E3 Rehab https://e3rehab.com/ Fri, 18 Apr 2025 18:39:03 +0000 en-US hourly 1 https://wordpress.org/?v=6.8.1 https://i0.wp.com/e3rehab.com/wp-content/uploads/2023/01/cropped-E3Rehab_Icon_RGB_Red.png?fit=32%2C32&ssl=1 E3 Rehab https://e3rehab.com/ 32 32 215494644 The Truth About Knee Valgus https://e3rehab.com/the-truth-about-knee-valgus/ https://e3rehab.com/the-truth-about-knee-valgus/#respond Sun, 20 Apr 2025 13:16:00 +0000 https://e3rehab.com/?p=24794 In this blog, I’m going to teach you everything you need to know about knee valgus! What Is Knee Valgus? Technically, knee valgus refers to abduction of the tibia relative to the femur.  I know this is confusing already, so let me explain by starting with the hip.  Imagine a skeleton in standing and drawing […]

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In this blog, I’m going to teach you everything you need to know about knee valgus!

What Is Knee Valgus?

Technically, knee valgus refers to abduction of the tibia relative to the femur. 

I know this is confusing already, so let me explain by starting with the hip. 

Imagine a skeleton in standing and drawing a line from the center of the pelvis, straight down to the floor. From here, the hip can abduct in one of two ways:

  1. In a non weight bearing position, the distal aspect of the femur can move away from the midline of the pelvis. You can think of a little alien or UFO abducting the distal end of the femur. This is what we call standing hip abduction and it is performed by muscles like the gluteus medius and gluteus minimus. 
  2. In a weight bearing position, the pelvis can laterally tilt in such a way that the centerline that we created moves further away from the distal aspect of the femur. This would be like standing on one leg and contracting the glutes on that leg in such a way that you start leaning toward that side. 

In both hip abduction scenarios, the distal aspect of the femur is moving further away from the midline of the pelvis. If the two move closer together, that’s known as hip adduction. If it’s helpful for you, you can also think about the angle between them getting bigger or smaller. In either case, we are describing the movement of one bone, the femur, relative to another bone, the pelvis. 

So let’s go back to the knee. As I initially said, knee valgus refers to abduction of the tibia relative to the femur. However, if it’s easier for you, you can still think about the distal aspect of the tibia moving away from the midline of the body. 

Most people have about 5-10 degrees of knee valgus in standing. This is known as genu valgum. For individuals with more than 5-10 degrees, you might hear the term excessive genu valgum, or “knock knees.”

When most people discuss knee valgus, they are describing what they observe during a movement.

We don’t have muscles that abduct the knee in the same way that muscles abduct the hip, so knee valgus is a byproduct of what’s happening elsewhere. This dynamic knee valgus, as it’s typically called, can be seen during a bilateral squat when the hips adduct and internally rotate, the feet pronate, and, as a result, the knees move toward the midline of the body.

Types of Knee Valgus

Not all knee valgus is created equally, though, especially as it relates to injury. Factors that need to be considered are:

  • The speed at which it occurs.
  • The forces or loads certain knee structures must tolerate. 
  • The knee flexion range of motion at which it happens. 
  • Whether the movement is double leg or single leg.
  • Whether the movement is planned, predicted, or reactionary.

Discussions about knee valgus usually revolve around squats, sports, and running, and these are the topics I will cover in the rest of this blog. Based on the factors I just mentioned, it is reasonable for you to assume that the most significant injuries associated with knee valgus involve athletes participating in sports like basketball, soccer, and football. 

For now, let’s start with the causes of knee valgus while squatting on two legs.

What Causes Knee Valgus While Squatting?

Keep in mind that the reason for knee valgus in an untrained lifter is likely going to differ from that of a competitive powerlifter or weightlifter, and I’ll discuss the practical implications of that difference. 

Starting with the feet, pronation is a natural motion that is required during a squat, but an “excessive” or “uncontrolled” amount is commonly cited as a cause of knee valgus. A systematic review and meta-analysis by Lima et al did find that “ankle dorsiflexion is correlated with knee valgus.” Based on these findings, it’s often inferred that a lack of ankle dorsiflexion encourages someone to use more of their pronation range of motion in order to squat to a sufficient depth, which in turn leads to knee valgus.

While it’s certainly more of a possibility in the untrained lifter, I’ll explain why it’s not a cause for concern shortly. 

The most popular theory as to why knee valgus occurs during a squat is weakness of the glutes, particularly as it relates to hip abduction and external rotation. I don’t think this is the case, at least for a double leg squat. 

A study by Bell et al discovered that individuals who demonstrated knee valgus during an overhead squat actually had greater hip strength. Perhaps more surprisingly, a systematic review investigating the association between hip muscle strength and knee valgus found inconsistent results – some people were stronger, some people weaker, and some people had no differences.

I say “perhaps more surprisingly” because these studies examined single leg squats, single leg step downs, and forward lunges – movements expected to have an association since they are more reliant on the hip abductors than bilateral squats.

A recent study by Loren Chiu compared squats with the “knees out” (hips externally rotated) vs squats with the “knees in” (hips internally rotated). The researcher found that squats with the “knees in” required participants to use more of their hip external rotation strength. For this reason, he suggests that internal rotation of the hips may simply be a strategy to preferentially load the gluteus maximus. 

This aligns with another theory, and one that Chiu also proposes, which is that the adductor magnus contributes to knee valgus. Findings from Kubo et al and Vigotsky and Bryanton demonstrate that the adductor magnus is a primary hip extensor, especially at deeper ranges of motion. Therefore, the gluteus maximus and adductor magnus work together at the hip by using whatever strategy allows for the greatest strength output. In some individuals, this presents as knee valgus. 

This makes more sense when we consider when knee valgus happens in highly trained lifters. It is rare to see knee valgus during low effort squats. Instead, it occurs when these athletes start approaching their 1 repetition maximum.

As the load increases in a squat, the amount of “hip dominance” increases. This is shown in the research, but this is also something that can often be seen visually during high effort attempts. As the knees cave in, the hips shoot back as a way of shifting more of the load to the hips during the sticking point.

For the untrained lifter, knee valgus during squats is frequently more of a motor control or skill issue from a lack of practice and understanding of the movement, whereas with the trained lifter, it’s simply a strategy to move the most amount of weight. 

Before discussing common strategies for fixing knee valgus while squatting, I want to answer the question…

Is Knee Valgus While Squatting Harmful?

To best answer this question, traumatic and non-traumatic injuries must be considered. 

When most people think about traumatic injuries associated with knee valgus, ACL tears usually come to mind. However, under normal circumstances, the ACL is not at risk of rupturing during squats. As the knee reaches greater angles of knee flexion, such as when knee valgus occurs, the strain on the ACL is minimal or virtually nonexistent. 

As I’ll discuss in the sports section, ACL tears occur at shallow knee flexion angles when the strain on the ACL is highest. Plus, compared to sporting tasks like landing, cutting, or pivoting on one leg, squatting involves a much slower rate of loading, the load is distributed between both legs, and it’s performed in a controlled environment. The same recipe for disaster doesn’t exist. This rationale applies to the Medial Collateral Ligament (MCL) as well. 

Now if someone completely folds under the barbell and their knees give out, that’s a different story and it’s not really applicable to the discussion at hand. 

Can knee valgus contribute to gradual, overuse-type injuries? Maybe.

Squats load a variety of tissues and how you squat can determine how that load is distributed across those tissues. 

For example, an upright, heels elevated barbell front squat is going to be more demanding on the knees, whereas a trunk forward, low bar back squat is going to be more demanding on the hips and low back (assuming all else is equal).

Neither is good or bad. What matters is whether or not you’re able to tolerate those specific stressors in the moment and also over time with regard to your ability to appropriately recover and adapt. Additionally, all of this is highly dependent on your programming as it relates to volume, frequency, and intensity. 

Even people with “perfect” technique get injured in the gym and elsewhere because technique is just one piece of a much bigger puzzle. And knee valgus is just one technical variable that may partially shift the distribution of load to different aspects of the hips, knees, and feet at a specific timepoint during squats.

If you challenge your muscles appropriately, they get bigger and stronger. If you don’t, they get smaller and weaker. The same is true for your bones and other tissues in your body. Your tissues either adapt or they don’t. Knee valgus doesn’t somehow make it harder for your tissues to adapt or suddenly negate all of the positive adaptations that come with squats. 

So, is knee valgus while squatting inherently harmful? 

No. It’s a movement pattern that exists that is no more dangerous than a different movement pattern. 

However, that doesn’t necessarily make it ideal at all times for all individuals, so let me explain when it may be appropriate to address and how to best go about changing it.

Fixing Knee Valgus While Squatting

For someone who displays knee valgus during their squats, we have to try to determine if that technique is detrimental or beneficial for performance and accomplishing their goals. 

If a competitive powerlifter or weightlifter consistently displays knee valgus when attempting to hit new personal records, is that something that needs to be changed?

More context might be needed. 

What if this individual has been predictably squatting this way for 10+ years, has had no major injuries associated with their technique, has progressively gotten stronger each year, and has performed well in competitions?

In this example, it’s possible that trying to alter their knee valgus could worsen their performance because it’s a predictable strategy that they use on a regular basis to successfully lift the most amount of weight. 

This is vastly different from a new trainee who looks like a baby giraffe trying to walk for the first time. In this scenario, it’s reasonable to ask:

  • Is this knee valgus intentional or predictable like the competitive athlete?
  • Is it a somewhat controlled motion?
  • Is it going to benefit their performance in the long run?

If the answer is “no” to any of these questions, modifying their technique doesn’t have to be overly complicated. It can be as easy as a two-step process:

  1. Demonstrate the preferred technique, provide some external cues and feedback, and set them up for success. Setting them up for success could mean using the appropriate weight or having them take a slightly wider stance with the feet rotated out as that alone can reduce knee valgus.
  2. Let them practice and learn the movement as you slowly reduce the amount of cues and feedback you provide over time. Technique is not meant to be perfect on the first repetition, day, week, or even month.

What if a person has reduced ankle dorsiflexion like I mentioned before? Four things come to mind:

  1. It might not matter as squat patterns vary significantly between individuals based on their anatomy, preference, etc.
  2. If this person has never squatted before, it’s reasonable to expect their dorsiflexion to improve with repeated exposure to the movement
  3. Use heel lifts, weightlifting shoes, or wedges as needed
  4. Incorporate drills to improve the range of motion if desired

What about the most common recommendation – the use of a band around the knees? 

You can use a band, but it’s not absolutely necessary, especially if the previous steps are followed. Additionally, a narrative review by Forman et al in 2023 found that light bands have no effect on knee valgus and heavy bands actually increase knee valgus.

Once again, you can use a band if that’s what’s been helpful for you or your clients. Please don’t come after me. It’s probably just not the solution for every problem.

Knee Valgus While Playing Sports

With regard to sports, there is no denying that the most common mechanism of injury for an ACL tear is valgus of a slightly bent knee combined with a large force applied quickly in a chaotic and unpredictable environment. 

But the important question to ask is… Can we predict who is going to tear their ACL based on movement screens like the single leg squat and drop vertical jump?

In 2005, a prospective study examining 205 female athletes did find that “Female athletes with increased dynamic valgus and high abduction loads are at increased risk of anterior cruciate ligament injury.”

However, studies done on thousands of athletes since then have found no association between dynamic knee valgus and ACL injury risk (example, example, example). Some of the leading researchers in this area made their findings and stance very clear with the title of their paper in 2023 – “Kiss goodbye to the ‘kissing knees’: no association between frontal plane inward knee motion and risk of future non-contact ACL injury in elite female athletes.”

The same group of researchers published a study titled, “I spy with my little eye … a knee about to go ‘pop’? Can coaches and sports medicine professionals predict who is at greater risk of ACL rupture?”

The answer is no. It doesn’t matter if you’re a coach, physical therapist, athletic trainer, or medical doctor, you cannot predict who is going to go on to tear their ACL. In fact, you’d do just as well by flipping a coin. 

This has nothing to do with the skill or knowledge of the coach or clinician. It has more to do with the fact that injuries are complex and multifactorial, and a simple movement screen evaluating knee valgus cannot account for or predict all the possible variables that contribute to injury.

Even if we could predict injuries with some certainty (which we can’t), some individuals who display knee valgus will never go on to tear their ACL while other individuals with seemingly perfect technique will eventually tear their ACL. 

What’s the solution here?

Well, it’s to provide an injury prevention program to every athlete rather than trying to be selective. These types of programs that include strengthening and plyometric movements work for reducing the incidence of injuries even if the athletes don’t demonstrate a reduction in knee valgus during biomechanical assessments. 

Not all knee valgus is dangerous either. 

We see it in skateboarders who use it to reduce their impact on landing, surfers use it for better control of their board, golfers use it to wind up their shot, and so on. 

Even for athletes who may be putting themselves at greater risk of injury in a competitive setting, taking those risks might be part of what makes them great.

Knee Valgus While Running

As for runners, dynamic knee valgus observed during a lateral step-down test is not correlated with dynamic knee valgus during running. 

A 2019 systematic review examining the biomechanical risk factors associated with running‑related injuries found that “Limited evidence indicated greater peak hip adduction in female runners developing patellofemoral pain and iliotibial band syndrome…” which can be visualized as an increase in knee valgus. 

If someone presents with these running mechanics and reports symptoms, getting a detailed history is key. For example, if the individual mentions doubling their running mileage in the past month in preparation for an upcoming race, having a detailed discussion about load management is likely a better focus of rehab. However, if there have been no changes in their training or other aspects of their life, it may be worth addressing. Fortunately, a systematic review by Neal et al in 2016 found that running retraining and strengthening exercises lead to favorable outcomes, so the plan doesn’t have to be overly complex. 

If you want to learn more about patellofemoral pain, IT band pain, or running-related injuries in general, check out our full-length videos about the topics.

Knee Valgus Summary

Let’s end with a brief summary. 

Technically, knee valgus refers to abduction of the tibia relative to the femur. However, we don’t have muscles that abduct the knee in the same way that muscles abduct the hip, so knee valgus is a byproduct of what’s happening elsewhere. This dynamic knee valgus, as it’s often called, can be seen during a bilateral squat when the hips adduct and internally rotate, and as a result, the knees move toward the midline of the body. 

When knee valgus is observed in highly trained lifters performing heavy squats, it is usually due to the gluteus maximus and adductor magnus working together at the hip to use whatever strategy is optimal to lift the most weight.

When knee valgus is observed in untrained lifters, it’s more of a motor control or skill issue from a lack of practice and understanding of the movement. The solution, as a coach or clinician, is no different than any other exercise – demonstrate the preferred technique and provide external cues and feedback that sets the individual up for success. 

Knee valgus during bilateral squats does not increase the risk of ACL injury and is not inherently more dangerous than other movement patterns. However, technique modifications should be considered if it does not support a person’s long-term performance or goals.

With regard to sports, there is no denying that the most common mechanism of injury for an ACL tear is valgus of a slightly bent knee combined with a large force applied quickly in an unpredictable environment. But, despite popular belief, coaches and clinicians cannot predict who is at greater risk of tearing their ACL through the use of screening tests like the single squat and drop vertical jump. Therefore, every athlete, regardless of whether they display knee valgus or not, should follow an injury prevention program that includes strengthening and plyometric exercises, as these have been shown to reliably reduce injury risk.

Lastly, runners with knee symptoms who demonstrate greater peak hip adduction and have not recently changed their training or lifestyle can successfully rehabilitate their knee through running retraining and strengthening exercises.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before?

Check out our coaching and consultation services!

Want to learn more? Check out some of our other similar blogs:

Posture, Shoulder Impingement, Flat Feet

Thanks for reading. Check out the video and please leave any questions or comments below. 

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]]> https://e3rehab.com/the-truth-about-knee-valgus/feed/ 0 24794 Do You Need To Fix Your Posture? https://e3rehab.com/do-you-need-to-fix-your-posture/ https://e3rehab.com/do-you-need-to-fix-your-posture/#respond Sun, 23 Mar 2025 13:00:00 +0000 https://e3rehab.com/?p=24770 Do you need to fix your posture? I’m not just talking about your posture specifically, but people in general.  Do people experiencing pain need to fix their posture? What if they don’t have pain? To save you time, my answer to these questions is probably not.  I want to be very upfront with you. This […]

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Do you need to fix your posture?

I’m not just talking about your posture specifically, but people in general. 

Do people experiencing pain need to fix their posture?

What if they don’t have pain?

To save you time, my answer to these questions is probably not. 

I want to be very upfront with you. This blog is not going to teach you the best posture exercises or promise a quick fix for any of your ailments. If anything, this blog might frustrate some individuals because I’m going to question many popular beliefs about posture. 

I previously made a video titled, “Stop Trying To Fix Anterior Pelvic Tilt.” Expectedly, it wasn’t a fan favorite. In fact, it’s our least liked video by far. One person commented, “Wow! I can’t believe this video. It is like you are working for the man.”

Trust me, it would be much easier for me to make a video titled, “The 5 Best Exercises For Fixing Your Posture.” It would be better for views, likes, revenue, and praise. But I think this information is far more important.

Research vs Personal Experience

Throughout this blog, I am going to reference some of the previous comments to facilitate discussion. For example, a person wrote – “Anterior pelvic tilt comes with tons of negative downsides that are well documented by decades of research.”

In actuality, the majority of high-quality research (examples below) demonstrates that posture isn’t correlated with pain, function, and prognosis, or long-term outcomes. However, I’ve learned that some people might not care about the research if it doesn’t match their personal beliefs or experiences.

I think part of the problem can be attributed to a breakdown in communication. Believe it or not, people don’t agree on what is “good” or “bad” posture.

Oftentimes, individuals are speaking different languages without even realizing it.

For instance, here’s another comment from the prior video: “No world class athlete has anterior pelvic tilt for a reason.”

I could try to refute this comment by showing images of Simone Biles, Usain Bolt, and Jon Jones, but it might not have the intended effect if our definition or understanding of anterior pelvic tilt differ. The same could be said for a forward head posture (Michael Phelps) or any other common example. 

One criticism of these pictures might be that they’re just cherry-picked snapshots of these athletes. I don’t necessarily disagree because…

Posture Isn’t Static

As one study concluded – “…results of short-term examinations differ considerably from the average values during real-life.” A single snapshot cannot predict how someone moves, functions, or feels. 

This is one of the reasons I don’t put much stock in the before and after photos you see online. They tell me nothing about a person’s symptoms, capabilities, or quality of life. Plus, the “before” postures are often exaggerated and the “after” pictures are typically a conditioned response.

The subject learns to stand up tall, pull their shoulders back, suck their stomach in, and squeeze their glutes when having their posture carefully scrutinized by a clinician or trainer. Or they’re explicitly told to do these things. 

Even examining yourself in the mirror isn’t completely unbiased. We’re often our own harshest critics, especially when we compare ourselves to the unrealistic standards found on social media. Most strangers don’t notice the same imperfections we find in ourselves. 

Unfortunately, many industries prey on the insecurities we have about our appearance to make money, including the health and fitness industries. Problems that don’t exist are created to sell a solution that we don’t actually need. 

Well-intentioned clinicians make mistakes, too. A study by Plummer et al in 2017 found that unblinded clinicians are more likely to label individuals with shoulder pain as having scapular dyskinesis compared to blinded clinicians. Essentially, we strive to find faults that prove our preconceived notions.

Variability In Posture Is Normal

…between individuals and within individuals, but for some reason there is this expectation that there’s a one-size-fits-all posture. 

Posture is often described as a rigid concept with no consideration for mood, situation, or context. The reality is that there is no single, perfect posture for all circumstances, which is why I think it’s better to adopt a mindset of variability and adaptability.

If you sit for 12 hours straight and experience low back pain, that’s not an issue with your posture. You probably just don’t want to be in that position all day. Similarly, if you stood for 12 hours straight and your feet got sore, it’s expected that you’d want to sit down from time to time. 

If you’re renovating your house, painting all of the walls and ceilings, and develop neck pain from looking up all weekend, that’s not a posture problem. It’s simply a repetitive or sustained movement that you’re not accustomed to and therefore unable to tolerate in high volumes.

If you suddenly take up a new gym routine that only involves the rowing machine 6 days per week and your low back becomes unreasonably sore, you’d probably consider introducing a more balanced program instead of blaming your posture.

My point is that variability and adaptability are beneficial as they relate to different positions, movements, and activities, so it’s unclear why such a rigid definition and expectation are applied when it comes to posture.

Does That Mean Posture Never Matters?

No, but posture’s role in rehab is trivial compared to the amount of attention it gets and how frequently it’s blamed.  

Despite popular belief, static posture does not predict:

You might be thinking – “Just wait 20 years. That bad posture is going to catch up with those people.”

Well, thankfully, we have research following individuals over 20 years showing that isn’t the case. 

We also have 5 year data demonstrating that “Females in late adolescence who sat in slumped thorax/forward head or intermediate posture rather than upright sitting posture had a lower risk of persistent neck pain as a young adult.”

Now, I’m not arguing that you need to walk around looking like the worms from Men In Black. I’m just trying to say that this topic is much more nuanced than typically believed. 

Many individuals will throw around the idea that “excessive” postures are the true problem. “Excessive” anterior pelvic tilt or “excessive” forward head posture. However, this suffers from the same communication barriers I mentioned earlier. What is meant by “excessive”? How is it measured? In what contexts does it matter? If I asked 20 people these questions, I assure you I’d get vastly different answers. 

