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Learn more about Rehab, Sports Medicine & Performance

Knee

Training to develop lower extremity power is important for staying safe on the playing field and functional in everyday life. More important is the ability to efficiently and properly absorb force during a landing. Box jumps are a basic power exercise that will improve these skills. If you are a snow skier, volleyball player, or runner then box jumps should be in your fitness program.

Competition vs. Athletic Enhancement

Box jumps have become popular in fitness competitions. The goal during these games is to get a number of jumps finished in a prescribed period of time. During these events the box jump is the field of play and not a training tool. Athletes who wish to improve performance and reduce the chance of an injury perform box jumps to retrain the neural system and enhance mechanics. Training for a box jump competition and training to improve performance are very different.

Box Jump Prerequisites

You should score a 2 or better on the straight leg raise, squat, and in-line lunge portion of the functional movement screen before you perform box jumps. See one of our trainers if you have not had a movement screen assessment. You should be able to perform a solid stable landing on a “step and catch” off a twelve inch box.

Box Jumps

Box jumps are performed on a plyometric box. At FFAC, we use the Plyosafe boxes made by UCS. These twelve, eighteen, and twenty four inch boxes are made of layered foam padding to absorb much of the force when landing a box jump.

  1. Start in front of a twelve inch box. Your toes should be about six inches from the side of the box with the feet shoulder width.Box_Jumps
  2. Hip hinge–bending a little at the ankle and knees and more at the hips. Do not permit the knees to crash inward. Use the arms to aggressively drive the jump. Throw the arms up as you drive off the floor with the hips.
  3. Do not look down. Keep the eyes up and think about jumping up and extending the legs out long. Do not pull the knees up and turn the jump into a hip flexion exercise. You want to displace the hips vertically and not flex the hips forward in an effort to reach the top of the box. You should never land on the top of the box in the “cannonball dive” position.
  4. Your take off position should be the same as your landing position.   “Stick the landing” by staying stationary for two counts.
  5. Land soft with minimal noise created when you impact on the top. Good plyometrics are seen and not heard.
  6. Use a mirror to assess your landing position. The knees should line up with the feet and never buckle inward. Keep your torso tall and eyes up. Make an effort to get rid of any wobble in your landing.
  7. Step down (do not jump down), reload your stance, and repeat. We want to avoid the eccentric stress and impact of jumping down and remove any influence of the stretch-shortening cycle.

Perform three to five box jumps and then take a short rest to let your neural system recharge. Three sets of three to five repetitions is a good start. Box jumps stress your nervous system so stay with a low volume of high quality box jumps. As you become more proficient, work on using a higher box (most of us will never need a 30 inch box). Avoid the high box jumps you see on the internet that are mostly a measure of hip mobility and sponsored by the local spinal surgery center. Holding a kettlebell, weight plate, or wearing a weight vest and performing a box jump offers little reward and carries lots of unnecessary risk.

We all have limited time to train so choosing the proper training activities is important. The combination of box jumps and some properly performed kettlebell swings will go a long way to prevent injuries, improve strength, and enhance vertical leap.

For video demonstration of the box jump, click on the link below:

-Michael O’Hara, P.T., OCS, CSCS

“Hamstrings” is the name given to the series of muscles on the back of the thigh that connect the pelvis to the lower bone of the knee. The hamstrings cross two joints, and like all bi-articular muscles, they are more prone to injury and create more difficulties when they become weak. Properly functioning hamstrings work at the knee like the reins on a horse. They tell the knee to slow down, speed up, turn in, and turn out. Lack of hamstring control at the knee makes you more susceptible to injury and pain problems.   At the pelvis, they work in concert with the gluteal muscles to produce hip extension and control the position of the pelvis. As anyone who has had a hamstring tendonitis will tell you, running, jumping, climbing stairs, and getting up off the floor suddenly becomes very painful.

Your friendly neighborhood gym has an answer in the form of a leg curl machine. Leg curl machines are designed to strengthen the hamstrings by bending the knee against a plate loaded resistance. While leg curl machines will make your hamstrings bigger, they produce little carry over to better functional performance. Leg curl machines do not train the hip extension component of hamstring function, and they completely separate the hamstrings from their functional teammates the gluteal muscles.

The saying in neurology is “What fires together, wires together.” Every time you perform an exercise, you neurologically reinforce the movement pattern of that exercise. It is like hitting “save” on your computer. If you reinforce faulty movement patterns with enough frequency and intensity, the pattern becomes your method of moving during stressful situations. Seated and prone leg curl machines reinforce a faulty motor pattern that will not save you from a fall, improve your performance on the field of play, or make you more durable.

