knee exercises

December 13, 2006

Thu Dec 14, 2006 4:00 am

... Motion and

Strenghthening Exercises

for Haemophiliacs Knee Exercises

by Theresa Kelly and June Zimmerman

By courtesy of Hemalog

Although the knee is more susceptible to damage than our other joints,

the right exercises can go far in reducing injury.

........

..Before factor, PWHs were advised to refrain from exercise. Not so today. With

factor and home infusion, physical activity is much less risky than ever before.

And with more PWHs putting their bodies to work, there is growing evidence that

exercise increases joint function and decreases the incidence of bleeds. To

keep your joints healthy, physical therapists urge you to strengthen the

surrounding muscles and increase their range of motion. This you can do through

regular exercise.

The Most Susceptible Joint The knee is the most susceptible to injury in

people with and without haemophilia. It's truly an irony of our physiology that

the knee joint, which enables us to participate in such vigorous activities as

football and rollerblading, is so delicate and so easily injured. Considering

that when you simply walk up a few stairs you are putting pressure across your

knee joints that is approximately four times your body weight, it isn't

surprising that nearly 50 million Americans have knee problems, either from

athletic injuries or simple everyday wear and tear.

To further understand the knee, let's take a closer look at its anatomy: The

knee is a relatively straightforward hinge joint which connects the thigh bone

(femur) with the leg bone (tibia). Where the bones meet, they are padded with a

tough substance called cartilage. In addition, between the bones and around the

joint are the synovial cells, which produce synovial fluid, a thick liquid that

protects and lubricates the joint. Surrounding the entire joint is a tough,

stretchy coating referred to as the capsule. The knee relies on several muscle

groups to work effectively. The quadriceps extend the knee; the hamstrings and

calf muscles flex the knee. There are also the hip abductors, located on the

outside of the leg, and the hip adductors located on the inside of the thigh.

These muscles provide strength and stability to the knee. Bleeds and the Knee

When PWHs bleed into the knee either spontaneously or as a result of an

injury, blood leaks into the joint space. If the area isn't treated with factor

immediately, the joint continuous to fill up with blood like a reservoir behind

a dam. This infusion of blood stretches and swells the capsule around the joint

far beyond its original size. The swelling creates so much pressure that

bleeding may stop by itself. But the swelling also leaves the joint severely

traumatised and painful. How significant is the damage? After several bleeding

episodes in the knee, degenerative changes may occur. Scar tissue may form which

shrinks the space inside the joint, making it harder to bend. Cartilage may also

get destroyed, leaving less padding between the bones. This can happen because

the synovial cells release enzymes to digest the extra blood and these enzymes

may also digest some cartilage. The result is haemophilic arthropathy. Hinge

joints such as the knee, elbow and ankle are

especially susceptible to bleeding, trauma and development of arthropathy

because they have a relatively large amount of synovium and they are less able

to withstand rotary and angular stress. Socket-type joints like the hip and

shoulder are less susceptible to trauma. Many PWHs get caught up in a

debilitating cycle of knee problems. Frequent injuries and bleeds into the joint

cause pain and decrease in mobility. With a decrease in mobility, muscles grow

weaker and can no longer protect the joint - and you need strong muscles to

support your joints! The greater the muscle strength, the greater the stability

of the joint. For example, if you jump down a step and your muscles are strong,

they actually absorb stress and minimise the compressive forces to your knees.

Weak muscles cannot do this and the impact is on the joint itself. Keeping

Muscles Strong

So it is particularly important for PWHs to participate in an exercise program

that will help strengthen the muscles around the knees, increase the joints'

range of motion and build up endurance. The goal of these exercises are both

reparative and preventative. As a PWH with joint damage, you'll find that both

range of motion and strengthening exercises help increase joint mobility. These

same exercises can also help prevent further joint destruction. To keep joints

strong, you also need exercise for endurance which increases your overall

strength and improves your stamina. This allows your muscles to handle more

stress. Swimming, cycling, rowing are some of the activities that can help you

build up your endurance without putting too much pressure on your knees. The

exercises on these pages improve joint range of motion and strengthen muscles.