In most cases…

Preparation Is More Important Than Posture

I have feet flatter than flapjacks and an anterior pelvic tilt that would send shivers down the spines of posturologists everywhere, but neither are problematic because I’ve adequately prepared myself for the demands of my daily and recreational activities. I can walk 20,000 steps or hike long distances with a weighted backpack or play sports on a whim without issue. 

And no, I don’t think that changing these aspects of my body would suddenly make me superhuman. 

Pain is complex and multifactorial, so it can be helpful to zoom out on life before quickly embracing a narrow approach.

  1. Do you exercise regularly?
  2. Do you set aside time for daily walks?
  3. Do you move around throughout the day to facilitate movement variability?
  4. Are you addressing aggravating activities?
  5. How’s your overall health as it relates to sleep, stress, nutrition, and social interaction? 

This all applies to general fitness and performance as well. 

Honestly, when you consider all of these factors and more, the overemphasis on static posture seems a bit boring, unimaginative, and lazy.

What About Posture Exercises?

Although you might assume I strongly oppose them, I don’t. If exercises like wall slides, prone swimmers, side bends, thoracic rotation, and glute bridges are regarded as posture exercises, I guess I do posture exercises. However, I don’t perform these movements with the goal of “fixing” my posture. I include them for the sake of having a little more variety in my routine.

You wouldn’t go to the gym and only do chest and biceps exercises.

Okay, some guys might. 

But you can feel good performing a well-rounded routine without overthinking it or overcomplicating it. 

How would you feel if your posture improved, but your symptoms didn’t?

What if your symptoms improved, but your posture didn’t?

What if your posture improved, but your symptoms got worse?

Which of these scenarios would be acceptable to you?

One final comment from the previous video – “I will say stretching my hip flexors and doing glute bridges helped my back pain.”

I don’t question this person’s experience at all. Many people report an improvement in their symptoms when they incorporate these types of exercises. The question is whether or not it was a change in their posture that was the primary driver of this improvement. Could there be an alternative explanation?

Was it the fact that they started exercising more or moving more throughout the day? Did it have anything to do with reducing their sedentary time? What if improving other aspects of their health and lifestyle simultaneously as part of their commitment to getting out of pain had the biggest impact?

“Fixing” posture is almost always framed as a net positive, but there are potential downsides, such as becoming overly self-conscious or hypervigilant, ruminating, catastrophizing, or developing negative expectations and fear avoidance beliefs. Constantly worrying about posture might be more detrimental than the posture itself.  

To finish what we started…

Do you need to fix your posture? My answer remains the same – probably not.

Only you get to make the final decision about changes you make to your body and health, but I encourage you to at least consider some of what I discussed in this blog.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before?

Check out our coaching and consultation services!

Want to learn more? Check out some of our other similar blogs:

Core Stability, Anterior Pelvic Tilt, Flat Feet

Thanks for reading. Check out the video and please leave any questions or comments below. 

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]]> https://e3rehab.com/do-you-need-to-fix-your-posture/feed/ 0 24770 Why Your Elbow Hurts https://e3rehab.com/why-your-elbow-hurts/ https://e3rehab.com/why-your-elbow-hurts/#respond Sun, 02 Mar 2025 14:00:00 +0000 https://e3rehab.com/?p=24531 In this blog, I’m going to tell you why your elbow hurts and what you should do about it! Be sure to also check out our Rehab Programs! Basic Elbow Anatomy The two bones of the forearm are known as the radius and ulna, while the arm bone is known as the humerus. Together, these […]

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In this blog, I’m going to tell you why your elbow hurts and what you should do about it!

Be sure to also check out our Rehab Programs!

Basic Elbow Anatomy

The two bones of the forearm are known as the radius and ulna, while the arm bone is known as the humerus. Together, these three bones form the humeroradial and humeroulnar joints, which make up the elbow. The radius and ulna also join here, and this is known as the proximal radioulnar joint. 

If you feel the bony prominence on the inside of your elbow, this is a part of your humerus known as the medial epicondyle.

If you feel a similar bony prominence on the outside of your elbow, this is a part of your humerus known as the lateral epicondyle.

Many of the muscles that control the movements of your forearm, wrist, and fingers attach to the medial and lateral epicondyles via their tendons (because tendons attach muscles to bones). 

The muscles that attach to the lateral epicondyle have 3 primary actions: wrist extension, finger extension, and supination, which involves turning your palm up toward the ceiling.

On the other hand, the muscles that attach to the medial epicondyle contribute to finger flexion, wrist flexion, and pronation, which involves turning your palm down toward the floor.

If you perform any of these actions or squeeze your hand into a fist, you should be able to see and feel these muscles contract. 

Tennis Elbow

There are a lot of names used to describe pain at the location of the lateral epicondyle: lateral epicondylitis, lateral epicondylalgia, tennis elbow, etc. This can be confusing.

Lateral epicondylitis refers to inflammation of the lateral epicondyle, or more specifically, inflammation of the tendons that attach to the lateral epicondyle. However, lateral epicondylitis has fallen out of favor as a diagnosis because current research suggests that local inflammation is likely not the primary driver of the condition. 

This is not to say that inflammation is never a contributing factor, but it likely doesn’t need to be the focus of management. This is important to know because most people associate inflammation with the need for complete rest, ice, and anti-inflammatory medication, which are not going to be the main recommendations in this blog.

As a result, the term epicondylalgia was introduced to replace epicondylitis. However, lateral epicondylalgia just means that the lateral epicondyle is painful, which is not very helpful. 

We also shouldn’t call it “tennis elbow” because it doesn’t only occur in tennis players. In fact, it’s most common in manual workers who use their dominant arm for repetitive movements or forceful activities on a regular basis. Shiri 2006, Van Rijn 2009, Walker-Bone 2012, Descatha 2016, Vicenzino 2017, Aben 2018. And, as some of you reading may be aware, golfers also get tennis elbow. 

So what should we call it?

According to Scott et al, lateral elbow tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading of the lateral elbow tendons. Mechanical loading refers to any movements or activities that load the lateral elbow tendons, such as working with your hands, lifting weights, and playing sports.

The diagnosis is typically given when someone’s pain is reproduced with pinpoint pressure to the tendons, stretching of the tendons, or loading of the tendons, such as with resisted wrist extension, resisted middle finger extension, or gripping. The tendon most often involved is believed to be the Extensor Carpi Radialis Brevis.

Based on this information, lateral elbow tendinopathy is generally considered a clinical diagnosis, meaning that imaging, such as x-rays and MRIs, are not indicated unless there is suspicion of something like a fracture, dislocation, or instability.

Want to learn more?

Check out our full blog about Tennis Elbow Rehab!

Golfer’s Elbow

There are also a lot of names used to describe pain at the location of the medial epicondyle, such as medial epicondylitis, medial epicondylalgia, and golfer’s elbow.

However, for the same reasons mentioned above, medial elbow tendinopathy is the preferred label. It’s common in workers who do repetitive movements or forceful activities with their arms, wrists, or hands on a regular basis, as well as sporting populations other than just golfers (including tennis players). Descatha 2003, Shiri 2006, Wolf 2010, Walker-Bone 2012

The diagnosis is typically given when someone’s pain is reproduced with pinpoint pressure to the tendons, stretching of the tendons, or loading of the tendons, such as with resisted wrist flexion, resisted pronation, or gripping.

Like lateral elbow tendinopathy, medial elbow tendinopathy is considered a clinical diagnosis, so imaging is not typically necessary. However, it is important to consider other diagnoses in this region as well, such as an injury to the ulnar collateral ligament or involvement of the ulnar nerve. I’ll talk more about these diagnoses soon.

Want to learn more?

Check out our full blog about Golfer’s Elbow Rehab!

Triceps Tendinopathy

As you might guess, triceps tendinopathy follows similar logic. 

The triceps brachii is a three-headed muscle that’s visible on the back of the arm. The medial and lateral heads originate on the humerus while the long head actually attaches up at the scapula, or shoulder blade. All three heads insert on the olecranon of the ulna via a common tendon and act to extend, or straighten, the elbow.

Since tendinopathy refers to persistent tendon pain and loss of function related to mechanical loading, triceps tendinopathy is characterized by localized pain at the back of the elbow that worsens with increasing demands on the triceps. For example, I would expect a 40lb dumbbell skullcrusher to cause more issues than a 20lb dumbbell skullcrusher because it’s a greater load. Similarly, a very fast repetition would likely be more problematic than a very slow repetition because tendons are also affected by the rate, or speed, of loading. Range of motion can play a factor as well.

Want to learn more?

Check out our full blog about Triceps Tendinopathy Rehab!

Distal Biceps Tendinopathy

The last tendinopathy to discuss is distal biceps tendinopathy. 

The biceps brachii consists of two heads – a short head and a long head. Both heads originate on the scapula and come together to attach to the radial tuberosity of the radius. At the elbow and forearm, the biceps brachii contributes to flexion and supination.

The diagnosis is more likely when there is localized pain associated with loading of the tendon, such as with lifting, pulling, twisting, etc.

For all tendinopathies, rehab is the preferred method of management.

Ulnar Collateral Ligament (UCL) Injuries

The ulnar collateral ligament, or UCL, is located on the inner portion of the elbow and is made up of 3 distinct bundles: anterior, posterior, and transverse. The anterior bundle provides the majority of resistance to valgus stress while the posterior bundle is a secondary stabilizer. The transverse bundle does not actually cross the elbow joint.

Although injuries can happen traumatically, such as from falling on an outstretched hand (FOOSH), they are typically associated with repetitive overuse or relative overload in overhead throwing athletes, particularly pitchers in baseball. 

Assessment of the injury may include a detailed history, palpation of the area, orthopedic tests, like the milking maneuver and moving valgus stress test, and imaging. 

Depending on the severity of the injury, the stability of the joint, symptoms, and desired goals, surgery may be required in some cases (frequently referred to as “Tommy John Surgery” named for the pitcher who first had the surgery in 1974).

Little League Elbow

Little League Elbow, or medial epicondyle apophysitis, affects youth overhead athletes. As the name implies, it’s common in young baseball pitchers. It’s an overuse-type injury in which the soft-tissue structures that attach to the medial epicondyle, like the ulnar collateral ligament, cause irritation of the growth plate due to repetitive tensioning of the area. 

Cubital Tunnel Syndrome (Ulnar Nerve)

As I mentioned earlier, any assessment of symptoms around the inner elbow should include an evaluation of the ulnar nerve. If you’ve ever hit your “funny bone,” you’ve actually hit your ulnar nerve. It runs just behind the medial epicondyle, so it’s easy to find, feel, and unfortunately, accidentally bump on a table or desk.

It’s possible for the ulnar nerve to be irritated in isolation, or for problems to co-exist with medial elbow tendinopathy or an injury to the ulnar collateral ligament. This is commonly referred to as cubital tunnel syndrome, but the ulnar nerve can be compressed or irritated in several locations along its path down the arm. 

From a sensory perspective, the ulnar nerve supplies the pinky side of the hand so numbness, tingling, burning, or other sensory disturbances may be felt down into this region.

The ulnar nerve is also responsible for innervating many of the muscles that control the hand; therefore, atrophy, weakness, or changes in the appearance and function of the hand may occur if the condition progresses.

Symptoms are commonly felt at night or with any activity that requires sustained or repetitive flexion of the elbow. 

Some people may also experience snapping or popping of the ulnar nerve as it rolls in and out of its groove behind the medial epicondyle during flexion and extension of the elbow.

Radial Tunnel Syndrome (Radial Nerve)

Less frequently, on the outer portion of the elbow, compression of a branch of the radial nerve can masquerade as lateral elbow tendinopathy. Two key differences are the location and nature of the symptoms. 

Radial tunnel syndrome, as it’s commonly called, will present as a deep, dull, diffuse ache that’s less localized than lateral elbow tendinopathy. Symptoms will also be experienced further from the lateral epicondyle than lateral elbow tendinopathy.

Two things to note here:

  1. I’m not going into extreme detail because the assessment of nerve-related issues can be a little more complex and it’s best to receive an appropriate evaluation and accurate diagnosis from a licensed healthcare provider. 
  2. The shoulder and neck should always be evaluated when someone is experiencing elbow symptoms because the shoulder can refer pain down the arm into the elbow and irritation of a nerve in the neck, known as cervical radiculopathy, can present similarly to some of the diagnoses I’ve discussed so far.

Olecranon Bursitis

Moving on, olecranon bursitis refers to inflammation of the bursa on the back of the elbow. A bursa is a small, fluid-filled sac that helps cushion and reduce friction between structures.

Olecranon bursitis may occur following minor trauma or sustained pressure to the area. The first time I went snowboarding I used my elbow as a brake and developed this condition after hours of repeatedly falling on it. In my case, it was extremely swollen and painful.

Other causes of olecranon bursitis include gout, infections, and rheumatoid arthritis.

Fracture / Dislocation / Instability / Distal Biceps Rupture

A common cause of elbow injuries is trauma, such as falling on an outstretched hand, falling directly onto the elbow, or from a direct blow to the elbow. These traumatic instances can result in fractures, dislocations, and soft tissue injuries. As you might expect, this can lead to other issues as well, like instability of the elbow joint. 

A distal biceps rupture also falls into this category of traumatic injuries.

What About Other Diagnoses?

What about other diagnoses that I didn’t mention? 

Well, I can’t cover every possible diagnosis. For example, I didn’t discuss osteoarthritis of the elbow as it’s much less common than other joints like the knee and hip. However, I tried to review the diagnoses we most often receive questions about. 

And hopefully this goes without saying, but this information should not serve as a substitution for a consultation with a medical doctor or physical therapist.

Why Did You Get Elbow Pain?

Trauma aside, you might be wondering why you developed elbow pain in the first place. 

Lateral elbow tendinopathy is the most common of the elbow tendinopathies, so let’s use it as an example. 

Think of it like this – you load your lateral elbow tendons every day when you’re working, lifting, playing sports, etc. However, if the intensity, frequency, and volume of that loading exceeds your capacity to recover and adapt from those loads appropriately, lateral elbow tendinopathy may occur.

Oftentimes, it comes down to doing too much, too soon. Here are three examples:

  1. You decided you wanted to get in better shape, so you started lifting weights every day without any prior experience.
  2. You’re a new tennis player who wanted to get good fast, so you joined a club to play after work each day.
  3. You took a week off of work to take care of a few projects around the house.

In these examples, you likely loaded your lateral elbow tendons more than what they’re used to. Therefore, the goal of rehab is pretty simple: it’s to initially reduce those loads to a tolerable amount and then make sure that your capacity is greater than or equal to the various loads you’re going to be experiencing on a day-to-day and week-to-week basis. 

How To Rehab Elbow Pain

Based on this information, my first recommendation for rehab is to modify aggravating activities.

If you’re a gym-goer who can’t tolerate your current training program, you need to temporarily scale back by doing less sets per day or throughout the entire week, reducing the amount of weight you’re lifting, or making other adjustments to your routine. Here are five examples:

1. If upper body exercises that require significant gripping like pull-ups, pulldowns, and rows are provocative, an easy modification is to use lifting straps.

2. If leg exercises with weights in your hands are uncomfortable, like dumbbell lunges or split squats, use lifting straps, try a barbell, or perform a machine-based exercise instead.

3. If heavy deadlift variations are problematic, even with lifting straps, pick a different exercise that trains similar muscle groups without placing any demand on your grip, such as single leg hip extension on a roman chair.

4. If you have pain with dumbbell lateral raises, you can put a cuff around your wrist and do them using the cable column.

5. If a certain position of your forearm is problematic, whether it’s pronated, supinated, or neutral, try a different position. You can also try equipment or handles that provide you with more movement variability.

There are a lot of options.

If you’re a tennis player, or any other athlete, reduce how often you play, the total time you play each session, or the intensity at which you play. This can actually be a good time to focus on your technique. 

Compared to your legs, trunk, and shoulder, your elbow should only be contributing a fraction of your overall power when you’re hitting the ball in tennis. Working with a coach might help you discover errors in your technique that are contributing to excessive loading of your elbow. This is true for tennis, golf, and other sports that may be contributing to your symptoms.

If you’re an office worker who spends a lot of time at your computer, you might have to adjust your workstation and incorporate periodic walking breaks. Set a timer on your phone or place a sticky note on your monitor as a reminder.

I understand that modifying aggravating activities may be more challenging for some individuals than others. For example, if your job requires repetitive bending and twisting of your elbow and wrist, you might need to get creative if you work for yourself or request modified duty if you’re employed by someone else. 

I also want to highlight that most of these changes are meant to be temporary. The idea is that you’re taking one step back, so you can eventually take two steps forward.

What About Exercise?

Research demonstrates that individuals with lateral elbow tendinopathy have weakness of their hand, forearm, elbow, and shoulder muscles. This is a chicken or egg scenario because it’s possible that the weakness is secondary to pain and deconditioning from disuse as opposed to being the reason for the development of symptoms in the first place. Regardless, this still ties into the goal of improving your tolerance to various forms of loading and gradually restoring your function. 

Fortunately, exercise prescription doesn’t have to be overly complicated. Oftentimes, 1-3 exercises performed a few times per week is a great starting point.

With regards to pain, some discomfort is usually acceptable during rehab. However, if you’re consistently pushing into unbearable pain and experiencing flare-ups, you probably need to temporarily scale back whatever it is that’s giving you problems. Once again, think of it as taking one step back so you can eventually take two steps forward. On the other hand, if you’re a person who has restricted yourself from all exercise and activities for fear of worsening your condition, you might just need to give yourself permission to move.

Is There Anything Else You Can Do?

Yes! There is a growing body of literature, including research related to lateral elbow tendinopathy, that tendinopathies are often associated with other lifestyle and metabolic factors, such as cardiovascular disease, diabetes, smoking, etc. 

This is not to say that they are the cause of your symptoms or even a contributing factor, but if you’ve been meaning to positively influence your general health and well-being by changing your exercise, nutrition, and/or sleeping habits, this might be a good time to kickstart your journey.

One of the easiest methods for improving health is simply walking more. Something is always better than nothing, and short walks throughout the day can be a great way to help break up any repetitive tasks that you’re doing with your wrist or elbow.

Individualizing Rehab

All of this information also applies to medial elbow tendinopathy, triceps tendinopathy, and distal biceps tendinopathy, but the activities you need to modify and the exercises you choose to perform will likely differ between the diagnoses. You want to personalize your rehab to your specific goals and needs.

These overarching principles apply to most other diagnoses as well, although the exact implementation will vary. For example, someone with an ulnar collateral ligament injury may need to take 6 weeks off of throwing completely to give the ligament the best chance of healing. During that time though, the person will likely still be performing exercises for their elbow, shoulder, trunk, legs, etc. When they resume throwing, it’ll be a gradual process of ramping up the number of pitches and the speed of those pitches as they try to get back to their prior level of function while minimizing the risk of reinjury. Examining their technique with a coach may be part of the process as well. There may even be aspects of their health they want to address, like sleep and stress management. 

With any diagnosis, there’s rarely a quick fix. Rehab often takes significant time, effort, and consistency. 

Before wrapping up, I want to remind you know that we have full-length blogs dedicated to lateral elbow tendinopathy, medial elbow tendinopathy, and triceps tendinopathy, so check those out if you’re looking for more in-depth information.

Don’t forget to check out our Rehab Programs!

Thanks for reading. Check out the video and please leave any questions or comments below. 

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]]> https://e3rehab.com/why-your-elbow-hurts/feed/ 0 24531 How To Rehab Tendon Injuries and Pain https://e3rehab.com/how-to-rehab-tendon-injuries-and-pain/ https://e3rehab.com/how-to-rehab-tendon-injuries-and-pain/#respond Sun, 09 Feb 2025 20:58:48 +0000 https://e3rehab.com/?p=24589 Whether you’re experiencing symptoms related to your shoulder, elbow, hip, knee, or ankle, I’m going to teach you everything you need to know about how to rehab tendon injuries and pain. Be sure to also check out our Rehab & Resilience Programs! What Is A Tendon? Tendons are a type of connective tissue that transmit […]

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Whether you’re experiencing symptoms related to your shoulder, elbow, hip, knee, or ankle, I’m going to teach you everything you need to know about how to rehab tendon injuries and pain.

Be sure to also check out our Rehab & Resilience Programs!

What Is A Tendon?

Tendons are a type of connective tissue that transmit forces from muscles to bones to produce movement. Their ability to store and release energy, especially as it relates to the patellar and Achilles tendons, improve power and movement efficiency, and help to protect muscles from injury.

The classification of tendon injuries has changed over time, and there is still debate and uncertainty about the exact cause of symptoms.

Tendinitis

For decades, gradual, non-traumatic tendon pain was labeled as “tendinitis” because it was believed to be an overuse-type injury that resulted in acute inflammation of the tendon. Based on our knowledge at the time, recommendations would often include rest, ice, and anti-inflammatory medication. 

However, research as far back as 1976 started to question whether this was truly the case. As these tissues began to be studied under a microscope in the 80s and 90s, scientists actually discovered an absence of inflammatory cells. 

In 2002, the British Medical Journal published an article titled, “Time to abandon the ‘tendinitis’ myth.”

Tendinosis

For a period of time, tendinosis became the preferred diagnosis for many medical doctors and physical therapists because various studies consistently found a degenerative process associated with painful tendons rather than acute inflammation. Therefore, tendinosis was considered a chronic overuse injury.