Roller Leg Curl

With the Sorinex Roller Leg Curl, you can train the hamstrings to work at both the knee and the pelvis at the same time.   As in all aspects of locomotion, the gluteals and hamstrings fire together. Just like when you run or sprint, a strong core stability demand is necessary. If you get strong enough to perform the single leg version, a challenge of rotational control at the pelvis is created.

In the supine position, with the knees extended, place a Sorinex Roller underneath both feet. Contract the gluteal muscles and lift the hips off the floor. Tighten up the hamstring muscles and pull the sliders up toward the hips. Slide back out to full knee extension but keep the hips up off the floor. Keep the ankles pulled up into dorsiflexion throughout the exercise. Perform two sets of five to ten repetitions. As your strength improves, you can add resistance in the form of a band attached to the roller or a sandbag on the hips. The ultimate goal is to progress to single leg training. We travel through life one leg at a time.

To view video demonstration of the Roller Leg Curl, click on the link below:

-Michael O’Hara, P.T., OCS, CSCS

We all need basic competence in fundamental movement patterns to function at an optimal level. A deep and stable squat keeps us free from injury and competent on the field of play. In physical therapy, we evaluate performance of the squat pattern with nearly every patient. One of the most common and damaging squat faults is an inward deviation of the knee during the squat.

Genu valgus is the term given to the inward deviation of the knee during a squat. Female athletes often land from a jump in a valgus knee position. Lower back pain patients are often unable to transfer out of a chair or ascend a step without significant inward deviation of the knee. This movement fault is not a healthy method of moving and should be trained away as quickly as possible. One of the simplest exercises to remedy genu valgus is the mini band squat.

Prepare to be frustrated when attempting to restore a movement pattern. Training movement demands higher neurological control than muscle isolation type training. Anyone can quickly master the preacher bench curl or seated knee extension, but restoring a squat pattern is hard work. Repetition drives the neural retraining that produces results.

MINI BAND SQUAT

You will need a mini resistance band. You can purchase them from www.performbetter.com ($2-$3 each).   Place the band just above your knees.   Position the feet shoulder width apart. The toes can point out about 20-30 degrees. Grip the floor with the feet—push the toes into the floor. Reach the arms forward and push the hips back. Descend into a squat and at the same time drive your knee outward into the resistance of the mini band. Hold the bottom position for five seconds and then return to the starting position. You should feel the gluteal muscles working while in the bottom part of the squat.

Pick an easy resistance level. Do not start with a heavy blue or black band. Only travel to a squat depth you can move through and remain comfortable and pain-free. You do not have to squat to the floor. As your motor control improves, you will be able to travel into a fuller movement pattern.

Perform five repetitions and then rest. Work up to four sets of five repetitions.

-Mike O’Hara, P.T., OCS, CSCS

To view a video demonstration of Mini Band Squats, click on the link below:

 

The knee meniscus is a cartilage structure located on the top of the tibia, the bottom bone of the knee. Most of us are unaware of our meniscus until it becomes damaged. At present, we can only repair or remove a meniscus, leaving a less than optimal operational environment for the knee joint. Melinda Beck wrote an interesting article in the May 4, 2015 edition of The Wall Street Journal on breakthroughs with meniscus replacements. The research looks promising, and hopefully, it will soon be available to the aging baby boomer population. In the meantime, what steps can we take to keep our knees healthy and pain-free.

Maintain a normal body weight

Larger loads on your legs produce more wear and tear forces on your joints.

Think first

This becomes more important as you get older. A single ill-conceived activity can produce a lifetime of knee trouble. That box jump workout of the day? Maybe not. Spartan, warrior, electric shock, mud hole, death run? Bad idea. Trampoline with the grandchildren? What were you thinking? We hear this in the clinic every day.

Reduce the number of lower extremity impact events in your fitness program

The current trend in fitness is toward a greater number of high speed deceleration events in a training session. This increases the opportunity for break down in the joint and a visit to the orthopedic surgeons office. My suggestion is that we devise training programs that produce a strong metabolic and/or strengthening response while managing impact.

Get stronger in lunges, squats, step ups, and hip hinge exercises

Your knee functions with the foot on the ground, in the standing position. The knee joint operates in coordination with the joints above and below the knee. The neurological component of balance and proprioception is involved in every knee activity. Training in a seated, non-weight bearing position with no coordination or balance demands is a waste of valuable training time and often makes knee pain problems worse. Get better at movement patterns that teach the joints and muscles of the lower extremity to work as a team.

