Forums General Chronic IT band/quad TIGHTNESS and knee pain (chondromalacia patella?) for 6 years!

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    • #70643
      AvatarRyan Cloutier

      Chronic anterior knee pain // chondromalacia patella // patella femoral pain

      Sorry my post is going to be a long 3 part post:
      Let me begin with some backround. I am 23 years old male currently living in Canada. I have had anterior knee pain in my right knee for over 6 years. It started when I played soccer, and it just got worse. My IT bands, quads, and hip flexors are really tight. Nothing seems to really loosen them, especially my IT band. I have tried physiotherapy from multiple physiotherapists, ART, electrically stimulated trigger point dry needling (PENS/electroacupuncture), acupuncture, massage therapy, foam rolling (lacross ball, PVC pipe, rumble roller), suction cupping, strengthing glute medius and maximus, VMO strengthening, core strengthening, balance work on wobble board, orthotics, intra-articular prolozone injections, joint supplements, heel wedge for leg length discrepency (my right leg is 1.1 cm shorter which was confirmed on an x-ray). I dont do any physical activity besides physiotherapy. My pain is at a constant 5/10, (it fluctuates sometimes its lower, but sometimes like in rainy days or cold days its even higher, as I am writing this its at a 7/10). Basically all the physiotherapists are perplexed at my issue and they say that I should not be feeling so much pain. They think my overall mobility and flexibility isn’t that bad and of them said hes never seen someone in so much pain with relatively good mobility. But when they massage they notice that my soft tissue is really tight with lots of “junk” or adhesive knots. Sometimes the tightness is really painful and feels almost like a cramp. If I massage, and self-myofascial release religiously for awhile and don’t do any activities it will loosen up a little, however its still tense/hypertonic. But even a little bit of daily physical activity will cause it to tighten up pretty harshly (i.e., cleaning the house, sexual activities, moving large furniture, dancing at the bar/club, doing physiotherapy workouts without doing self-myofasical release and stretching at the end)
    • #73430
      AvatarRyan Cloutier

      Joint supplements:
      1) NEM – natural egg shell membrane (500mg)
      2) pycnogenol (100mg)
      3) fish oil (2000mg)
      4) krill oil (500mg)
      5) curcumin (500mg) 

      6) Serrapeptase – 270 000 IU (for muscle tightness and joint)
      Note: They dont seem to have helped much. I am thinking of replacing my curcumin with Thorne Meriva (a high potency curcumin, with 20x more absorption) based on all the good reviews. Someone even said its worked better than cortisone shots. I have also tried MSM and type 2 collagen from fortigel.
      General Health Supplements:
      1) Magnesium Biglycinate (200mg)
      2) Vit D (2000mg)

      Diagnostic imaging done:
      1) X-ray on knee – showed nothing abnormal besides patella tilt
      2) ultrasound on/and around knee- showed mild inflammation in my right knee, nothing serious
      3) MRI – getting it done in January

      4) X-ray for leg length – showed that my right leg is 1.1 cm shorter (the leg with the knee pain is shorter)

      Previous treatments:
      1) Many Physiotherapists/massage therapists/FMS certified strength and conditioning specialist- looked at mobility, muscular imbalances, glute medius, glute maxmus, VMO strengthening, core strengthening, stretching, self myofascial release, foam rolling, suction cupping, ART, massage therapy, orthotics, gait analyses, heel wedge for leg length discrepency, electrically stimulated trigger point dry needling (PENS/electroaccupuncture), acupuncture, went to Fowler and Kennedy sports medicine clinic in London Ontario and many other places. I am currently seeing a new physiotherapist whose focusing on postural work.

      2) Dr Robert Banner (London ON) – 6 treatments of Prolozone injections, once every month so far. Only noticed temporary relief of pain, maybe for 2 weeks after each injection (The pain relief was dramatic tho, about 75% pain relieving effect). Has recommended EMF (electromagnetic field) protective devices such as diodes. He says it may help since my symptoms are worse on rainy days. Seems very pseudoscience tho. 

      3) Osteopath – Just started seeing one, had 2 treatments done. She noticed my right hip is tilted anteriorally (hip-misalignment). She is trying to re-align the pelvis. So far no benefits from treatment besides my back feeling a lot looser, and I come out of it with a better posture (which doesn’t usually last). She is inexperienced (still in school, but seems really competent), but charges a very cheap rate. She also noticed my upper back is kyphotic and lower back has some lordosis (I already knew this). 

    • #73431
      AvatarRyan Cloutier

      Possible Future treatments:
      1) Botox (Dr. Gordon Ko in Markham) – into the vastus lateralis (any maybe hip flexor). This has shown to be effective in some recent studies for patients with refractory anterior knee pain. The idea is you shut down the vastus lateralis for 3 months, and you continue to do physiotherapy, this gives you a window of time for selectively strengthening and isolating the VMO. This will help with tracking and tilt issues, and can give symptomatic relief of muscle tightness during the 3 months. Its good for addressing muscular balance issues. Dr. Gordon Ko also does PRP, prolotherapy, hyaluronic acid, and botox into the joint.

      2) HGH/testosterone/IGF-1/dextrose/PRP/PSGAS/hyaloronic acid – have read this has helped some people.I am looking into injecting into my own knee to save thousands of dollars. This can help regenerate possible cartilage damage I might have.

      3) Dr. Anthony Galea (Etobicoke/Toronto) – he is a prominent sports medicine physician infamous for treating athletes and giving them HGH. Don’t know what kind of treatment he would give me. I know he does PRP, but I dont know if he can give HGH anymore since its illegal here in Canada and hes gotten in trouble for that.

      Help me:
      I am desperately looking for some advice and how to proceed. My chronically tight IT Band, quadriceps, and Hip flexors just dont seem to loosen up! My new physiotherapist has me doing postural work/exercises now. I have been doing them for about 1 month now. He thinks that bad posture might be contributing. 1 month ago he said to give it 3 months, and I should see improvements. (He even said that I can expect to see an 80%, but my case is a little unique so he doesnt know for sure), He is really surprised I am feeling so much pain, and tightness for not even doing that much physical activity. So far their has been no improvements with the postural exercises. 

    • #73432
      AvatarAnonymous

      Has anyone determined a cause for the tightness you are experiencing?
      It sounds like the people you have seen are going after symptoms, but not what is causing the symptoms.
      The symptoms will continue or continue to display new symptoms until the cause is addressed.
      Have you looked upstream/downstream of the issue?
      IT Band/ Hip flexor episodes
      Episode 361: Pathomechanics and IT Band Hell Part 1


      Episode 361: Pathomechanics and IT Band Hell Part 2
      Episode 361: Pathomechanics and IT Band Hell Part 3
      Episode 61: IT Band Hell, And Help…
      Pro Episode # 35 – MWod Pro-User Request Friday: The IT Band Primer
      Episode 142: Tight IT Band and Hip Flexor Fix: Runners?
      Episdoe 23: Runner’s Legs

      How long did you stay with a treatment?
      It could take a few weeks to start to see a change. Some will depend on how long you have had the issue and how it is being addressed. Have you done the treatments alone or is there someone who can check that you have proper positioning etc?
      It doesn’t sound like a mobility issue.
      “relatively good mobility” how are they defining this term?
      This wording shows there is room for improvement with mobility.

      If you aren’t seeing improvements with the supplements you take are you still them?
      What is your nutrition like?
      This is a place that can have significant impact.
      I would recommend getting blood work done so you can identify if you have low levels anywhere.
      I recommend contacting Wellness FX they have a few different packages available and you consult with a doctor you choose from their network.
      Have you considered seeing a chiropractor?
      An adjustment may realign your hips/pelvis and solve the difference in leg length.
      Knee Pain? Got Full Knee Power/Range of Motion/Potential–Terminal Knee Extension Part 1
      Knee Pain? Got Full Knee Power/Range of Motion/Potential–Terminal Knee Extension Part 2
      Knee Pain? Got Full Knee Power/Range of Motion/Potential–Terminal Knee Extension Part 3

      Posture
      Why Sitting Wrecks Your Mad Hip Action
      Episode 274: The Standing Athlete
      Episode 251: High Skilled Sitting/Abdominal Bracing

      Episode 187: Death by Chair. How Much Do Actually Sit?
      Episode 88: Desk Athlete Hip Rescue

    • #73436
      AvatarJames Beatty
      Participant

      Can you specify where exactly the pain is? ie. Below the knee, above the knee, medial, lateral, in the middle, etc. And what movements cause the most pain?