But, as of 2025, tendinosis is not the preferred diagnostic label because the only way to truly determine the extent of degenerative changes in a clinical setting is with imaging. However, imaging usually isn’t recommended because these changes are quite common in the asymptomatic population and imaging doesn’t typically influence the diagnosis or treatment. Plus, there are a variety of studies showing that individuals can have an improvement in symptoms and function despite no changes in tendon structure on imaging (example, example, example). 

What should we call it then?

Tendinopathy

In 2019, an international group of tendon experts suggested that “Tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading.” Mechanical loading just refers to anything that loads the tendon. In the case of the patellar tendon, that would mean squatting, jumping, decelerating, etc. For the elbow, it would be related to things like gripping, lifting, and twisting. 

As it relates to symptoms, there’s a dose-dependent relationship with the magnitude and rate of loading. Sticking with the patellar tendon example, I’d expect a single leg squat to hurt more than a double leg squat. I’d also expect a double leg jump to hurt more than a double leg squat. Tendons are affected more by the speed of the movement, or the rate of loading, and this will be an important consideration for exercise selection and programming. The range of motion can also play a role, which I’ll talk about later.

So, instead of focusing on inflammation or what the tendon looks like on imaging, the goal of rehab is two-fold: 

  1. Improve your tolerance to various forms of loading and
  2. Restore the function of the affected tendon and muscle, the rest of the involved limb, and you, the person, in general.

Understanding and Monitoring Pain

A fundamental component of rehab is understanding and monitoring pain. Do you have to avoid pain during exercise or is it safe to push into a little pain?

Well, the majority of researched exercise programs use pain-based criteria for progressing exercises. In fact, some papers actually increase the difficulty of an exercise if participants have a decrease in pain (Alfredson 1998 for example). 

Silbernagel et al in 2007 helped popularize the model that’s most often used today, which involves exercising to a tolerable level of pain. This is unique to you. One person reading this blog might only be comfortable exercising with slight pain while someone else might be comfortable exercising with moderate pain. There’s not necessarily a right or wrong way to go about it, but there are some strategies that you can use to help find what works best for you.

You’re not only going to monitor symptoms during exercise, but immediately after and the following day.

Ask yourself 3 questions:

1. Is my pain tolerable during exercise? If it’s helpful for you, you can rate your pain on a scale from 0-10 and determine the highest acceptable number for you. Some physical therapists might recommend staying at a 3/10 pain or less while others might suggest 5/10 pain or less. You get to decide.

2. Is my pain better, worse, or the same after exercise? Tendinopathies may exhibit a warm-up phenomenon in which symptoms actually improve with physical activity, so it’s possible that you feel better after exercising for a short period.

3. Is my pain better, worse, or the same the day after exercise? This is the most important question because it gives us an understanding of how you’re responding to the current dosage of exercise. If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit.

You can assess your next-day symptoms with your normal functional activities or use a specific assessment, such as a single leg squat variation in the case of patellar tendinopathy.

For example, you rate your pain on day 1 with the single leg squat variation as a 3/10 pain. You then perform your exercise routine within tolerance, go about your day, and go to bed without any major issues. The next morning you perform the movement again, but this time you rate your pain as a 6/10. This means that even though your symptoms were tolerable during exercise, you might have done more than what you can currently recover from. You didn’t do any harm, but decreasing the volume or intensity would be recommended.

For the Achilles tendon, it could be heel raises. For the hip, it could be walking or standing on one leg. For the elbow, it could be gripping. For the shoulder, it could be a lateral raise. Anything works as an assessment as long as it loads the affected tendon, it brings about some level of discomfort, and you’re consistent with your choice. But if you’re going to test it, test it once, not 30 times per day and accidentally flare-up your symptoms. 

So to summarize, do you have to avoid pain during exercise? Not necessarily. Is it safe to push into a little pain? Yes. However, you’re going to have to find what works best for you.

Load Management and Activity Modifications

Two other fundamental components of rehab are load management and activity modifications. This is a simplified explanation, but most tendinopathies are thought to occur when the intensity, frequency, and volume of tendon loading exceeds your capacity to recover and adapt appropriately. It often comes down to doing too much, too soon, although that will look slightly different for more active individuals vs less active individuals.

Let’s tie the goals of rehab, pain monitoring, and load management together by reviewing the boom-bust cycle. Tell me in the comments if it sounds familiar.

You have a spike in activity over the course of a day, week, or month that contributes to an increase in symptoms. You decide to rest completely and your symptoms go away. Excellent! You recognize that you overdid it last time, so you don’t do quite as much this time around. However, you have a flare-up despite doing less of the same activity! You rest again until your pain goes away and repeat this process until your activity level is severely diminished.

This is not an uncommon cycle. It’s often driven by the belief that pain is bad and rest is good, while also using a reduction in pain as the primary metric for success.

But that’s not the way to approach quadriceps tendinopathy because rehab can take 3 months, 6 months, or even a year or longer. Symptoms will fluctuate on a day-to-day and week-to-week basis, which is why your focus should be on function while monitoring pain to guide the appropriate amount of physical activity.

An increase in function will not always correlate with a linear decrease in pain. If you go from running 1 mile with a 3/10 pain to running 3 miles with a 3/10 pain over the course of 3 months, that’s actually significant progress. The pain may seem like it’s staying the same, but technically it’s getting better because it requires more activity to reach the same level of pain that you initially experienced.

Remember, one of the primary goals of rehab is to restore function. You’ll monitor your symptoms during and after exercise to ensure that you’re not exceeding your current capacity, while keeping track of your progress with the various exercises. At the same time, you’ll reduce the frequency, intensity, or volume of activities that are aggravating your symptoms and limiting your functional progress, such as running, going to the gym, or playing a sport. If needed, you can replace the reduction in that specific activity with a different activity that doesn’t exacerbate symptoms to maintain your fitness.

Before outlining the exercises, I want to revisit the concept of inflammation.

Revisiting Inflammation

As more studies were done on tendons, researchers discovered that inflammation does exist in tendinopathies (review, review, review). I want to bring this up because I think some individuals may have misinterpreted what I’ve said in previous blogs. I normally say something along the lines of this:

“Although inflammatory markers are present, inflammation is not believed to be the primary driver of the condition and some inflammation just reflects the normal response to regular tendon loading and adaptation.”

There are different types of inflammation. 

Inflammation can be more acute or chronic. 

It’s complex.

For tendinopathies, the inflammatory markers present aren’t changing the plan for rehab. The previous model of complete rest and ice often leads to the boom-bust cycle I described. Plus, loading is healthy for tendons when the appropriate dosage and recovery is provided.

Systemic Drivers of Tendinopathy

What may be more important is knowing that chronic, low-grade inflammation can influence tendinopathies, particularly as it relates to lifestyle and metabolic factors. Sleep, stress, nutrition, alcohol intake, smoking, exercise habits, and anything else that affects your overall well-being can also affect the onset and persistence of symptoms. How much this matters will vary case-to-case and I’ll give an example toward the end of the blog, but even if you’re dealing with rotator cuff tendinopathy and you’ve been wanting to improve your general health, I wouldn’t underestimate the power of small changes, such as simply increasing your daily step count.

Rehab Framework

Let me break down the typical framework of rehab for Achilles and patellar tendinopathy, and then I’ll describe how this process relates to other body regions. 

Rehab is often divided into 4 stages:

  • Isometrics
  • Heavy, Slow Resistance
  • Energy Storage & Release
  • and Return To Sport

In reality, these aren’t distinct stages. There’s going to be overlap and in many cases, you’ll be performing all of these categories simultaneously.

The idea is that you are gradually increasing the demand and complexity of movements over the course of weeks and months. Specifically, ramping up the amount of load, and more importantly, the speed of loading throughout the stages. 

Plyometrics and sport-specific movements are crucial for getting you back to your previous level of function and performance, but we’ve learned that quicker movements don’t actually cause the positive adaptations we’re looking for in tendons, particularly increasing their stiffness. As theorized by Mersmann and colleagues, some of the leading researchers in this field, “A loading-induced increase of tendon stiffness would reduce tendon strain at a given force, which could prevent the development of structural impairments and pain in tendons.”

To be clear, tendon stiffness is different from the sensation of stiffness. This has more to do with the strength of the tendon. 

In order to do this, tendons require heavy loading for a duration of at least 3 seconds at a time. Isometrics and heavy, slow resistance serve the same purpose of trying to create these positive tendon adaptations, which is partly why they’re at the start of this rehab framework. 

Now, you have no idea if your tendon stiffness is actually improving as it requires specialized equipment to measure, so focus on the process I’m going to lay out and the goal of improving your function. I say this because research is messy, and there are many studies in which people get better despite not having the predicted tendon adaptations (example, example, example).

Stage 0: Isometrics

Most tendinopathy protocols have isometrics listed as stage 1, but they’re listed here as stage 0 because I don’t think there’s an isometric milestone that you need to pass before performing the next group of exercises. And although isometrics can temporarily reduce pain for some individuals, they are not a magic bullet like previously believed. 

The benefit of isometrics lies in your ability to easily control the range of motion, intensity, and rate of loading for whichever exercise you perform.

Here are 5 examples for patellar tendinopathy:

  1. Double Leg Wall Sit
  2. Single Leg Wall Sit
  3. Heel Elevated Wall Sit. The single leg and heel elevated variations are both progressions of the double leg wall sit.
  4. Spanish Squat. With a strap or band anchored around your legs and a squat rack, you’ll sit back until your hips and knees are at roughly 90 degree angles. 
  5. Single Leg Seated Knee Extension.

You can perform the seated leg extension with a machine, band, or some other setup with your knee between 90 and 60 degrees of flexion.

You’re going to choose what works best for you based on your preference, equipment availability, tolerance, function, etc.

Here’s an example of how the seated leg extension is applied in research:

  1. Bend your knee to roughly 60 degrees
  2. If you’re using a machine, make sure it’s too heavy for you to move
  3. Push at your maximum tolerable effort for 3 seconds, relax for 3 seconds, and repeat for 4 total repetitions
  4. Rest 1-2 minutes
  5. Repeat 4 more times for 5 sets total
  6. Perform this 3 times per week

A few things to note:

  1. Try it on your unaffected side first so you know what it feels like.
  2. Ramp up and ramp down your effort the first few times you try it, so you don’t accidentally get a spike in symptoms. 
  3. I recommend pushing at your maximum tolerable effort because it should feel hard.

This is one protocol that’s been used in research to improve tendon stiffness that’s easy to implement and doesn’t take much time. For some people, this might be all they do. For others, they might just add this to their pre-existing programs. 

Keep in mind that if your knee is bent to 75 degrees, that’s okay. If you hold each contraction for 3.5 seconds, that’s also okay. 

Unfortunately, this is not a perfect science. You’re just aiming for a high load in a fairly neutral or stretched position at least a few times per week. 

For the Achilles tendon, you can do a seated or standing heel raise.

For the elbow tendons, you can do isometric wrist flexion or extension.

For the rotator cuff, you can do external rotation or abduction.

For gluteal tendinopathy, you can do hip abduction.

What about other protocols? They’re fine too, although it’s possible they’re contributing more to muscular adaptations. A previous example I’ve given is to pick one exercise option to complete for 3-5 sets of 30-45 second holds with a 2 minute rest between sets. This can be done as a warm-up prior to your workouts or as an independent stimulus, 1-2 times per day.

A greater volume and frequency of loading doesn’t seem to lead to better adaptations of the tendon, but that doesn’t mean these exercises can’t be performed 4-7x/week instead of 3 if that’s what you prefer. As I said, the tendon adaptations don’t always perfectly align with an improvement in symptoms and function, and a variety of protocols over the years have been shown to work.

You just want to take these overarching principles and apply them to your specific situation.

Stage 1: Heavy Slow Resistance

For the next stage, you can pick any exercise as long as it is tolerable and sufficiently loads the tendon. Here are 4 options for the knee again:

  1. Squat. Progressions can be made by increasing the resistance over time or choosing a variation that emphasizes the knee extensors more, such as a heel elevated squat.
  2. Split Squat. Similarly, progress the resistance, range of motion, or amount of forward knee travel over time.
  3. Step Down. Progress by elevating the height of the step or your heel, or increase the amount of forward knee travel. 
  4. Single Leg Seated Knee Extension

You can perform 1-2 exercises for 2-4 sets of 6-12 repetitions, 2 to 3 days per week. I’d recommend picking at least one single leg variation. 

The speed of each repetition should be slow. For example, if you’re performing a squat, descend over the course of 3 seconds, pause for 1 second at the bottom, and ascend for 3 seconds. That’s a 7 second repetition! If you want to ensure consistency with your tempo, you can download a metronome app on your phone.

Remember to manipulate the range of motion, intensity, etc. as needed, and focus on consistency, gradual progressions, and strategies that align with your goals.

Let me answer a few questions I anticipate receiving:

What about eccentrics? 

Does it have to be heavy? 

  • Not necessarily, as research has demonstrated clinical improvements with moderate loads, but your aim should be to progress the load or difficulty over time.

When can you progress from isometrics to these exercises? 

  • Whenever. It’s a bit of trial-and-error. And when you start doing these exercises, you might still continue performing isometrics 2-3x/week. 

What else should you be doing?

  • Training the rest of your body as needed. If you’re a basketball player with patellar tendinopathy, you should be including hip and ankle exercises, conditioning, etc. If you’re a tennis player with elbow tendinopathy, you probably want to include some shoulder exercises. The focus is the affected tendon, but you still want to take a holistic approach to rehab.

Stage 2: Energy Storage and Release

Along with the isometrics and heavy, slow resistance training, stage 2 includes jumping, landing, plyometrics, and exercises that prioritize a faster rate of loading. These exercises should be performed 2-3 times per week with an emphasis on execution. 

There’s an infinite number of possibilities and loading schemes here, so I’m just going to provide 2 options for the knee. You don’t have to follow the exact order of either option.

1. Countermovement jump to a box, countermovement jump, bilateral depth drop, bilateral depth jump, single leg depth drop, and single leg depth jump.

2. Forward lunge, forward lunge with step back, step and land, step and land with a step back, and running with a step back. 

For the Achilles tendon, you’d want to work through a progression that eventually gives you the confidence in hopping multi-directionally on a single leg.  

The energy storage and release aspect of this stage applies more to the patellar and Achilles tendons, but the idea of integrating faster, functional movements applies to the other tendons as well.

Stage 3: Return To Sport

There are no distinct exercises that need to be performed in this stage. Instead, this stage is about gradually returning to your preferred sport or activity. 

For example, if you’re a marathon runner, you’d train for that marathon over the course of several months as you build up your volume. If you’re a recreational basketball player, the same thought process applies. You can’t expect to just jump back into hours of full court games after doing 3 months of exercises in the gym. You have to build back up to it.

Guidelines, Not Rules

Please understand that these are guidelines, not hard and fast rules. My hope is that you take this information and individualize it to your specific goals and needs. 

Let me give 4 examples:

1. If you’re a basketball player in the playoffs, you might have limited flexibility as it relates to your training and games. For that reason, you would probably just do the isometric protocol 3 times per week.

2. If you’re a recreational gym-goer with biceps or rotator cuff tendinopathy, you might incorporate isometrics 3 times per week while also modifying your exercise selection, intensity, and tempo. Some of your normal training can be heavy, slow resistance. 

3. If you have gluteal tendinopathy but you’re also dealing with other comorbidities, you might choose to prioritize your overall health as a means to improving your symptoms and function. Over time, you could place a greater emphasis on direct loading of the gluteal tendons. 

4. If you’re a runner, do you have to stop running completely? 

Not necessarily. You can incorporate your runs into this rehab framework, but you probably have to change something. You might have to do less weekly miles or fewer runs per week, but you can make up that difference with the exercises in this blog or through other forms of training. 

If you continue to run, but can’t stop yourself from consistently overdoing it and falling into that boom-bust cycle, then it might be worth considering taking a break from running.

You don’t want to be your own worst enemy here. Don’t turn a 6 month process into a 2 year process by being impatient initially.

If nothing else, remember the goals of rehab:

  1. Improve your tolerance to various forms of loading
  2. Restore the function of the affected tendon and muscle, the rest of the involved limb, and you, the person, in general.

Surgery, Injections, Adjunct Treatments

What about foam rolling, massage, icing, or whatever else you can think of? If it’s low cost and low risk, you can pretty much try out anything. However, these things aren’t the focus of rehab because they don’t have an additive benefit to exercise alone. Don’t let them take away from the goal of progressively improving your function.

With regards to injections, the research isn’t promising. For example, a randomized controlled trial by Kearney et al in 2021 found that a PRP injection is no better than a sham, or fake, injection for Achilles tendinopathy. Here are similar findings for the knee and elbow. 

Corticosteroid injections often have positive short-term effects on pain, but lead to worse long-term outcomes (example, example, example). A paper by Dean et al states – “This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.”

Unfortunately, there’s not a quick fix. Rehab takes time, consistency, effort, and dedication to a structured plan.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Rehab & Resilience Programs!

Want to learn more? Check out our full-length tendinopathy blogs:

Achilles Tendinopathy Rehab, Peroneal Tendinopathy Rehab, Tibialis Posterior Tendinopathy Rehab, Quadriceps Tendinopathy Rehab, Patellar Tendinopathy Rehab, Proximal Hamstring Tendinopathy Rehab, Gluteal Tendinopathy Rehab, Biceps Tendinopathy Rehab, Triceps Tendinopathy Rehab, Golfer’s Elbow Rehab, Tennis Elbow Rehab

Thanks for reading. Check out the video and please leave any questions or comments below. 

The post How To Rehab Tendon Injuries and Pain appeared first on E3 Rehab.

]]> https://e3rehab.com/how-to-rehab-tendon-injuries-and-pain/feed/ 0 24589 Why Your Hip Hurts https://e3rehab.com/why-your-hip-hurts/ https://e3rehab.com/why-your-hip-hurts/#respond Mon, 27 Jan 2025 22:07:34 +0000 https://e3rehab.com/?p=24464 In this blog, I’m going to tell you why your hip hurts and what you should do about it! Be sure to also check out our Hip Resilience Program! Basic Hip Anatomy The hip is a ball-and-socket joint where the head of the femur, or thigh bone, meets the acetabulum of the pelvis.  The labrum […]

The post Why Your Hip Hurts appeared first on E3 Rehab.

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In this blog, I’m going to tell you why your hip hurts and what you should do about it!

Be sure to also check out our Hip Resilience Program!

Basic Hip Anatomy

The hip is a ball-and-socket joint where the head of the femur, or thigh bone, meets the acetabulum of the pelvis. 

The labrum is a fibrocartilaginous ring that increases the depth of the socket and improves the stability of the hip.

InjuryMap, CC BY-SA 4.0 , via Wikimedia Commons

Lastly, the hip is surrounded by a connective tissue known as the joint capsule and reinforced by the iliofemoral, pubofemoral, and ischiofemoral ligaments. 

Intra-Articular vs Extra-Articular

Diagnoses of the hip are often categorized as intra-articular or extra-articular. 

Anything within the capsule that affects the hip joint itself is known as intra-articular, such as osteoarthritis, femoroacetabular impingement, labral tears, dysplasia, and avascular necrosis. 

Everything that occurs outside of the hip joint is labeled extra-articular, like adductor strains, gluteal tendinopathy, proximal hamstring tendinopathy, piriformis syndrome, and the other diagnoses I’m going to discuss.

Location of Symptoms

The location of symptoms can be helpful for differentiating between potential diagnoses. For example, symptoms of proximal hamstring tendinopathy will always present toward the back of the hip where the hamstrings attach to the pelvis. On the other hand, intra-articular problems frequently have a component of groin pain and individuals may use the “C-sign” to indicate their deep, anterior hip pain.

In anatomical terms, the front of the hip is anterior, the side of the hip is lateral, and the back of the hip is posterior. 

Let’s begin with the intra-articular diagnoses.

Hip Osteoarthritis

Symptoms associated with hip osteoarthritis include:

  • Morning stiffness
  • Pain with climbing stairs or walking down slopes
  • Pain on initial steps after rest
  • Pain on walking
  • and pain relieved by sitting

Groin pain is most common, but individuals may also report pain in the buttock region, thigh, or knee. 

Additional findings may include:

  • A limp with walking
  • Hip muscle weakness when trying to stand on one leg
  • Buttock pain while squatting
  • Pain with resisted hip movements
  • and decreased hip range of motion compared to the uninvolved side

This is not an all-inclusive list, but if you’re older, gradually start experiencing symptoms, and you’re noticing an associated decline in strength, range of motion, or overall function, hip osteoarthritis becomes higher on the list of possible diagnoses.

Although hip osteoarthritis is typically described as a degenerative joint disease related to “wear and tear” of the cartilage within the hip joint, it should be thought of as a systemic condition as other factors influence symptoms and the progression of the disease, such as genetics and metabolic health. Plus, many of the structural changes seen on imaging associated with hip osteoarthritis are often found in people with no symptoms.

Therefore, imaging is only recommended if surgery is a consideration or if there’s suspicion of an alternative diagnosis. Otherwise, a clinical examination by a medical doctor is sufficient. 

Since the severity of symptoms can vary over time, non-operative management is considered the first line of treatment, including a regular exercise routine.

Want to learn more?

Check out our full blog about Hip Osteoarthritis!

Femoroacetabular Impingement (FAI)

“Femoroacetabular” refers to the hip joint, so you may also hear it be called hip impingement. 