Don’t ignore pain

The majority of our brain is devoted to managing movement. The presence of pain neurologically changes brain signals and alters how we move. Left untreated it can permanently alter neurological control, creating aberrant movement patterns that linger long after the pain has resolved. Perform enough cycles of inefficient movement and you develop early breakdown of essential joint structures. “Training through the pain” can take a graceful athlete and turn him or her into a lifelong speed limper.

Get a Functional Movement Screen (FMS)

To make the fitness journey as efficient and productive as possible, you must begin with an evaluation. I advise everyone have a FMS evaluation every six months. It is the fitness equivalent of taking your blood pressure during your annual physical. Find out where you excel and where you struggle in basic movement patterns. Let the FMS help guide your fitness decisions and your road will be smoother and more direct.

To read the article “New Fixes for Worn Knees,” click on the link below:

http://www.wsj.com/articles/new-fixes-for-worn-knees-1430761617

-Michael O’Hara, P.T., OCS, CSCS

Last summer, Marty started having pain in the front of his right knee.  Initially, he only had pain at the end of a work day, or whenever he had to perform more stair climbing.  Rest resolved the pain, but over time, it took less activity to recreate the symptoms.  Marty had an x-ray that showed arthritis in his knee and significant thinning of the joint cartilage.   After evaluation by an orthopedic surgeon, Marty had visco-supplementation injections.  The injections did not produce any improvement in his knee pain, and in August, Marty was referred for physical therapy by his family physician.

The most significant finding during Marty’s evaluation was a deficit in his knee flexion range of motion.  In prone lying, he could bend his left knee 125 degrees, but his right knee only bent 90 degrees.  Passive right knee flexion past 90 degrees recreated the pain in the front of his knee.  The right knee would bend fully in supine and seated and was pain-free.  Palpation revealed sensitive trigger points in a muscle called the rectus femoris.

rectus_femoris_trigger_pointsThe rectus femoris is one of four muscles that make up the quadriceps (big front thigh muscle).  The rectus femoris muscle is unique in that it crosses both the hip and the knee joint.  In order to fully mobilize this muscle, you must extend the hip and flex the knee at the same time.  Most of us never perform a full range stretch of this muscle.  Trauma to the front of the thigh can cause myofascial adhesions to develop in the rectus femoris muscle.   Overuse is not uncommon in soccer players, bicycle riders, and runners.  Rectus femoris muscle trigger points refer pain across the front of the knee and thigh.

Rectus femoris strain is a fairly common sports injury.  Last summer, we treated a soccer player who tore her rectus femoris completely off the hip origin and had to have surgical repair.  Sitting places the rectus femoris in a shortened position, and given enough time, the muscle will adaptively shorten.  Exercise machines such as stair steppers, ellipticals, and stationary bikes are devoid of the movement pattern that elongates the rectus femoris muscle.  You need hip extension combined with knee flexion to move the rectus femoris through a complete stretch.

Marty was started on a physical therapy treatment program of soft tissue mobilization and daily low-level stretching of the rectus femoris.  After three sessions, Marty reported his pain was no longer present with walking and he felt 50% better.  Prone knee flexion was full range in three weeks, and he was able to graduate to standing rectus femoris mobility exercise—see video.  Marty was pain-free in four weeks and graduated physical therapy with a foam roll for self myofascial release and a daily home program of exercise.

If you sit for extended periods of time and have developed pain in the front of the knee, give the prone knee flexion exercise a try and see if your pain decreases.  Stay with the prone stretch for a few weeks and then try the standing rectus femoris stretch.  It is surprising how often this simple exercise resolves the pain.  More stubborn cases can be resolved with some hands on myofascial treatment.

To view video demonstration of the rectus femoris mobility exercise, click on the link below:

https://www.youtube.com/watch?v=boMqX3x6xU0&feature=youtu.be

-Michael O’Hara, P.T., OCS, CSCS

“You can observe a lot by watching.” 

-Yogi Berra

Chris logged 25 to 30 miles a week running on the roads.  He had completed well over forty marathon races and could be found nearly every weekend at a 10 kilometer run.  In March, he started having lower back and then right knee pain during his runs.  He moved off the road and started using a treadmill, but the pain persisted.  He tried switching between biking and running, but the pain did not go away.  After three months of self-treatment, he was referred for physical therapy by his family physician.shutterstock_109581608

The only time Chris had the pain was when he was running.  Symptoms began after approximately ten minutes of running and were particularly painful whenever he had to run downhill.  During his musculoskeletal evaluation, we could not recreate Chris’s pain.   He demonstrated good range of motion, normal strength levels, and he had no neural tension problems.  We put Chris of the treadmill, and after five minutes of running, his problem became obvious.  With every right foot strike the knee collapsed inward, the hip joint fell into extreme internal rotation, and the pelvis dropped.  Chris could not feel his running gait deteriorate, but the changes were glaring.  Ten minutes of running on the treadmill in front of the mirror, and he was convinced.  We both knew what had to be fixed.