Beginners should aim for sets of six repetitions ( " reps " ), then increase reps

over time. If you feel any pain during an exercise

stop immediately. A PWH should never work toward the pain (as in " no pain, no

gain " ) that is a popular credo in some gyms. For exercises that call for

weights, begin with one or two pounds and slowly progress from there. Avoiding

Injury

For many PWHs, the fear of injury is perhaps the greatest obstacle to

exercise. Don't start your exercise on an overzealous note. PWHs who are

sensible and careful about working out usually avoid injury. This means that you

have to perform these exercises slowly, steadily and regularly. It's best to

exercise your joints twice a day regularly for five days a week. If you are just

beginning to exercise you may experience some bleeds at first. Most likely, as

you build your strength up, these bleeding episodes will decrease or stop. Be

sure to discuss this exercise program, and any other you are considering, with

your doctor before you start. Or work out under the guidance of a physical

therapist who can monitor the intensity of the exercise and then help you

progress. The following exercises are geared to teenagers and adults. Since

young children don't generally like regular exercises programs, we suggest that

parents (under direction of a physical therapist) encourage

children in more playful forms of exercise such as kicking a ball, safe and

supervised jumping and bicycling with an elevated seat which puts less pressure

on the knee. Once you begin working out, you'll find that regular exercise

reaps great psychological benefits too. Not only will you have the satisfaction

of knowing you are doing something positive for your body you'll have far more

energy and strength for other activities as well.

Strengthening Knee Exercises

1. Knee Flexion

Sit upright on a chair and cross legs with the left leg on the bottom. Slowly

use the right leg to to push the left leg underneath the chair while keeping

hips flat on the chair. Hold this position for six seconds. Return to starting

position and do six repeats. Repeat entire exercise with right leg on bottom.

2. Knee Extension Sit up straight with your back against a chair. Slowly

straighten your left knee. Hold this position for six seconds. Relax and lower

your leg to the standing position. Do six repeats with your right knee.

3. Heel Slide Knee Extension Lie on your back, with left knee bent and

left foot flat on floor. Slowly slide the left heel away from your body so that

both legs are parallel. Hold for six seconds. Do six repeats and repeat the

exercise with right leg.

THE KNEE JOINT Anterior Cruciate Ligament: Injury & Prevention

IN BRIEF: The knee joint anterior cruciate ligament guides the tibia (shin

bone) through a normal stable range of motion. When torn in a skiing or cutting

sports injury, the joint loses its stability, and further destruction of the

articular and meniscal cartilage results over time. Specific exercises can

diminish the incidence of cruciate ligament injury, and new surgical approaches

can promptly treat this injury with an early return to skiing. This article

describes the mechanism of injury, the author's preferred treatment, and the

means to prevent it. " Doc, I fell and twisted my knee. I heard a pop. It hurt

briefly. When I stood up, the knee felt as if it were not underneath me, and my

knee gave way. It swelled up by the next day and ever since feels as though it

would pop out when I twist or even cross the street quickly. " This common

complaint describes the traumatic rupture of the anterior cruciate ligament of

the knee joint. The injury is serious and usually

requires surgical repair or reconstruction in an athletic person. Fortunately,

the state-of-the-art in the 21st century is that a skier, after a properly done

cruciate repair or reconstruction, can return to skiing within the year.

The anterior cruciate ligament is the most commonly injured ligament in the

knee. Over the last 15 years, ankle sprains have decreased by 86% and tibia

fractures by 88%, but knee ligament injuries have increased by 172%. Twenty-five

percent of all reported skiing injuries involve the knee. The injury usually

occurs in either a slow twisting fall, a sudden hyperextension, or a sudden

hyperflexion as when landing from a jump on flat terrain. The anterior cruciate

ligament originates from the back of the femur (thigh bone) and inserts on the

top of the tibia (shin bone). (See diagram on page 49.) The ligament is a broad,

thick cord the size of a person's index finger. It has long collagen stands

woven together in a fashion that permits forces of up to 500 pounds to be

exerted prior to rupture. The ligament is crucial for guiding the tibia in a

normal path along the end of the femur and maintains joint stability. The

ligament has a relatively poor vascular supply and has no

ability to heal a complete tear. Complete ruptures of the ligament produce

bleeding into the knee; the reason why you get a swollen knee after a rupture is

that the swelling represents blood in the joint. Once torn, the knee usually

becomes unstable. The patients who remain athletic have a 75% chance of further

damage to one or more of the important cartilage structures within the joint and

progressive arthritis.

The advent of stiffer boots and improved bindings during the 1970s shifted the

incidence of skiing injuries from fractures of the lower leg to rotational

injuries of the knee joint. Specifically, this occurs because the bindings were

designed to read tension generated in the lower extremity and transferred to the

boot binding interface. Release occurred prior to fracture of the bone, as

determined by estimates of the skier's height, weight, and level of ability. But

no binding measured the forces generated by the femur (the thigh bone) on the

ligamentous attachments to the tibia. As the rotational forces increased through

the knee, or as hyper-extension or flexion occurred (essentially amputating the

ligament), increased numbers of cruciate ligament injuries occurred, even as

tibial fractures were declining.