    • #73438
      AvatarRyan Cloutier

      Hey Alpha919

      The pain is between the femor and patella (right in the patellofemoral joint, under the knee cap), more so on the lateral side , and it seems to be more near the proximal aspect of the patella (the part closer to my head and further from my foot). Its a dull achy pain that is often times difficult to describe and hard to pin point. Almost feels like their is a lot of pressure on that lateral side, and its compressed and cant breath. I don’t think theirs anything wrong with the quad lig/tendon because I have had ultrasound done showing nothing, also many physiotherapist, and OS checked via manual testing. They all seem to think its chondromalacia patella, femoral pain syndrome, and from the vast research I have done, I seem to have a VERY bad case of it that wont go away.
      Its a constant pain (with or without movements). So just sitting here writing this I am in about the same amount of pain as if I were to squat. Sometimes sitting for longer periods will make the pain worse. Also squatting/bending activities/exercises wiithout being warmed up is more painful than when I am warmed up. Also, if I do any exercises/activities such as physiotherapy without foam rolling and streching and self-myofascial release at the end, my IT band and quads will get really tight. This tightness will persist for days, and will aggravate my knee symptoms even more. (So its not so much during the activities that cause me more pain, its after the activities). So I have been avoiding activites/exercise unless its physiotherapy/rehab related. Although this seems to be palliative in nature.
      I have been doing patella taping, it helps with the pain a little, nothing to dramatic (brings my pain down 1 point on 10 point scale). It works better taping it medially and inferiorally as opposed to just taping it medially. 2 Tapes are typically used. 1 for the tilt, and 1 for the tracking. Again, this seems to only be palliative in nature, and not addressing the cause.
      I should be getting an MRI done early in January. But even with the MRI results, their is something causing this chronic tightness that’s pulling the knee cap that needs to be addressed. It feels like its compressed, and very painful. 
    • #73439
      AvatarRyan Cloutier

      Hey Kaitlin

      Glancing over some of your other posts, you seem really passionate in helping
      people heal. I have the same passion, but I feel like I have hit a roadblock
      with myself that I can’t pass. I know that I am missing something in the puzzle
      on healing myself. Glad you can offer some advice.

       Therapist have tried determining the
      cause of my tightness. I was instructed it was a muscular imbalance, and that weakness
      in my glute medius was the main culprit. Also was instructed, and read that
      glute max, the deep core muscles, and VMO had a lesser role, although still
      important to address. So I was first doing basic exercises such as clam shells,
      bird dogs, X-band walks, hip thrusts, planks, lying side leg lifts against wall
      etc.., then I added 90/90 split squat, single leg squats, single leg deadlifts,
      wobble board balance. This was in order to activate the glute medius, glute
      max, and then start getting VMO involvement as well as doing more functional
      exercises.

      After doing  all that for years I still have knee pain, I
      was doing it really religiously this past summer (it actually feels like my
      knee pain is worse now), But the tightness I have in my IT band and quads may
      have decreased roughly 30% in the last year, and the patella seems to be
      tracking better, although it feels really compressed and tilted (i.e., the
      lateral half of the patella is more compressed/tilted towards the femor, this
      is also slightly shown on the x-ray where their is a slight decrease in joint
      space were I feel the pain coming from, although the sports medicine physician
      says everything is fine, and thats just a slight tilt in the patella and their
      seems to be no cartilage damage). More recently (this past month) I am also
      doing postural exercises as advised by a new physiotherapist I am seeing that
      is highly regarded in my area. He has me focusing on keeping an aligned spine
      while maintaining different positions, and also doing body weight squats with
      an aligned posture. He says I have an anterior pelvic tilt, lordosis in my
      lower back, and kyphosis in my upper back. He thinks the posterior excercises
      will address those issues, and subsequently reduce my knee pain and help with
      the entire kinetic chain, and result in less IT band tension. He says he is
      really surprised tho that I have such knee pain given that my posture isn’t
      that bad (he has seen people with worse posture and in no pain), and given that
      I dont do extensive physical activities, he says hes seen cases similar to mine
      but the difference being is that they are overdoing physical activities such as
      running a lot (marathons etc..) But in their cases their symptoms subside
      dramatically once they reduce physical activities, and through some corrective
      excercises their issues are resolved within a few weeks-months. I asked him
      about self-myofascial release and ART etc.. He says that will only bring
      temporary relief as that is only addressing the symptoms, not the cause. 

      I typically do physiotherapy exercises every 2-3 days now
      (once upon a time I was really strict and was doing it every 2 days but noticed
      I wasn’t really getting anything out of them, so I slowed down a little), The
      exercises last over 1 hour, and I follow it with foam rolling, and stretching,
      and suction cupping which also lasts over 1 hour. The whole session ends up
      being between 2-3 hours. I also do postural exercises (in separate sessions
      from the physiotherapy exercises) every day followed by foam rolling (if I dont
      foam roll after the exercises my muscles will be very tight and be in pain).
      The postural exercises are about 20 minutes followed by 20 minutes of foam
      rolling. The physiotherapist told me to do it 4 times a day. But I dont see
      that as realistic (were am I going to do them in school, and were am I going to
      find the time since I am already doing so much rehab work. I have done them at least
      once a day, and sometimes twice. These exercises I was doing at home, but
      I was going to physiotherapy periodically to ask questions, and so they can
      check my form. 

    • #73440
      AvatarRyan Cloutier

      About 1-2 months ago, I have also been seeing a strength and conditioning specialist whos FMS certified at hybrid fitness center in London ON. He gave me an assessment and found that I have really good mobility for someone with my symptoms (although its not perfect), so I have been working on mobility and have improved but mysymptoms are the same. He also said he couldn’t pinpoint what is going on, and the results are inconclusive. He mentioned that the biggest issue he found was that my right anterior pelvis is shifted forward (hip-mis alignment). He said that he thinks that their is tightness and “junk” in my right hip area, and he hypothesized that the symptoms I am seeing might be due to that. His sessions are 60 minutes: 30 minutes had me doing various exercises, also had me do some capsule stretches, watching my form, the other 30 minutes he would give me aggresive ART, massage therapy for the right leg and right side of pelvis area.

      I am still taking the supplements and have added cissus and serrepeptase more recently. I stopped taking curcumin as their seems no benefit. I have been taking joint supplements now for about 1 year with no help. Serrepeptase is an interesting one as it apparently reduced muscle adhesions and scar tissue and is fibrolytic. No impact on me thus far tho.

      My nutrition is very good, being mostly paleo, high in omega 3, and low in omega 6, and low carbohydrate (no/or very low flour, sugar, bread), organic meats, avocados, lots of veggies, vegetable shakes with lots of healthy stuff in it, eggs, beans, legumes, quinoa, nuts, seeds, coconut/avocado/olive oils etc…I drink green tea with fresh cut ginger inside for added anti-inflammatory and other health benefits. My cheat food is a decaf coffee, with a little bit of honey, and dark chocolate. I have always been pretty good in the nutrition department. I might still consider getting blood work done, but at the age of 23, and with a good BMI and what I have been told as being a fit strong person, I am not sure if its a priority. Perhaps one of the later options if nothing else seems to help?

      I have considered seeing a chiropractor, but right now I am seeing an osteopath just because of convenience and price. She works at hybrid fitness center (the place where my strength and conditioning specialist works and my more recent physiotherapist who gives me postural exercises is affiliated with them). She only charges 25$ per 30 min sessions, but thats because she is still in school. She even said she will try to ask her professors and/or other peers for help on my case, and see what she can do. She also noticed that my right hip is more anterior and she noticed that my right leg is shorter. She said she will try to fix the leg length discrepancy and hip mis-alignment. I than told her that the leg length discrepancy is an anatomical one not a functional one (as confirmed on x-ray). First treatment she tried to align my pelvis and she couldnt. She said it wouldnt budge. Although she did make my back feel a lot better/looser (not really what I wanted tho!). 2nd treatment she was able to align my pelvis. She said she was surprised it aligned so easily, given that the first time it didnt want to budge. Again, no improvements however in any of my symptoms.

      Thank you for the videos I will need to take a good look at them. I appreciate your time and concern to help.

    • #73441
      AvatarJames Beatty
      Participant

      I was in a similar situation recently. Long story short, at the beginning of June I began getting this anterior knee pain, right above the knee. I would wake up in the morning with my knee feeling stiff, like it was under constant pressure. The pain worsened after prolonged periods of sitting, and seemed to hurt most when my knee was in more flexion. The pain would die down to around a 1-2/10 after a really good warmup / session of foam rolling and stretching. Despite being a trainer myself, I let this go on for almost 5 months. Training for the AF > focusing solid mobility (bad).  Out of frustration I visited a Physio who told me to do quarter squats off of a phone book, and ice it. $30 wastedddd.

      I’m going to say I don’t believe in VMO imbalances causing this kind of knee pain, and that’s an outdated theory, and anyone prescribing quarter squats and TKE’s is probably wasting your money. 

      I finally decided to sack up and research the hell out of the situation and commit to rehab 100%.

      The problem with your approach is that you said you do physio exercises only 3 days a week, but 2-3 hours long. You need to do them maybe max 1 hour, but EVERYDAY, twice a day. If your situation is like mine, your tight quads, hip flexors, and calves are all pulling on your knee either directly, or indirectly through fascia. After loosening those up, my “weak glute” started firing just as strong as the unharmed side.

      This is how I kicked what would have been a never ending cycle of misdiagnoses from doctors for years:

      1) Smash your quads, ITB, and hip flexors. Specifically, your rectus femoris. Show no mercy; you need to drop the foam roller and start smashing that with a barbell and a softball. Spend 8:00 per leg, twice a day.

      2) Couch/wall stretch like it’s your job. I’m talking like at least 3 times per day, at 2:00 per leg (6:00 per leg / per day). This is the most important in conjunction with #1.***

      3) Voodoo band your high hip, mid quad, suprapellar pouch, and high calf / right below your patella. Perform squats (good form) and calf raises / stretches while in the bands for ~ 20 reps.

      4) Smash and stretch your calves.

