, “All that running. It’s no wonder he’s got arthritis.”

The fact is, there are plenty of non-runners with osteoarthritis, too, and there is a lack of evidence to support the notion that running causes arthritis.

In his excellent book, “Lore of Running,” Dr. Timothy Noakes cites a variety of research studies designed to examine the relationship between running and arthritis. Studies published in 1994 and 1997 determined that recreational joggers are not at any increased risk of developing osteoarthritis. A study published in 1985 found that the incidence of osteoarthritis in a group of runners who competed between 1930 and 1960 was lower than a matched group of swimmers who competed at the same time. A Danish study published in 1990 found that a group of athletes that ran 20 to 40 km per week for 30 years had an incidence of osteoarthritis that was no different from that of a comparison group. And a 1986 study found that runners with an average age of 60 who had run an average of three hours per week for 12 years did not have a greater prevalence of osteoarthritis than a comparison group.

Though at no greater risk of developing osteoarthritis than others, runners can and do experience pain from soft tissue injuries, such as hip bursitis, iliotibial band (ITB) friction, and tendonitis. Pain resulting from these other causes can be serious enough to interrupt training and recreational running. The runner with poor mechanics may never train long enough to develop osteoarthritis from running. And clearly an athlete who has jogged for 30 years has the correct biomechanics to run without breaking down.

Excluding injuries resulting from falls, runners’ injuries are almost always due to progressing their training too quickly or overloading the muscle support around the affected joint. A runner’s muscular strength around his or her load-bearing joints must be considerably stronger than that of non-athletic individuals of the same age and sex. Furthermore, different types of running such as sprinting, long-distance, cross-country, and asphalt training have different muscle support requirements.

The running program at Physical Therapy of Los Gatos is a goal-directed training program designed to prevent running injuries, get runners who have been injured or recovering from orthopedic surgery back into training, and increase running speed. The evaluation for the running program includes a comprehensive interview process where we measure baseline parameters of running fitness, uncover specific deficiencies, analyze your running form, and help you clarify your goals. For additional information on preventing running injuries, rehabilitation of running injuries, and increasing running speed, please contact Physical Therapy of Los Gatos by calling (408) 358-6505.

An unintended consequence of the increase in sports participation by girls and young women over the past thirty years has been an extraordinary rise in the incidence of anterior cruciate ligament (ACL) injuries in young female athletes. At the college level, one in ten young female athletes participating in sports such as soccer, volleyball, and basketball will suffer an ACL tear injury. These girls are typically unable to practice or compete for one or more seasons and face potential loss of scholarship funding and significant psychological trauma. A widely cited 1985 study found that at the high school level, the knee injury rate among female athletes is one per 100 participants, and noted the need for preventative measures.

In 1983, sports medicine researchers determined that four-fifths of ACL injuries are non-contact injuries, that is, they are caused by the athlete’s own motions rather than collisions with other players. To the researchers, this finding meant that the high incidence of ACL tear injuries in young female athletes might be greatly reduced if those motions could be identified and avoided.

The ACL is one of four major ligaments that connect the upper and lower leg at the knee. The ACL provides joint stability and supports cutting and pivoting motions. Oftentimes, the ACL will tear with a “pop” that can be heard by spectators and other players. Pain and immediate swelling follow. ACL tears require surgical reconstruction using tendon grafts from other areas of the knee or from cadavers, followed by a long period of rehabilitation.

The frequency and seriousness of ACL tears in young female athletes has led to research studies aimed at understanding the problem. These studies are now yielding valuable data. Three major hypotheses to account for the higher number of ACL tears in female athletes versus male athletes have been examined: hormonal differences causing laxity of the female athlete’s ACL, a smaller and more narrow space within the knee for the female athlete’s ACL, and sex-based differences in lower extremity strength and coordination. The last of these three hypotheses is receiving the most scientific support from study data.

Certain aspects of lower extremity strength and coordination can be captured and measured by videotaping athletes while they perform athletic movements in the research lab. While video recordings do not capture complex three-dimensional movements and the rotational stresses that these movements place upon the knees, the recordings do enable researchers to make close measurements of joint and limb positions in a single plane. These measurements were found to have predictive value.

In one well-designed study of 205 young female athletes, researchers found that athletes with a specific way of posturing their lower extremities, known as “valgus” (or “knock-kneed”) alignment, during certain athletic movements were more likely to suffer ACL injury than athletes with more “neutral” or straighter lower extremity alignment. This valgus alignment can be seen by analyzing the angles formed between the ankles, knees, and hips when the athlete lands from a jump off a small box and when she jumps vertically from a crouched position. A separate study that included videographic analysis of 325 young female athletes showed that a six-week neuromuscular training program corrected the lower limb valgus alignment associated with injury during jump landing and takeoff.

It is already well-known to physical therapists that muscular strength stabilizes the knee by helping to maintain the correct relative positions of knee structures during sports movements and by allowing muscles in the legs to absorb forces that would otherwise subject the joint to potential injury. But physical therapists treating young female athletes must now consider the implications of the new studies. Physical therapists familiar with these studies infer that rehabilitation from ACL injury should, in addition to conventional strength training treatment methods, include specific neuromuscular training aimed at improving the athlete’s ability to avoid valgus alignment of the lower extremities during high-risk sports.

It is no longer acceptable to reconstruct the ACL but leave neuromuscular control deficient.

The jump strength training program at Physical Therapy of Los Gatos is an element of rehabilitation from surgical reconstruction of the ACL as well as a standalone performance improvement module. The program includes jump analysis, strength conditioning, and neuromuscular training designed to improve power and acceleration. The neuromuscular training methods employed include visual, auditory and proprioceptive cues to train athletes to use muscular strength to absorb jump impacts in a controlled fashion, and, if necessary, to correct jumping, landing, and pivoting techniques in order to avoid forces associated with injury. For additional information about prevention of ACL injury, rehabilitation from surgical ACL repair, and jump strength performance training for athletes, please call Physical Therapy of Los Gatos at (408) 358-6505.