Treatment

The torn anterior cruciate ligament represents a loss of the key guide wire of

the knee. With increasing instability, the shear forces across the top of the

tibia increase, the meniscal cartilages tear, and the articular cartilage

erodes. This erosion is the degenerative arthritis felt as grinding and pain,

particularly with stair climbing, running, or jumping. Fortunately, newer

surgical techniques have evolved to repair and reconstruct the torn cruciate

ligament, both immediately after rupture and even, though less optimally, years

later. Now that the critical role of the cruciate ligament in joint health has

been recognized, early intervention after a serious knee injury is recommended.

When the skier falls, twists the knee, a pop is heard and swelling occurs, he or

she has a 75% chance of having had an important injury to either the cruciate

ligament, the meniscus cartilage, or the articular cartilage. Early examination,

arthroscopy, and/or magnetic resonance imaging

(special techniques for producing pictures of the interior structure of the

body) are essential for accurate diagnosis. If the cruciate is torn and if the

athlete desires to remain athletic, then repair and/or reconstruction of the

ligament is possible.

Newer techniques of surgical intervention can save the patient's torn ligament

strands and incorporate them into a primary repair of the ligament or a

reconstruction using a portion of the patient's patellar tendon. The techniques

are ideal for the skier as they preserve the normal anatomy of the cruciate and

use tissue from the patient that heals back to its original strength.

Additionally, since no foreign materials are used for the graft, the risk of

infection or graft breakage is markedly reduced. Lastly, since native collagen

tissue strengthens as it matures over time, the repair and reconstruction can be

expected to last a lifetime. Recent data on early return to sports after

ligament reconstruction has strengthened the conviction that a carefully guided

rehabilitation program can include bicycling and swimming within two weeks of

surgery and skiing at four to six months.

Prevention

Protection against ligament injury and early return to athletics after

ligament surgery can best be achieved by strengthening the muscles around the

knee that act as shock absorbers and joint stabilizers. Specifically, hamstring

strength protects the tibia from the anterior translocation that can rupture the

cruciate. For instance, when a skier 'catches an edge, " the muscular ability to

recall the deviant ski is based on the strength of the medial hamstrings. If

they are weak, the knee goes into hyperextension, the skier falls, and the " pop

and swell " scenario can begin. On the other leg, when the skier " catches an

edge, " stability is often dependent on the quadriceps and hamstring power for

balance on one ski while attempting to reign in the wayward leg. If the

quadricep muscles are weak, the leg wobbles under the unexpected load, twists as

the skier falls, and " pop and swell " occurs.

Dramatic decreases in knee injuries have occurred after specific knee

strengthening exercises have been initiated. The program concentrates on a

single stance one-third knee bend performed by bending one leg behind the body

and standing on one leg. A series of flexions and extensions from approximately

30 degrees to 80 degrees is performed at a steady rate for three minutes,

working up to five minutes on each leg. No specific exercise machines are

required, though resistance may be added by using an elastic cord after the

initial levels are achieved. Specific hamstring and side to side exercises

should be added as a preseason and intra-season workout. A program of 20 minutes

a day concentrating on the knee musculature can dramatically increase strength,

improve performance, and diminish injuries.

Summary

The anterior cruciate ligament is the key guide wire within the knee joint.

Injuries to it are fortunately treatable, and early return to athletic

performance can be expected. All skiers can and should train to ski. The

training improves performance and diminishes cruciate ligament injuries.

Knee Exercises

Repeat these exercises several times with each leg. Over several weeks,

increase the resistance by adding ankle weights or by looping purse straps or

the handle of a weighted pail over your ankle. Start with one or two pounds,

adding one-half pound at a time as you build strength.

Bent-Leg Raises This strengthens the inner thigh muscle to balance the pull

on the knee joint from the outer thigh, which is often stronger.

Sit on a chair and straighten one leg.

Hold for one minute.

Bend your knee to lower that leg about halfway to the floor (a 45-degree

angle).

Hold for 30 seconds.

Return to starting position and rest for one minute.

Repeat.

Work up to four repetitions for each leg.

Straight-Leg Raises This strengthens the thigh muscles to help support the

knee joint.

Sit in a chair with one leg extended, resting your foot on a chair.

Lift that foot a few inches while keeping your leg straight.

Hold for 10 seconds.

Return to resting position for 10 seconds.

Repeat.

Work up to three minutes of lifting for each leg.

Runners knee - every year, one in five runners suffer from runners knee

injuries For instance, about 60 per cent of all runners are injured in an

average year, and about one-third of those misfortunes occur at the knee,

producing a yearly knee injury rate of one in five runners ('Running Injuries to

the Knee,' Journal of the American Academy of Orthopedic Surgeons, vol. 3, pp.

309-318, 1995).

If your knee injury pain is lateral (on the outside edge of a knee), then it's

likely that you are suffering from one of the most common knee complaints -

iliotibial band syndrome (ITBS). As you may have learned the hard way, ITBS may

aggrieve your knee enough to drastically limit or even completely stop your

training.