FAI was defined by Griffin et al in 2016 as a “motion-related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings. It represents symptomatic premature contact between the proximal femur [the thigh bone] and the acetabulum [the socket part of the pelvis].”

Symptoms include pain in the hip or groin, and in some cases, also the back, butt, or thigh. Additionally, people may experience clicking, catching, locking, stiffness, or limited range of motion. Symptoms commonly occur at the end ranges of an individual’s available hip range of motion, such as during a deep squat, deadlift, certain yoga poses, sitting for long durations, and various sporting activities.

Clinical signs involve the tests and measures that a physical therapist or medical doctor may perform during their examination. The most useful maneuver is bringing the hip into flexion, adduction, and internal rotation (FADIR). If a person does not experience symptoms, it is unlikely that they have FAI.

Flexion, abduction, and external rotation (FABER) may also be used to evaluate symptoms and differences in side-to-side range of motion.

Additionally, hip range of motion is independently assessed, with an emphasis placed on hip internal rotation when the hip is flexed to 90 degrees.

Along with symptoms and clinical findings, imaging is necessary to diagnose FAI. X-rays can be performed to assess changes in the shape of the hip bones. Cam morphology refers to changes of the femoral head, pincer morphology refers to changes of the acetabulum, and mixed morphology describes a combination of the two.

Imaging findings, clinical signs, AND symptoms are all required to make the diagnosis because it is possible to have changes on imaging without symptoms.

Therefore, imaging is necessary to definitively diagnose FAI, especially if surgery is a consideration, but it is not required to initiate rehab because in most cases, 3-6 months of rehabilitation is recommended first since surgery doesn’t guarantee a return to normalcy, the monetary cost is higher, and there are more risks involved.

Want to learn more?

Check out our full blog about Femoroacetabular Impingement (FAI) Rehab!

Hip Dysplasia

Hip dysplasia can be thought of as a “shallow” socket that does not provide sufficient coverage of the femoral head. 

As stated in a recent paper by Evans et al, Developmental Dysplasia of the Hip (DDH) refers to the condition in infancy and Acetabular Hip Dysplasia (AHD) refers to an adolescent or young adult onset.

In the same paper, the authors developed the ALPHA alert mnemonic to increase the diagnostic awareness of acetabular hip dysplasia. 

  • A stands for Age of symptom onset as it is expected in adolescents or young adults; predominantly females.
  • L stands for Limp on examination or patient-reported with the potential for a leg length discrepancy or hip weakness.
  • P stands for Pain that is progressive in nature with no known cause. Deep hip flexion is frequently problematic. 
  • H stands for History, such as any childhood hip concerns or a family history of hip issues. 
  • A stands for Articulation. Individuals will often report hypermobility, feelings of instability, hip joint sounds, and difficulty with sitting cross-legged.

A combination of these features may warrant X-rays for further evaluation.

Like the previous two diagnoses, imaging findings indicative of hip dysplasia may be present in individuals with little to no symptoms, so non-operative management is often the first line of care when it is detected early.

Want to learn more?

Check out our podcast episode about Hip Dysplasia!

Labral Tears

Labral tears rarely occur in isolation. Instead, they frequently coincide with other conditions like hip dysplasia and FAI. As you may have guessed by now, labral tears are also often found in individuals without symptoms. For this reason, rehabilitation is usually the first step in management.

Avascular Necrosis

Avascular necrosis, or osteonecrosis, of the femoral head is essentially bone tissue death due to a lack of blood supply. Traumatic causes involve fractures and dislocations while the most common non-traumatic causes are corticosteroid use and excessive alcohol intake. Depending on symptoms and the stage of the condition, management may range from rehabilitation to pharmacological treatments to core decompression to a total hip replacement.

Extra-Articular Sources of Groin Pain

Aside from the hip joint-related groin pain that I’ve already discussed, there are several extra-articular sources of groin pain: adductor-related, iliopsoas-related, inguinal-related, and pubic-related. Generally, pain or tenderness localized to one of these structures, in addition to a reproduction of pain through contracting or stretching that specific structure, can help determine the source of symptoms. Notably, the pain felt with resistance testing must be in the location of that structure being tested.

Adductor-Related Groin Pain

Adductor-related groin pain is common in athletes who participate in sports that involve kicking and cutting. It is identified by the presence of pain or tenderness in the adductor area with palpation, as well as resistance testing that reproduces pain in the adductors. It is more likely the culprit of groin pain if symptoms are also present with stretching the adductors.

The most commonly affected muscle is the adductor longus, and it is usually strained from kicking or changing direction.

Iliopsoas-Related Groin Pain

Iliopsoas-related groin pain refers to pain and tenderness at the front of the thigh, along the iliopsoas, that is reproduced with resisted hip flexion and/or stretching of the hip flexors.

The rectus femoris, which also falls under this category, is most commonly strained during sprinting and kicking while the iliacus and psoas can become strained from change of direction movements.

Two things I want to mention here:

  1. Contrary to popular belief, the hip flexors are rarely the cause of, or answer to, all of your hip-related problems. 
  2. An irritated hip flexor is more commonly a symptom of an underlying intra-articular pathology as opposed to being the primary issue itself.

Inguinal-Related Groin Pain

Inguinal-related groin pain is characterized by pain in the inguinal area which is between the lower abdominals, pubic bone, and the bone at the front of the hip called the anterior superior iliac spine, or ASIS. Symptoms may be reproduced with coughing, sneezing, and resisted trunk flexion.

Although it can initially be difficult to differentiate inguinal-related groin pain from adductor-related groin pain, adductor-related groin pain will typically improve with adductor-specific exercises. Inguinal-related groin pain, however, will not improve and may in fact worsen with adductor-specific exercises or with increases in activity in general. 

It’s important to note that an inguinal hernia does not fall under this category of groin pain. Therefore, a palpable bulge should not be present.

Pubic-Related Groin Pain

Pain at the pubic symphysis, which is where the left and right sides of the pelvis come together, and the bones next to it is the hallmark sign of pubic-related groin pain. There are no specific resistance tests for pubic-related groin pain, but it can be more likely if both resisted trunk flexion and resisted hip adduction reproduce symptoms in the pubic area.

Imaging is usually unnecessary for these sources of groin pain and structured rehabilitation is typically the initial focus.

Want to learn more?

Check out our full blog about Groin Pain Rehab!

Gluteal Tendinopathy / Hip Bursitis

If you put your hand on the side of your hip, you should feel a bony prominence known as the greater trochanter, which is part of your femur. The greater trochanter serves as an attachment site for the gluteus medius and gluteus minimus tendons.

In a non-weight bearing position, these two glute muscles act to abduct the hip. More importantly though, they stabilize the pelvis when standing on a single leg, such as when walking, running, and going up stairs.

There is also a trochanteric bursa, which is a fluid-filled sac that serves to cushion and reduce friction in this area. Over the top of these structures lies the iliotibial (IT) band. 

Hip bursitis, the diagnosis often provided to people experiencing pain in this region, generally refers to inflammation of the trochanteric bursa. However, research spanning across 20 years (Bird et al 2001, Connell et al 2003, Kong et al 2007, Silva et al 2008, Blankenbaker et al 2008, Woodley et al 2008, Fearon et al 2010, Long et al 2013, Lange et al 2022) has determined that bursitis is actually unlikely to be the primary contributing factor to symptoms. 

In fact, MRIs often find bursitis in hips that are completely pain-free.

Much of the same research found that the tendons of the gluteus medius and minimus are more often involved. Therefore, gluteal tendinopathy, which refers to pain and impaired function associated with the loading of these tendons, has been proposed as the preferred diagnosis. 

Having said that, it’s important to point out that tendon changes seen on MRI are also common in people without symptoms.

Since these “pathological” findings are present in individuals with and without symptoms, imaging is unnecessary in most instances.

The diagnosis is most common in older, less active perimenopausal women, but it can also occur in a younger, more active population like runners. 

In addition to reporting symptoms with sleeping on the affected side or with activities that load the gluteal tendons, such as walking, running, and climbing up stairs, a study by Grimaldi et al in 2017 concluded that “…a patient who reports lateral hip pain within 30 seconds of single-leg-standing is very likely to have gluteal tendinopathy.”

Alternatively, if pain isn’t elicited when pressing on the greater trochanter, gluteal tendinopathy is unlikely. 

With that information in mind, the naming of a diagnosis matters in how it informs management. 

Many people associate bursitis with the need for ice, complete rest, and anti-inflammatory medication, and that sometimes creates the idea that management of their symptoms is out of their control.

Gluteal tendinopathy provides more options for self-management, including activity modifications and exercise therapy as needed. It’s also been well-documented that other lifestyle and metabolic factors influence the health of tendons, such as diabetes, hypercholesterolemia, adiposity, and certain medication usage like statins and antibiotics. Therefore, any lifestyle interventions to improve overall health (like regular physical activity) can be considered a component of rehab.

Want to learn more?

Check out our full blog about Gluteal Tendinopathy Rehab!

Snapping Hip Syndrome

Snapping hip syndrome refers to a snapping sensation felt on the front or side of the hip that occurs with various motions. The snapping can be painful or painless, and loud, quiet, or completely inaudible. There are 2 primary types: internal and external.

Internal snapping, also sometimes called “Dancer’s Hip”, refers to the iliopsoas tendon (hip flexor) snapping over one of two locations: the head of the femur or a bony prominence on the front of the pelvis known as the iliopectineal eminence. It can be felt when the hip is moved from flexion, abduction, and external rotation to a more extended, adducted, and internally rotated position. 

It’s somewhat confusing, but internal snapping is NOT intra-articular although there are other causes of intra-articular joint noises and sensations, such as labral tears and loose bodies. 

External snapping is usually attributed to the IT band or gluteus maximus moving back and forth over the greater trochanter. It can be felt during side lying flexion and extension of the hip, or during different weight bearing movements, such as a single leg deadlift. 

Whether someone notices the snapping develop randomly or shortly after an injury, it’s typically nothing to worry about. Snapping is common, often happens in people without any pain, and does not mean that anything is wrong with the hip or that issues will arise in the future. 

I like this quote from world-renowned hip specialist, Dr. Thomas Byrd – “For most patients, the treatment is then little more than assurance that this is a normal variant and that the snapping is not indicative of future problems.” For this reason, I prefer to drop the word “syndrome” because it makes snapping hip sound scarier than it is. 

With all that being said, I do understand that pain isn’t the only concern for some people. For example, here’s a top comment from our video about the topic: “It just feels jarring… Like nails on a chalkboard feeling in my body. I know my nails on the chalkboard aren’t harming me, but it makes me feel like I’m going [to] be sick…”

Sometimes that snapping sensation goes away on its own and sometimes activity modifications and a dedicated exercise plan can help.

Want to learn more?

Check out our full blog about Snapping Hip Rehab!

Since I’ve discussed symptoms toward the front of the hip and the side of the hip, let’s shift the focus to the back of the hip. 

Proximal Hamstring Tendinopathy

The hamstring muscles originate on the ischial tuberosity, also referred to as the sit bone, and consist of 3 muscles: the semimembranosus, semitendinosus, and the long head of the biceps femoris. They insert onto the lower leg and primarily contribute to knee flexion and hip extension.

Similar to other tendinopathies, proximal hamstring tendinopathy is characterized by persistent tendon pain and loss of function related to mechanical loading.

This pain is located around the lower gluteal region, which may or may not radiate down the back of the thigh and often occurs during activities and positions that place more stretch, load, and/or compression through the proximal portion of the hamstring tendon. Examples include running uphill, sprinting, movements involving deeper hip flexion (like squatting or lunging), stretching, and sitting for prolonged periods of time.

A sudden increase in some of these activities may be a contributing factor as to why this condition developed in the first place. A simplified explanation is that the loads placed on the affected hamstring tendon through different positions and movements may have exceeded its capacity to recover and adapt appropriately. Think of it as doing “too much, too soon.”

This load is often associated with external factors, such as the intensity, volume, and frequency of training.

For example:

  • Recently incorporating uphill running and sprint intervals into training sessions
  • Or practicing yoga and including more stretching at the end range of hip flexion 

This is why rehabilitation is the focus of management. 

Also, it is worth noting that since hamstring tendon pathology is common in people without pain, imaging is usually not required.

Want to learn more?

Check out our full blog about Proximal Hamstring Tendinopathy Rehab!

Piriformis Syndrome

Trying to neatly categorize other conditions contributing to posterior hip symptoms is, well, a pain in the butt. Oftentimes, symptoms in this region are quickly labeled as “piriformis syndrome.”

However, except in very rare cases, piriformis syndrome probably doesn’t exist in the way that most people think it does. In most instances, it is more likely that irritation of a nerve or structure in the lower back is contributing to symptoms in your butt, thigh, or down the back of your leg. There are different medical terms for this, such as referred pain, radicular pain, and radiculopathy.

The low back should be the top consideration for symptoms in this area until proven otherwise. 

And if not the lower back, the second most common culprit is frequently the hip joint itself. Buttock pain can be a symptom of the intra-articular diagnoses I mentioned earlier, such as osteoarthritis, FAI, and hip dysplasia.

Want to learn more?

Check out our full blog about Piriformis Syndrome Rehab!

Deep Gluteal Syndrome

That doesn’t mean that all posterior hip pain is stemming from the lumbar spine or hip joint, but if you read through the literature or speak to different clinicians, the definitions, explanations, and understanding of symptoms in this region can vary considerably. 

Deep gluteal syndrome was introduced in 1999 by McCrory and Bell as a catch-all phrase to account for any structure contributing to symptoms in this area, including the piriformis, and it’s become much more popular in recent years. As stated by Park et al in 2020, deep gluteal syndrome is “defined as compression of the sciatic or pudendal nerve by any anatomical structure in the deep gluteal space.” If we could see through or pull back the gluteus maximus, that’s essentially the deep gluteal space. 

Park and colleagues include the following diagnoses in deep gluteal syndrome:

  • Piriformis syndrome
  • Gemelli-obturator internus syndrome, named for the gemellus superior, gemellus inferior, and obturator internus muscles
  • Proximal hamstring syndrome, in which irritation of the hamstrings and sciatic nerve co-exist because of their close proximity and
  • Ischiofemoral impingement syndrome, resulting from compression of the sciatic nerve and/or quadratus femoris muscle between the ischial tuberosity and lesser trochanter of the femur when the hip is extended, such as during a long stride when walking or running. 

There is no universal consensus, though. Some authors include different diagnoses and syndromes, while others don’t include ischiofemoral impingement as a subset of deep gluteal syndrome at all. 

Nerves

Having said that, I don’t want to diminish your current experience or a previous experience you’ve had. I’m also not trying to neglect the role that nerves play in contributing to symptoms. There are a lot of nerves innervating the hip and pelvis, and it’s possible for an irritation of one of these nerves to contribute to tingling, burning, numbness, weakness, etc.

However, I encourage clinicians to always perform a thorough examination of the lumbar spine, and for patients to hold their providers accountable for examining their low back so the piriformis muscle isn’t blamed too hastily. 

Sacroiliac Joint Pain

Sacroiliac joint pain is another entity that can be confused with posterior hip pain. 

Sacroiliac joint pain is typically characterized by one sided pain below the level of the lumbar spine that may radiate into the buttock or thigh. Fortin 1994, Slipman 2000, Young 2003, Han 2023, Szadek 2023

It can follow a traumatic event, such as a motor vehicle accident or fall onto the buttock. It can also result from repetitive activities, such as lifting or running. In some cases, the cause of symptoms is unknown. However, sacroiliac joint pain is most commonly related to pregnancy. Ostgaard 1991, Chou 2004, Gutke 2006

Want to learn more?

Check out our full blog about Sacroiliac Joint Pain Rehab!

Fall-Related Fractures & Stress Fractures

Perhaps the most impactful issue I haven’t mentioned yet is fall-related fractures in older adults as the consequences can be severe. Fortunately, many of these falls are preventable. I highly recommend watching our video on how to improve balance and prevent falls. 

Stress fractures can also be quite impactful. The following information is taken from a recent consensus statement by Hoenig et al: 

  • Stress fractures fall under the umbrella of bone stress injuries, which are overuse injuries to bone resulting from “repetitive loading coupled with inadequate time for tissue recovery.”
  • These injuries are most frequent in military personnel and athletes, particularly runners. 
  • “Bone stress injuries in athletes can be termed as low-risk or high-risk based on their anatomical location and risk for progression and/or healing complications.” With regards to the hip, the superior cortex of the femoral neck is considered high risk whereas the femoral shaft is not. 
  • Some risk factors for developing a bone stress injury include increases in training volume or intensity, previous history of a bone stress injury, low body mass index, poor bone health, and insufficient caloric intake to meet energy demands.
  • “Treatment approaches include activity modification, protected weight-bearing, immobilisation, physical therapy, nutritional counselling and, in some cases, surgical fixation.” The experts in this consensus statement largely agreed that most stress fractures should be initially managed non-surgically.

Pediatric / Childhood Conditions

Although I briefly mentioned Developmental Dysplasia of the Hip (DDH), pediatric, or childhood, conditions are not the focus of this blog. However, here are three diagnoses to be aware of: 

  1. Legg-Calve-Perthes Disease, which is basically a type of avascular necrosis that occurs in young children. Its name comes from the 3 surgeons who first described it. 
  2. Slipped Capital Femoral Epiphysis (SCFE), often referred to by its acronym – SCFE, most commonly happens in adolescents. According to Gholve et al “SCFE occurs when the capital femoral epiphysis (the femoral head) displaces posteriorly on the femoral neck at the level of the physis (the growth plate). [However] SCFE is a misnomer because it is actually the femoral neck metaphysis that displaces anteriorly and superiorly in relation to the capital femoral epiphysis.”
  3. Apophyseal Avulsion Fractures, which typically occur when a rapid and forceful contraction of a muscle pulls off part of the bone where it is attached. A study by Ferraro et al in 2023 reported the following: “The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%).”

Cancer, Infection, & Pelvic Floor

The list of diagnoses I have mentioned so far is not all-inclusive and there are non-musculoskeletal causes of hip pain that must always be on the radar of healthcare providers, such as cancer, infections, and organ-related issues. 

There can also be a link between pelvic floor problems and hip symptoms. We have a 30 minute video on the topic if you’d like to learn more. 

Hopefully all of the information up to this point helps you appreciate the complexity of the hip and the importance of a thorough assessment from a licensed healthcare provider.

How To Rehab Your Hip

Before I outline my general recommendations for rehab, I want you to keep in mind that not every problem can be solved with exercise alone. There are times when surgery is necessary for hip osteoarthritis or another diagnosis, and it can be life-changing. Similarly, sometimes bone stress injuries require a period of unloading or immobilization. For the most part, though, rehab is going to have some overarching themes. Here are 5 things most people should consider doing:

  1. Modify aggravating factors, whether that’s related to the gym, recreational and sporting pursuits, or day-to-day tasks. Some discomfort is usually acceptable during rehab, but if you’re consistently pushing into unbearable pain and experiencing flare-ups, you probably need to temporarily scale back whatever it is that’s giving you problems. Think of it as taking 1 step back so you can eventually take 2 steps forward. On the other hand, if you’re a person who has restricted yourself from all exercise and activities for fear of worsening your condition, you might just need to give yourself permission to move. 
  2. Identify if there’s anything you can do that would positively influence your overall health. Sleep, stress, nutrition, alcohol intake, medication usage, and anything else that influences your health and well-being can also influence the onset and persistence of symptoms. My advice would be to reach for the lowest hanging fruit, start small, and write down your intentions so you can reflect on your progress each week. 
  3. Implement targeted exercises to address any deficits in your strength, range of motion, confidence, etc. Exercise can also be used to improve your tolerance to specific activities, such as walking, stair climbing, running, or playing sports. It doesn’t have to be overly complicated. Oftentimes, 1-3 exercises performed a few times per week is a great starting point. 
  4. Use feel good treatments as needed, but you’ll probably get the most benefit from the things that challenge you. 
  5. Recognize that there’s rarely a quick fix. Rehab often takes significant time, effort, and consistency.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Hip Resilience Program!

Hip Resilience Program

Thanks for reading. Check out the video and please leave any questions or comments below. 

The post Why Your Hip Hurts appeared first on E3 Rehab.

]]> https://e3rehab.com/why-your-hip-hurts/feed/ 0 24464 Why Your Knee Hurts https://e3rehab.com/why-your-knee-hurts/ https://e3rehab.com/why-your-knee-hurts/#respond Sun, 05 Jan 2025 14:00:00 +0000 https://e3rehab.com/?p=24356 In this blog, I’m going to tell you why your knee hurts and what you should do about it! Be sure to also check out our Knee Resilience Program! Patellofemoral Pain Let’s start with the front of the knee by discussing patellofemoral pain, also known as “runner’s knee.” “Patello” refers to your patella, or kneecap, while […]

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In this blog, I’m going to tell you why your knee hurts and what you should do about it!

Be sure to also check out our Knee Resilience Program!

Patellofemoral Pain

Let’s start with the front of the knee by discussing patellofemoral pain, also known as “runner’s knee.”

“Patello” refers to your patella, or kneecap, while “femoral” refers to your femur, or thigh bone. The patellofemoral joint is where these two bones meet. Therefore, patellofemoral pain is just a fancy way of saying that your knee hurts. 

It’s usually non-traumatic in nature with diffuse pain gradually presenting behind or around the patella with squatting, jumping, running, or going up and down stairs.

Symptoms may also be present with kneeling or prolonged periods of sitting, which has been labeled the “movie theater” sign.