      5) Smash your anterior tibialis; use a tennis ball, or lax ball and start to “peel” it off your tibia.

      Assuming your situation is similar, commit to this for a couple of weeks and you’ll just notice one day that you’re pain free. Unfortunately, I don’t have any time tonight to hunt down links for those 5 things, but Kaitlin is usually a wizard when it comes to links, so she may beat me to it sometime this weekend. Good luck!

    • #73445
      AvatarAnonymous
    • #73448
      AvatarRyan Cloutier

      Hey Alpha919 and Kaitlin

      You and Kaitlin have really gotten me thinking now. So frustrating how from all the therapist I have visited, you guys are the only ones that told me that something is wrong with my routine and that I should focus on frequency over duration. All the therapist didn’t even bother breaking down everything I do, so much for caring for their patients (or perhaps they just didn’t know any better).
      I still have some questions before I change my approach to your recommendation:
      1) Isn’t it hard to fit in all the various exercises required within a 1 hour period? Would I focus on different parts during each session, or would I do the same part for both sessions (i.e., would I roll out the rectus femoris with a barbell in both sessions? and if so wouldnt it get bruised or damaged for so much work?). Why was doing the exercises for 3 times a week but for longer periods of time wrong?
      2) Your 5 points all mention mobility/stretching/self myofascial release work, but you havent mentioned any strengthening for muscular imbalances (i.e., glute, core strengthening, and functional exercises-besides the squats). Did you not do any strengthening to correct for muscular imbalances? Why were you tight in the first place? I have been told that self-myofascial work will only correct the symptoms, after which I will get tight again. I have tried doing self-myofascial work twice a day before for an extended period of time to no avail.
      3) The barbell, and soft ball sounds very interesting. Are they better than a PVC pipe, rumble roller, and lacrosse ball that I have been using? I have an E-Z bar at home will that suffice? I rolled out my rectus femoris with that last night by putting the bar with protrusions on top of my leg and dragging it slowly, seemed to be effective for that muscle, and some of the adductors and vastus lateralis. Cant seem to get any other muscle groups with the EZ bar tho.
      4) You mention couch wall/stress each leg. My problematic knee is the right one, although I have tight IT band/quad/hip flexor complex on both sides. Should I still do both legs, or focus more on my right leg?
      5) I am not fimiliar with voodoo banding the high hip, mid quad, and high calf. I have seen one of kellies videos were he vodoo bands somones suprapatellor pouch with a half lacross ball under the band, and makes him do squats. What will voodoo banding those areas you mention do? And If I voodoo band do you suggest to have half a lacrosse ball under the band? Is their a video that shoes voodoo beanding the hi hip, mid quad, and high calf while performing squats. I checked all the videos you posted Kaitlin. Maybe I missed it.
      6) All the exercises/stretches kelly performs with some type of band, around the high hip and gluteal fold area while stretching the hip flexor/high quad complex. Is that with a voodoo band? You did not mention performing those exercises, did you not perform them,? Are those capsule stretches?
      I appreciate all the help thus far.
    • #73450
      AvatarJames Beatty
      Participant

      1) Isn’t it hard to fit in all the various exercises required within a 1 hour period? Would I focus on different parts during each session, or would I do the same part for both sessions (i.e., would I roll out the rectus femoris with a barbell in both sessions? and if so wouldnt it get bruised or damaged for so much work?). Why was doing the exercises for 3 times a week but for longer periods of time wrong?

      A) Every time you smash, follow up with a 2 min stretch. But if you’re just waiting around somewhere, feel free to stretch too.

      B) Use the barbell smash only a few times a week, if you’re banged up, slow it down.

      C) I don’t know the exact physiology on why, but you need to make a neuromuscular change that will require higher frequency.

      2) Your 5 points all mention mobility/stretching/self myofascial release work, but you havent mentioned any strengthening for muscular imbalances (i.e., glute, core strengthening, and functional exercises-besides the squats). Did you not do any strengthening to correct for muscular imbalances? Why were you tight in the first place? I have been told that self-myofascial work will only correct the symptoms, after which I will get tight again. I have tried doing self-myofascial work twice a day before for an extended period of time to no avail.

      A) In my particular instance, I don’t think I have any major muscular imbalances. My personal theory is that the notion of strengthening the posterior chain for knee pain doesn’t solely help because of muscle imbalance, but rather that people who have strong posterior chains usually have better biomechanic (ie. don’t leg press a squat) and don’t let their anterior chains get overworkedand tight (through indirect anterior stretching; you can’t finish full hip extension if your anterior chain is out of wack).

      B) I was tight in the first place because I was running 4-5 times a week, swimming 3 days a week, and fin swimming 2 days a week (Air Force). I neglected stretching. I wasn’t as strict on my biomechanics either. That’s the first change to make. No knee valgus, no excessive knees over toes, etc.

      C) You need to stretch/mobilize to not get tight. But you need to break up all that stiffness with the myofascial work to aid the mobilization. It’s like peanut butter and jelly.

      3) The barbell, and soft ball sounds very interesting. Are they better than a PVC pipe, rumble roller, and lacrosse ball that I have been using? I have an E-Z bar at home will that suffice? I rolled out my rectus femoris with that last night by putting the bar with protrusions on top of my leg and dragging it slowly, seemed to be effective for that muscle, and some of the adductors and vastus lateralis. Cant seem to get any other muscle groups with the EZ bar tho.

      I don’t know necessarily what is better, but I prefer the PVC pipe, softball, and occasionally the barbell. I think the lax ball is too small and causes bruising for my legs.

    • #73451
      AvatarJames Beatty
      Participant

      4) You mention couch wall/stress each leg. My problematic knee is the right one, although I have tight IT band/quad/hip flexor complex on both sides. Should I still do both legs, or focus more on my right leg?

      Ideally as a coach, I would tell you to do both equally. When I was in full mob-mode, I probably paid 70% attention to the bad one and 30% to the okay one. As things eased up, I even them out. Don’t neglect the other one, it could end up like the other one if you don’t! But I’m not gonna lie, couch stretching like 3-5 times a day sucks, it’s not fun. That’s probably why I didn’t want to double it.

      5) I am not fimiliar with voodoo banding the high hip, mid quad, and high calf. I have seen one of kellies videos were he vodoo bands somones suprapatellor pouch with a half lacross ball under the band, and makes him do squats. What will voodoo banding those areas you mention do? And If I voodoo band do you suggest to have half a lacrosse ball under the band? Is their a video that shoes voodoo beanding the hi hip, mid quad, and high calf while performing squats. I checked all the videos you posted Kaitlin. Maybe I missed it.

      Voodoo flossing helps restore sliding tissues, and also helps flush out joints as well as get some new blood to them. Above the knee often gets matted down with all the common muscle insertions. I’ll post some videos here in a little.

      6) All the exercises/stretches kelly performs with some type of band, around the high hip and gluteal fold area while stretching the hip flexor/high quad complex. Is that with a voodoo band? You did not mention performing those exercises, did you not perform them,? Are those capsule stretches?

      That is just a jump stretch band. It’s not a bad idea to throw those in when you can. It can be awkward to set up though. I only used banded distractions about 10% of the time.

      After I get all the links to videos, I’ll resubmit my 1-5 to help make things clearer.

    • #73452
      AvatarRyan Cloutier
      Previous Therapy Routine: (3 times a week, ends up being like 2 hours) everything written is in the sequence performed. I was doing this for about 6 months now ( I was doing something similar before this routine for 1 year). Please feel free to criticize it and advise me were improvements can be made. 

      Warm Up: (10 minutes)
      1) Skip (aprx 2-5 minutes)
      2) Various leg and hip swings (aprx 5 minutes)
      3) Wobble board balance (3 sets, until fatigue/improper balance)


      My strengthening Routine: aprx 45 minutes, and I usually do 5 exercises, I perform the exercises as a circuit. 

      1) Glute medius:  x-band walks and/or side lying leg raise against wall (3 sets, each set until fatigue, aprx 50 reps per set)
      2) Glute max: hip thrusts (single leg and/or double leg on yoga ball – 3×10
      3) Core activation: Planks (front plank and/or side plank  – 3×10, and/or barbell ab rollouts 50×3)
      4) Single leg functional movement pattern: single leg squats and/or lunges (3×10), using only body weight
      5) Double leg functional movement pattern: squat (3×10), using only body weight, been doing wall squats, (double leg squats is a more recent addition to my regime, started doing it only about 1 month ago)
      Self-Myofascial Release: aprx 30 minutes (PVC pipe, rumble roller, and lacrosse ball), mostly been focusing on right leg)
      1) Hip flexor – rumble roller, lacross ball
      2) Quadriceps – rumble roller (sometimes PVC pipe)
      3) IT band – rumble roller (sometimes PVC pipe)
      4) Calve and/or ant tibialis and/or hamstring and/or adductors – rumble roller and lacrosse ball (sometimes PVC pipe) (I alternate between the calves, ant tibialis, hamstring, and adductors on different days).
      Stretching: 3 minutes total, 1 set x 40 seconds (do it for my right leg, sometimes I also do it for my left leg)
      1) Rectus femoris/hip flexor stretch – against the wall 
      2) Hip flexor stretch – knee on a mat, use different angles
      3) hamstring stretch – leg on desk, use different angles
      4) Piriformis/hip flexor stretch – back lying on mat, 
      Massage IT band with rock followed by Suction Cupping: 
      -I would put some skin lotion on thigh, and start massaging the IT band with a rock for 1-2 minutes
      -I followed this with suction cupping
      Suction Cupping – 15 minutes
      -Quads, IT band 
      -sometimes add hip flexors, ant tibialist, calves, hamstrings
    • #73454
      AvatarRyan Cloutier

      Separate from the above routine I have also recently added (in the last month) postural exercises.