Iliotibial band syndrome has been around since man (and woman) first learned to

run, but it wasn't actually described in the medical literature until 1975

(Sports Injuries and Their Treatment, p. 56, J. B. Lippincott Publishers,

Philadelphia, 1975). The syndrome is often labelled an 'overuse' injury, but

that's a very poor way to describe the origin of the problem, since it implies

that the main source of difficulty is excess mileage. The truth is that runners

can be afflicted with ITBS on a regime of just five to 10 miles per week, even

though such volume would hardly constitute overtraining. The key source of

iliotibial band syndrome disorders is actually a lack of strength and

flexibility in the iliotibial band, sometimes combined with a perverse fondness

for running either on the track or on crowned roads, as you'll see in a moment.

Abduction and adduction

What exactly is the iliotibial band? It's not a jazz group whose members tap in

time to their music with their tibias. The central feature of the iliotibial

band is a key muscle, the tensor fascia lata, which runs down the outside of the

thigh just below the hip. Like all muscles, the tensor fascia lata has a band of

connective tissue at each end which bind it to bone. The upper band merely

ascends vertically a short distance to attach at the top of the hip (thus the

name ilio-), but the lower one runs all the way down the side of the thigh

before attaching to the lateral side of the tibia, just below the knee (hence

the name -tibial).

Overall, the iliotibial band scoots down the outside of the leg from the hip to

below the knee, kind of like a broad stripe in one's 'musculo-tendinous

uniform'. If you're curious about the muscle's name, the word 'tensor' means

'makes tense', 'fascia' means 'band', and 'lata' signifies 'wide', providing a

pretty accurate description of the characteristics of this key muscle.

If you do some digging in any human anatomy book, you'll find that the key

action of the tensor fascia lata and its associated bands of connective tissue

is supposedly to 'abduct the thigh' (in the patois of human anatomy, 'abduction'

means moving a body part away from the midline of the body). At first glance,

this 'key action' seems to make sense. If you activate a muscle which originates

at the hip and runs down to the outside of the leg just below the knee, wouldn't

it simply pull the leg outward, away from the other leg and from the imaginary

centre line of the body, a bit like flapping a wing? Of course it would, but how

useful is that motion during running? In fact, how instrumental is it to

everyday life?

Someone who makes a habit of abducting his legs during movement should set his

sights on the ballet stage, instead of athletic competitions. The real function

of the iliotibial band during running is not to flap the leg outward but to

control and decelerate adduction of the upper part of the leg. Adduction is the

reverse of abduction; it's the movement of an anatomical structure toward the

body's midline. And it's this very motion which requires constant control during

running.

If that's not exactly crystal clear, picture yourself running for a moment.

Let's say that you have 'toed off' from you left foot, soared through the air

for a fraction of a second, and have just landed on your right foot. As you do

so, your right foot tends to pronate (the ankle joint rotates in a clockwise

direction and the foot rolls to the inside), your tibia rotates in a clockwise

direction, and - lo and behold! - your femur (the bone in the upper part of the

leg) moves inward (goes through adduction). If you still can't picture this, see

for yourself by going through your running mechanics in semi-slow motion.

The role of the iliotibial band is to control this adduction - about 90 times

per minute per leg as you run and almost 22,000 times during a four-hour

marathon! No wonder the ITB sometimes complains! What makes things especially

tough for the tensor fascia lata is that when the right foot makes contact with

the ground and the left leg begins to swing through there is a natural tendency

for the left hip to drop temporarily, pulled down by the omnipresent force of

gravity. As it does so, the pelvic girdle 'rocks' like a seesaw; the right hip

goes up as the left hip goes down.

As you probably guessed, since the ITB runs from the hip down to the knee, the

upward movement of the right hip stretches the tensor fascia lata and overall

ITB at the precise time that it is trying to shorten and control adduction of

the right thigh. That constitutes an 'eccentric' movement of the tensor fascia

lata, and you no doubt know that eccentric actions are the ones which can be

especially trauma-provoking to muscle tissues.

Of course, that's one reason why mere stretching of the ITB can never be the

complete answer to real or potential ITB troubles. One also has to fortify the

tensor fascia lata and its associated connective tissues - making them strong

enough to withstand all that relentless eccentric yanking. We'll show you how to

buttress your iliotibial bands in a moment, but for now let's make it clear how

to tell when you truly have ITB syndrome and not some other condition.

How to diagnose ITB syndrome

As mentioned, a key aspect of ITB syndrome is lateral knee tenderness.

