Case Study 1:
A high jumper with anterior knee pain
This frustrated mid-20s female high jumper had for a whole year been struggling to put together a successful training and competition season because of pain in her (R) jump-leg knee, which had gradually become worse since she had picked up her training towards a national competition. She had been unable to compete due to the pain and so had pulled out. This pattern repeated itself until finally she had to take a number of months off to rest totally and receive treatment from various therapists - all of which added to her confusion and despair since the pain gradually became worse as her training lessened. A year after its onset she was unable to do any strength training, let alone jump-specific work, as even going up and down stairs caused her pain. Reluctant to fork out more money and ready to give up, she presented for help at the Sports Injury Centre, Crystal Palace.
Initial assessment quickly revealed that she had patellar tendinitis in her jump knee, with mild effusion and significant tenderness over the lower patella and tendon insertion - this was not difficult to diagnose. She was, however, also slightly over-weight for a high-level jumper, and had significantly reduced quadriceps size on the same leg, poor pronation control in both sub-talar joints (ie, she had moderately flat feet as do
many of Afro-Caribbean descent), and demonstrated little ability to maintain good alignment of her hip/knee/foot, and some trepidation when dipping down on to the single leg, which caused her pain.
An in-depth assessment revealed pain-inhibited vastus medialis and poor recruitment/strength of gluteus maximus/medius in a closed-chain position, very tight and tender lateral retinaculum, LR (connective tissue sheath holding the outside edge of the patella to the femur underneath) and ITB (ilio-tibial band), stiff medial glide of
her patella, pain
and a click with an inner-range quad contraction, and a pronounced hallux valgus (distorted big toe) on her jump foot.
Treatment & rehabilitation
Where do you start? With a multifactorial chronic injury like this, it was important for me to prove to her (and to myself!) that I could help her by getting rid of some of her pain, so on the first day I decided to try and reduce her pain on a single dip. This was done by loosening off her restricted LR to establish initially how much of the tendon pain was due to inflammation and how much was due to restriction of normal patellar movement. It instantly cleared her pain on the single-leg dip, confirming that her tendon pain at this point was most likely mainly due to patello-femoral joint dysfunction (from muscle imbalance and poor biomechanics) and not from an active inflammatory process. Had her pain been unaltered by manual treatment to her patella or to the tendon, we might have had to consider in the diagnostic picture the possibility of cystic or degenerative changes or a partial tear in her patella tendon, confirmed by ultrasound or MRI scan. Or one might do blood tests to rule out arthropathies or diabetes-induced changes.
The actual treatment over the ensuing weeks continued along this same line of loosening her LR, deep-tissue massage of her ITB, and trigger-point releasing of her TFL muscle. It seemed apparent from early on that it would not be necessary to employ patellar-tendon taping until a later date when she had started jumping again, as enough pain relief and progress was obtained simply from the manual techniques. Taping is often required, however, to reduce pain so that strength exercises can be undertaken (or for improved proprioceptive feedback - not relevant in her case as she had sufficient body awareness). We would only have had to wean her off the taping at a later stage, anyway, which can disrupt the smooth rolling of the snowball towards full competitive strength.
It was also vital for her to be continually aware of the role of muscle-balance factors in the control of her pain, and not to rely on masking the pain with tape. Many athletes become dependent on tape and other gadgets for unloading tendon structures at the expense of fully correcting and maintaining muscle balance - in other words, instead of aiming for 100% muscle strength and joint position control, they settle for 80%, plus a pain-relieving gadget, plus less than optimum performance!
So in this case we were able to avoid tendon taping until she had almost full strength back and was starting to jump again. The taping helped to restore her confidence and to prevent any pain that might psychologically set her back again.
Strength work also began and was progressed from day one - first, recruiting all the right muscles in a static position of ideal alignment: double-leg squat back to a wall, in front of a mirror to keep knees over feet and high arches, squeezing glutes together, squeezing a ball between knees, and keeping her back against a wall. A lot to think about initially! Gluteus maximus recruitment work was started early on - soon she was able to do light leg-press work and return to CV work in her gym.
We progressed on to single-leg stance work - static, then on wobble-boards, with elastic resistance. Concentric stair dips gradually got deeper, including hand-held weights, and finally became eccentric with 'quick drop down, slow return up'. Soon she was capable of mini-plyometric drills involving stair hopping, mini-bounds, hopping and run-up drills which were incorporated into her weekly training regime. Don't forget that it is not only crucial for the tendon to develop eccentric strength but also for the stability muscles like obliques/transversus abdominus, glutes max/med, vastus medialis and tibialis posterior/soleus.
A number of strength/technique drills were next in line, and this involved liaison with her coach. She had now begun sprint sessions/weekly jogs (to lose extra weight), and more power work such as front/back squats and clean and snatch to improve global strength. Finally it was decided to modify her run-up to reduce the change in direction that took place as she approached the bar - ie, she began her run-up wider of the mat and closer to the line of the bar - and to begin actual jumping drills.