Imaging is not usually recommended.

Rehab, consisting of exercise and education, is the focus of treatment. 

While joint noise is associated with patellofemoral pain and may be unpleasant or undesirable, it is not an indication that exercise is dangerous or harmful.

Want to learn more?

Check out our full blog about Patellofemoral Pain Rehab!

Knee Osteoarthritis

Knee osteoarthritis is typically described as a degenerative joint disease associated with “wear and tear” of the cartilage within the knee joint. However, it should be thought of as a systemic condition as other factors influence symptoms and the progression of the disease, such as genetics and metabolic health. Plus, many of the structural changes seen on imaging that are associated with knee osteoarthritis are often found in people with no symptoms. 

Aside from pain that can present almost anywhere in the knee, common signs and symptoms include stiffness, swelling, reduced range of motion, and muscle weakness.

Imaging is actually not required for the initial diagnosis and non-operative management is considered the first line of treatment. Some options include:

  1. Education about prognosis and self-management strategies  
  2. Aerobic and strengthening exercise 
  3. Weight loss 

Depending on the severity of symptoms, these interventions may significantly delay, or completely eliminate, the need for surgery.

Want to learn more?

Check out our full blog about Knee Osteoarthritis!

Quadriceps Tendinopathy

Moving up, the quadriceps tendon attaches the muscles of the thigh, known as the quadriceps, to the top of the patella. Pain that is localized to this area is referred to as quadriceps tendinopathy.

The term “tendinopathy” just means that there is persistent pain and a loss of function related to loading of the affected tendon, such as with jumping, squatting, kicking, etc. Tendinopathies usually occur as a result of relative overload or overuse – think “doing too much, too soon.”

Tendinitis, used to indicate an inflammatory process, is not the preferred diagnostic term because acute inflammation is not believed to be the primary driver of the condition and may reflect the normal response to tendon loading and adaptation. Plus, people often associate inflammation with the need for ice, anti-inflammatory medication, and complete rest, which are not the primary treatment strategies recommended. 

Tendinosis, used to indicate a degenerative process, is also not the most appropriate terminology as abnormalities on imaging can be found in people without symptoms and are not always predictive of future issues.

Want to learn more?

Check out our full blog about Quadriceps Tendinopathy Rehab!

Patellar Tendinopathy (Jumper’s Knee)

Patellar tendinopathy, also frequently called “Jumper’s Knee,” is similar except pain is localized just below the patella because the patellar tendon attaches from the bottom of the patella to the tibial tuberosity of the tibia, or shin bone.

Patellar tendinopathy is much more common than quadriceps tendinopathy.

Imaging is not required for either diagnosis and the primary treatment strategies involve education and exercise.

Want to learn more?

Check out our full blog about Patellar Tendinopathy Rehab!

Osgood-Schlatter Disease

Osgood-Schlatter Disease is characterized by localized pain and swelling at the tibial tuberosity where the patellar tendon attaches. It is also painful to the touch. 

It is aggravated with exercises and activities that load the knee, which is why it’s most prevalent in adolescent athletes, particularly those who specialize in a single sport.

Infrapatellar Fat Pad Syndrome (Hoffa’s Syndrome)

Infrapatellar fat pad syndrome, also known as Hoffa’s syndrome, refers to irritation or inflammation of the fat pad that sits behind the patellar tendon. Pain and swelling can occur along either side of the tendon. 

Causes can include surgery, a direct blow or fall to the area, a hyperextension injury, or activities that repetitively stress the structure.

Symptoms may be felt with standing, walking, or activities that involve repetitive extension of the knee. 

Non-operatively, the primary treatment strategy is to try to offload the affected area to allow inflammation and symptoms to resolve.

Medial & Lateral Meniscus

Let’s start moving outward by discussing the medial meniscus toward the inside of the knee and the lateral meniscus toward the outside of the knee. 

Pain is typically described as being felt along the joint line. If you bend your knee, this is the space between the tibia and femur as you move away from either side of the patellar tendon.

However, pain can also be present in the back of the knee. 

Traumatic injuries may need to be managed surgically in some cases, but degenerative meniscus tears, which are a natural feature of aging, should be treated nonoperatively as real surgery has proven to be no more effective than placebo surgery.

Want to learn more?

Check out our full blog about Meniscus Tear Rehab!

Iliotibial (IT) Band

On the outer portion of the knee, the iliotibial band, commonly referred to as the IT band, is named for its attachments to the ilium, or pelvis, and tibia.

It is the lateral thickening of the fascia lata, which is the deep fascia that envelops the thigh like a sausage casing. 

The expansive nature of the IT band allows it to contribute to stability of the hip and knee, as well as store and release energy to make walking and running more economically efficient.

Despite popular belief, IT band-related pain is not a friction syndrome due to tightness of the IT band that requires vigorous rolling or stretching. Although the exact mechanism isn’t fully understood, it’s thought that an error in workload, such as a large spike in running mileage or intensity, is a primary contributing factor.

Want to learn more?

Check out our full blog about IT Band Rehab!

Pes Anserine

On the inner portion of the knee is the pes anserine. The pes anserine, which means “goose’s foot” in Latin, is where the tendons of the sartorius, gracilis, and semitendinosus muscles come together on the tibia.

Pes anserine bursitis refers to inflammation of the bursa that sits underneath these tendons. A bursa is a small, fluid-filled sac that helps reduce friction between structures.

Tendinopathy of these tendons can also occur.

Ligament Sprains

Let’s move on to the ligaments of the knee. Ligaments, which attach from bone to bone, provide passive stability to the knee joint. A sprain is an injury to one of these ligaments, such as the medial collateral ligament, lateral collateral ligament, anterior cruciate ligament, and posterior cruciate ligament.

Medial Collateral Ligament (MCL)

The medial collateral ligament, or MCL, is located on the inner part of the knee and consists of superficial and deep layers. The superficial portion is a long, flat band, while the deep portion is a continuation of the joint capsule with connections to the medial meniscus. Both have attachments on the femur and tibia.

The MCL primarily acts to stabilize the knee against valgus and rotational forces.

The most common mechanism of injury is a “direct blow to the outside of the thigh or leg while the foot is planted, producing [a] valgus movement”. An example is a player getting tackled in football. An injury can also occur when a “valgus stress is coupled with tibial external rotation,” such as during skiing or sports involving cutting and pivoting.

In severe cases, other knee structures can be injured as well, including the medial meniscus, lateral meniscus, posterior cruciate ligament, and most commonly, the anterior cruciate ligament.

Regardless of the severity of the injury, an isolated MCL injury can often be treated nonoperatively due to its high intrinsic healing potential.

Want to learn more?

Check out our full blog about MCL Rehab!

Lateral Collateral Ligament (LCL)

The lateral collateral ligament, or LCL, is the analogous structure on the outer part of the knee. Like the MCL, the LCL helps to stabilize the knee against rotational forces. However, its primary function is to resist varus forces and it is less commonly injured.

An injury to the LCL may occur from a direct blow to the inside of the knee while the foot is planted or from a non-contact mechanism during sport. 

The severity of the injury, the stability of the knee, and the involvement of other structures will influence whether or not surgery is needed.

Anterior Cruciate Ligament (ACL) & Posterior Cruciate Ligament (PCL)

The anterior cruciate ligament, or ACL, and its lesser known counterpart, the posterior cruciate ligament, or PCL, are located within the knee and therefore cannot be palpated. Whether a suspected injury occurs while playing sport or during a motor vehicle accident, imaging is typically necessary. 

Newer research has demonstrated that surgery is not ALWAYS required, but it’s dependent on a variety of factors, such as your goals and the stability of your knee. Regardless, rehabilitation is always recommended, including before and after surgery. 

Let’s move on to the back of the knee.

Want to learn more?

Check out our full blogs about ACL Rehab and PCL Rehab!

Baker’s Cyst

A baker’s cyst is an accumulation of fluid that may be associated with swelling, pain, stiffness, and a sensation of tightness or fullness. For those experiencing symptoms, it is often secondary to an underlying issue, such as knee osteoarthritis. 

Treatment can vary from doing nothing at all to exercise and pain medication to draining of the fluid and a steroid injection.

Popliteus Muscle Injury

The popliteus is a small, deep muscle located on the back of the knee that contributes to stability of this region and is often described as the “key to the knee” for its role in “unlocking,” or flexing the knee, from a fully extended position.

An isolated injury to the popliteus is rare, but if a strain or tendinopathy is suspected, modification of aggravating activities and a structured exercise program are recommended.

Distal Hamstring Tendinopathy

The last diagnosis I’ll touch on is distal hamstring tendinopathy. The hamstrings are the muscles on the back of the thigh that play a significant role in flexion, or bending, of the knee and their tendons can be felt along either side of the knee. 

Although rare, localized discomfort of these tendons with flexion-based exercises or movements should be managed similarly to the other tendinopathies previously discussed.

What About Other Diagnoses?

What about other diagnoses that I didn’t mention? Well, here are 3 things to consider:

1. I can’t cover every possible diagnosis. For example, I didn’t discuss fractures or other injuries that may require immediate medical attention.

2. A specific diagnosis or imaging finding doesn’t always dictate management or rehabilitation. Two people may technically have the same diagnosis or imaging finding, but they might have significantly different symptoms, severity of symptoms, aggravating factors, functional capabilities, goals, lifestyles, etc. Oftentimes the person dictates the rehabilitation process more than the diagnosis itself.

3. Some diagnoses aren’t always as useful as previously believed. For instance, a common concern for individuals with knee pain is chondromalacia patellae. “Chondro” refers to cartilage, while “malacia” means softening. Therefore, chondromalacia patellae refers to a softening or breakdown of the cartilage on the back side of the patella. However, a paper by van der Heijden et al in 2016 found “no difference in composition of the patellofemoral cartilage.. between patients with patellofemoral pain and healthy control subjects.” Some researchers and clinicians have actually suggested that we stop using the terminology. 

This information is important to know because sometimes a diagnosis or imaging finding can cause people to become fearful of certain movements, exercises, or activities. An example of this would be someone with knee osteoarthritis who stops exercising completely because they’ve read or heard that exercise wears out the joint faster. In reality, tolerable exercise is recommended for the knee and the overall health of the person. 

X-rays and MRIs have their place, but there are times when they can create unnecessary worry and lead to further medical tests or treatments that are unwarranted.

It’s also important for me to briefly point out that not all knee pain is related to the knee. Sometimes hip and low back issues can masquerade as knee pain. For example, a person with hip osteoarthritis may experience pain down the front of their thigh or in their knee.

Why Did You Get Knee Pain?

Now that I’ve reviewed the various diagnoses, you might be wondering why you developed pain in the first place. 

In the case of a traumatic injury, like a sudden ACL tear during sport, the ligament is unable to withstand the forces experienced in that moment. 

For non-traumatic cases, a simplified framework for why most injuries occur is that the volume, frequency, and intensity of loading over the course of days, weeks, or months exceeds your current capacity, or your ability to recover and adapt appropriately.

If you’re an active individual, such as a regular runner, it might come down to doing too much, too soon. For instance, if you normally run half marathons but suddenly increase your total running mileage in preparation for a marathon that you want to do next month, that spike in training load may exceed your current capacity. As a result, perhaps you developed patellofemoral pain.

But this process of doing “too much, too soon” can also occur in less active individuals. For example, you might have decided to try a couch to 5K running program or maybe you just went on a vacation that required a lot more walking and stairs than you’re used to. 

As I said, though, this is a simplified framework and it’s not always easy or possible to identify the exact cause of your symptoms. Plus, pain is complex and multifactorial. More than just physical load must be considered.

Sleep, stress, nutrition, alcohol intake, medication usage, and anything else that influences your overall health and well-being can also influence the onset and persistence of symptoms. As I alluded to in the knee osteoarthritis section, there’s been increasing research into how chronic, systemic low grade inflammation can impact different musculoskeletal diagnoses and symptoms. In some ways, this could be thought of as a good thing because it gives you more options for trying to address whatever issue you’re dealing with.

How To Rehab Your Knee

Before I outline my recommendations for rehab, I want you to keep these 4 things in mind:

  1. Unfortunately, there’s not always a quick fix. Rehab often takes significant time and effort. 
  2. There’s usually nothing inherently wrong with you, meaning the shape of your feet or your knees or the way that you walk or whatever it may be probably isn’t the reason for your symptoms. Rehab shouldn’t make you feel bad about yourself or overly self-conscious about a part of your body. 
  3. If it sounds overly complicated, it probably is. Contrary to popular opinion, worrying about how your patella tracks or trying to isolate the activation of certain muscles like the VMO is unnecessary. 
  4. You rarely need anything fancy or expensive for recovery. The basics that I’m going to list work well.

To avoid making this blog any longer than it needs to be, here’s a quick, general blueprint for rehab:

  1. Modify aggravating factors, whether that’s related to the gym, recreational and sporting pursuits, or day-to-day tasks. Some discomfort is usually acceptable during rehab, but if you’re consistently pushing into unbearable pain and experiencing flare-ups, you probably need to temporarily scale back whatever it is that’s giving you problems. Think of it as taking 1 step back so you can eventually take 2 steps forward. However, if you’re a person who has restricted yourself from all exercise and activities for fear of worsening your condition, you might just need to give yourself permission to move. 
  2. Identify if there’s anything you can do that would positively influence your overall health. My advice would be to reach for the lowest hanging fruit, start small, and write down your intentions so you can reflect on your progress each week. 
  3. Implement targeted exercises to address any deficits in power, strength, range of motion, etc. Exercise can also be used to improve your tolerance to specific activities, such as walking, stair climbing, running, or playing sports. If you do incorporate an exercise routine, be sure to include exercises for your quads and hamstrings. Feel free to train your glutes, calves, and other muscles as well; just don’t exclude the muscles that actually cross your knee joint. 
  4. Use feel good treatments as needed, such as tape and massage, but you’ll probably get the most benefit from the things that challenge you.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Knee Resilience Program!

Thanks for reading. Check out the video and please leave any questions or comments below. 

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]]> https://e3rehab.com/why-your-knee-hurts/feed/ 0 24356 PCL Rehab https://e3rehab.com/pcl-rehab/ https://e3rehab.com/pcl-rehab/#respond Sun, 22 Dec 2024 14:00:00 +0000 https://e3rehab.com/?p=24263 In this article, I’m going to teach you everything you need to know about PCL injuries, including whether surgery is necessary, as well as provide you with a comprehensive rehab program. Be sure to also check out our Knee Resilience Program! Anatomy & Function The posterior cruciate ligament, or PCL, attaches from the femur, or thigh […]

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In this article, I’m going to teach you everything you need to know about PCL injuries, including whether surgery is necessary, as well as provide you with a comprehensive rehab program.

Be sure to also check out our Knee Resilience Program!

Anatomy & Function

The posterior cruciate ligament, or PCL, attaches from the femur, or thigh bone, to the tibia, or shin bone and is located just behind the ACL. As the largest and strongest ligament in the knee, it plays a crucial role in maintaining knee stability.

Dr. Johannes Sobotta, Public domain, via Wikimedia Commons

Its primary function is to prevent the tibia from moving backward in relation to the femur, however it also helps stabilize the knee against extreme inward (varus), outward (valgus), and rotational stressors.

PCL Injuries

A PCL injury occurs when a high-energy force causes the tibia to abruptly move backward relative to the femur. The most common causes include motor vehicle accidents when the knee hits the dashboard, or during sports, such as falling onto a bent knee. It can also result from a direct force that causes the knee to hyperextend.

The severity of the injury is typically graded on a scale from 1-3 based on findings from a clinical examination and imaging:

  • Grade 1 involves a partial tear of the PCL with minimal joint laxity.
  • Grade 2 has a tear greater than 50% and moderate joint laxity.
  • Grade 3 has a complete tear of the PCL and significant joint laxity.

Since a PCL injury results from higher forces, they are often associated with other injuries, most commonly involving the ACL, MCL, meniscus, and/or the posterolateral capsule of the knee.

PCL Injury Management

Since the PCL has an intrinsic capability for healing, an isolated tear can be managed nonoperatively with bracing and rehabilitation in many cases. Wang et al 2018, Patel et al 2007, Jacobi et al 2010, Vaquero-Picado et al 2017, Agolley et al 2017

In fact, a 2018 article by Wang et al found that “Nonoperative treatment of isolated PCL injuries results in good subjective outcomes and high rate of return to sport.”

Based on the current evidence, here i s an algorithm for the treatment of PCL injuries:

  • For an isolated grade 1 or 2 tear of the PCL, nonoperative treatment is recommended.
  • An isolated grade 3 injury can also be treated nonoperatively if symptoms are mild and overall activity demands are low. This means the patient does not intend on participating in sports or activities involving jumping, running, twisting, etc. Wang et al 2018, Kew et al 2022.
  • If symptoms and instability continue to persist after conservative treatment for an isolated grade 3 injury, referral to a surgeon would be recommended.
  • Finally, if there is involvement of another structure, such as an ACL tear, surgery would be the preferred treatment. 

Of course, deciding whether to have surgery is always going to be a bit more nuanced — it depends on factors like the severity of your injury, your function, and your personal goals. It should go without saying, but if you suspect you have a PCL injury, you should consult your surgeon to determine the most appropriate option for your specific situation.

PCL Injury Rehab Overview

Whether or not you have surgery, the goal of rehab is to address the main symptoms and deficits associated with a PCL tear. This involves managing pain and swelling, while improving your knee range of motion, strength, and stability during functional activities. These activities range from daily tasks like going up and down stairs to sport-specific movements such as decelerating, jumping, cutting, and pivoting. Wang et al 2018, Vaquero-Picado et al 2017, Agolley et al 2017

The comprehensive rehab program that I am going to present will consist of 3 overlapping categories of exercises that will focus on improving your knee range of motion, strength, stability, and power.

My intention is that you will use these categories as a framework for programming exercises based on your current function, tolerance, and goals. I’ll provide more details and examples of how you can do this later in this article.

Since isolated PCL injuries typically do not require surgery, the rehab principles in this article are geared toward nonoperative cases. Post-operative rehab will be somewhat similar to nonoperative management, but there are some differences due to factors like healing timelines and post-surgical precautions. For instance, following surgery there are typically weight bearing and range of motion restrictions for a set duration of time to protect the surgical reconstruction. Timelines and precautions may also vary depending on whether other structures were surgically addressed, such as your ACL or meniscus.

Immobilization and Bracing

Before diving into the exercises, I want to quickly discuss 2 main considerations to keep in mind during the initial weeks following a PCL injury.

First, one of your primary goals will be to monitor and manage your knee pain and swelling as best as you can. While icing and elevation can help, the key is actually finding the right dosage of activity and exercise without overdoing it. If you push too hard or too fast too soon, it may cause a flare-up and delay your progress.

This ties directly into the second consideration which is immobilization, bracing, and the use of assistive devices. If you’re unable to fully bear weight while walking, crutches may be used initially to manage your pain and swelling by offloading the knee joint. 

Additionally, you will likely wear a knee brace since it is recommended for nonoperative cases and is required following surgery. The most common type is called a dynamic PCL brace. This has a spring mechanism that applies a constant, forward force on the tibia, placing the PCL in a more optimal position for healing. Your doctor may also recommend that the brace is locked into extension for a set duration of time. There are generally 2 main reasons for doing this:

1. It prevents you from bending the knee too much too early, since deeper knee flexion may place more strain on the PCL.

2. It limits hamstring activation through large ranges of knee flexion. Various papers show that contracting the hamstrings at knee flexion angles greater than 10-30° increases strain on the PCL based on how they pull the tibia posteriorly.

Therefore, locking the brace into knee extension theoretically gives the PCL a better chance to heal.

There’s no set guideline on how long to keep the knee brace locked or how long to wear the brace. However, based on a handful of studies looking at nonoperative management, most authors recommend about 2-4 weeks in full extension, and wearing the brace for anywhere between 12-16 weeks following the injury. 

If you had surgery, this timeframe is highly variable depending on your surgeon’s protocol and if other structures were involved, but some recommendations will have the brace locked in extension for about 3-6 weeks and continuing using the brace for up to 4-6 months or longer.

Category #1: Range of Motion Exercises

This involves restoring your knee extension and flexion range of motion.

For knee extension, your goal is to get your knee completely straight, or close to it, as soon as possible. Depending on your previous range of motion, you may even achieve a few degrees of hyperextension.

However, for more severe injuries and following surgery, it’s recommended to avoid pushing into hyperextension early on since this can place more strain on the PCL. 

To improve your knee extension, the main exercise you will want to perform early and often is quad sets. Whether you are sitting or lying on the floor, straighten your leg as best as you can and then squeeze your quadriceps, the muscles on the front of your thigh. Hold for 10 seconds, relax, and repeat 10 times.

When it’s appropriate to do so, more advanced variations include using a strap to pull up on your foot and propping your heel on a small object in order to move through more range of motion. You can perform these quad sets multiple times a day, every day.

For knee flexion, normal range of motion is generally around 135°, or being able to bring your heel to your butt or very close to it. If you had surgery, you will likely have restrictions against how much knee flexion you are allowed in the first few weeks, so it’s important you follow your surgeon’s recommendations. 

Also, as I mentioned earlier, one of the early goals of rehab is to minimize hamstring activation through larger ranges of knee flexion. Therefore, here are two exercises to help restore knee flexion with minimal hamstring contribution.

