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)

Tennis elbow, also known as “lateral epicondylitis,” often affects active adults between the ages of 30 and 60 years, and causes pain on the outside of the elbow joint where the forearm meets the elbow. Internally, tennis elbow pain is localized where the muscles of the forearm merge into tendons and attach to end of the upper arm bone. A patient with tennis elbow will typically feel pain upon extending (unbending) the wrist (think of the wrist motion required to rev a motorcycle). As an aid to evaluation, a therapist can reproduce the pain by resisting the patient’s wrist motion. Sometimes tennis elbow can be so painful that the patient cannot raise his or her hand, even when no resistance is applied.

Although the condition is known by two names, neither is very accurate. You don’t have to play tennis to get tennis elbow! In addition to the high tensile stresses of the backhand tennis stroke, any other activity involving a firm grip, such as using a hammer or screwdriver, or heavy lifting, such as lifting suitcases away from the body with the palm facing the ground, can cause tennis elbow. And the “-itis” suffix of the name “lateral epicondylitis” signifies that the condition is characterized by inflammation, which is not the case. Factors normally associated with inflammation, such as certain white blood cells, cytokines, and chemokines, are not found at the site of the lateral epicondyle of the elbow. What surgeons do find, however, upon opening and examining an affected elbow, is disorganized connective tissue in the form of a characteristic yellow-brown scar. By contrast, healthy tendon tissue is glistening white and is composed of cells organized in neat rows along the axis of tension between the muscles of the forearm and the lateral epicondyle of the elbow.

Palliative measures for tennis elbow include rest and anti-inflammatory medication. Tennis elbow patients are also sometimes instructed to use a tight band around the upper forearm to help rest the painful area and protect it from damaging tensile loads. Although these measures are effective at reducing pain while they are used, they rarely result in full recovery, because they do not restore proper connective tissue alignment.

Fortunately, there are more effective measures. Twenty years ago, exercise physiologists discovered that eccentric exercise is a necessary component of rehabilitation from tendinitis. Eccentric exercise occurs when a muscle generates tension as it is lengthening. For instance, when you place a coffee cup down on a table, you are performing eccentric exercise: your biceps muscles must lengthen in a controlled manner to lower your forearm and place the cup down gently. You may think of eccentric exercise as the braking force needed to slow down the motion. The opposite of eccentric exercise is concentric exercise, which involves active muscle shortening.

Although the exact way in which eccentric exercise improves tendinitis is not known, researchers have discovered that muscle elasticity is a key feature of eccentric muscle contraction, and that eccentric exercise increases muscle elasticity. The leading hypothesis is that muscle tissues that have been made elastic by eccentric exercise effectively distribute and absorb forces that would otherwise lead to fraying of the tendon, formation of disorganized scar tissue, and tennis elbow pain.

At Physical Therapy of Los Gatos, treatment for tennis elbow begins with a thorough evaluation of the problem and a discussion of the patient’s rehabilitation goals. Movements associated with the activities that cause tennis elbow pain must be identified and analyzed. If the patient began having tennis elbow pain after playing tennis on rainy days, perhaps he or she needs only a short course of treatment and to stop hitting wet, heavy tennis balls. In other cases, we may find that improper use or involvement of the neck, shoulder, or wrist during sports or other activities has caused excessive loading of the elbow. In these cases, therapy includes instruction and retraining to balance the physical forces required for the chosen activity correctly.

However, regardless of the other required elements of effective treatment, rehabilitation of tennis elbow will include progressive, eccentric muscle training. Eccentric muscle rehabilitation involves using wrist motion to lower a weight over the edge of a table while the forearm is supported. The patient uses his or her forearm muscles to raise the weight and then lower the weight in a controlled manner. The greatest eccentric muscle force occurs when the patient changes the weight’s direction of motion from downward to upward. Therefore, the amount of weight and the speed at which the weight is moved downward and upward can be varied to increase or decrease the intensity of training. As training progresses, the amount of weight and the speed of weighted movements are both increased. Effective eccentric muscle rehabilitation can also be accomplished using elastic resistance bands.

When going over the instructions for eccentric muscle training, patients might be surprised to hear that their tennis elbow pain should increase towards the end of each exercise session. This is a case where “no pain, no gain” applies. Insufficient loading of the tendon (inadequate intensity) or loading along the wrong axis, will delay recovery.

Progressive, eccentric muscle training is the only type of exercise known to increase muscle elasticity and tendon strength and is the process by which disorganized connective tissues associated with tennis elbow pain are remodeled to become functional once again. In the treatment of tennis elbow, progressive eccentric muscle training as prescribed by a qualified physical therapist is a reliable and effective means of achieving specific recovery goals. The precise method, intensity, frequency, and duration of eccentric muscle training must match the recovery goals of each patient, allowing the tennis player to return to playing tennis and getting the carpenter back to work swinging a hammer without pain.

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.