We decided to incorporate a simple unloading tape technique for her patellar tendon, which she applied herself as required to prevent any aching of her knee post-training.
She had a pair of orthotics made by an NHS podiatrist, but found them very uncomfortable to run and jump in, so she had not used them at all. I might have made her a temporary pair if there had ever been any need, but for her I would only recommend a new prescription if the pain returns or her performance is flagging.
The fear of putting the full weight through the jumping leg after a long period of injury can be profoundly debilitating, and so regaining confidence may require a visit to a sports psychologist. Our high jumper benefited further from this.
This rehabilitation took some months and went without any major glitches. She competed in her first county competition after 20 months in good strength, totally pain-free and not reliant on any tape or knee-strap.
Case Study 2:
A Commonwealth Games diver with low back pain
The sport of diving takes a very heavy toll on certain joints of the body, since it requires a fine combination of good flexibility, awesome trunk strength, fantastic coordination and body awareness, and a whole heap of intestinal fortitude (guts are a prerequisite!). Injuries are common in the wrist and spine, especially since you are hurtling towards the water from a 10-metre height while spinning, rolling, stretching, and finally straining to hit the water like an arrow. Try getting a gymnast to do his/her routines while bungee jumping and you have some idea of what it's all about! All those who are serious about the sport are used to heavy training from four-five hours a day and all carry niggling and some moderately serious injuries - which were to become my responsibility for the month-long training camp and competition period that was the 1998 Commonwealth Games. This is the account of the one injury that was to give me the most sleepless nights.
The first time I met this young male diver in his early twenties was at Heathrow Airport lining up for our tickets. I had only heard rumours of him before this: he was one of the best chances for a medal as the top British platform diver. Many hopes were pinned on him to do British diving proud and give it the international boost it had not had for many years, In total, there was a team of about 15 of us flying out to Brisbane, Australia, to train and acclimatise for two weeks before the Kuala Lumpur games began.
My briefing from his physiotherapist in Sheffield where he is based was that he had quite a history of low back pain with problems on and off for about two years. It all began with a hyper-extension (over-arching) injury that occurred because of a poorly-timed water entry as he was straightening out from a pike position. After taking a month or two to recover, with no significant findings on scans, he had gradually resumed training and was now mainly feeling very 'stiff' in all his low back after training and for a few days after a heavy session. This diver, though young, has became famous for experimenting with new 'high difficulty' dives that involve multiple twists together with somersaults in the air before hitting the water. He was able consistently to 'cut' the water like a knife through butter, generating minimal water disturbance each time.
The problem worsens
The divers' training was to go up a notch for the next two weeks before the competition, since they do not 'taper down' in the same way that endurance sports (ie, any events that take longer than 1.5 seconds!) do. Towards the end of the first week, our platform diver began getting more intense back stiffness after, and gradually during, his routines. His back movements would be limited into flexion and right-side flexion, with pain and some muscle spasm around the L3 and L4 segments on the right of the centre, and no neural signs or referred pain. After each training session his pain would disappear after releasing the spasm, mobilising/stretching related joint and muscle structures, and icing. His back was gradually getting worse, so he was constantly worrying and his confidence was suffering. In conjunction with his coach, it was decided that he should have two or three days to rest and do relatively easy 'land training', spending the time having physio, listening to sports psychology tapes and mentally rehearsing in order to keep out negative thoughts.
It had become clear as the coach and I analysed and video-taped his diving that there were some serious issues surrounding his posture and inability to control the position of his low-back joints that had to be addressed. If they weren't, there was the stark possibility that he would have to pull out or even do some serious damage to his back - a number of international divers over the past decade have had to retire from diving prematurely because of low-back problems. But in two weeks how much could we change without threatening his dive confidence and technique?
Essentially the problem revolved around a likely hyper-mobile L3-L4 facet joint (ie, this segment joint on his right side was moving too much relative to adjacent joints) that was causing inflammation of the disc. It may well have been that the injury two years ago sprained the joint - as in spraining an ankle - and the muscle controlling the joint stability ('multifidus') never fully recovered from the consequent inhibition, allowing the joint in time to over-stretch to the point where the disc was taking some of the strain and becoming inflamed. We began re-educating the core stability muscles that facilitate the multifidus muscle, ie, the obliques and transversus abdominus, to control the movement of the joint into lumbar flexion/extension. We used tape to give him feedback, broke his dives into small segments, and got him rehearsing on land and off the side of the pool. It was only a few days before he was starting to do some dives again, though we kept a strict limit on the number and intensity right up until the Games began. We were religious with the icing and taping, and with anti-inflammatory medication to control the joint irritation, so that his control improved and his confidence soared.
When it finally mattered, though his training had been cut in half, he successfully earned a bronze medal for platform, contributing to the best English team performance at an international competition for 15 years,