      Postural Exercises: 2 times a day (if it fell on a day I was doing the physiotherapy exercises above, I would only perform this once that day). Physiotherapist advised me however to do them 4 times a day as he said volume is key. Hard to find a spot in school, and looks kind of socially awkward/gay to do them in public.
      This is what I was advised by the physiotherapist:  
      Stretches/movement (hold for 15 seconds, repeat 4 times in a row, 2-4 sessions per day)
      – standing knee to chest keeping lumbar and pelvis position
      – standing modified pigeon (hip external rotation – keep foot neutral to protect knee)
      – upper thoracic extension over a roll keeping mid back neutral
      – isolated lumbar extension with mid back neutral in standing
      Also work on (repeat 10 times, 4 sets per day)
      – wall squat with neutral foot position – knees over toes and 2 inches past toes at bottom of squat
    • #73455
      AvatarRyan Cloutier
      Note: On off days I would still do self-myofascial release for about 30 minutes. So I am doing and have been doing self-myofascial release every day. This is in addition to getting ART and/or massage therapy every 2 weeks, and electrically stimulate trigger point dry needling every 2 weeks (from separate physiotherapists). 

      Things that might contribute to my problem: 
      1) I sit for extended periods of time during the day (as a student I am studying a lot)
      2) Previous injuries (shin splints/stress fracture, and strain in lower abdominal/groin area: like a sports hernia in both legs) – both happened like 6 years ago, they healed/resolved through rest/cessation of activities, and physiotherapy, but my right knee hasn’t. I had PFPS on both knees roughly around the same time as all the other injuries through overuse. The left knee has no pain after doing physiotherapy, and rest, but the right knee is still very painful. Both IT bands are really tight. I cant do any sports, or recreational activities without intense IT band and quad pain. If I isometrically contract and flex my quads, they become really tight quickly, and painful. 
    • #73457
      AvatarAnonymous

      1) You are covering too much at one time.
      As Kelly has noted keep it to 3 mobs a day.
      Trying to mob everything all the time doesn’t work well and there isn’t time for that everyday.
      Determine where the biggest performance limiters are and start there.
      You don’t need to be as concerned with the individual muscles addressed vs you are impact anything that is tight in the targeted area.
      Episode 321: Programming for Mobility
      Post 400: Movement Hierarcy- Movement Complexity, Injury Rehab, and Making the Invisible Visible
      An MWod Model for Post Surgery/Post Injury Rehab
      Spending so much time at once isn’t wrong per se, but there are more effective ways to go about it.
      Only doing it 3 times a week is not frequent enough. You are breaking habit and forming new ones.
      Your body needs the stimulus for the new position/rom/movement pattern more often because they are a new position/rom/movement pattern. The more the stimulus is there the better.  As you work with these changes they will become habits/default patterning and you won’t need to think about it so much to have the correct movement pattern/positioning.
      This can take some time because you are retraining things. You are creating new neuropathways for the changes in position/movement pattern.
      Yes, you can work on the same areas more than once a day. If you are bruising I would recommend taking another look at things. I have not bruised from mobility work.

      You may not be seeing improvement because you aren’t addressing the cause of the issue. If you are only addressing symptoms symptoms or new symptoms will continue to occur because the cause of the issue is still there.
      You need to take a systems approach.
      Pro Episode # 21 – Pro-User Request Friday: Not Seeing The Change? You Need a Systems Approach.
      Do you know there are strength imbalances?
      Pro Episode # 25 – Matt Hasselbeck Edition: Advice for the Uni-Lateral/One Sided Athlete
      Sometimes when movement patterns are improved and mobility is addressed imbalances go away because the system is no longer compensating for something else. SMR corrects symptom when it is addressing symptoms. Same thing applies if the cause is not addressed the improvements will not remain. You can chase symptoms forever. 2 times a week is not frequent enough to see change/improvements. There are no days off with this stuff.

      3) The tools you use can change based on what the goal is and what you are addressing.
      Yes, a barbell is better than PVC for areas that need something more than PVC. A rumble roller is great for some areas other areas I would not use a rumble roller. I would recommend getting a Gemini to replace the 2 lax balls taped together, and a supernova. These up the anti another few levels.
      The ez bar could work if there is enough weight to the bar. A regular bar is 33 or 43 pounds.
      Use it and see. This is a question you will need to answer.
      Don’t be as concerned with the individual muscles targeted vs you are impacting anything tight in the targeted area.
      4) YES, you need to address both sides. You may spend more time on the side that is tighter, but where both sides are tight you need to improve both sides.
      5) Voodoo flossing hits compression which is another way to address an area to see change.
      Try it and see what it does for you. What do you have to lose by trying it?
      I did not list every video that addresses the areas mentioned. Do a search and look through the episodes and daily rx. This will help with your understanding as well.6
      6) No, those are jump stretch bands.
      Voodoo Band http://www.roguefitness.com/voodoo-floss-bands.php?SID=vu5m001h0g9qo75e46ilpo2pf5
      There are episodes where Kelly uses a voodoo floss band.
      Different tool, bands etc. are used to address different properties.
      It goes back to the goal of the mob and what aspect(s) you are looking to improve.
      You should always use a band when able to use one.

    • #73467
      AvatarRyan Cloutier

      Awesome advice guys. I am going to give this a go. 3 mobs a day it is.

      I am trying to design a new recovery program for myself right now.
      For my strengthening exercises, should I still keep that at 3 times a week? (or should I do some type of strengthening exercise every day just in a shorter session? i.e., hit the glute medius every day?)
      Also, whats your opinion on suction cupping, and just dragging the suction cup along the muscles? 
      The EZ bar I used was a 10 pound bar. I added 40 pounds of weight to it, and dragged it on my quads, and lower hip flexor area on different angles. It am still a little sore from it (nothing to serious), and a tiny bit of bruising. It was definitely more intense than anything else I have rolled out on thus far, and seemed to loosen the muscle more effectively.
      I will look into buying: Voodoobands, jump stretch bands, a gemini, and a supernova. Were can I purchase a jump stretch band. I want to make sure its a good one that wont snap. Can they also be used for x-band walks and other resistance exercises? I have resistance bands (therabands) at home (they tend to snap after prolonged use), do you have any ideas on how I can implement them for mobility work?
      Would warming up before the mobility work make it more effective? Like if I skip for 2 mins and/or do leg swings etc.. Or does it not really matter if I warm up or not? 
      Regarding footwear and the orthotics and barefoot debate. Should I go barefoot for must of my exercises and should I wear minimal shoes in public rather than normal shoes. Should I ditch the orthotics I have lying around at my house? I just got the orthotics 2-3 months ago. But was reading all this conflicting info on whether or not to go barefoot. I haven’t really been wearing the orthotics lately. 
      What about a heel wedge for my leg length discrepency. My right leg is 1.1 cm shorter (confirmed on x-ray). I have been given a 0.5cm heel wedge about 2 months ago. I use it for my shoes when I go outside etc.. (not when I do my physiotherapy/mobility, I just go barefoot for that). You think its bad not being consistent in wearing the heel wedge? Its like changing the level of the pelvis constantly. But then again I heard its better to go barefoot, however does this apply to people with a leg length discrepancy?
    • #73468
      AvatarNathan Richer
      Participant

      Just curious – is your leg length discrepancy a permanent structural issue or do you find it is correctable via, say, a chiro who manipulates you and he can get your legs the same length for at least the short while?

    • #73470
      AvatarJames Beatty
      Participant

      Videos as mentioned. Do these several times a day, but don’t go overboard for more than an hour. Let us know how things go, good luck.

      1) Smash your quads, ITB, and hip flexors. Specifically, your rectus femoris. Show no mercy; you need to drop the foam roller and start smashing that with a barbell and a softball. Spend 8:00 per leg, twice a day.

