Thursday, April 2, 2015

Jumpers Knee/Tendonitis

So, I spent the weekend before last watching March Madness. By “spent the weekend watching” I mean that it was on at my cousin’s house while I was there doing laundry for 2hrs, but thankfully it was enough to inspire this week’s blog. Duke was playing San Diego State and there was a lot of sprinting, cutting, and jumping happening. Obviously my chiropractic brain started thinking about knee injuries. It actually made me think of one injury in particular given the season we’re entering into. According to the calendar at least, Spring is here and I’m seeing more and more runners logging their miles through the streets of Boston now that the Earth has started to thaw (fingers crossed). The overuse knee injury that plagues runners and jumpers most commonly this time of year is Patellar Tendonitis, or Jumper’s knee. It sneaks up on you, and can be surprisingly painful, so let’s take a second to talk about the injury and some ways to treat it.

A lot of people who show up to the office with knee pain caused by this injury are just confused. They haven’t tripped, they didn’t run into anything, and they can’t really pinpoint when the pain started. All they know is that their knee has been bothering them during their last few runs or pick-up basketball games. The hardest thing for people to wrap their minds around is that the pain associated with this injury is caused by a combination of cranky muscles and tendons, and not some major tear or fracture. Patients suffering from this injury present with stories so similar to one another that sometimes it feels like déjà vu. They sit on my exam table, point to the front of their knee right under the knee cap, and tell me they haven’t “done” anything but it sure does hurt when they exercise. When I ask how it feels to go up and down stairs they look at me like “How did you know?!” While I wish it was because I am brilliant and can also read minds, the truth is that the nature of this injury dictates what activities are painful, and stairs are almost always one of them.

When we’re talking about the knee, there are a couple of muscle groups to consider. Some of the muscles of the thigh/quad attach from the pelvis to the femur/thigh bone, and others attach from the femur/thigh bone to the shin bone. It is these muscles, the ones that cross over the knee on their way to the shin, that create movement at the knee joint. When the muscles of the quad contract, they extend the lower leg out straight. The opposite happens when the muscles of the hamstring contract. This brings your heel towards your buns.  For now, let’s focus on the muscles in the quad.

The main muscles of the quad are the rectus femoris and the vastus lateralis, medialis, and intermedius. They are all responsible for extending the knee and all play an important role in walking, jumping, running, and squatting as a result. The rectus femoris is particularly important because it attaches up into the hip and is important in swinging the leg forward while walking/running. It also travels down to the knee where it surrounds the kneecap before it turns into the patellar tendon and attaches to the shin bone. You can imagine how a muscle that crosses not one but TWO major joints is probably both very important and also under a lot of stress. This is especially true when it comes to the point at which the muscle attaches to the shin bone below the knee. Any overuse of the muscles (think runners with constant knee flexion and extension through their stride, basketball players jumping AND running, etc) can irritate that attachment point and cause tiny tears, inflammation, and weakness in the tendon, resulting in knee pain. Any imbalance of the muscles of the quads (or even the hamstrings/gluts for that matter) that affects how they work can make things even worse. The muscles start contracting in ways they aren’t meant to, and your body reacts with irritation and discomfort in that patellar tendon right below the kneecap. Eventually, the biomechanics of your knee are just “off” enough to cause that cranky, nagging  pain that you’re feeling.

So, how do we diagnose Patellar Tendonitis? Well, we rule out the bigger/badder stuff first. We use orthopedic tests to figure out if anything else can be causing your pain. Sometimes we take X-rays to make sure the bones aren’t involved. The rest of our diagnosis comes from testing the muscles for imbalances, assessing the joints of the knee for motion or lack thereof, and figuring out where the tenderness/pain is coming from.

Now the important part: How do we fix it?

Rest: There isn’t an athlete on the planet that likes to be told to rest, but sometimes it’s necessary to let things heal. Now, 2 weeks of rest won’t fix the cause of the injury, but it will help with the pain and inflammation.

Foam Rolling: I’m sure that you’ve seen someone at your gym rolling around on one of these over-sized pool noodles. They’re great for working through muscles that are so tight that stretching just isn’t going to cut it. If you’re tight enough it might feel like torture, but it works to loosen up both the muscle and the covering of the muscle that tends to develop adhesions and scar tissue over time. This allows the muscle to work more appropriately and takes stress off of that cranky insertion point we’ve been talking about. To use it, put it on the floor and lower yourself onto the roller so that your upper body is supported by your forearms in a plank position, and your lower body is supported by the roller under your quads (perpendicular to your body) with your feet off the ground. This probably WON’T feel good. I’m sorry! The goal is for you to roll up and down your quads 15-20times in this position. If it’s too much pressure, feel free to put one foot on the ground while you roll out the other leg to take some of the pressure away.

Graston: If this isn’t the first blog of mine that you’ve read, you’ve probably heard me talk about Graston. It’s that soft tissue technique that looks like a medieval torture technique but is actually AWESOME for soft tissue injuries. Your chiropractor can use it to break up adhesions in the covering of the quad muscles or around the tendon just under the knee cap. It hurts, but it’s a really effective way to get the muscles contracting the right way, taking pressure off stressed out joints.  

Muscle imbalances: Because there aren’t too many ways to tackle this one yourself, you may want to consult with your chiropractor. You may have thought that your chiro was just there to address your low back and neck pain, but we can do knees and extremities too! We are able to figure out which quad muscles are doing what, and target them accordingly. I’d love to tell you there’s a magic formula for everyone’s Jumper’s knee, but I’d be lying to you. Sometimes we need to put you through different squatting routines, practice proper sit-to-stand technique, or add some strengthening/stretches exercises to your gym routine. Proper function and biomechanics can make all the difference in this kind of injury.

Adjustments: Sometimes the way the joints of the knee are moving , or not, is the cause of the problem. If joints aren’t moving or gliding the way they should be, the muscle attachments in that area can get stressed, begin to work improperly, and create pain where that muscle inserts. In this case, irritated quad muscles due to restricted knee joints can result in inflammation just below the kneecap. The same is actually true for the low back and pelvis as well. If joints aren’t moving properly in these areas, the muscles that connect these areas into the legs get tight and irritated. If these muscles go to the knee, you might have yourself some knee pain. Ask your chiropractor to evaluate your spine and knees for good motion in the joints, and address them with adjustments if necessary .

The moral of the story is that knees are sensitive, and even if you haven’t sustained a major injury there are plenty of soft tissues and joints that can cause more pain than you’d expect. Take time to figure out where your pain is coming from, and get it treated before the real Spring season arrives. Stay healthy and injury free, and good luck with your March Madness brackets!!