As often as not, the pain won't really hit home until the first one or two miles

of a workout have been completed ('Iliotibial Band Friction Syndrome in

Runners,' American Journal of Sports Medicine, vol. 8, pp. 232-234, 1980). Once

it starts, the pain tends to be persistent if you keep going - and frequently

gets worse during downhill running (and while walking down steps). The

discomfort may radiate up and down the leg, but - strangely enough - the pain

will often almost disappear if you stop running and begin to walk slowly and

with short steps.

If you have iliotibial band syndrome, a unique examination called the Noble

compression test will often be 'positive'. As you lie on your back, your doctor

will place his or her thumb over the lateral epicondyle of your troubled leg

(the lateral epicondyle is the hard knob on the bottom, outside part of your

thigh bone). With the thumb on your epicondyle, you will actively flex and

extend your knee. If maximal pain occurs at about 30 degrees of knee flexion,

watch out! You probably have ITB syndrome.

The reason your knee 'cries out' during this test is very simple: when your leg

is straight, the ITB lies in front of the epicondyle; as you flex your knee the

ITB actually passes over the lateral epicondylar surface. As you repeatedly flex

and extend your knee (as you would during running), the ITB keeps moving back

and forth against the epicondyle; if the ITB is inflamed and swollen, the

friction associated with this epicondylar 'rub' can produce quite a bit of pain,

especially when your doctor is forcing the ITB to be in close contact with the

bone. Similarly, if you have ITB and you stand with all your weight on your

affected leg and flex the knee to about 30 degrees or so, you will probably feel

a lot of pain if you apply pressure to the outside of your knee.

(As an aside, walking 'stiff-legged' with the affected knee locked in place will

often eliminate most of the pain, because it keeps the ITB from rubbing back and

forth against the epicondyle.)

In truth, though, ITB problems don't always occur at the knee. Pain may also be

present below the knee, where the ITB actually attaches to the tibia, and

discomfort may also occur much higher up - in the tensor fascia lata itself or

in its tendinous connection with the hip. Many runners recall an especially

intense or prolonged workout just before their ITB troubles started. Often, ITB

strikes near the beginning of the cross-country or track season, when athletes

are attempting to step up their training loads. Having 'bow legs,' excessive

leg-muscle tightness, a leg-length discrepancy, or very pronounced foot

pronation can all increase the risk of ITBS.

Traditional iliotibial band syndrome treatment

The widely accepted way of taking care of ITBS once it arises is certainly less

than perfect. Usually, athletes are told to cut back on their intensity and

volume of training and to work out only on smooth, non-hilly terrain. Icing and

non-steroidal anti-inflammatory medications are recommended to reduce discomfort

and inflammation, and athletes with ITBS are cautioned never to try to 'run

through' the pain.

Obviously, those are decent and logical suggestions, but note that not one of

these strategies actually addresses the true cause of the ITBS. The athlete who

alleviates the symptoms of ITBS with reduced workouts, drugs, icing, and hill

phobia and then returns to normal training is often destined for another serious

ITB flare-up, with the second episode frequently worse than the first.

Unfortunately, severe cases of ITBS can last for up to six months!

Of course, stretching the ITB is often recommended as an ITBS cure-all, and

stretching is almost never a bad idea. However, it's important that the

stretching routine you adopt actually improves the flexibility of the ITB in a

functional way. That can hardly be said for the traditional, popular ITB

stretches prescribed for runners, which never mimic the biomechanical patterns

associated with running. An over-emphasis on stretching may also lull runners

into thinking they are truly getting at the root of their ITB problems, when in

fact their gains in flexibility must be combined with advances in strength in

order to make the ITB highly resistant to injury.

How to strengthen your iliotibial bands

To truly strengthen your ITB area, simply perform 'Walt Reynolds's ITB Special'

on a nearly daily basis. Walt's ITB-saver is easy to carry out. The only

equipment you'll need will be a wall or railing for support and some kind of

four- to six-inch elevation (a bench or aerobic step will work fine).

Here's exactly what to do. Stand on the aerobic step or bench with your involved

leg (the 'involved' leg is the one with the ITB problem), holding on to a rail

or the wall with the opposite hand for support. Your legs should be fairly

straight as you do this

Now, with both knees 'locked,' lower the opposite, non-involved foot and hip a

few inches toward the floor (of course, the non-involved leg is between the

involved leg and the wall you are using for support. As you do so, your involved

hip will move upward somewhat, so that it is actually higher than the

non-involved hip. Your involved hip should also move a bit in a lateral

direction (toward the outside). This 'swivel-hip' action is crucial to the

exercise - and in fact is exactly what happens to the hips during the 'stance'

phase of the gait cycle.

Next, attempt to shift most of your body weight to the inside part of the foot

of the involved leg. This simulates the natural pronation of the foot which

occurs during running, and it also engages and puts tension on your tensor

fascia lata and iliotibial band, exactly as it would when you run. Make sure

that a fair amount of your body weight is directed through your heel, not just

your toes.

