Thoughts.

I thought I’d post up the e-mail transcript of an exchange between myself and a reader–as a former JET, we got talking about ultimate and life in Japan, and eventually about his knee troubles, a topic I’ve a done a lot of reading, experimenting, and self-diagnosis/treatment in. (UPDATE: Part 2, with links to some resources, is here).

Hopefully it proves useful/instructive for those of you out there with knee pain or similar trouble. Without further ado:

…It all started on a long jog back in December. Next day there was a little discomfort above the right kneecap. Tried to play through it at a hat tourney in Vietnam–bad idea. Rested for two months, pain/discomfort basically went away just in time for DC in March. Whew.

But the pain returned a month ago at a tourney in Jeju (Korea). Same process: niggle at first, then progressively gets worse. I’ve rested since, and it’s better, but this time the pain is more diffuse: sometimes above the kneecap, sometimes medial, sometimes… everywhere.

X-ray and MRI say no structural damage; two docs say just rest. One mumbled something about jumper’s knee, but I doubt it because the pain is mildest below the kneecap. Symptoms are soreness in the morning, and dull to acute pain when standing from a sitting position, or sometimes going up/down stairs. I also experienced sudden bouts of severe pain when sitting for long periods on a recent flight to Atlanta. Strange, and scary.

I can accept resting for as long as it takes to heal properly. But I’m 31, and can’t help but worry that this is serious and might not just go away. I’m looking for a knee specialist around Tokyo, but no luck so far. Not really knowing is the worse part, know what I mean?

That bites. Ultimate’s a terrible sport for that sort of thing too, with all the high impact combined with the weekend-long duration…I assume you already use it, but ibuprofen is mandatory when you play–from the sound of it, if you don’t have any structural damage you’re likely feeling the pain from inflammation and swelling. The aching when you fly has to do with the pressure differences, as well as just the lack of movement from the tight confines; I’ve gotten that sometimes too, with ankles (rolled both at one point or another) and the knee (a few years ago when it was still an issue)…though not the “sharp pain” you describe. Weird indeed. They’ve definitively ruled out meniscal tears?

It certainly sounds like there’s some tendinitis/tendonosis, even if it’s not jumper’s knee. How are you flexibility/strength wise? I always had knee issues when my legs were so tight that it affected my footstrike and kept my hips from taking the brunt of the impact. I’d wager you’ve got tight hips and (perhaps) quads, tight/weak hamstrings, and perhaps tight calves too (the latter is more of a personal thing for me rather than what I’ve read/seen, but it might apply to you). Especially if you’re sitting all day and don’t do a lot of training with mobility in mind (ie, if you run lots but don’t do much in the way of squatting or lunging or the like).

Are you familiar with the Samson stretch? (I can probably get you a .pdf with more details if you want). Great for loosening up the hips/quads, good for daily stretching and highly recommended for pre- and post-workout/play. If you don’t do squats or lunges or the like I’d definitely recommend getting into them–I can get you LOTS more information to that end. Docs in the states might tell you to avoid squatting but with the right technique (going to the right depth, and engaging the right muscles), it’s far more protective than destructive.

Here’s the rehab menu from the last doc:

1. Sit with legs dangling, massage quad vigorously (like meading).

2. Sit with legs stretched out in front and knee slightly bent, massage calf.

3. Sit with legs stretched out in front and small pillow directly under knee, engage quad by pushing down on pillow. Hold quad, especially inner quad muscles tight for 3 secs, slowly release.

4. Sit with legs stretched out in front and gently massage kneecap forward (towards toes). He says my kneecap is likely being pulled up (towards head) by tight quad and calf muscles, and this off-centering is causing irritation.

5. A new exercise is lying down face-up and with knees bent, and lifting butt off the ground until the body is straight (knees still bent). Focusing on core, butt and hamstring muscles.

I’ve been following this regimen pretty consistently over the last month, and there is improvement. But something is def still off. The last few days, for example, I’ve been feeling pain in the inner knee area. But other times its medial, or above. Strange, and frustrating.

Not sure if I’m ready for the Samson stretch — seems like a fairly intense exercise, want to make sure I don’t aggravate the knee. But will give it a try. Any other advice for low-impact strengthening exercises for the quads and hammies?

How bad is the pain?  Is it debilitating?

I’d imagine you could step up the vigor a bit if this stuff isn’t pushing you too hard. For instance, on that last one you do (I know them as “shoulder bridges”), you could try doing them on a single leg with the other extended straight–I’d also recommend keeping your hands on your butt cheeks while you do it, and really focus on contracting those muscles (the extra tactile sense from the touch can help you body figure out what muscles to activate). 

Based on the other stuff, it sounds like you’ve probably got chronic tightness and weakness in the quads…the Samson stretch might sound intense, but you can definitely ease into it and I think it’d do you a lot of good. A similar stretch that’d probably hit the areas you need to stretch really well is pretty similar–the same lunge position, but you put the foot of your back leg up on a bench or other raised surface such that the back leg is bent–this will focus the stretch on a deeper part of the quad, that I think tends to contribute a bit more to the knee pain.  I can dig up pictures or the like if you need a better explanation than that.

In terms of strengthening, my knee troubles coincided with an inner quad strength/mobility deficit–specifically, my right Vastus Medialis (VMO–the “teardrop” shape) was a lot smaller and activated (contracted) a lot less easily than my left, and I had right knee troubles.  Again, doing some stuff single-leg can likely help with this (holding the top position on single-leg shoulder bridges, for instance).  If you’re able to find a trainer and able to bear some weight/range of motion, getting somebody knowledgeable to coach you in doing lunges or Bulgarian squats or other single-leg types of exercises can help a lot.

The one issue I’d raise with all the rehab stuff you’re doing–all of which makes sense and is reasonable to prescribe–is that, while it addresses the muscular deficits (strength and flexibility), it’s not doing much to reinforce good movement habits–in other words, it might fix the symptom, but your body is at this point probably so used to, for instance, running whilst compensating for the deficiencies that without some kind of re-programming you’re probably going to continually struggle.

That’s why I think it’d be a good idea to incorporate good lunges and perhaps some squatting or even deadlifting into the mix eventually.  Doing those exercises with decent form and the right sort of flexibility/strength will help reinforce good habits, and if, for instance, you do mobility drills (again, something I can send you more info on) as part of your warm-ups, it’ll help continue to reinforce good habits.

One last thing–are you familiar with foam rolling at all?  This email is long enough, but it’d probably go a LONG way towards helping you improve your mobility if you haven’t been doing it yet.

Yeah.  So, let me know if you want me to dig up some resources for that stuff.  I’m not surprised if your rehab specialists haven’t been aware of this sort of stuff, as thinking in terms of mobility, foam rolling, and the like is still more…hm, cutting-edge, and has only recently started getting enough data and support that it’s becoming popular, accepted, and therefore, taught to aspiring therapy professionals.

More to come in a later post, including some resource references.  Anyone out there have advice or insight to offer that I’m missing?  Especially if you think I’m talking out of my ass at any point I’d love to be corrected–I’m basing this largely off my own history, along with some advising of teammates, so I’m hardly a professional.

Related posts:

1. Treating Chronic Knee Issues: An E-Mail Case Study (Part 2)
2. Mobility And Injury Prevention
3. The Importance of Progression
4. Flexibility