      Correct Quad Smash Technique:
      http://www.youtube.com/watch?v=5nlarY4AdQw

      Barbell Smash:
      http://www.youtube.com/watch?v=c57xVyqTEjw

      2) Couch/wall stretch like it’s your job. I’m talking like at least 3 times per day, at 2:00 per leg (6:00 per leg / per day). This is the most important in conjunction with #1.***

      http://www.youtube.com/watch?v=-ZX1QMTdAC4

      3) Voodoo band your high hip, mid quad, suprapellar pouch, and high calf / right below your patella. Perform squats (good form) and calf raises / stretches while in the bands for ~ 20 reps.

      http://www.youtube.com/watch?v=-RYMV0salw8

      http://www.youtube.com/watch?v=JVRTnKUgARA

      How To Make Your Own Voodoo Bands:
      http://glennpendlay.wordpress.com/2012/02/17/got-tendonitis/

      4) Smash and stretch your calves and anterior tibialis:

      http://www.youtube.com/watch?v=fCFlfgCqpK8

      5) Pay Attention to exercise form, and other mobility aspects above and below the knee.

      http://www.mobilitywod.com/2013/07/pro-episode-31-user-request-friday-live-from-the-games-patellar-tendonitis/

    • #73476
      AvatarAnonymous

      I have not used suction cupping, but if you are seeing improvements with it continue doing it.
      Have a plan 30 minutes of mobility work 2 or 3 times a day. Morning, night, and if you have the opportunity to spend time during your lunch at work that may be another option to work on it.
      Doing strength 3 times a week works.
      If adding weight to the bar work continue doing it.
      If aren’t able to add weight to the bar for something you may consider getting a heavier bar. Sometimes you can find used bars on Craig’s list. You may not be ready for a heavier bar.
      You can get everything from Rogue Fitness:
      Voodoo Bands 
      Jump Stretch Band  1 option OR 2nd option
      Supernova
      Gemini 
      Therabands don’t have enough resistance. You will not have a problem with jump stretch bands or their durability. You want a green and a blue.
      Yes you can use them for x band walks. This video shows someone using one How to do xwalks
      Yes doing a dynamic warm up before mobility work could help. Message me if you want ideas on it.
      Warm up and mobility work are 2 different things so yes a warm up is helpful.
      When I workout I wear shoes. You want a flat shoe DC, Vans are a good option, Nanos, All-Stars. For Oly sessions wear Oly shoes.
      For every day life something flat DCs, Vans, All Stars if you need a dress shoe there are flat options there.
      Orthotics may be worn for some time, but you want to strengthen your foot so your foot is making the change not the orthotic making the change for your foot.
      Have you watched the Rebuilding your feet 3 videos or the Flat Foot Solution?
      Start here for moving away from wearing orthotics.
      Yes you should go barefoot at home whenever possible.
      If you wear a wedge in your shoe you should always wear it.
      Going back and fourth can throw things off and cause you to make compensations when you don’t have the wedge in your shoe.
      I asked before, but is this something that can be corrected having a chiropractor adjust your hips/pelvis?
      I ask because I know someone who had a situation like this rectified. At first it can take 3 adjustments per week moving to 2 then one then when needed as the muscles learn the new positioning and can hold the position.

    • #73482
      AvatarNathan Richer
      Participant

      to echo Kaitlin’s comment – in my early days of PT, a PT guy found that one of my legs was slightly shorter than the other.  So he gave me orthotics with a slight lift.  These worked for a while. but then i started working with another PT and he worked soft tissue and adjusted spine/pelvis and found that he could get my legs the same length. Whoa. later i learned that many with leg length issues could be fixed without orthotics, but required other types of therapy.  i tossed my orthotics and fixed my movement patterns.  Everything worked naturally better.  So yeah it was in vogue to use orthotics many years ago, and for some who have permanent structural problems like true bone length issues, they will require orthotics.  but for people like me, it’s better to fix the muscular and skeletal problems, as well as fix movement patterns.  then i don’t need orthotics as a crutch, which was probably causing other problems like cramping out during a marathon, etc.

      and thx to Kstarr in one of his videos he showed how to adjust pelvis by yourself – voila i could fix leg length all by myself now!
      Running around with unequal leg lengths is only going to lead to compensations and increase the probability of injury…
    • #73485
      AvatarRyan Cloutier

      It’s a permenant/structural leg length discrepancy. The right leg is shorter than the left by 1.1cm. This was confirmed by an x-ray. The osteopath mentioned she could try to even the leg length a little because my right hip seems to be more “junky” and tight than the left, which is also causing the right hip to be tilted forward/anterior. But is it even possible to even out a leg length discrepancy if its anatomical?

      I was reading that 1.1 cm isn’t a signifcant leg length discrepency, and that must of the population has some sort of length length discrepancy (0 – 0.5 cm). I also read the opinion of a hospital website that said it is recommended to wear heel wedge if you have a leg length discrepency of 2cm or greater. I also read that heel wedge can throw off biomechanics, and running gait, and lead to injuries. 
      All this conflicting info leaves me confuse. Should I wear a heel wedge? If so it is recommended to constantly wear them. That means I cant go barefoot. However, I have read that barefoot is highly recommended, and helps with injuries. A guy named Michael Sandler had a leg length discrepancy and wrote a book regarding barefoot running. He advocates going barefoot. 
      Options:
      1) Should I go barefoot and/or minimalist shoes with no heel wedge
      2) Always wear shoes, even indoors with a heel wedge 
      3) Go barefoot indoors and/or at home, wear heel wedge outdoors (this means I would be constantly alternating and changing the level of my pelvis, dont know if this is recommended)
    • #73486
      AvatarRyan Cloutier

      Alpha why dont you recommend not to go overboard for over an hour? Like if I have a lot of free time, such as the holidays, wont doing more increase my progress at a faster rate?

    • #73487
      AvatarRyan Cloutier
      I have come up with a daily routine that I tried to keep realistic in terms of fitting in with my schedule. Feel free to critique it. I left out the details of the specific exercises, but they will be similar to the ones in Kellies videos, opening up the hips, hip flexor/high quad complex, quad/IT band, hamstrings, calves, Tib Ant etc.. I have no were at home to hook the jump stretch bands in order to do capsule stretching/band distractions, so I have left those out for now unless I can come up with an idea, or start going to the gym.

      Daily Mobility/therapy Routine:

      A) Morning Routine: aprx 50 mins
      1) Warm up (aprx 2 mins)
      2) SMR back/shoulder/posture (aprx 5 mins)
      3) Postural exercises (aprx 15mins)
      4) SMR legs/pelvis (aprx 20mins)
      5) 3 Stretches (aprx 6 mins) 
      B) Mid day: aprx 6 mins
      1) 3 stretches (aprx 6 mins)

      C) Night: aprx 50 mins
      1) Warm Up (aprx 2 mins)
      2) SMR back/shoulder/posture (aprx 5 mins)
      3) Postural exercises (aprx 15 mins)
      4) Voodoo band squats (10-20 reps)
      5) SMR legs/pelvis (aprx 20 mins)
      6) 3 stretches (aprx 6 mins

      Three days a week I will also do my strengthening/corrective exercises routine to address muscular imbalances. i.e., glutes, core, functional movements such as lunges, single leg squats, etc.. I have been doing these for a while now, I am surprised I still have ant pelvic tilt and tight IT band with my consistence in performing these corrective exercises. You think these exercises are essential to my progress? Perhaps the tight antagonist muscles were restricting them from activating fully before?
    • #73488
      AvatarJames Beatty
      Participant

      There’s probably a diminishing returns point where duration isn’t going to help as much as more frequent times throughout the day. And the routine looks good. If your posture and shoulder aren’t hurting you, you can probably take those out to cut down mornings and nights down to 30min. Then maybe throw the back/shoulder stuff in a couple days a week, but probably no need to do it as much as the leg/hip stuff. 

      For now, just focus on the mob work and see where it gets you, with your 3 days of strength training a week.

    • #73498
      AvatarAnonymous

      When having long sessions the quality of the session can be less than the quality of a shorter more focused session.
      The anatomical leg length discrepancy can come from the “right hip seems to be more “junky” and tight than the left, which is also causing the right hip to be tilted forward/anterior.” If you clean that up and have a better position the difference may be corrected.
      Episode 352: Dealing With Old Junky Tissue
      Going barefoot is a good strengthening activity for the feet.

      If the difference is 1.1cm and it is recommended to wear of wedge for 2+cm difference then it doesn’t sound like it is recommended to wear a wedge.

      If you are working on something for an extended amount of time and not seeing an improvement you need to change your approach.
      Pro Episode # 21 – Pro-User Request Friday: Not Seeing The Change? You Need a Systems Approach.
      Are the corrective exercises you are doing focus on the symptom of the pain or focus on the cause of the ant pelvic tilt or tight IT band? Are you doing any of the MWODs that address these?
      If the exercises only address symptoms the situation is not going to improve because the cause is still present.
      Some situations can take some time to improve because you are retraining muscle/tissue to a new position.
      You are unlearning one habit and creating a new neuropathway for the changed positioning.
      This can take some time us with breaking any habit and creating a new habit.

    • #73604
      AvatarRyan Cloutier

      Update: I have been following the routine for 2 weeks now. However, I havent done voodoo band work and band distractions yet  because I haven’t been able to order the jump stretch bands and voodoo bands yet. I also havent gotten a soft ball yet, I will try to get one ASAP. I also tried using a 20 pound barbell with 25 pounds on one side, It didnt seem that effective, it was hard to create pressure on the muscle, I find the EZ bar to be more effective as it gives  more pressure to the muscle and can be easier to manipulate. I have noticed some improvements in symptoms. Muscles are less tense, knee pain has slightly decreased. I dont know if these changes are permanent because my muscles still tighten easily. The improvements have only been mild. I also noticed that taping my patella medially and downard seems to help slightly. I Will keep at it, getting a little frustrated however. I will order the voodoo bands, and jump stretch bands, and my own electroacupuncture machine in the beginning of January. I also have an MRI appointment on January 7th. I haven’t seen any therapist for 2 weeks because of the holidays. I have also been sitting a little less, and have decided not to use the heel wedges for my leg length discrepancy.

