Walk This Way

Walk This Way

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O'Brien, Timothy
Summer in Montana means many folks are eager to kayak, mountain bike, hike the trails, fly fish, and play organized sports like soccer, baseball, and softball. But with the rush to sports also comes the unfortunate injuries.

As an orthopedic surgeon who specializes in sports medicine, I see injuries of all types. There are the "overuse injuries" that can be avoided with proper training, there are the muscle strains that come from not stretching, and there are the popping sounds and swelling associated with anterior cruciate ligament (ACL) tears, which often need surgery.

Clearly, the most important element in preventing knee injuries is to begin conditioning, strengthening, and stretching early. Start training slowly and never increase the duration or intensity of your workouts by more than 10% each week. Advance into steps, hills, or uneven terrain gradually, and alternate activities so that there is adequate time to rest and recover between intense bouts. Also alternate between low-impact weight-bearing and non-weight-bearing workouts (switching between weights and a stationary bike or the pool, for instance).

Other key elements in prevention are proper activity technique, equipment fit, and shoes with appropriate arch support. It's also crucial to warm up prior to activity. A hot pad or warm soak for 10-15 minutes before stretching and strengthening is ideal.

Knee Anatomy / Common Injuries
The knee is stabilized by four main ligaments: the medial collateral (MCL) on the inside, lateral collateral (LCL) on the outside, and two ligaments that cross in the middle (ACL and PCL). Isolated injuries to the LCL and PCL are fairly rare. Isolated and combined injuries to the ACL and MCL are much more common.

These injuries are often non-contact and happen with the foot planted and a twist of the body to change direction. The athlete often hears or feels a pop and has near-immediate swelling with an ACL tear. With an MCL injury there is typically less or no significant swelling. ACL tears usually do not heal on their own and often require surgical reconstruction. MCL tears usually do heal without surgery but require appropriate bracing.

Other common injuries are called "overuse injuries" or in many cases more appropriately "under-prepared injuries." These can be somewhat avoided by proper training. For example, I see many cases of "chondromalacia patella" also called "anterior knee pain" or "patellofemoral pain." By focusing on building quadriceps strength and proper body mechanics, the athlete can lessen or avoid this condition entirely. This is common in hiking and all running sports.

Similarly, I see many patients with "Iliotibial Band Syndrome." The patients usually point to the outside part of their knee as the site of the pain. Other patients present to the office with have pain on the inside of the knee over the insertion of the hamstring tendons, a condition we call "pes anserine bursitis." These are common in runners and horseback riders.

Stretching should focus on the hamstrings, quadriceps, and calves, and also the iliotibial (IT) band. Here are some effective stretches; hold each comfortably for 30 seconds and repeat two or three times.

Hamstrings: Place leg forward and outstretched on a stable object about hip level. Slide hands down toward your toes and hold. Another option is to lie on your back near the edge of a doorway and place your leg up the wall, keeping the knee straight. Slide the buttocks as close to the wall as possible with the other leg flat on the floor.

Quadriceps: Lie on your stomach and grasp your foot with your opposite hand and pull toward your buttocks. This can also be done standing, but grasp a stable object with your free hand to avoid falling.

Calf: Face a wall with hands eye level and one leg back with foot flat on the floor. Lean into the wall until a stretch is felt. Hold and then slowly bend your knee toward the wall to stretch the entire length of the calf musculature.

IT Band: Stand in a doorway with feet planted next to one side of the frame. Lean in the opposite direction so that your hip is pushed away from your feet. You should feel the stretch along the outside of your leg.

Strengthening should focus on the quadriceps muscle, specifically the vastus medialis oblique (VMO), hamstrings, and hip abductors. Perform three sets of 15-20 repetitions.

Straight Leg Raise: Lie on your back or sit with one knee bent. Raise the straight leg from the ground and hold for five seconds. To isolate the VMO, perform this exercise with your foot turned out from the body. Use ankle weights for added resistance.

Side-Lying Leg Lift: Lie on your side with the bottom leg slightly bent. Lift the top leg into the air and hold for five seconds. Use ankle weights for added resistance.

Step-Up: Stand with one foot on a step and the other flat on the floor. Lift your foot from the floor and straighten your knee. Return to start position and repeat.

Wall Squat with Ball: Stand with your back to a wall. Place a rolled-up towel or small ball between your knees. Slowly squat, using the wall for support while squeezing the ball, to almost sitting and hold for 10 seconds.

Timothy O'Brien is an orthopedic surgeon at Alpine Orthopedics in Bozeman. Melissa Humpal Fisher, who assisted with this article, is an athletic trainer at Alpine Orthopedics.
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