You've now come to a crucial part of the exercise. Bend your weight-supporting,

involved knee slightly (about 10 to 20 degrees), but keep the non-involved foot

off the ground or floor. Now, move the involved hip forward about four to six

inches, while keeping the involved heel in contact with the step and your weight

on the inside of your involved foot. As you do this, all of the action should be

at the hip! Your knee angle should stay about the same throughout the exercise

(eg, don't try to rock forward at the knee - do it from the hip). If you think

of your pelvic girdle as a bowl of milk, that 'bowl' is rocking backward (ie,

the bottom of the bowl is coming up and toward the front as the top of the bowl

goes back slightly). As your involved hip moves forward, your upper body should

move backward.

Very key points: as your involved hip moves forward, make sure that it stays in

a lateral position (if it's your left hip, your left hip should be shifted to

the left), and also be certain that your involved hip is higher than your

non-involved hip. After you've moved your hip forward, move it straight backward

- making sure it goes back four to six inches beyond the straight-up, starting

position (the total hip-movement distance in this exercise is around eight to 12

inches, four to six inches toward the front and four to six inches back).

As your hip moves backward, your upper body will tend to bend forward. This

action may seem strange to you, especially when you realize that in effect your

hip is swinging back and forth over your foot in two different planes of motion

- front to back (the sagittal plane) and also sideways (the frontal plane). Most

runners envision the biomechanics of running quite differently - and tend to

think that the key action during running is the swinging of the foot back and

forth around the 'anchor point' of the hip.

However, the truth is that when the foot is on the ground, the foot is the

anchor point, and the hip essentially rotates around the foot, not vice-versa.

It's this action which puts mega-stress on the ITB, and that's why Walt has

rather brilliantly designed this exercise to mimic the hip rotation involved in

running and maximally fortify your iliotibial bands. It is this same

back-and-forth motion which occurs 85 to 90 times per minute at each hip when

you run - and which can turn one of your iliotibial bands into a tattered,

complaining mass of red-hot tissue.

As you do the exercise, you should feel the burn - or if not the burn at least

some pretty heavy-duty pulling and stress - up toward the side of your hip. If

you don't feel anything happening, go back to the basic position and try again,

making sure that your involved hip ends up in a lateral position and higher than

the other hip - and also making certain that your weight is shifted to the

inside of the involved foot. As your weight shifts to the inside of the foot and

your hip moves laterally, your thigh is adducted, exactly as it is when you run,

and your iliotibial band must work hard to control this adduction as your hip

moves back and forth.

Try these advanced versions

Once you get really good at doing the exercise, you can try the advanced

versions of Walt's Special, getting the arm on the involved side of the body

into the act.

First, move the involved arm laterally and forward as your hips swing forward.

Then, try moving the involved arm forward and over the front of the body as the

hips begin to swing forward.

Of course, if your iliotibial band syndrome is red-hot right now, you'll have to

wait a bit before you try Walt's Special. Otherwise, the remedial exercise

itself might exacerbate your flare-up. If you're on the road to recovery from an

ITBS setback, do the exercise as your symptoms allow, being careful not to

overextend your iliotibial bands (start with just a few reps).

If you're basically symptom-free now but have had trouble with ITBS in the past,

you can be fairly aggressive with this exercise. Start with 10 reps per day on

each leg, and gradually build up to a set of 20 to 30 reps - carried out at two

different times during the day. If you do so, your ITBS problems will become

distant memories.

If you've never suffered from the agony of ITBS, do 10 to 15 reps of the

exercise three to four times per week, anyway. And always use the exercise as an

injury prophylactic during the weeks leading up to a major increase in your

training (remember that ITBS tends to occur when the volume and/or intensity of

training increase).

For example, if you are in a 'base' period of training but are planning to

sharply increase your miles as you begin preparing, say, for a marathon, do at

least one set of 15 reps of Walt's Special twice per day on each leg during the

last three weeks before your training volume begins to rise significantly (this

should be done almost daily). The same would apply to a shift from high-volume,

'aerobic' running to an emphasis on speed work.

Walt's unique exercise will keep you out of ITBS trouble in the future; as it

bolsters your iliotibial bands, it will enhance your ability to control the

adduction and rotation of your thigh bones (femurs) during running, reducing

both fatigue and muscle soreness. As you gain greater control of your hips and

thighs, there's also a good chance that your running economy will improve.

Remember that you do not want to carry out the exercise only on the leg which

has given (or is giving) you trouble. To balance your strength properly, do the

same number of reps on each leg, even though one leg may be trouble-free.