      Question: whats the best modality to decreasing muscle tension/muscle tightness. I have been reading a lot about the effectiveness of voodoo bands. Are voodoo bands better at decreasing muscle knots/tightness and tension than rumble roller and/or lacross ball?
      Question: Is anyone familiar with electro accupuncture/electrically stimulate trigger point dry needling? How do you think it compares with other modalities such as self-myofascial release with rumble roller and lacross ball?
    • #73605

      Have you approached this with a smash session, a hot bath, and then a banded distraction session?  The heat of a hot bath helps the muscles relax. The heat acts like a sweat warmup in which you can get into the mobs without a much of a wait for that warm feeling.

    • #73710
      AvatarRyan Cloutier

      No I havent. Wouldnt the hot bath go before the smash session? Plus I usually warm up. isn’t this sufficient.

    • #73711
      AvatarRyan Cloutier

      how bad is sitting for prolonged periods of time in my situation? Will sitting negate the effects of the mobs?

    • #73713
      AvatarAnonymous

      Daily Rx August 21 hits on hip flexion and the seated position

    • #73885
      AvatarRyan Cloutier

      Got my MRI results, and went over them with the primary care sports medicine physician.

      Findings:

      “1) No cartilage damage
      2) meniscus, ligaments, tendons all normal
      3) Fluid: Soft tissue lesion at the proximal tibiofibular joint: might be a ganglion cyst or a soft tissue hemangioma.

      Fluid: A loculated lubulated serpiginous high T2 signal focus is present in close proximity to the proximal medial tibial fibular joint, the inferior aspect incompletely included in the scanning range. The visualized portion of the soft tissue abnormality measures 2.9 x 1.2 x 0.5 cm sagitatal, AP and transverse respectively. On the 3-S series, questionable subtle fluid-fluid levels are present within a few of the locules.

      Impression:
      No major internal derangment

      Soft tissue lesion possibly arising from the proximal tibiofibular joint, incompletely included in the scanning range, of uncertain clinical significance. The finding may represent a proximal tibiofibular ganglion cyst. A soft tissue hemangioma is included in the differential diagnosis. An ultrasound is suggested to delineate the full extent of the pathology.”

      I am not feeling pain in the proximal tibio fibular joint, so I dont think this is related to my anterior knee pain (pain that appears to be between the patella and femor slightly laterally and proximally). She mentioned the cyst might be due to the prolozone injections I got. Maybe its compressing the peroneal nerve? The doctor says I have patella femoral Pain syndrome, and to keep strengthening my core, VMO, glute medius. 

      Whats everyones thoughts on this?

    • #74040
      AvatarRyan Cloutier

      Update (Last 2-3 weeks): added voodoo band work 2-3 times a day. Been doing this for about 2-3 weeks now. Also, have been giving myself electroaccupuncture (electrically stimulated trigger point dry needling) a few times for quadriceps and gastrocnemius. Kept up with the mobs twice a day. Been trying to avoid sitting. Also seen my osteopath twice. Muscle tightness and adhesions have decreased pretty dramatically in my quads, and IT band. I don’t know if its permanent or if I am masking the symptoms and the underlying cause of the issue is still their. I am still feeling knee pain (although a bit less than before). Its very frustrating, the anterolateral knee pain is still persistent. Might try to get another video gait analysis, but this time a 3-d analysis rather than a 2d analysis (which I got), and have it analyzed by a professional whose well qualified rather than a chiropodist. Also, thinking of seeing asking my sports medicine physician for a referral to see a PM$R (physical medicine and rehab) physician. 


    • #74042
      AvatarAnonymous

      Good to hear you are seeing improvements in your situation.
      When there is a long standing issue it will take time and alot of time to correct. The amount of time things remain in place following a session will increase as more returns to its proper place/positioning.
      You are working to improve the situation which will not happen over night. As more items are corrected more will come into better placing/position.

      If you are completing something for another look you may need to do it with another doctor if you weren’t satisfied with the evaluation from the prior time.
      Is there a coach with a strong knowledge and mechanics& technique background that can look at your movement patterns with different skills?
       

    • #74136
      AvatarRyan Cloutier

      Thanks Kaitlin and David for all the help thus far. I have asked my sports medicine primary care physician to refer me to PM&R (physiatrist) doctor specializing in sports medicine. I dont know yet when the appointment will be. 

      I  had my first appointment today with a new osteopath (experienced one this time). She recommends a heel wedge for my leg length discrepancy (right leg is shorter by 1.1 cm, which is the side of my knee pain). I had an argument with her whether or not heel wedges should be advised for 1.1 cm discrepancy. She said she did her thesis on leg length discrepancy, and says the osteopathic manipulations wont be of much help if I dont address the leg length discrepancy with a heel wedge. She said the body is out of alignment due to the leg length discrepency and this is causing the right pelvis to shift/rotate anteriorly. She said if I dont use the heel wedge and she does the manipulations the body will just get out of alignment again. 

      I am confused on what to do. I was wearing the heel wedge for 1-2 months from oct-nov and it didnt help. In fact my knee pain was slightly increasing during this time (dont know if its due to the heel wedge or some other reason such as colder weather or extended periods of sitting etc..). She thinks it didnt help becasue I did not get osteopathic manipulations done during the same time. Their is a lot of conflicting info:

      People who told me not to wear a heel wedge: family physician, clinical biomechanical expert who does research at my university and is focused on gait analysis, and foot mechenics, sock-doc (a highly regarded chiropractor on the internet who specializes in this area, website is: sock-doc.com), a massage therapist whose FMS certified, and other internet sources such as Harvard University Boston Children hospital.

      People who told me to wear a heel wedge: initially the PM&R physician in Markham Dr. Ko (physiatrist) with a chiropractor who work together, and now the osteopath I have seen today.

    • #74151
      AvatarAnonymous

      Sounds like the cause of the discrepancy is not from something out of alignment.
      Then it sounds like the heel wedge will start to address the situation.
      It sounds like she knows alot about the subject.

      When you had a heel wedge before was it the correct size? Is the one suggested the same?
      Have you addressed the type of shoes you are wearing and working out in?
      Did you make any adjustments is anything when wearing the heel wedge in the past?
      This changes things if you continued wearing the same pair of shoes they may have been off from your movement patterns when not wearing the wedge.

      Did anyone who told you not to do use a wedge offer any other advice?
      Did anyone who told you not to see you in person?

    • #74157
      AvatarPawan Lalwani
      Participant

      Wow, found this searching for an issue I’m having with a chronically tight IT band,hip flexors, and quads. It’s scary how much we have in common. I’ve only had this specific issue for a couple years, I had other knee issues prior to the IT Band hell.

      I’m mostly into cycling and ski mountaineering, with a little climbing thrown in now and then. In the past I played hockey and lacrosse, but haven’t played those for some time. Currently 32, issues started occurring 3 years ago. Original issue that popped up for me was some medial knee irritation caused from cycling. I fixed that issue with a bike fit, it comes back to haunt me if I ride a bike with too narrow of a q-factor.

      Fast forward to after fixing that issue and going back to training hard, riding 6 and 12 hour solo races.  I started to feel some tightness in both IT bands after one especially hard effort racing.  I foam rolled, stretched, and followed all the conventional wisdom out there that I could find at the time and went back to overtraining.  Well, the next time the issues popped up they were here to stay.  At first it was mostly chronic tightness felt throughout my lower extremities, mostly IT band, quads, hip flexors, and calves, but lately I’ve also been having some lateral knee pain, which I believe is caused by lateral patellar tilt and tracking.  The tight IT band feels like it is pulling that lateral renticulum and causing the edge of the kneecap to graze the cartilage underneath my patella.  I also feel pressure sometimes, like something is pulling my kneecap towards the back of my knee.  Pain has never been too bad, but the long term issues this could cause scare me.  I should mention that I’m a desk jockey, work in an office, and sat for long periods previously.  I now have a standing desk, which has seemed to help, but definitely isn’t the magic bullet some people would have you believe.

      I’ve gone through a number of PT’s and finally found one that got me started on the right track.  Working on hip mobility, strengthening my core, glutes, and hamstrings.  Like you I have only been doing my exercises 3 times a week, with myofascial release on a more regular basis.  Following a similar routine as you, rumble roller, lacrosse ball, etc.  I’ve also been doing some self administered astym or gua sha to the lateral side of my quad and IT band.  This seems to help reduce local adhesions.  Unfortunately PT’s in UT aren’t allowed to practice dry needling yet, I would be first on the list if they were able to.  Anyways, I can get temporary relief from the tightness and associated pain by firing up my glutes doing isometric holds of either clamshells or side lying single leg windshield wipers with an exercise ball.  This seems to reduce the tones of the muscles pulling on the IT band. Also incorporating single leg hamstring curls, single leg romanian deadlifts, and various planks.  I’ve been laying off the sqauts for a bit since the lateral knee pain popped up.  The deadlifts and isometric glute exercises give me the most benefit.  Also, noticed lately that when I really dig into my rectus femoris I can feel the lateral knee pain pop up, so I’ve been focusing on stretching and massaging that as well.  I too feel like there is something I’m missing to get back to 100%.

      I think Alpha919 is onto something above when he mentioned that once he started focusing on all these areas and “smashing” those structures his glute started firing normally on the affected side and the pain subsided.  Right now when I contract my glutes the affected side contracts less than my normal side.  I really have to work to get it to fire with the same intensity.  I feel like all the tight structures are causing this.  I’m going to commit going forward and start on a daily routine, please post back with how the flossing is going.  I think I need to start that as well.