All parameters of fitness must be at optimal levels to run distances and stay injury free.  Managing tens of thousands of repetitions of joint loading on a daily basis can easily create tissue overload and pain symptoms.  The first sign that a runner is heading toward a pain problem is when his or her running gait starts to deteriorate.  Forty thousand strides a week with excessive internal rotation and not enough hip extension will eventually take a toll.  The good news is that nearly all gait changes are detectable by simply watching how you run on the treadmill.

You do not need a computer with infrared sensors or force plates in your shoes.  You just need a big mirror.  Position the treadmill facing a mirror.  You need to be able to see your feet hit the treadmill when you run.  Start up the treadmill and work up to your training tempo. Keep your eyes open and look for these problems.  Be patient as many of the worst problems only show up after muscles start to fatigue.

Valgus Knee

If after foot strike the knee rolls inward during the stance phase, you have a problem.  For many runners this deficit can be extreme.  Distance running with valgus knees earns you the early knee replacement medal.

Vertical Displacement

Efficient runners are smooth runners.  The more you move up and down the more shock you must attenuate when you land.  Runners with poor strength and endurance often start out smooth and finish bouncy.

Unequal Stride Length

As fatigue sets in, one leg moves well and the other starts to exhibit a stride restriction.  It is not uncommon to witness a 20% decrease in stride length.  Stride asymmetry causes all sorts of tissue tension problems in the lumbar spine and pelvic girdle.

Tilt

This covers all of the head and torso positional changes:  The head leans to one side, shoulder rotation is full on one side and absent on the other, one side of the pelvis is up and the other down.  Watch the finish of any 10 kilometer run.  Nearly everyone has some tilt.

Most recreational runners do not like to pay attention to any aspect of their training.  Their time on the road is a form of mental relaxation or mediation.  Many people who run for exercise actually hate running, and they watch television while on the treadmill to counteract the boredom.  My suggestion is to spend some portion of your training evaluating how well you are moving.  Stop swearing at Chris Matthews and Bill O’Riley while you run and do something that will actually help improve your performance.  Be more mindful of your gait and make corrections before the pain starts.

Chris was able to return to running after three weeks of manual therapy and corrective exercise.  He has set up a mirror in front of his home treadmill and reports the results have been revealing.

-Michael O’Hara, P.T., OCS, CSCS

Whenever we crawl, get up off the floor, walk, run, or sprint we use our legs in a reciprocal pattern:  One hip comes forward and the other hip backward.  We work on this pattern from the moment we are placed in the crib.  The control of reciprocal hip movement is a skill we must all master in order to successfully carry our body through space.  Unfortunately, age, inactivity, poor training choices, and injury can rob us of this basic movement skill.  The good news is that with some dedicated half-kneeling training you can improve the reciprocal hip pattern.

What is the half-kneeling position?Half_Kneeling

Sister Agnet taught me how to genuflect in first grade:  One leg forward, one leg back.  Get that back knee down to the ground with the eyes up and the torso tall.  I could tell that practice made perfect as Sister Agnet had to be at least 100 years old and could perform a flawless, split stance squat on either leg.  She had a rapid walk and a tall posture that made her look as though she could easily run you down on the playground.

The half-kneeling position is the bottom of the genuflexion.  The tibia (shin bone) of the front leg and the femur (thigh bone) of the back leg are held perpendicular to the floor.  Keep the torso tall and the head pulled back and up.

Why you need half-kneeling exercise?

Exercising from the half-kneeling position has multiple benefits. Not only do you need the split stance position to get up and down off the floor, but it will also improve your posture when you walk or run.  Becoming stronger in the half-kneeling position makes you a more efficient athlete and improves balance.   It also creates a buffer zone of functional mobility and strength that makes you less likely to suffer an injury.  Half-kneeling is the antidote for the physical damage produced by prolonged sitting.

Easy Half-Kneeling Progressions

There are many half-kneeling exercises you can perform.  Three of the most basic progressions are listed below.  Start slow with these drills and do not hesitate to add resistance and repetitions.

Sustained Half-Kneeling

Many fitness clients are unable to get into the half-kneeling position.  These are often the same clients who present with postural deficits and gait asymmetries (good stride and balance on one leg and not so good on the other).  The goal for these patients is to simply get into and sustain the half-kneeling position for thirty seconds on each side.  Make this exercise more challenging by holding a medicine ball at chest level for thirty seconds.