Option 1: Scooting Knee Flexion. Sit in a chair with your foot flat on the ground, then use your arms to scoot your hips forward, which will help bend your knee further. Perform for 2-3 sets of 30-60 second holds.

Option 2: Seated Heel Slides. Sit on the edge of a chair and place your foot on a slider if you’re on carpet or a towel if you’re on a hard surface. Using your other leg, gently slide your foot backward, trying to bend your knee as much as you can. Hold the end position for a few seconds, then return to the starting position. Repeat for 2-3 sets of 10-20 repetitions.

Once symptoms and function allow, or as your surgeon reduces restrictions, you can progress to assisted heel slides and riding a stationary bike.

For the heel slides, lie on your back, wrap a towel or strap around your foot, and gently pull on it, sliding your heel toward your butt. Perform this exercise for 2-3 sets of 10-20 repetitions.

And finally, the last option is riding an upright stationary bike. Depending on your knee range of motion, you might start by performing half revolutions with the seat high. You can progress by lowering the seat and completing full revolutions. You can do this for anywhere between 5-30 minutes, daily, as tolerated.

Category #2: Strengthening Exercises

The main focus will be on restoring your quadriceps and hamstrings strength. However, if you are looking for a more comprehensive program, I’m also going to review three additional groups of exercises: one focused on strengthening your calves, another targeting your hips and trunk, and a third aimed at improving dynamic balance.

The first group involves strengthening your quadriceps since they are important for improving your knee function and stability, as well as reducing the risk of future injuries. 

In addition to the quad sets mentioned earlier, you’ll also perform straight leg raises in the early stage of rehab. Lie on your back with one knee bent, straighten the other by squeezing your quads, and lift until your thighs are in line with one another. Slowly control back down. An important milestone is being able to perform this movement with your knee completely straight. Once you can do that, build up to 3 sets of 10-20 repetitions.

Other options for strengthening the quadriceps include squats, step downs, and gym based exercises like a leg press.

Many protocols recommend performing these exercises with a limited range of motion early on, as deeper knee flexion can put more strain on the PCL. However, there is no universal consensus for how deep you should go or for how long these restrictions should last. Your physical therapist might progress these movements based on your function and tolerance, while in surgical cases, you will have restrictions based on your surgeon’s protocol. 

Regardless, these exercises will generally start with less range of motion and intensity, and gradually progress over time. For example, the leg press can be performed with two legs through a partial range of motion – which avoids deeper knee flexion – and can be progressed by performing with a single leg, and eventually moving through your full range of motion.

For squats, here is a simple progression I like to use. While holding onto a stable object for support, gently tap your butt to a pad or pillow placed on top of a chair or box, then stand back up. To make this more challenging, you can perform these without upper body assistance. Eventually, you will remove the pad or pillow so you move through more range of motion. And if you want to make them harder, you can hold a weight in your hands. 

When cleared to do so, you can remove the chair or box and perform bodyweight squats to a comfortable depth.

These can be progressed by adding weight in the form of a dumbbell, kettlebell, barbell, etc. 

Ultimately, you can sit into an even deeper, more upright squat by elevating your heels. One of the chief complaints after a PCL injury is pain in the back of the knee when sitting in a deep squat, so carefully improving your tolerance to this position over the course of your recovery can be helpful.

In addition to squats, you will include single-leg exercises to address asymmetries in strength while improving stability and control on each leg. Here are 2 progressions:

Option 1: Split Squats. Start in a stride stance and slowly lower yourself down to a pad or object, before standing back up. If you need to make these easier, use your hands for assistance. Over time, you can make them more challenging by removing the pad, and then eventually holding a weight in your hand.

If you are looking for a more advanced variation, you can try elevating your front foot so you move through more knee flexion range of motion.

Since a main deficit after a PCL injury is difficulty and apprehension with deceleration, incorporating forward lunges can be beneficial for athletes looking to return to field and court sports.

Just like the front foot elevated split squat, this will place increased strain on the PCL and therefore should be reserved for the later stages of rehab.

Another common issue following this injury is difficulty with descending stairs and walking downhill. That leads me to the second single leg progression: step downs. Start with step ups at a lower height either with or without your hands for assistance. Over time, you can gradually increase the height of the step. From here, you can stand sideways and perform lateral step downs or face forward and perform forward step downs. To make these harder, increase the height of the step.

Another option for quad strengthening is leg extensions. Your physical therapist might have you start with two legs through a partial range of motion in order to avoid deeper knee flexion angles.

Over time, progressions include using a single leg and moving through your full range of motion.

If you don’t have access to a leg extension machine, you can do isometrics with a band for 3-4 sets of 15-45 second holds, provided you’re cleared to perform exercises with more knee flexion.

All of these quadriceps exercises can be performed anywhere from 3-4 sets of 5-20 repetitions, depending on the stage of rehab and desired adaptation. For the single leg exercises, you will perform them on both legs. 

The next group of exercises will focus on strengthening your hamstrings.

As I mentioned earlier, there is research showing that contracting the hamstrings at knee flexion angles greater than 10-30° increases strain on the PCL. This means that theoretically a prone hamstring curl through your full range of motion will be more strenuous on the PCL than an isometric prone hamstring curl performed with the knees in a more extended position.

This is the main reason why so many protocols restrict knee flexion-based hamstring strengthening in the early stages of rehab. For example, this literature review of various surgical protocols found that the recommended initiation of resisted hamstring exercises varied from 6 weeks to up to 4 months or longer following PCL surgery. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088114/

Again, your physical therapist might start and progress hamstring exercises based on your function and tolerance. If you had surgery, you will eventually perform the same exercises but you will have restrictions based on your surgeon’s protocol that may limit hamstring strengthening for up to 3-4 months. This is important because this means you will have to work very hard on regaining your hamstring strength in the later stages of rehab, especially if you want to return to sport. 

A general starting point will be performing isometrics with the knee in a more extended position since this places little to no load through the PCL. For instance, you can lie on your back, straighten your legs so your knees are slightly bent, then dig your heels into the ground and think about pulling them toward your butt.

If you have access to a prone hamstring curl machine, you can load up the weight stack and perform an isometric by driving your ankles into the pad at a tolerable effort level. You can do this with two legs or a single leg.

When symptoms and function allow, or you are cleared to do so, you can perform knee flexion strengthening through your full range of motion. This can be done using the prone hamstring curl machine, a seated hamstring curl machine, or on an exercise ball. 

Start with a double leg variation and progress to a single leg over time.

Another option is this slider progression. Start with double leg eccentric only, progress to double leg through your full range of motion, then single leg eccentric only, and finally on a single leg through your full range of motion.

Some athletes may even want to include advanced options like the Nordic hamstring curl in the later stages of their rehab.

Since the hamstrings also contribute to hip extension, you can incorporate movements in which the knees remain relatively straight. These should place less strain on the PCL, so they can be initiated as your symptoms and function allow.

Options include Romanian deadlifts and roman chair hip extensions either with two legs or with a single leg.

You can also work your way through a feet elevated long lever bridge progression. Start with two legs, progress to an eccentric variation where you bridge up on both legs, remove one leg then slowly lower down, and finally you can perform on a single leg.

Similar to quadriceps strengthening, these hamstring exercises can be performed for 3-4 sets of 5-20 repetitions or 15-45 second holds for the isometrics. Again, if you are doing a single leg variation, you will perform the exercise on both sides. 

For those looking for a more comprehensive program, here are 3 additional groups of exercises you can include in your rehab program.

For the calves, a simple standing progression starts with two legs on flat ground and progresses to a single leg on a step with weight.

You can also perform seated heel raises using a machine or with weights on your knees either with your feet on the floor or on a step.

For the hips and trunk, there are endless options but some examples include double leg and single bridges and hip thrusts, short side planks, regular side planks, and side lying hip abduction with or without resistance.

And lastly, you might want to consider adding dynamic balance exercises to help improve your tolerance to rotational and lateral stresses.

Once you can stand on a single leg for at least 30 seconds without losing balance, here are 3 options you can progress to.

Option 1: 3-Way RDL. Start with a single leg RDL without letting the other foot touch the ground. From here, progress to a 3-way RDL, where you reach your arms in 3 directions – to the left, middle, and then to the right. And finally, you will progress the previous movement by adding a knee drive.

Option 2: Y Balance. Stand on one leg and then reach your opposite foot in three different directions, creating a Y shape. You can start with smaller distances, but if you want to make it more challenging, try reaching as far as you can in each direction.

Option 3: Single Leg Rotation. Stand on one leg, rotate your torso as far as you can in one direction, and then rotate as far as you can in the other direction. Start with small rotations and work up to your full range of motion. To make this more challenging, you can add resistance by holding a band.

Any of these dynamic balance options can be performed for 3-4 sets of 30-60 seconds on each leg.

Category #3: Plyometric Exercises

There is limited data on what criteria must be met prior to initiating plyometric exercises following a PCL injury. However, based on a few surgical protocols, some recommendations include possessing full, pain-free knee range of motion, the ability to demonstrate a good quality single leg step down, and quadriceps and hamstring strength of at least 75% compared to the uninjured side. These are actually similar recommendations for beginning plyometrics after an ACL reconstruction.

There are endless options to choose from, but I am going to show you 2 progressions and explain the rationale for each.

The first option is a vertical jump progression since they have been shown to be better suited for improving overall knee function.

Level 1: Box Jump. Start with a box jump since this will reduce landing impact forces.

Level 2: Vertical Jump. Perform a vertical jump, building up to a maximal effort.

Level 3: Depth Drop. Step off an elevated surface and land on two legs.

Level 4: Depth Jump. Step off, land on two legs, and then quickly jump up as high as possible.

Level 5: Single Leg Depth Drop. Step off an elevated surface and land on one leg.

Level 6: Single Leg Depth Jump. Land on one leg, then immediately jump up as high as you can.

In this progression, you can make any level easier by reducing the height of the box and/or reducing the effort of each jump. However, your goal is to use an elevated surface about 12 inches high and/or jump at maximum effort before progressing to the next level.

The second option focuses on deceleration since this is a common difficulty seen in athletes following a PCL injury. 

Level 1: Forward Lunge. Just like the exercise presented earlier, perform a slow and controlled lunge with an emphasis on driving the knee forward.

Level 2: Forward Lunge with Step Back. Same as previous, but after controlling the deceleration, you will push back to the start with power.

Level 3: Forward Step & Land. Jump forward off one leg and land on the other with control. Step back and repeat.

Level 4: Forward Step & Land with a Jump Back. Jump forward, land on the other leg, then quickly jump back to the start.

Level 5: Running with a Step Back.

Obviously these are only some examples. If you want to learn about other plyometric exercises, you can read this article.

To program these in the simplest way possible, you can aim for 2-4 sets of 4-10 repetitions, 2-3 days per week. However, understand that programming will ultimately need to be customized based on your function, symptoms, tolerance, goals, etc.

Individualizing Your Program

If you have made it this far, you might be wondering how you can put all of this information together. Let me provide 4 additional considerations and examples. 

1. These exercises are only some options as the possibilities for exercise selection are limitless. 

2. Timelines and rate of progression vary from person to person. This is influenced by your symptoms, tolerance, and function. However, if you had surgery, you will also have to wait until restrictions are lifted by your surgeon or physical therapist.

3. As I said at the beginning – these categories will have overlap. For instance, even once you begin the plyometrics, you will still be performing the quadriceps and hamstring strengthening exercises.

4. You don’t have to do every exercise or exercise category. To demonstrate what I mean, let me show you 2 sample programs for different patients in the later stages of rehab.

The first patient injured their PCL in a car accident and only wants to be able to return to daily activities. Therefore, they might only focus on restoring their knee range of motion and including functional strength exercises like squats and step downs, 2-3 days a week.

On the other hand, a younger athlete looking to return to sport may incorporate all of the exercise categories presented. This includes progressing to the advanced strength movements like forward lunges and Nordic Hamstring curls, other exercises targeting the calves, hips, and trunk, the dynamic balance options, and the plyometric progressions. Since they are doing more volume overall, they may decide to split these exercises across 2-4 days a week.

This athlete will also need to understand how to safely return to running and sport.

Return to Running & Sport

Running can be initiated when you meet the criteria for starting plyometrics. 

This usually starts with walk-to-jog intervals on a treadmill and progresses to continuous jogging before slowly ramping up to faster running speeds. 

This straight-line running on a treadmill will eventually turn into full sprints, cutting, and multi-directional drills. These are crucial for exposing your knee to lateral and rotational forces at progressively faster speeds.

Returning back to sport will also follow a gradual progression. An article by Kew et al. in 2022 looked at return to play after PCL injuries and noted 4 common criteria:

1. Demonstrates quadriceps strength >90% of the uninjured leg.

2. Has no evidence of instability or giving way.

3. The athlete is psychologically ready.

4. Demonstrates >90% function on return to sport testing.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9789230/

Based on the precautions with knee flexion-based hamstring strengthening, I also think an athlete should be able to demonstrate hamstring strength >90% of the uninjured leg to help maximize return to sport and reduce the risk of future injuries.

Understand that when you return to sport, this doesn’t mean you are immediately returning to full competition. Since data on PCL injuries is currently lacking, I like this progression from Brinlee and colleagues when returning athletes back to competition following an ACL reconstruction:

  • It begins with non-contact practice, followed by small-sided contact practices, then full practice, return to competition with a restricted workload, and finally, return to competition without restrictions.
  • An athlete should be able to work through these steps without apprehension, pain, instability, effusion, or compensations.
https://pubmed.ncbi.nlm.nih.gov/34903114/

The takeaway here is that you are gradually increasing the intensity, volume, and complexity of your training. If you haven’t played your sport in months to years, that’s a lot of work that you need to make up.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Knee Resilience Program!

Thanks for reading. Check out the video and please leave any questions or comments below. 

Want to learn more? Check out some of our other similar blogs:

ACL Rehab, Meniscus Tears, MCL Sprain Rehab

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]]> https://e3rehab.com/pcl-rehab/feed/ 0 24263 Why Your Ankle Hurts https://e3rehab.com/why-your-ankle-hurts/ https://e3rehab.com/why-your-ankle-hurts/#respond Sun, 15 Dec 2024 14:00:00 +0000 https://e3rehab.com/?p=24169 In this blog, I’m going to tell you why your ankle hurts and what you should do about it! Be sure to also check out our Ankle Resilience Program! Ligament Injuries (Sprains) Not only am I going to discuss the location of these injuries, but I’m going to try to categorize them by the type of […]

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In this blog, I’m going to tell you why your ankle hurts and what you should do about it!

Be sure to also check out our Ankle Resilience Program!

Ligament Injuries (Sprains)

Not only am I going to discuss the location of these injuries, but I’m going to try to categorize them by the type of tissue involved, beginning with ligaments. 

A ligament, which attaches from bone to bone, provides passive stability to joints and an injury to this structure is known as a sprain. Let’s start by reviewing the most common ankle injury.

Lateral Ankle Sprain

A lateral ankle sprain occurs when you twist or roll your ankle inward at a high speed. The ligament usually involved is the anterior talofibular ligament, or ATFL, and sometimes the calcaneofibular ligament, or CFL. Both ligaments attach to the fibula, the bone located on the outer part of your ankle.

Lateral ankle sprains are typically graded on a scale from 1 to 3. Grade 1 is a mild injury with a relatively quick return to activity. Grade 2 is a moderate injury with a slightly longer recovery. Grade 3 is a severe injury that takes the longest to rehabilitate. Generally speaking, a grade 3 injury will also present with the most swelling and bruising.

Regardless of the degree of injury, proper rehab is crucial because up to 40% of individuals develop chronic ankle instability after a first time ankle sprain. 

Want to learn more?

Check out our full blog about Lateral Ankle Sprain Rehab!

Chronic Ankle Instability

Chronic Ankle Instability (CAI) is defined as a “condition characterized by repetitive episodes or perceptions of the ankle giving way; ongoing symptoms such as pain, weakness, or reduced ankle range of motion (ROM); diminished self-reported function; and recurrent ankle sprains that persist for more than 1 year after the initial injury.” 

Essentially, it’s an ankle sprain that never fully healed and continues to give you problems.

Want to learn more?

Check out our full blog about Chronic Ankle Instability Rehab!

Fractures (Ottawa Ankle Rules)

Before moving on, it’s important for me to point out that after any traumatic injury to the ankle or foot, the Ottawa Ankle Rules will be used by a healthcare professional to rule out the possibility of a fracture. These criteria suggest that if you don’t have the ability to bear weight and walk four steps immediately after the injury or if you have tenderness at specific bones (the lateral malleolus, base of the 5th metatarsal, medial malleolus, or navicular), x-rays are indicated. 

High Ankle Sprain (Syndesmosis Injury)

A high ankle sprain, also known as a syndesmosis injury, refers to an injury to the distal tibiofibular joint, which is the connection between the tibia, or shin bone, and fibula. 

The primary ligaments that support this joint are the anterior inferior tibiofibular ligament (AITFL) in front, the posterior inferior tibiofibular ligament (PITFL) in back, and the interosseous ligament in between. 

Unlike a lateral ankle sprain in which you twist or roll your ankle, a syndesmosis injury occurs when your foot is planted, your ankle is dorsiflexed, and your foot is rotating outward relative to your tibia. The majority of injuries involve contact, such as being tackled in football. Click here for a video. 

This injury may be suspected based on certain characteristics, such as the mechanism of injury, location of pain, difficulty walking, or the inability to hop on one leg. 

Due to the high-force mechanism of injury, it’s also possible for disruption of the deltoid ligament and fractures to occur.

Want to learn more?

Check out our full blog about High Ankle Sprain Rehab!

Medial Ankle Sprain

An isolated medial ankle sprain, which is an injury to the deltoid ligament on the inner portion of the ankle, is rare for 2 reasons:

  1. The bony anatomy of the ankle mostly prevents the extreme range of motion that would injure this ligament. 
  2. The deltoid ligament, which actually consists of 4 ligaments, is very strong.

Instead, injuries often coincide with fractures or high ankle sprains as previously mentioned. 

Osteochondral Lesion

Sometimes trauma, or repetitive trauma, can lead to damage or a breakdown of the cartilage and underlying bone of the ankle. This is known as an osteochondral lesion, specifically of the talus bone. Symptoms may include deep, diffuse pain toward the front of the ankle, as well as swelling and the sensation of the joint being blocked.

Anterior Impingement (Footballer’s Ankle)

Anterior impingement, also referred to as footballer’s ankle, is another reason why someone may report discomfort in the front of their ankle and the feeling of it being “blocked” when moving into dorsiflexion. This may result from irritated soft tissue structures or the development of a bone spur.

Keep in mind that except in the cases of more severe or impactful injuries, rehabilitation is usually the first line of treatment for most of the diagnoses I’m discussing in this blog.

Tendon Injuries (Tendinitis/Tendinopathy)

Let’s move on to tendons, which connect muscles to bones.

Despite popular belief, tendinitis is not a recommended diagnostic label for tendon-related pain because acute inflammation does not seem to be the primary driver of symptoms.

This means that rehabilitation does not need to take an anti-inflammatory approach involving ice, medication, and complete rest for an extended period of time. 

Rather, tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading.

Unlike ankle sprains, tendinopathies are usually gradual in nature with no distinct mechanism of injury. Although their onset is multifactorial, it’s easiest to think about tendinopathies as load-related issues.

Load refers to any position, movement, or activity that challenges the affected tendon, such as walking, running, jumping, hopping, etc. Capacity is your ability to tolerate those loads, recover, and adapt appropriately. Therefore, tendinopathies are thought to arise when these various loads exceed your capacity to tolerate them.

Much of the time they’re described as repetitive overuse or relative overload injuries, along the lines of “doing too much, too soon.”

It’s important for me to point out that your capacity is influenced by a variety of factors, such as certain medications, lack of sleep, and your metabolic health.

Now let’s review the tendinopathies of the ankle.

Achilles Tendinopathy (Mid Portion and Insertional)

Named for the Greek mythological hero, Achilles, the Achilles tendon is the strongest and thickest tendon in the human body. During walking and running, the load experienced by the Achilles tendon reaches up to 4 and 8 times your bodyweight. The primary calf muscles, the gastrocnemius and soleus, attach to the calcaneus, or heel bone, via the Achilles tendon. 

Individuals with Achilles tendinopathy will typically report localized pain of the tendon that is provoked with palpation, stretching, or loading, such as with walking and running. Stiffness, especially in the morning, and thickening of the tendon are also common.

Achilles tendinopathy is categorized based on the location of symptoms as either mid-portion or insertional. Mid-portion Achilles tendinopathy is the more common diagnosis of the two.

Want to learn more?

Check out our full blog about Achilles Tendinopathy Rehab!

Achilles Tendon Rupture

Individuals with Achilles tendinopathy are often fearful about rupturing their Achilles tendon, but it’s actually unlikely to occur in those experiencing pain. 

Unfortunately, there usually aren’t warning signs or symptoms leading up to the injury.

An Achilles tendon rupture most commonly occurs from a sudden and forceful contraction of the calf muscles while the ankle is dorsiflexed, such as during sport-specific movements like forward acceleration, cutting, and jumping.

https://pubmed.ncbi.nlm.nih.gov/36172398/

People describe the feeling as if they were “kicked in the back of the leg” or as “a popping or giving way sensation in their heel.”

It typically presents with swelling and bruising, and there may be a palpable gap, most frequently 2-6 cm above the heel bone.