      Don’t mean to take over the thread, but would love to share what’s working for both of us in an effort to try to beat this thing.  Appreciate all the other posts with all the info, videos, and encouragement.  It’s a frustrating injury as it doesn’t heal like a broken bone and there can be so many causes.

    • #74159
      AvatarRyan Cloutier

      Kaitlan

      The heel wedge I had before was about half the size of the discrepancy (0.5mm). This is the typical protocol to follow according to all the sources. You dont want to shock the system with by adding to much. Plus the body has already adapted somewhat to the discrepency in other ways. 
      I havent addressed the shoe. Right now its winter her were I am so I am wearing winter shoes outside. While I am indoors or doing my physio exercises I am barefoot. 
      During the time I was wearing the heel wedge I was trying to wear it indoors and outdoors constantly. I was wearing it with my old workout shoes indoors and various other shoes I have for outdoors. So when doing my physio exercises I was wearing the heel wedge. 
      The people who told me not to wear the wedge didn’t really offer me other advice besides keep doing the physio exercises and try to learn to manage the pain. Must of the people who told me not to wear the wedge didn’t evaluate me extensively, for instance I just met the clinical biomechanical expert at school without an official appointment and asked him a few questions. I asked him if a leg length discrepancy of 1.1 cm should need to be addressed with a heel wedge. He said in a laughing way who told you such a small difference would need to be addressed? He then said such a difference isn’t clinical significant. Must sources online agree that 2mm or greater is the cut off point needed for it to be clinical significant. Soc doc told he wouldn’t recommend a heel wedge but that was through online exchanges. 
      It weird. If my injury was truly due to a leg length discrepancy you would think it would heal with all the physio exercises and mobs and also from a cessation from physical activity and/or sports. I would understand that If I was doing some kind of physical activity that the leg length discrepancy might be causing it not to heal and causing injuries and imbalances. But all I do is study must of the day, and walk sometimes.
      I wonder what the theory is of how it might be causing or contributing to my tight IT band and patellofemoral pain syndrome.
      I am thinking of going to : http://www.solescience.ca/ to ask for a 3-d gait analysis and also ask for the opinion of another field leader (Coling Dombroski) in foot mechanics and gait about my case. Hes canada’s only Canadian Certified Pedorthist with a PhD in Health and Rehabilitation Science. Hes also the owner of solescience and did his thesis on leg length discrepancies in regards to gait and balance. 

    • #74161
      AvatarRyan Cloutier

      jtrue

      Its a really frustrating injury. My knee pain has become manageable (but still persistent) but it has changed my mood. Its made me mildly depressed, I have forgotten all the joys of life. I cant be active without some sort of pain and stiffness with the patella grinding harshly. I feel like a stiff old man always consciously thinking of my moves and positions and not to trigger knee pain or tightness in IT band. 
      I might think about buying myself a graston kit ASTYM kit. Or seeing a health professional who does graston.
      Have you tried osteopathic manipulations. Maybe an osteopath or chiropractor will find a contributing factors to your situations during the evaluation. Look into making an appointment with a PM$R physician specializing in sports medicine. They are really well trained in the neuromuscular system and can do EMG or gait analysis. 
      Try rolling out your hip  flexors and stretching them prior to your physio routine if your not doing so already. You will be able to activate the glutes better that way. The tight muscles are restricting full range of motion of your glutes. This might be causing the hamstrings to take predominance over any hip thrust/glute bridges and bird dogs or other glute exercises.. 
      Also try capsule stretching with the bands from rogue fitness. They are also good for lateral side steps for glute medius activation. 
      Do you have a leg length discrepancy? Maybe thats contributing.
      Keep us updated on what seems to work. Looking forward to your posts.
    • #74162
      AvatarPawan Lalwani
      Participant

       My pelvis on one side was further back than the other
      side, which was causing a functional leg length discrepancy. When my PT
      corrected that via manual manipulation I felt a release of tightness down the lateral side of . 
      The trick was keeping myself in alignment, I’m finally to the point that
      I stay in alignment.  I think overall I have some anterior pelvic tilt
      though.  The exercises I mention above seem to correct for that, but I
      constantly have to remind myself to keep my pelvis underneath my core.

      I totally hear you about how this can change your mood.  I too feel like an old man when I should actually be in my prime athletically.  I can actually stay quite active as long as I keep up with my routine, but it’s no way to live.  I literally spend most of my down time at home rolling around on a foam roller, doing self massage, researching, etc.  I feel the best on the weekends if I do my strengthening routine on Friday and stay active throughout the entire weekend.  If I just lay around at home or work at my desk in one position it seems to bring the tightness back.  I think part of what I’m experiencing is a postural issue or the lack of control I have over my pelvis.  My quads are ridiculously strong, but I have weak hamstrings, and core, which seems to contribute to the patellofemoral pain.  Seems like this occurs a lot in communities where skiing and cycling are the main activities.  Everything I do is quad dominant…

      One thing that seemed to help when I was feeling horrible bi-lateral tightness in both quads and IT bands was to sleep with a pillow underneath my pelvis/lower back.  Not sure why this helped as it seems like it would put more stress on the hip flexors and quads, but it felt like the tone reduced in the tight muscles.

    • #74160
      AvatarPawan Lalwani
      Participant

      Looking at picking up some more mobility tools, Kaitlin has a great list above.  Which jump stretch band do I want for getting into the hip capsule?  Looks like I would only be able to use that band at the gym with something solid to attach it to?  Is the black 41″ band sufficient for muscle distraction?  X-Walks look good, assuming the 12″ band will work for those?

      Kefu, have you noticed a good outcome with the electro acupuncture machine?  I have a cheap e-stim, but if there is an equivalent to dry needling I’m all ears.

    • #74164
      AvatarNathan Richer
      Participant

      The two bands i would recommend getting are the green one and black one from Rogue.  these will allow most people to do any kind of band distraction for upper and lower body.

      you can anchor to a door using a Theraband door anchor available on amazon.
      i also use two heavy KBs, with handles laying on the floor and i loop the bands around both KBs.  they are a 70 and 80 pounders.
      the rogue door strap might also work but i think you’ll have to buy a big carabiner from a climbing store to hook straps around it. the strap holes are too small to loop around a stretch band. they are built for the strap used by rings.
    • #74165
      AvatarPawan Lalwani
      Participant

      As it turns out someone at my workplace gym has a green rouge band that is just living on the pull up bar.  I’ll probably hold off and just borrow that one for now.  Did a couple of the recommended mobility exercises, including the barbell quad smash and the wall stretch.  Quad smash was good, didn’t feel much worse than my black rumble roller, but had better control over the pressure I was applying, vastus lateralis felt the tightest.  The wall stretch was an eye opener, couldn’t get my foot anywhere close to vertical against the wall like Kelly(http://www.mobilitywod.com/2010/08/episode-02-dont-go-in-the-pain-cave/) tons of tightness felt in the rectus femoris mostly.  Going to target the quads for a week along with some ankle drills while I’m standing at my desk.

    • #74167
      AvatarRyan Cloutier
      Hey jtrue

      I currently use the blue jump stretch band (I bought the package that came with blue, green and purple). The blue works well for x-band walks. I think the green might be to thick to do x-band walks. Also, I use the blue jump stretch band at home to do banded distractions by placing it under one of the legs by my washing machine. The laundry machine is really stable and doesn’t move.

      The electro-accupuncture seems to be the must effective modality in terms of relieving muscle tension, and adhesions. Find a therapist if possible to try it out. I leave it on for 10-15 minutes while its stimulating needles inserted into tight areas. Causes the whole muscle to contract and relax rhytmically and the tone immediately is reduced. It doesnt seem to be addressing the underlying issue however as I have been using it for some time now with ongoing knee pain. 
      Heres how I would rank different modalities I have tried from best to worse: 
      Electro-accupuncture > voodoo band flossing > ART  > suction cupping > massage therapy > lacrosse ball > rumble roller > barbell/EZ-bar > PVC pipe > acupuncture > stretching
      Ofcourse each has its limitations. For example electro-accupuncture would need to be addressed by a health practitioner to target most of your muscles (or a superfriend). If you buy your own electro-accupuncture machine you will be limited in the muscles you use it on. (You cant really target any muscles effectively besides the quadriceps). You can also get the gastrocnemius from the front but its not as effective as if you were to get it from the back. The TFL is possible but its hard as your TFL will be in a flexed position when trying to put the needles in, theirs risk of getting nerves in that area as well as its highly innervated, its hard putting in the needles into a motor point while trying to relax the TFL, you get the lower TFL/upper quad area but higher TFL areas are better left to a health care practitioner. 
      Barbell / EZ bar smash I ranked lower just because its hard to target muscles with that plus doesn’t dig and create shear like a lacrosse ball. Lacross ball can be pretty much used everywhere, it really is amazing. Works well digging it into my quads with that creating some shear, and psoas and TFL
      Voodoo flossing is excelling for the thigh, very quick, and cheap.
      ART is expensive, and probably not worth the price. You can get must of the benefits from ART just by using a lacross ball and rumble roller. Maybe regular check ups are useful to see whats spots you have missed.
      Suction cupping is really good, especially since we are always compressing our tissues. Its a good way to create some tension and pull the tissue apart rather than compress them. 
      Massage therapy, not really worth the price. 
    • #74168
      AvatarRyan Cloutier

      I read a study for PFPS where the home physio strengthening exercises were prescribed to be done twice a day. I am wondering if their is any benefit in doing strengthening exercises twice a day (1 set of each exercise) or doing it 3x a week (3 sets of each exercise). 