Special risk factors

If you love to run on crowned roads, watch out! You are at increased risk for

ITBS, compared to the runner who prefers flat surfaces, and your ITB troubles

are likely to strike on the 'down' leg, the one positioned toward the outside of

the road. That's why runners who run with the traffic tend to have ITB troubles

in their right leg; those who run against traffic get the flare-ups in their

left appendage. The reason for this, of course, is that the outside foot and leg

are moving downward at a faster speed when they strike the pavement, compared to

the inside foot and leg, because they have fallen a slightly greater distance.

It's as though the outside leg is always running downhill. Thus, the total force

on the outside leg will be greater, and there will be an increased need for

'thigh deceleration' by the tensor fascia lata and its associated iliotibial

band. The tensor fascia lata will be shortening and generating more force at the

same time that the 'pull' on it is

unusually great. That's a recipe for injury! It's best to get off the 'crown'

and run on the usually flatter shoulder - or else to choose a different,

non-sloped location for your workouts.

It's an unwritten law of the universe that runners must run on a track

counter-clockwise (anti-clockwise), rather than clockwise. This means that for

the person who trains excessively on the track, ITBS will almost always strike

in the left (inside) leg, because the left tensor fascia lata and its bands must

control a greater deceleration of adduction than the right (outside) hip.

As Walt Reynolds puts it so eloquently, 'When a person runs on a curve to the

left, he/she will compensate for the outward-pushing centrifugal force by

leaning slightly to the left. The faster they run, the greater the lean must be

(that's why very fast track sessions pose an increased risk for ITBS). You see

the same thing in flop high jumpers' approach runs; they run fast and lean far

to the inside - toward the bar. This lean with the upper torso can drastically

change what happens biomechanically. As you lean into a left curve and your left

foot hits the ground, pronation is exaggerated compared to running straight

ahead, since the left foot tends to land more toward the outside and thus must

roll to the inside to a greater extent than usual (there is more frontal-plane -

side-to-side - movement than usually occurs). As this happens, the left thigh

accelerates inward (adducts) to a greater extent than normal, creating a need

for greater deceleration than usual by the

iliotibial band and stressing the ITB considerably more, compared to running

straight ahead. If you must run on the track, you should alternate back and

forth between clockwise and counter-clockwise intervals.'

Get a longer leg!

Having a leg-length discrepancy also increases the risk of ITBS. When the two

legs are unequal in length, the shorter leg receives greater stress in much the

same way that the outside leg takes in more force during running on a crowned

road. The momentum and ground reaction forces are higher for the shorter leg

because that leg falls a greater distance before the foot makes impact with the

ground. This increases ankle pronation and thigh-bone adduction - and thus the

stress placed on the iliotibial band.

Women should suffer from ITBS more frequently than men, since their wider hips

promote greater thigh-bone adduction and thus greater stress on the ITB.

However, the research doesn't support this idea - and in fact suggests that men

may actually be plagued by ITBS more often, perhaps because of their greater

muscle tightness and inflexibility.

Speaking of inflexibility, it's important to stress once again that traditional

stretches don't work very well at preventing or relieving ITBS. In one of the

most popular ITB stretches, if the right leg is the afflicted leg, the left leg

is crossed over in front of the right one, and the upper body is inclined to the

right (a wall is usually used for support), placing a fair amount of stretch on

the right iliotibial band.

One problem with this 'venerable' move is that it is not very functional (it

doesn't replicate the movement patterns associated with running), but the other

key drawback is that it does not strengthen or increase the resiliency of the

ITB. It gives the ITB a little bit of a pull, but the tensor fascia lata and its

associated bands don't have to control a blessed thing. The best exercises

always bolster both flexibility and strength, and Walt's special exertion

certainly does that!

If you've already got a severe case of iliotibial band syndrome, stay in shape

by swimming and aquarunning: they will keep you fit without aggravating your

condition. Cycling and stair climbing are usually out, because they can produce

considerable rubbing of an inflamed ITB band on the outer edge of the femur,

potentially delaying recovery.

Owen Anderson (text) and Walt Reynolds (exercise)

REHAB DURING THE EARLY DAYS OUT OF BED

ONE LEGGED BALANCE

back to GYM

This simple exercise should not be under-estimated.

EARLY REHAB SECTION

PRINCIPLES

WEIGHT-BEARING

ASSISTED FLEXION

MINI SQUATS

MINI STORK

ASSISTED PASSIVE EXTENSION

STEP-UPS

SHORT ARC EXTENSIONS

ONE LEGGED BALANCE

TIP TOES

Stand comfortably near to a support, such as a wall.

Lift the good leg, and balance for 10 seconds on the bad leg.

Close the eyes and continue for another 10 seconds. Repeat 3 times a day.