In the physical therapy setting, specific clinical tests like the Thompson test help confirm the diagnosis. While the patient is lying on their stomach, the calf muscles are squeezed. Normally, this results in ankle plantar flexion, but in cases of an Achilles rupture, no ankle movement will occur.

Want to learn more?

Check out our full blog about Achilles Tendon Rupture Rehab!

Sever’s Disease

Although the location of symptoms may be similar, Sever’s disease should not be confused with insertional Achilles tendinopathy.

Sever’s is an irritation of the growth plate where the Achilles tendon attaches to the calcaneus. It usually occurs in children and adolescents involved in sports requiring repetitive jumping and running.

Posterior Impingement (Dancer’s Heel)

A diagnosis located in the back of the ankle that does occur in adults is posterior ankle impingement. Unlike individuals with anterior impingement who experience symptoms with dorsiflexion, people with posterior impingement experience symptoms with plantarflexion. This is why it’s often referred to as dancer’s heel.

Peroneal Tendon Injuries

The peroneal longus and brevis muscles are located in the outer compartment of the lower leg. The tendons of these muscles wrap around the lateral malleolus, the bony landmark on the outer portion of your ankle, and are held in place by the superior and inferior peroneal retinacula.  

There are three primary types of peroneal tendon injuries: subluxations, tears, and tendinopathies.

An acute peroneal tendon subluxation, in which the tendon has slipped out of its groove behind the lateral malleolus, may occur when the superior peroneal retinaculum is torn. The mechanism of injury often involves a contraction of the peroneals when the ankle is in a dorsiflexed and nonneutral position during stopping, landing, or cutting in sports, such as skiing, gymnastics, soccer, basketball, and football.

A complete rupture of a peroneal tendon may also occur during a high-force mechanism of injury.

Non-traumatic injuries are not acute in nature and don’t require prompt medical attention. For example, it’s possible to have chronic peroneal tendon subluxations (indicated by a history of snapping or popping) or a partial tear, while having little to no symptoms or loss of function.

Peroneal tendinopathy may be related to activities like running or playing sports, or associated with recurring lateral ankle sprains. It’s not uncommon for chronic ankle instability and peroneal tendon issues to go hand-in-hand. Symptoms may be reproduced with palpation of the tendons, stretching of the tendons into dorsiflexion and inversion, or contraction of the tendons into eversion.

Want to learn more?

Check out our full blog about Peroneal Tendinopathy Rehab!

Tibialis Posterior Tendinopathy

On the opposite side of the ankle, the tibialis posterior tendon passes behind the medial malleolus.

The tibialis posterior’s main functions are highlighted in standing, walking, and running as it helps to support and control the medial longitudinal arch of the foot. 

For simplicity, it can be helpful to think about tibialis posterior tendinopathy occurring along a continuum. 

On one end, it might happen in an otherwise healthy runner who recently had a spike in mileage that resulted in an acute overload of the tendon. Toward the other side of the continuum, this might be a chronic issue in a relatively sedentary individual with a higher body mass, resulting in a significant decrease in function.

In addition to pain along the inner aspect of their foot and/or ankle, individuals diagnosed with tibialis posterior tendinopathy may present with a more pronated foot posture. This too can occur along a continuum and progress as the condition worsens. 

For instance, someone may present with a flexible flatfoot deformity, which is “characterized by forefoot abduction, a lowered medial longitudinal arch and/or hindfoot eversion.” A rigid flatfoot deformity would represent a more fixed posture of the foot in weight bearing and non-weight bearing, and would likely coincide with a significant progression of the condition along with other comorbidities.

Please understand that having “flat” or “flatter” feet is often normal and does not necessarily mean you’re going to develop tibialis posterior tendinopathy. 

Lastly, people with tibialis posterior tendinopathy may experience pain and difficulty with performing single leg heel raises, or the complete inability to perform them.

Want to learn more?

Check out our full blog about Tibialis Posterior Tendinopathy Rehab!

Flexor Hallucis Longus Tendinopathy (Dancer’s Tendinopathy)

The flexor hallucis longus tendon is located in close proximity to the tibialis posterior tendon. Flexor hallucis longus tendinopathy, or dancer’s tendinopathy, is generally seen in dancers, gymnasts, and other sporting populations. 

Symptoms can include pain along the path of the tendon, pain and weakness with resisted flexion of the big toe, limited and painful extension of the big toe, and difficulty with heel raises and pushing off of the foot, such as with walking and running.

Clicking, popping, and swelling may also be present.

As they’re frequently referred to as dancer’s heel and dancer’s tendinopathy, posterior ankle impingement and flexor hallucis tendinopathy can occur simultaneously.

Tibialis Anterior Tendinopathy

The tibialis anterior tendon is located toward the front of the ankle and top part of the foot. The tendon can be seen and felt when performing dorsiflexion.

Although tibialis anterior tendinopathy is rare compared to the other tendinopathies I’ve discussed, it may be suspected if localized symptoms started after a recent change or increase in activity involving repetitive dorsiflexion.

Bone Stress Injuries & Stress Fractures

Since I mentioned that fractures may result from a traumatic injury, it’s important for me to briefly touch on bone stress injuries and stress fractures as well. 

As defined by Warden and colleagues, “Stress fractures are a type of ‘bone stress injury’ (BSI). A BSI represents the inability of a generally normal bone to withstand repetitive loading leading to localized bone weakness and pain.”

These types of injuries are said to be the result of training errors or errors in workload, which is why they’re most common in runners and military recruits. Diet and nutrition, among other factors, also play an essential role. 

Many bones of the foot and ankle can be affected. Localized bony tenderness and a decreasing tolerance to weight bearing activities, such as walking and running, should raise suspicion. 

MRIs, not X-rays, are the gold standard for the diagnosis of bone stress injuries.

Nerves

The final group of tissues I want to discuss is nerves. Nerves can get irritated as the result of an acute event, like an ankle sprain, if they’re quickly overstretched, but problems can also happen more gradually. Typical signs and symptoms include tingling, numbness, burning, and weakness in the ankle or foot. 

Keep in mind that nerve issues can originate higher up in the leg or low back, so it can be helpful to work with a healthcare provider to determine the source of symptoms.

What About Other Diagnoses?

What about other diagnoses that I didn’t mention? Well, there are 2 things to consider:

  1. I can’t cover every possible diagnosis, but I did my best to review the ones that are most prevalent. 
  2. As you’re about to learn, most of the strategies and goals for rehab are similar between diagnoses.

How To Rehab Your Ankle

Assuming you don’t have a fracture, you’ve received clearance from your medical doctor, and you have no other contraindications to exercise, you should be ready to jump into full training, right?

Not necessarily.

Consider these two ankle sprain examples:

  1. A person experiences a grade 1 lateral ankle sprain, takes it easy for a day or two, and then gradually gets their ankle moving and resumes normal activity within a couple of weeks with no major problems.
  2. A different individual suffers a more severe ankle sprain with significant swelling and bruising. Based on their symptoms and function, this person decides to use crutches for a few days, an ankle brace for a month, and it takes them longer to fully recover.

You rarely need to completely rest and avoid all symptoms after an injury, but you also shouldn’t approach rehab with a “no pain, no gain” mentality. Unfortunately, it’s not a perfect science. Rehab is about finding that fine line between doing too much and doing too little. Whether you need more or less movement depends on different factors, such as the recency of your injury and the severity of your symptoms.

In the case of an ankle sprain, you want to allow the injured tissues to heal while minimizing swelling, managing pain, and slowly restoring function. Sometimes the temporary use of tape, a brace, or assistive devices are beneficial for helping to accomplish those goals. 

With regards to exercises, your selection will be dependent on your needs. Sticking with the ankle sprain example, exercises might focus on:

  1. Swelling
  2. Range of Motion
  3. Single Leg Balance
  4. Ankle and Foot Strength (with an emphasis on heel raise variations)
  5. General Lower Body Strength 
  6. Jumping and Hopping Progressions

These would likely be performed during different phases of your rehab over the course of weeks or months. 

As you resume your normal activities and sports, you’d want to do so using a graded approach. Small, structured progressions in your rehab help ensure that you’re adequately prepared for whatever it is you want to get back to.

Although I’ve been referencing ankle sprains, this information would apply to tendinopathies and other overuse-type injuries as well. However, there might be slight differences in priorities. For example, a runner with Achilles tendinopathy may not need to address swelling or work on improving their range of motion. Instead, their emphasis should be on improving the capacity and tolerance of their calf and Achilles complex through heel raises and, eventually, jumping and hopping. There should also be a focus on appropriate load management, meaning the runner adjusts the speed, distance, and frequency of their runs to a tolerable level, while implementing reasonable progressions over time.

For any injury, your overall health should not be overlooked. For instance, at the very least, a person with a bone stress injury should evaluate their diet and nutrition. An individual with tibialis posterior tendinopathy and Type 2 Diabetes may simultaneously address their ankle and foot while also trying to adopt a healthier lifestyle.

For those of you wondering about shoes and orthotics, they can be used as part of a comprehensive treatment plan. However, it’s usually best to think about shoes and orthotics as shifting forces to, or away from, certain tissues of the foot and ankle as opposed to changing the structure of your feet. For example, someone with a highly symptomatic Achilles tendinopathy may opt for shoes with a greater heel-to-toe drop to temporarily reduce the load on their Achilles tendon. Similarly, an individual with tibialis posterior tendinopathy may choose to use supportive, athletic footwear or trial inverted foot orthoses to reduce the demand on the tibialis posterior tendon during walking.

With all that being said, just be aware that rehab can require significant time and effort. 

And as a reminder, we have full-length blogs dedicated to most of these diagnoses, so check those out if you’re looking for more in-depth information.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Ankle Resilience Program!

Thanks for reading. Check out the video and please leave any questions or comments below. 

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]]> https://e3rehab.com/why-your-ankle-hurts/feed/ 0 24169 How To Improve Your Knee Range of Motion https://e3rehab.com/how-to-improve-your-knee-range-of-motion/ https://e3rehab.com/how-to-improve-your-knee-range-of-motion/#respond Sun, 08 Dec 2024 14:00:00 +0000 https://e3rehab.com/?p=24024 In this article, I am going to show you how to improve your knee extension and flexion range of motion after an injury or surgery! Be sure to also check out our Knee Resilience program! Knee Extension Range of Motion Normal knee extension is typically 0°, meaning the knee is completely straight. In some cases, […]

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In this article, I am going to show you how to improve your knee extension and flexion range of motion after an injury or surgery!

Be sure to also check out our Knee Resilience program!

Knee Extension Range of Motion

Normal knee extension is typically 0°, meaning the knee is completely straight. In some cases, the knee may extend slightly beyond this into hyperextension.

Whether you’re recovering from an injury or surgery, the goal is typically to restore your knee extension to the same amount as your uninvolved side. This means if you can achieve 5° of hyperextension on your uninvolved side, then your goal is to regain 5° of hyperextension on your involved side. You’re aiming for symmetry.

If you’ve had surgery on both sides or your uninvolved side isn’t a good reference due to a prior injury, then I would recommend, at the very least, aiming to get the knee completely straight.

Restoring your knee extension as quickly as possible is a primary goal following most knee injuries and surgeries because getting your knee straight sooner makes walking and other activities easier. I’ll review two main options that will improve your knee extension, as well as reduce swelling and improve your function. These exercises are usually introduced within the first few days after an injury or surgery.

The easiest thing you should be doing throughout the day, every day, are quad sets. Straighten your leg as best as you can, then squeeze your quads (the muscles on the front of your thigh) by trying to push the back of your knee into the floor or surface you’re resting on. Hold for 10 seconds, relax, and repeat 10 times.

If your knee has limited extension after surgery, you can place a small towel under your knee for comfort. To progress the quad set, prop your heel on a towel or small object in order to move through more range of motion.

You can also do quad sets from a seated position. If you are sitting in a chair, on the couch, or on your bed, scoot forward to the edge, and straighten your leg as best as you can. From here, squeeze your quads for 10 seconds, relax, and repeat 10 times.

If you’d like to intensify the movement as your range of motion improves, you can use a strap to pull up on your foot, adding a calf and hamstring stretch while you perform the same quad contraction.

You should start these quad sets early and perform them as often as possible – multiple times throughout the day, every day. These are essential for restoring knee extension, reducing swelling, and improving function, which, again, will make walking and other activities easier. It’s hard to overdo these, so I can’t stress enough how important they are. 

Another exercise most individuals will want to do, especially after surgery, involves propping your heel on a towel or object, trying to accumulate about 30-60 minutes a day. 

Since some people might not tolerate this duration initially, it’s okay to break this up into 5-15 minute sessions, 2-6 times a day. Some individuals may even need more or less time depending on their injury, surgery, personal circumstances, or their physical therapist’s recommendations. 

Over time, you can progress by increasing the frequency and duration, or by adding weight to increase the stretch, such as placing a small weight on your thigh or a bag over your leg.

As you gain more strength and control, here are 3 additional exercise options:

Option 1: Straight Leg Raise. Lie on your back with one knee bent, straighten the other by squeezing your quads, and lift until your thighs are in line with one another. Slowly control back down. An important milestone is being able to perform this movement with your knee completely straight. Once you can do that, build up to 3 sets of 10-20 repetitions.

Option 2: Banded TKE. Grab a moderate to heavy resistance band, securely anchor it to a sturdy object in front of you, and place the other end behind your knee. Push the back of your knee into the band by squeezing your quads, hold for 10 seconds, relax, and repeat 10 times. If you don’t have a band, you can also perform a similar movement by pushing the back of your knee into a towel, small ball, or another soft object against a wall.

Option 3: Retro (or Backward) Walking. Take a small step back, slowly lower your heel to the ground, and straighten your knee by squeezing your quads. This can be done in open space or on a treadmill for 5-15 minutes at a time.

I’ll discuss programming a bit later in this article, so for now let’s move on to exercises for improving knee flexion range of motion.

Knee Flexion Range of Motion

Normal knee flexion is typically around 135° or getting your heel to your butt, or very close to it.

In most cases, your goal is to restore the same amount of knee flexion as your uninvolved side, if feasible. For instance, after an ACL reconstruction, meniscus repair, or mild ligament sprain, this is a reasonable goal. In contrast, following a total knee replacement, achieving 135° of knee flexion may not be realistic or even necessary. To give you some context, many post-surgical protocols recommend restoring about 115-120° of flexion by 2-3 months after surgery.

I’m going to review 7 options of varying levels of difficulty. If you don’t have restrictions, these can usually begin within the first few days after an injury or surgery.

However, keep in mind that certain surgeries will have restrictions for a set duration of time to protect the surgically addressed structures. For example, after a meniscus repair, your surgeon may restrict knee flexion to no more than 90° for a month or longer.

Option 1: Heel Slides. The first (and probably most popular) option is heel slides. While lying on your back, slide your heel toward your butt, bending your knee as much as you can. Hold the end position a few seconds, then slowly straighten your knee, and repeat. You can place your foot on a slider if you’re on carpet, a towel if you’re on a hard surface, or simply hover your heel just above the ground.

To increase the intensity, wrap a towel or strap around your foot, slowly slide your heel toward your butt, and then gently pull on the towel or strap to help bend your knee further. These heel slides can be performed for 2-3 sets of 10-20 repetitions.

Option 2: Recumbent Bike. Position the seat further back and begin with partial revolutions, moving your knee in and out of as much flexion as tolerable. Once you’re able to complete full revolutions, gradually move the seat forward to expose the knee to more flexion.

You can also follow a similar progression on a stationary bike. Start with the seat at a higher level and do partial revolutions. As your mobility improves and you can complete full revolutions, move the seat down to further challenge and increase your knee flexion.

This can be done daily for 5-30 minutes, gradually increasing the duration as tolerated. Early on, you may only manage 5 minutes a day, but as your tolerance improves, you can slowly work up to 20 minutes or more.

Option 3: Scooting Knee Flexion. Sit in a chair with your foot flat on the ground, then use your arms to scoot your hips forward, which will help bend your knee further. Perform for 2-3 sets of 30-60 second holds.

Option 4: Seated Heel Slides. Sit on the edge of a chair and place your foot on a slider if you’re on carpet or a towel if you’re on a hard surface. Gently slide your foot backward, trying to bend your knee as much as you can. You can use your other leg to provide gentle overpressure if desired. Hold the end position for a few seconds, then return to the starting position. Repeat for 2-3 sets of 10-20 repetitions.

The next two options involve a component of kneeling, which might not be comfortable or realistic for everyone, especially soon after surgery when the wound is healing and is more sensitive to pressure.

The first kneeling option is a kneeling progression. Start on your hands and knees and gently rock your butt back toward your heels as far as comfortable. To progress, perform a tall kneeling rock back, where you transition from a tall kneeling to a low kneeling position. Finally, if you want to bias one knee, start in a half kneeling position and sit your butt back to your heel. Hold the end position for a few seconds and repeat for 2-3 sets of 10-20 repetitions.

For any level, you can place a small towel behind your knee which may make the bottom position more comfortable and allow you to move into more knee flexion.

The second kneeling option is called a couch stretch. Set up in a half kneeling position with your back foot resting on a bench, chair, or couch. Gently rock backward, trying to bring your butt toward your heel. Aim for 2-3 sets of 30-60 second holds or 10-15 repetitions, moving slowly in and out of your end range.

The last exercise option is squats, which everyone will incorporate at some point in their recovery to improve range of motion, strength, and tolerance to weight-bearing knee flexion.

Depending on your injury or surgery, you will likely start with mini squats and progress to regular squats over time.

Some individuals might even work their way up to heel elevated squats. By elevating your heels on plates, wedges, or another object, you’re able to squat even lower, especially if you build up to holding a weight in your hands. Aim for 2-3 sets of 5-15 slow and controlled repetitions.

 Knee Range of Motion Exercise Recommendations

Before I discuss programming, I have two important recommendations:

First, while regaining range of motion may feel uncomfortable at times, it should never be unbearable. If you’re gritting your teeth or holding back tears during the exercises, it can be counterproductive, as the resulting pain and swelling can delay your progress.

This leads to the second recommendation: closely monitor and manage your symptoms. In the early days and weeks after a knee injury or surgery, it’s crucial to find the right balance of exercise, activity, and movement that will improve your symptoms and function without overdoing it. For example, you might want to rush off your assistive device as quickly as possible, but crutches, walkers, and canes are meant to help offload the knee temporarily. Discontinuing an assistive device before you’re ready can also be counterproductive. 

Restoring your range of motion is going to be a lot easier if your pain and swelling are managed appropriately. Along with the recommendations just mentioned, other options for managing symptoms include compression, ice, and elevation, if desired.

Programming Knee Range of Motion Exercises

So, how do you put all of this information together to create a structured program?

Well, your exercise selection and rate of progression will vary based on numerous factors including your injury or surgery, function, tolerance, symptoms, access to equipment, and goals. I will show you 4 examples to illustrate what I mean, but keep in mind that your unique circumstances should be discussed with your surgeon and physical therapist.

1. You are recovering from an ACL reconstruction.

In this case, exercises can usually be started in the first few days after surgery. To help restore knee extension, the heel prop exercise can be performed for 5-15 minutes, 2-6 times a day while the quad sets should be done as often as possible every single day. For knee flexion, you might ride a stationary bike for 5-10 minutes every day and perform the assisted heel slides for 2-3 sets of 10-20 repetitions, 2-3 times a day.

As your range of motion, symptoms, and tolerance improves, you can progress the volume and intensity of exercises. For instance, you might add a weight to the heel prop exercise and increase hold times to 10-15 minutes, start performing straight leg raises, and ride the bike for longer durations, all while continuing with the assisted heel slides until full knee flexion is achieved. You’ll likely be doing other exercises relevant to ACL rehab as well.

Your goal is to restore the same amount of knee extension and flexion as your uninvolved side (assuming it’s feasible) as soon as possible. Typically, regaining your knee extension will take a few weeks, while restoring full knee flexion may take about 2-3 months or longer.

2. You recently had your meniscus repaired.

Your programming will eventually look very similar to the previous example, but there is one major difference – your surgeon may place a restriction that prevents you from bending your knee past 90° for a month or more. This means that until your restrictions are lifted, you may be limited in your exercise selection and range of motion.

3. You had a total knee replacement.

Again, your programming may look similar to the ACL example, however your timeline, expectations, and end goals might differ. For instance, while your goal is to restore full knee extension, it’s important to understand that achieving full knee flexion may not be realistic or even necessary. There are some surgical protocols that recommend reaching about 115-120° by 8-12 weeks, but this may not be the case for everyone.

4. You experienced a minor knee injury a few days ago while practicing jiu jitsu.

If you notice knee swelling, active exercises like the heel slides and supine quad sets can be used early on to reduce your swelling and regain your range of motion. Over the next couple of weeks, you might decide to perform banded TKEs to improve knee extension strength and control, while also working on kneeling and deep squats to build tolerance to end-range knee flexion and better prepare for your return to sport.

Exercises like the heel props don’t necessarily need to be included since your range of motion will likely improve as your swelling goes down and your tolerance improves.

Summary

Here are the 3 main takeaways I want you to know about restoring your knee range of motion after an injury or surgery.

1. Keep exercises tolerable, try to minimize flare-ups and increases in swelling, and follow the post-operative restrictions and recommendations from your surgeon and physical therapist.

2. In most cases, your goal is to restore the same amount of knee extension and flexion as your uninvolved side. 

3. Perform these exercises early and often within tolerance. The sample programs I provided might seem like a lot, but regaining your knee range of motion is extremely important for improving symptoms, restoring function, and ensuring the rest of rehab goes smoothly. 

