Modify Training to Get to Root of Knee Pain

I’m a 53-year-old female and have been running for a year and a half. About a week ago I suddenly developed pain overnight in both kneecaps. I think this could be runner’s knee, but the pain occurs only when I’m going up or down steps, or going from a standing position to a sitting position. It hurts most when going down steps. I don’t feel it at all otherwise. I run about 10 to 15 miles per week. I run a fair number of hills because that’s all we’ve got here, but they aren’t very steep. Is it OK to continue running since I have no pain while running?

Kim Weymark

It does sound as if you are suffering from runner’s knee, which is patellofemoral pain sometimes brought on by the stress of hill running, especially downhill. Be sure to confirm this with a visit to a sports medicine physician so that you can be sure this is the problem. While you can continue to run if it doesn’t hurt, I would modify your training. It is important to make sure you correct the training errors that contributed to the problem. Typically the greatest forces on the kneecap are at around 45 to 60 degrees of knee flexion.

One immediate step is to back off hills as much as possible. On hills, the knee is inevitably forced to bend more. If flats are not available, move to the treadmill. Often, when you develop runner’s knee, the vastus medialis obliqus (VMO) of the quadriceps (the inner thigh muscle that attaches to the inner aspect of the patella) is not working as well as it could. A visit to a physical therapist may be helpful to isolate and strengthen this muscle in both its lengthening (eccentric) and shortening (concentric) modes. Meanwhile, straight-leg leg lifts and terminal extensions (seated, weighted knee extensions extending from just the last 30 degrees) can begin to strengthen this muscle.

Consider purchasing a compression brace such as a Cho-Pat band that can be placed around the patellar tendon to offset the shock absorption of the kneecap. Try it on one knee and see if you notice an improvement.

Robert Meislin, MD
Phoenix, AZ

Aching Hamstrings After Just Sitting

Several years ago I pulled the hamstrings on both legs. I slipped on a rock and fell into a splits position (not while running). My doctor advised me to start a flexibility program to stretch the hamstrings during the healing process so that they would not shorten as a result of the injury. While I was able eventually to return to my regular mileage, my hamstrings have given me trouble since and as a result limit my running. Now I have trouble sitting for any length of time before my hamstrings begin to ache. The pain is at the upper attachment of the muscle. At times the entire buttocks and sacroiliac are flooded with a dull pain.

Mark Ambrovich
South Bend, IN

Hamstring injuries can be difficult to heal and often require a more comprehensive approach to rehabilitation. Strengthening the muscles is as important as maintaining flexibility. Since the hamstring acts on both the knee and the hip, it is important to do hamstring strengthening exercises for both knee flexion and hip extension. Exercises should be performed in both a concentric and eccentric fashion, that is, exercises should activate the muscles while they are shortening and lengthening. This can be accomplished by performing exercises with both a slow up and a slow down motion. Compression shorts or a compressive thigh sleeve may also help alleviate some of your discomfort. However, you may be acting on an erroneous assumption at this point.

Your hamstring problems are getting worse with symptoms extending beyond the original injury. Buttock and sacroiliac pain suggest that the lumbar spine may be involved and you may need to be evaluated by a physician who has expertise both in sports injuries as well as the lumbar spine. Sciatic nerve impingement (pressure on the sciatic nerve from the spine) can cause the symptoms you describe including pain in the low back, buttocks and hamstrings, and these problems would require treatment different from the treatment for a chronic hamstring pull. Make sure that your doctor has considered and ruled out all the possible causes of pain in this region.

Robert Wilder, MD
Charlottesville, VA

Return to Running After Hernia

I have an inguinal hernia that is causing discomfort and need advice regarding treatment and how it will affect running and participating in other sports. If I have it repaired, when can I run again, and how should I progress?

Stephen Caicedo
Youngstown, PA

A hernia is the protrusion of any structure, usually the bowel, through a weak point in the abdominal wall. The most frequent mechanisms of injury are repetitive lifting activities, activities that increase intra-abdominal pressure (such as weightlifting) or a sudden blow to the lower abdomen (such as the impact of handlebars from a bicycle). Most often there is a preexisting condition such as abdominal muscle weakness or a congenital defect. Hernias are noticed when they cause symptoms of bulging and possibly pain. An inguinal hernia is the most common type that occurs in adults. They are classified as indirect, direct or femoral.

Indirect inguinal hernias account for 50% to 70% of all hernias. They are considered “congenital.” In over 80% of male newborns, the path the testis follows as it descends into the scrotum remains open. By the age of two, about half remain open, and by adulthood only 25% remain open. Clinical symptoms often do not appear until years later.

A direct hernia is acquired and is usually seen in males over 40 years old. This type of hernia occurs when increased intra-abdominal pressure causes a protrusion through the posterior abdominal wall of the inguinal canal as a result of weakened abdominal wall muscles. A femoral hernia is less common and typically occurs in females.

Most hernias can be diagnosed by a physical exam. Sometimes a special X-ray using a contrast dye is needed. The treatment for large or painful hernias is surgical repair. Surgery is necessary to prevent incarceration and strangulation of the herniated bowel, which can cause serious complications. You should not neglect it or delay a consultation with your doctor.

Here are the standard recommendations for returning to sports following a hernia operation:

  • Avoid activities that stretch or pull the abdominal muscle for the two weeks following the operation.
  • Progressive resistance exercises and conditioning can begin at two to three weeks.
  • Abdominal strengthening can begin after the fourth week.
  • For indirect hernia repairs, an athlete can return to non-contact sports at six to eight weeks and contact sports eight to ten weeks after surgery.
  • For direct hernia repairs, an athlete can return to non-contact sports at eight to ten weeks and contact sports at 12 weeks after surgery.

If your surgery can be performed laparoscopically, your layoff will be much shorter than if your surgery is performed through an abdominal incision. For laparoscopic repairs you may be able to return to walking/light running, as you feel ready, probably within two to four weeks. For your return to your running program, start out slowly with walking, then alternately walking and jogging. As is always true whether you are a new runner or returning from a layoff, reconditioning should proceed gradually in order to avoid injury. Limit your increases in mileage and speed to 10%, as a rule of thumb. What that means is to make a gradual, gentle progression. Stop and rest if you feel discomfort. If it persists, contact your doctor.

Troy M. Smurawa, MD
Clermont, FL

Orthotics—Or Your Feet—Can Change Over Time

I purchased orthotics about four and a half years ago when I injured first one foot, then the other. Now the pain is recurring. Do these hard plastic orthotics wear out? In the intervening years, have more comfortable materials become available?

Darren Thompkins
San Francisco, CA

Yes, orthotics can wear out over time, and the needs of your foot can also change. If the problems with your feet and the resulting pain are identical and the orthotics you’ve had were effective, then you may be able to have them refurbished. However, there are many types of materials that can be used for the orthotic along with shock absorbing materials for top-covers and extensions that you might find more comfortable. It would be a good idea to have your feet re-evaluated, since they have begun to give you trouble, to determine the options available.

Janet Simon, DPM
Albuquerque, NM

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