If it is too difficult, hold small weights in your hands, or

stretch your arms out to the side.

last updated January 2004

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November 2003

Knee Exercises for Walkers

There are two specific threads of discussion on this topic.

A walker must improve his flexibility and style to ensure that his style

helps him land with a straight leg and then lends itself to rotating through the

stride with a leg that remains straight. I will discuss this at some time in the

future as this is a big topic.

The knee must be generally healthy - ie have a range of movement and be

strong and able to support a straight legged action on an ongoing basis.

In this article I will restrict myself to the second of these two points -

how to build up knee strength and health. We are really talking here about the

sort ot exercises that a physiotherapist might for someone after a

knee operation. Here is what might be given to you by way of recuperation

exercises:

Perform these exercises sitting on the floor with your back against a wall.

Note that exercises A-C can be carried out standing up if no floor space is

available.

A. Stiffen knee by pulling knee cap towards you with foot turned up. Hold for

10 - 30 seconds, then relax. REPEAT 10 TIMES HOURLY.

B. Stiffen knee as before, lift with leg straight then lower slowly with knee

straight - Relax muscle when leg lowered. REPEAT 10 TIMES AT LEAST TWICE A DAY.

C. Stiffen knee as before, lift one inch off floor, take leg out to side and

back, keeping knee straight - Relax muscle when leg lowered. REPEAT 10 TIMES AT

LEAST TWICE A DAY.

D. Stretching exercise. Whilst standing, grab foot and bend leg backwards as

far as possible, hold for 10 seconds and perform as often as you like.

Once you are comfortable with this and feel the extra strength and suppleness

in the knee, progress onwards..

B. Build up to 3 sets of 10 lifts (ie. 30 lifts), pause for 30 seconds between

sets. When 30 lifts become too easy, add weight (eg. 1kg to foot and repeat as

before.

C. Lift weight on side when ready, lying on good side.

E. Lying on stomach, cross legs at ankles - bend knees to 45 degrees resisting

own knee bending - Hold for 10 seconds and relax. REPEAT 10 TIMES AND THEN

CHANGE LEGS - TWICE A DAY.

Isometric Knee Exercises

Quadriceps Set:

Sit on the edge of a chair or lie down with your knee straight. Tighten the

muscle on top of your thigh by straightening your knee as much as you can. Place

your hand on top of your thigh to feel the muscle tighten. Hold the muscle tight

for a count of 5. Relax and repeat 5-10 times. Try to do the exercise with each

leg several times throughout the day.

Straight Leg Raise:

Lie flat on your back on either a bed or on the floor. Bend one knee, placing

your foot flat on the bed. (This helps to stabilize your pelvis and protects

your lower back.) Straighten the other knee. Tighten the muscle on the top of

the thigh of the straight leg and slowly raise the entire leg 12 to 18 inches

off the bed. Slowly lower the leg and relax. This exercise should only be done

if you can keep the small of your back pressed against the bed with the

abdominal muscles gently tightened. Repeat this exercise until you can do it 10

times, and then progress to doing 3 sets of 10 repetitions with a 1 to 2 minute

rest between sets. This will improve its strength. Repeat with the other leg.

Remember to bend the opposite knee, placing the foot flat on the bed. This

exercise is isometric at the knee, but not at the hip.

Hamstring Set:

Lie on your back resting your heel on the bed, or sit at the edge of your chair,

resting your heel on the floor. Bend the knee slightly. Dig your heel down into

the bed or the floor squeezing it toward you, but don’t allow it to move. You

should be able to feel the muscles on the back of your thigh tightening. Hold

for a count of 5. Repeat 5-10 times with each leg several times throughout the

day.

Be sure to breathe.

Seated Combination Quadriceps/Hamstring Set:

Seated in your chair, cross your right ankle over your left. Your left foot is

flat on the floor. Push back with your right ankle against your left. You can

feel the muscle on the back of your right thigh tighten. Add a forward press

with the left ankle against the right, and you will feel the muscle on the top

of your left thigh tighten as well. Hold for a count of 5.

Be sure to breathe.

Repeat several times, and then switch legs. PRECAUTION: Avoid this exercise if

it aggravates your knee pain.

Short Arc Quadriceps:

Although this exercise is not completely isometric, it is often tolerated well

when the knee is painful because the knee is exercised only in a small part of

its range of motion. Lie on your back, and put a 1-2 pound coffee can or a

rolled up towel bolster measuring 3 to 6 inches in diameter under your knee.

Straighten the knee. You will feel your knee pushing down into the bolster as

your heel lifts up and the quadriceps muscle on the front of your thigh

tightens. Hold for a count of 5. Relax. Repeat several times with each leg.

Knee Exercises Exercise 1: AROM hip abd uni sidelying

Perform 2 sets of 10 repetitions, once a day.