If your range of motion remains restricted after a certain period of time, it may be recommended to follow up with your surgeon. For example, someone struggling to regain at least 0° of knee extension by 4-6 weeks after an ACL reconstruction may need further evaluation.

Lastly, for those who are planning to have surgery, the exercises reviewed in this article can be used to help prepare you for both the procedure and the post-operative rehabilitation process.

Looking for 1-on-1 help? Check out our consultation and coaching services!

Thanks for reading. Check out the video and please leave any questions or comments below. 

Want to learn more? Check out some of our other similar blogs:

ACL Rehab, Meniscus Tears, MCL Sprain Rehab

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]]> https://e3rehab.com/how-to-improve-your-knee-range-of-motion/feed/ 0 24024 Why Your Shoulder Hurts https://e3rehab.com/why-your-shoulder-hurts/ https://e3rehab.com/why-your-shoulder-hurts/#respond Tue, 03 Dec 2024 21:17:42 +0000 https://e3rehab.com/?p=24073 In this blog, I’m going to tell you why your shoulder hurts and what you should do about it! Be sure to also check out our Shoulder Resilience Program! Basic Shoulder Anatomy The shoulder complex is made up of 3 different joints: Glenohumeral Joint (what most people think of when discussing the shoulder) Acromioclavicular Joint Sternoclavicular Joint […]

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In this blog, I’m going to tell you why your shoulder hurts and what you should do about it!

Be sure to also check out our Shoulder Resilience Program!

Basic Shoulder Anatomy

The shoulder complex is made up of 3 different joints:

  • Glenohumeral Joint (what most people think of when discussing the shoulder)
  • Acromioclavicular Joint
  • Sternoclavicular Joint
https://www.anatomystandard.com/ossa-et-juncturae/extremitas-superior/humerus.html (image adapted for this blog)

The glenohumeral joint, often referred to as a ball-and-socket joint, is where the glenoid fossa of the scapula, or shoulder blade, meets the head of the humerus, or arm bone. The shallow socket of the shoulder allows it to be the most mobile joint in the body. 

The labrum (labeled “glenoid lig” in the image below) is a fibrocartilaginous ring that increases the depth of that socket and improves the stability of the shoulder. The tendon of the long head of the biceps brachii muscle partially blends with the top portion of the labrum. I’ll revisit the importance of this relationship later.

Gray's Anatomy Textbook (Public Domain)

The glenohumeral joint is then surrounded by a connective tissue known as the joint capsule.

The three rotator cuff muscles located on the back of the shoulder blade are the supraspinatus, infraspinatus, and teres minor. The rotator cuff muscle located on the front of the shoulder blade is the subscapularis.

https://commons.wikimedia.org/wiki/File:Rotator_cuff_muscles.svg

Although these muscles contribute to individual joint actions of the shoulder, such as external rotation, internal rotation, and abduction, they are most well known for their role in providing “dynamic stability,” which means they actually help control and support the shoulder with every movement.

This is largely due to the fact that they are somewhat interconnected, surround most of the shoulder, and blend together with the joint capsule.

The acromioclavicular, or AC, joint is the connection between the acromion of the scapula and the distal end of the clavicle, or collarbone. It is supported by a joint capsule, the acromioclavicular ligament, and the coracoclavicular ligament, which consists of two parts: the trapezoid and conoid ligaments.

https://upload.wikimedia.org/wikipedia/commons/1/18/AC_Separation_XRAY_%28enhanced%29.png
https://upload.wikimedia.org/wikipedia/commons/3/3b/Gray326.png

Ligaments attach from bone to bone and provide passive joint stability. An injury to a ligament is known as a sprain.

Lastly, the sternoclavicular joint is where the proximal end of your clavicle meets the top of your sternum.

Sternoclavicular Joint Injuries

Compared to the other diagnoses I’m going to discuss, sternoclavicular joint injuries are relatively uncommon. Traumatic injuries, resulting in sprains, dislocations, or fractures, typically follow motor vehicle accidents, collisions in contact sports, or falls. In non-traumatic cases, such as an older individual with osteoarthritis or younger person with hypermobility, symptoms may include pain, tenderness, stiffness, popping, or subluxations, especially with overhead movements.

Acromioclavicular (AC) Joint Injuries

An AC joint injury is usually the result of a direct force to the top part of the acromion, such as a fall on the shoulder with the arm at the side. It can also occur from falling on an outstretched hand (FOOSH). More severe injuries may result from a motor vehicle accident.

An AC joint injury is classified according to the Rockwood classification system via an x-ray.

https://upload.wikimedia.org/wikipedia/commons/1/18/AC_Separation_XRAY_%28enhanced%29.png

There are 6 types:

Type 1 – involves a mild sprain of only the acromioclavicular ligament.

Type 2 – consists of a ruptured acromioclavicular ligament and joint capsule, and a mild sprain of the coracoclavicular ligament. 

Type 3 – both ligaments and joint capsule are ruptured and the distal end of the clavicle is moderately elevated.

This type often presents with a piano key sign, where applying downward pressure on the distal clavicle causes temporary reduction. Upon releasing the pressure, the clavicle returns to an elevated position, similar to pressing a piano key.

Type 4 – presents similarly to type 3 but with a posteriorly displaced distal clavicle, possibly penetrating the trapezius muscle.   

Type 5 – the distal clavicle is severely elevated and there is a high probability that both the deltoid and trapezius muscles are detached from the clavicle.

Type 6 – the distal end of the clavicle is inferiorly displaced under the coracoid process of the scapula (behind the coracobrachialis and short head of the biceps tendon).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5174051/

Symptoms can include swelling, limitations in range of motion, and pain with lying on the affected shoulder.

Additionally, pain may be felt toward the top or front of the shoulder when moving the arm across the body (horizontal adduction), overhead, and behind the back (extension) since these place more stress on the AC joint.

In severe cases (types 3-6), a visible deformity may occur due to the displacement of the distal clavicle.

Since this injury results from trauma, it is important to rule out other diagnoses, such as a clavicle fracture, injury to the sternoclavicular joint, and any neurovascular involvement.

In the event of an AC joint injury, there are two primary treatment options: nonoperative management and surgery.

For a low-grade type 1 or type 2 injury, nonoperative management should be the first line of treatment in most cases.

For more severe injuries (types 3-6), various factors, such as a person’s symptoms, function, goals, and response to rehabilitation, will influence the decision to have surgery or not.

It is also worth noting that since more severe injuries (types 3-6) have a displaced clavicle, the cosmetic appearance of the shoulder may play a role in someone’s decision to have surgery. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9940602/

Want to learn more?

Check out our full blog about Acromioclavicular Joint Injury Rehab!

Glenohumeral Joint Diagnoses

When it comes to the shoulder, pain can often be divided into 3 broad categories:

  1. The Stiff Shoulder, like Frozen Shoulder or Adhesive Capsulitis
  2. The Unstable Shoulder, which relates to a history of dislocations or subluxations
  3. The Weak & Painful Shoulder

Under this umbrella of the weak and painful shoulder are the following diagnoses (among others):

  • Rotator Cuff Tears
  • Shoulder Impingement
  • Rotator Cuff Tendinitis or Tendinopathy
  • Biceps Tendinopathy
  • Subacromial Pain Syndrome
  • Rotator Cuff Related Shoulder Pain

Frozen Shoulder

Frozen shoulder, frequently referred to as adhesive capsulitis, is a clinical diagnosis most commonly seen in women between the ages of 40 and 65. Individuals usually present with a gradual onset of pain and stiffness that’s often worse at night and negatively impacts sleep. 

There are two types of frozen shoulder.

For people with primary frozen shoulder, also called idiopathic frozen shoulder, the exact cause is unknown.

On the other hand, secondary frozen shoulder is associated with diabetes, thyroid disorders, stroke, trauma, and various shoulder pathologies.

Individuals with frozen shoulder will present with passive external rotation loss that is greater than 50% of their uninvolved shoulder, or less than 30°.

Deficits in range of motion of greater than 25% in 2 other planes are also expected.

For example, shoulder flexion and abduction may be limited by 25% or more compared to the other shoulder.

X rays are not necessary, but can help rule in or out other conditions, such as severe osteoarthritis.

Frozen shoulder is sometimes characterized by 3 overlapping stages:

  • A “freezing” phase, in which pain worsens.
  • A “frozen” phase, in which stiffness peaks.
  • A “thawing” phase, in which symptoms gradually improve.

This is a simplified framework though as symptoms may take up to 2 years or longer to resolve. Rehabilitation, as well as lifestyle modifications to diet and exercise habits when appropriate, are recommended to regain full function.

Unfortunately, there are no quick fixes. For this reason, aggressive, painful stretching is NOT recommended.

Want to learn more?

Check out our full blog about Frozen Shoulder Rehab!

Shoulder Dislocations & Instability

Moving on to shoulder instability, there are 2 main types.  

The first is traumatic which results in a partial or complete separation of the glenohumeral surfaces, commonly known as a subluxation or dislocation. This is usually the result of falling on an outstretched hand or from a direct blow to the shoulder.

About 97% of dislocations occur anteriorly, meaning the head of the humerus is forced out of the joint socket in the forward direction. They can also occur posteriorly or inferiorly, but these are rare.

Traumatic injuries typically involve structural damage, most often in the form of a Bankart lesion, which is when the anterior and inferior portions of the labrum separate from the glenoid fossa. 

Other associated injuries can include:

  • A Hill-Sachs lesion, which is a compression fracture of the humeral head
  • A glenoid rim fracture, also known as a bony Bankart
  • A neurological injury, such as damage to the Axillary nerve 
  • A rotator cuff tear

Before reducing a dislocation, or putting it back into its normal position, X-rays are performed to determine the direction and if there are any other injuries, like a fracture. 

The second type of instability is atraumatic, which may happen without any history of a significant preceding injury. An example would be a swimmer who developed pathological laxity from repetitive overuse. There may be structural abnormalities found in the shoulder, but they are not a result of a single traumatic experience.

It is also worth noting that the presentation of shoulder instability can change over time. For instance, someone who had a traumatic anterior shoulder dislocation may develop recurrent instability years later.

Other classification systems include a third type that is also atraumatic, but is defined by a loss of muscle control without structural damage. These are less common, but someone with Ehlers-Danlos Syndrome would fall into this category.

It’s important to understand that shoulder laxity or hyperlaxity by itself is just a sign, while shoulder instability is a term associated with clinical symptoms. 

These symptoms can include pain, apprehension, and feelings of instability with various movements or positions, such as when your arm is away from your body or when reaching back behind you.

Regardless if you have traumatic or atraumatic instability, management options include surgery and rehabilitation, or rehabilitation alone.

For anterior shoulder dislocations, multiple studies show that younger athletes who received stabilization surgery experienced lower rates of recurrent instability and decreased need for future surgery compared to those who received nonoperative management only. Handoll et al 2004, Belk et al 2021, Alkhatib et al 2022, Zaremski et al 2016

For atraumatic instability, a 2023 randomized, placebo-controlled trial found that surgery, where the joint capsule was “tightened”, did not lead to better results than a placebo surgery in terms of improvement in pain and functional impairments.

These studies provide some insight, but the decision to undergo surgery is nuanced, as it depends on various factors such as age, sport, type of instability, degree of tissue damage, etc. 

In the cases of atraumatic instability, rehabilitation is often the first-line recommendation. However, in some cases, if symptoms do not improve, referral to an orthopedic surgeon might be necessary.

Want to learn more?

Check out our full blog about Shoulder Dislocation & Instability Rehab!

SLAP Tears

Symptomatic SLAP tears can involve deep shoulder pain, as well as popping, clicking, or catching. 

SLAP stands for “Superior Labrum, Anterior and Posterior.” In other words, the top of the labrum, front and back. 

Snyder and colleagues, who introduced the term in 1990, described 4 types of SLAP tears:

  • Type 1 involves fraying or degeneration of the superior labrum. The labrum remains attached with the biceps tendon intact. 
  • Type 2 is characterized by detachment of the superior labrum and biceps tendon.
  • Type 3 is a bucket-handle tear of the superior labrum with the biceps tendon intact. 
  • Type 4 is a bucket-handle tear of the superior labrum that extends into the biceps tendon. 

Although additional types and subtypes have been presented, the original classification by Snyder continues to be the most recognized and referenced in research and practice.  

When SLAP tears result from acute trauma, they are often categorized as compression-type injuries or traction-type injuries. The most common compression-type injury involves falling on an outstretched hand (FOOSH). Traction-type injuries involve a sudden pull, such as when water skiing, grabbing something overhead to stop a fall, or losing hold of a heavy object.

Traumatic injuries can also involve motor vehicle accidents or a direct blow to the shoulder.

On the other hand, chronic injuries are typically attributed to throwing in sport or other repetitive overhead activities. 

However, not all SLAP tears need to be categorized as injuries because “abnormalities” of the labrum found on imaging are actually quite common in asymptomatic individuals. 

For example, a study by Schwartzberg et al in 2016 investigated 53 adults between the ages of 45 and 60 and discovered superior labral tears in 55% to 72% of these participants despite them having no symptoms. A study by Lansdown et al in 2018 suggests that SLAP tears become increasingly prevalent with aging. 

Tears of the labrum are also common in athletes, especially those involved in overhead sports, such as volleyball and baseball. Miniaci 2002, Lesniak 2013, Del Grande 2016, Pennock 2018, Hacken 2019

For instance, a study by Cooper et al in 2022 examined asymptomatic, elite-level rock climbers and reported that “Labral pathology was present in 69% of shoulders, with discrete labral tears identified in 56%.”

Therefore, nonoperative management is often the first-line recommendation. 

Want to learn more?

Check out our full blog about SLAP Tear Rehab!

The Weak & Painful Shoulder

Let’s move on to the diagnoses that fall under the umbrella of “the weak and painful shoulder,” including rotator cuff tears, bursitis, and shoulder impingement. 

It’s often believed that imaging, injections, and surgery are required for these conditions, but in general, exercise therapy is the first-line recommendation because symptoms related to any of these diagnoses likely have more to do with current tissue sensitivity from sudden or gradual changes in activity and your overall health as opposed to compression of structures, excessive local inflammation, or new tears of your rotator cuff. 

Rotator Cuff Tears

For example, rotator cuff tears are common in people without symptoms, increase in prevalence with age, and don’t always correlate with a person’s function. 

A systematic review by Teunis et al stated the following: “The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.”

Am I talking about partial-thickness tears or full-thickness tears? 

Both.

A recent study by Hinsley et al found that 48.4% of full-thickness tears were asymptomatic in the population studied. 

How is this possible?

Rotator cuff tears are often thought to be like a rope cut in half, but they’re more similar to a hole in a piece of cloth due to their interconnecting nature that I discussed at the beginning.

The cloth still works fine, which is why many people don’t experience pain or changes in function despite having a rotator cuff tear.

Does that mean surgery is never indicated? No. You should always consult with your medical doctor before making any decisions, especially if trauma was involved. 

However, exercise is safe and recommended because shoulder activity level is not related to tear progression risks, tears don’t always progress in size, and an increase in tear size doesn’t necessarily mean a worsening of function or symptoms anyway.

As I mentioned, symptoms are more about the shoulder being currently sensitive to certain positions, movements, and exercises rather than the occurrence of irreparable damage. It’s actually acceptable to have some discomfort during rehab if it’s tolerable for you and you’re slowly progressing toward your goals over time. You’re not hurting yourself. 

Want to learn more?

Check out our full blog about Rotator Cuff Tear Rehab!

Shoulder Impingement

This is true for shoulder impingement, sometimes called subacromial pain syndrome, as well. 

The area between the humeral head and the acromion, coracoacromial ligament, and acromioclavicular joint is known as the subacromial (under the acromion) space. Within this space is the supraspinatus tendon, long head of the biceps brachii tendon, subacromial bursa (fluid-filled sac that reduces friction), and the capsule of the shoulder joint.

When most people discuss shoulder impingement, they are referring to these tissues being compressed in this space. 

The shoulder impingement theory was popularized by a surgeon in the 1970’s before he proposed a surgery to treat the issue. Since then, here’s what we’ve learned:

  1. If symptoms were solely caused by compression of these overlying structures, we’d expect their removal to improve symptoms and function. However, research demonstrates that subacromial decompression is no better than placebo surgery.
  2. Subacromial decompression also doesn’t seem to change the long-term prevalence of rotator cuff tears. As I mentioned, rotator cuff tears are present in asymptomatic individuals and are more common as we age, like many other imaging findings. 
  3. Compression of tissues in the subacromial space is common, occurs equally in people with and without symptoms, and happens with normal, day-to-day tasks. 
  4. A smaller subacromial space is not correlated with symptoms or disability. 

So shoulder impingement exists, but it’s not the bogeyman it’s been made out to be. 

This is important to know because sometimes a diagnosis can be unhelpful or even harmful, especially when up-to-date information is not provided. For example, a study found that people labeled with impingement expressed “feelings of psychological distress, uncertainty, and that the condition is serious and has a poor prognosis.” Without appropriate context, a diagnosis can negatively influence expectations, cause people to become fearful of certain movements, exercises, or activities, and act as a barrier to rehab. 

This doesn’t mean that the general rehab process needs to be significantly different from what’s already being used – it’s the explanation that changes and matters:

  • Exercise is safe and encouraged.
  • You’re not damaging your rotator cuff when you lift your arm and experience pain.
  • You don’t have to worry about removing a piece of bone to get better. 
  • Compression of tissues is normal in the shoulder and elsewhere. We compress nerves, tendons, ligaments, and muscles all day long when we sit, bend, lift, twist, and walk. 

Want to learn more?

Check out our full blog about Shoulder Impingement!

Biceps & Rotator Cuff Tendinopathy

Tendons attach muscles to bones. When a muscle contracts, its associated tendon is affected. Despite popular belief, tendinitis is not the recommended diagnostic label for tendon-related pain because acute inflammation does not seem to be the primary driver of symptoms.

This indicates that rehabilitation does not need to focus on a predominantly anti-inflammatory approach involving ice, medication, and complete rest for an extended period of time.

“Tendinopathy” is the preferred term, which just means that there is persistent pain and loss of function associated with loading of the affected tendon. Much of the time tendinopathies are described as repetitive overuse or relative overload injuries, along the lines of “doing too much, too soon.”

Pain in the front of the shoulder is often attributed to the long head of the biceps tendon based on its location, whereas pain toward the side may be attributed to the rotator cuff. 

Biceps and rotator cuff tendinopathy can occur independently or, very commonly, co-exist. 

Both are related to a loss of function and pain with loading of these tendons, which can include daily tasks like reaching out, behind, or above you, or recreational activities like lifting weights and playing sports.

Want to learn more?

Check out our full blog about Biceps Tendinopathy Rehab!

What About Other Diagnoses?

What about other diagnoses and why is this information potentially so much different from what you’ve heard elsewhere?

Unfortunately, I can’t cover every possible diagnosis without making this blog longer than it already is.

Accurately diagnosing frozen shoulder, osteoarthritis, instability, and trauma-related injuries is important because these diagnoses may respond well to specific medical management, such as an early injection for frozen shoulder or surgery for an anterior shoulder dislocation. In the case of frozen shoulder, it’s also important to know that symptoms can take up to 2 years or longer to resolve. 

For diagnoses like rotator cuff tendinopathy, partial rotator cuff tears, shoulder impingement, subacromial pain syndrome, rotator cuff related shoulder pain, etc., it’s often difficult to determine the exact tissue structure that may be contributing to symptoms for 2 main reasons:

  1. The orthopedic special tests that we use aren’t actually that special. They mostly just tell us that your shoulder hurts.
  2. So-called “abnormalities” on imaging are common in people who don’t have symptoms.

Uncertainty is unsettling, which is probably why many of these labels exist and why new ones get created. 

However, a specific diagnosis or imaging finding doesn’t always dictate management or rehabilitation, especially for many cases that fall in the category of the “weak and painful” shoulder or symptoms that come on gradually without trauma.

What’s often more useful for me as a physical therapist is knowing your age, occupation, lifestyle, exercise habits, goals, what makes your symptoms better, what makes your symptoms worse, etc.

You might have the exact same diagnosis as someone else, but your answers to these questions could be vastly different. And those answers influence rehab. 

Although rehab itself can be challenging, the goal is pretty simple – it’s to temporarily modify any aggravating activities, improve your overall health with lifestyle modifications and exercise where possible, and incorporate an exercise routine that’s manageable, tolerable, and addresses any of your deficits in strength, range of motion, confidence, etc.

Cervical Radiculopathy & Referred Pain

The last topic I want to briefly discuss is shoulder pain NOT related to the shoulder. For example, symptoms in the upper traps or the area between the shoulder blades are often caused by irritation of a nerve or other structure in the neck. If symptoms are more related to positions and movements of the neck instead of the shoulder, the neck should be suspected as the probable issue.

A less common reason for shoulder pain, although significantly more important to identify, is pain originating from the heart, lungs, gallbladder, etc. For instance, symptoms of a heart attack can include shoulder and arm pain, as well as chest and jaw pain, shortness of breath, sweating, nausea, dizziness, and more. Always consult with a medical doctor regarding any concerns. 

Before wrapping up, I want to remind you that we have full-length blogs dedicated to most of these diagnoses, so please check those out if you’re looking for more in-depth information.

Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Shoulder Resilience Program!

Thanks for reading. Check out the video and please leave any questions or comments below. 

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