Half-Kneeling Rotation Stability

Once you can sustain a half-kneeling position, try adding on some rotational stability training with a resistance band or cable unit.  You will need an Airex pad or exercise mat under the knee.  Set up in the half-kneeling position with the right knee resting on an Airex pad and the left foot in line with the left hip.  Align the body so the resistance tubing, or cable column, is set up on the right side at waist level (standing).  Stay tall through the torso and pull the tubing or cable to the chest.  Do not allow your body to move as you push the arms out and back.  Keep the abdominal and gluteal muscles braced so the pelvis does not move.  Perform ten repetitions on each side.

Half-Kneeling Single Arm Rows

Set up in the half-kneeling position with the right knee resting on an Airex pad and the left foot in line with the left hip.  Align the body so the resistance tubing, or cable column, is in front of the body at shoulder level.  Place the handle in the right hand (same side as the down knee).  Stay tall through the torso and pull the tubing or cable so the right thumb moves toward the right armpit.  Keep the abdominal and gluteal muscles braced to keep the torso tall and prevent the legs from moving.  Hold for two counts and then return to the starting position.  Perform ten repetitions on each side.

You can purchase an all-purpose band ($25.00) from performbetter.com.   They have two handles and attach easily in any door.  Most people can start with the pink or orange bands.

To view video demonstrations for the above half-kneeling exercises, click on the link below:

https://www.youtube.com/watch?v=77p3tUyC9Ag&list=UUje3hqQBygH_JOPhWLQjtVw

-Mike O’Hara, P.T., OCS, CSCS

David Epstein is my favorite Sports Illustrated writer.  Last year he published his first book, The Sports Gene.  I highly recommend it to anyone who works with athletes on a regular basis.

Mr. Epstein has traveled the world and has consulted with hundreds of scientists, coaches, and experts on the training environment that produces optimal results.  If you are the parent of a youth athlete, I urge you to take a look at the June 10, 2014 article he wrote in the New York Times.  I can personally vouch for the injury information in this article.

To read the article, click on the link below:

 http://www.nytimes.com/2014/06/11/opinion/sports-should-be-childs-play.html?_r=1

ACTIVITY GOAL:
Enhance single leg power production and prevent injury

OBJECTIVE:
Build explosive single leg power in your hips and legs
Improve coordination and core stability

STARTING POSITION:
Start in a half kneeling position, making sure the knee of your front leg is behind your toes.
Rest your arms at your sides.

PROCEDURE:
From the ½ kneeling position, drive through the front foot’s heal and explode into the air. Once in the air, quickly switch your legs so that you land with the opposite foot forward. Land in the same ½ kneeling position with the back knee stopping 1-2” above the ground.

COMMON MISTAKES:
Not landing deep enough
Not spreading the feet far enough apart
Not jumping high enough

-Jeff Tirrell, B.S., CSCS

Box Squats

ACTIVITY GOAL:
Improve squatting mechanics, alleviate stress from knees, and build hamstring and gluteal strength/control.

OBJECTIVE:
Strengthen gluteal muscles, hamstrings, and core musculature.  Improve gluteal and hamstring activation during the squat.  Decrease knee discomfort compared to traditional squats.

STARTING POSITION:Snapshot 1 (6-13-2014 1-04 PM)
Start by standing approximately 4-6 inches in front of a box.  Feet should be slightly wider than shoulder width apart.  The toes should be straight ahead or angled slightly outward.  If using weight, a barbell can be held in the front “rack” position, placed behind the neck, or you can hold a Kettle Bell in the Goblet position.  If using a barbell on your back your shoulder blades should be pinched together.

PROCEDURE:
Start by pushing the hips back.  The knees will naturally start to bend, continue to push your hips back as you sit onto the box.  You should move slowly and with control during the eccentric (descent) portion of the exercise.  Once your butt touches the box you need to briefly relax your legs.  However, you must keep bracing your core, and keep your upper back tight if applicable.  Once your legs have been completely relaxed you need to re-engage your glutes and hamstrings by pressing your heels into the ground and “spreading” the floor.  Do not rock backward or forward in order to generate momentum to get up.  Stand up at a normal speed.

COMMON MISTAKES:
Using a box that is too short so that you can’t control the eccentric portion due to weakness in the glutes or hamstrings. This causes you to fall/plop onto the box.  Allowing the knees to bend first and not pushing the hips back far enough.  Rocking on the box once you are seated in order to generate momentum to help yourself up.

Jeff Tirrell, B.S., CSCS

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