    • #74169
      AvatarPawan Lalwani
      Participant

      For myself I can feel a difference as soon as I start my routine. Firing up the glutes and hamstrings seems to reduce the tone in the other muscles that are tight, reducing the pull on my IT band and allowing my kneecap to track straighter.

      My issue has been that after a rest day the tightness returns. I would think if you continue to fire up those muscles that help keep you in better alignment it would generally help. So maybe lifting heavy a couple days a week to increase strength and doing very lightweight or bodyweight exercises as a form of active recovery on the other days would be helpful. Going to test my theory this week and see how I feel. Not sure about doing the same exercise multiple times during the day, but can’t see how it would hurt.

    • #74170
      AvatarRyan Cloutier

      Do you do your self-myofascial work/mobs after the strengthening routine. I noticed that if I dont my muscles will tense up after my strengthening routine, but if I do my muscles feel a lot looser right after especially the following day. 

      I have a similar issue in that when I have a large gap between my strengthening routine, my muscles will start to tense up again and IT band pain starts returning. Mobs only temporary help. But right after my strengthening especially the next day my knee feels a lot better and my tight quads and IT band feel a lot looser.
      I currently don’t lift heavy, I am working more on activation using my own body weight. I used to life heavy doing single leg deadlifts and split squats followed by some body weight exercises, but now i strictly do body weight for better form, and focusing on activation. I think part of the problem was that my hip flexors were so tight from constant sitting that when I went to do my glute activation exercises I would be activating my hamstrings insteads because the hip flexors were restricting my hips into going in full extension. So what I think this is were minimizing sitting, and rolling and stretching the hip flexors prior to my glute activation routine comes into play. My glutes feel a lot more sore doing it this way. My hamstrings used to cramp up before when I was trying to do glute bridges/hip thrusts on yoga ball and single leg glute bridges/hip thrusts. Then haven’t cramped up in the last 2 weeks. This tells me I am starting to activate the glutes over the hamstrings during some of these exercises. 
      I am really starting to lean towards getting botox injections into the vastus lateralis to promote more VMO activation and decrease the lateral pull of the VL. Maybe even get some botox into the TFL, to get more glute activation, and help strengthen the glutes over the overactive TFL. I would also imagine this would help with anterior pelvic tilt. 
    • #74171
      AvatarRyan Cloutier

      My plan:


      Keep up with my routine right now while I get the following things below done:

      1) 3-D gait analysis and pedorthist – Get another opinion on whether or not my leg length discrepancy requires a heel wedge – going to make an appointment with Solescience (Colin Dombroski) and get a 3-d video gait analysis.
      2) EMG and PM&R sports med physician – Get an appointment with a PM&R (physiatrist) physician specializing in sports medicine – ask him whether or not my leg length discrepancy requires heel wedge. Ask for EMG to be done to firing ratio of the VMO with the VL and to check the timing of muscle firing to see if the VL is firing before the VMO (delayed onset). Also, if possible check the firing of other muscles such as gluteus max, glute medius, hamstrings. Also, I will ask his opinion on botox injection for PFPS. This information will help me decide whether or not I should get botox and heel wedge. Will also ask for help in my case in general and his opinion on my proximal tibiofibular ganglion cyst, doing ectroaccupuncture and if he knows anyone else that might be able to help. 
      3) MRI – Get another MRI for my proximal tibiofibular joint to fully elucidate whether or not their is a ganlgion cyst their or if their is any differential diagnosis and if this is related to my knee pain.
      4) Osteopath – Keep seeing my current experienced osteopath once every 2 weeks
      5) Physiotherapist – I found a highly regarded physiotherapy in my area named Rob Werstine whose past president of the Canadian Physiotherapy Association (CPA) which meant he was part of a board of 8 members representing all physiotherapist across Canada, and he past chair of National Orthopedic Division. He also an adjunct professor teaching physiotherapy. –> I am thinking of making an appointment with him as well to get his input on my case. Would like to get the 3-D gait analysis and EMG done first and go to him with that information. 

    • #74173
      AvatarPawan Lalwani
      Participant

      Yeah, I usually do the myofascial and mobility drills afterwards.  I don’t think I warm up as well as I should, probably need to work on that.  I feel like for me strengthening gives the most benefits so far, just like you the muscles that were tight are less so after my routine.

      My left hip flexor on my affected side was extremely tight for a bit, started doing hamstring curls along with the other exercises and that seemed to make a huge difference.  What is your hamstring to quad strength like?  I get cramps in my adductors for some reason if I really push it aerobically ski touring or cycling.  Haven’t focused on them all that much, other than some foam rolling every now and then.

      Flossed for the first time last night, did my calves and above my patella.  Need to try to get into the high hip area tonight.  Not sure how much of a difference it made, felt pretty good today, but I usually do the day after my routine.  Went to the gym did some clams, light one legged deadlifts, quad smash with barbell, and wall stretch.  That wall stretch is tough, upper quads are very tight, along with insertion into the hip flexor.  Since I have a standing desk I’ve also been concentrating on my posture, especially keeping my feet pointing straight.  I have  a tendency to toe out.

      What is your leg anatomy like?  I’m a bit bow-legged.

    • #74174
      AvatarRyan Cloutier

      My quads are dominant over hamstring. I spent years training as a competitive soccer goalie jumping A LOT during training sessions from various weird positions. I would continue to train even after fatigue, this is when my form would probably start to break down, I wouldve probably been loading the knees a lot. Physiotherapist back then noticed I was quad dominant over my hamstrings and recommended me strengthening my hamstrings. Also I was able to do 400lb knee extensions in grade 9 but only 100lb hamstring curls!  I will try to confirm if I still have an imbalance their and to what degree with an EMG or some sort of muscle testing with a biodex perhaps. 

      So I am quad dominant overall but also I am pretty sure I am hamstring dominant over my glute max and TFL dominant over my glute max/medius. I will try to confirm all of this via EMG or muscle testing for precise measurements and with a new physiotherapist I will see for less precised measurements.
      I noticed I had to get the voodoo band more tight than the recommended 70% for it to be effective. Also, I noticed more benefits if I did it 4 times a day. I would migrate up the leg starting closest to the knee and making my way up. By the 4th set at the end of the day I was doing high hip. I did this for about a week before I could be sure their was a benefit (although I felt slight improvements after 2-3 days I wasn’t sure it was placebo). I now do them only twice a day. 
      My leg anatomy seems fine. No health practitioner has commented on anything for them. I dont toe in or out. My knees are aligned (their not in valgus). My arch isn’t flat (the physiotherapist said it isnt the greatest arch however and its a little low, but nothing concerning). 
      Thats weird that your a bit bow-legged because that should put you at more risk for medial knee pain rather than lateral knee pain. Usually knock knees is a risk factor for patellofemoral pain. 
      Toeing out 5-10 degrees is fine.
    • #74175
      AvatarRyan Cloutier

      Are you familiar with Bret Contreras, Mike Robertson, Eric Cressey, Mike Boyle, Mike Reinold,  Chad Waterbury, and Gray Cook?

    • #74177
      AvatarPawan Lalwani
      Participant

      Know of Contreras and Reinold out of that list.

    • #74178
      AvatarRyan Cloutier

      I have been researching the effectiveness of self-myofascial release/rolling lately and came up with this really interesting read. I encourage you to read it:

    • #74183
      AvatarAnonymous
    • #74184
      AvatarPawan Lalwani
      Participant

      Ok, so I haven’t been doing squats for a bit since they seem to irritate my knee.  Worked with the Voodoo bands on the 18th, doing bodyweight squats with good form.  Next morning it seemed like the tightness was coming back, pulling on my kneecap.  On the 19th I went through my strength routine, no squats, or anything that really works the quad for that matter, also did some self administered astym, mostly on the spot the IT Band attaches to the kneecap.  Feel good so far this morning.  I’m wondering if my quads are just overactive/tight so anytime I work them they start pulling on things they shouldn’t?  I’ll read throgh those articles Kefu and Kaitlin

      On my affected side my hamstring is so much weaker than the other side, glute also seems more inhibited.  Just going to work on hip and quad mobility as you have suggested before I do my strength routine, as well as after, along with glute, hamstring, and core strengthening.  Staying away from any quad strengthening.

    • #74185
      AvatarRyan Cloutier
      Update:

      1) 3-D gait analysis and pedorthist: I went to solescience for an assessment with Colin Dombroski (a field leader in leg length discrepancies in Canada). He said he recommends a full foot lift of 0.5cm for my 1.1cm discrepancy. He says even small discrepancies might cause problems. In the research hes doing hes seeing that small discrepancies can throw off gait, and kinematics. He was also saying that in the orthopedic literature they say 2cm is the cut of for treatment because they are biased. Must hip surgeries cause a leg length discrepancy below 2 cm, so the clinicians want to keep the performing surgeries so they say 2cm is the cut off. He said having a discrepencie is like I am constantly stepping in a divot loading the joint more. Overall tho he analysed my gait visually and said it looks pretty good even with someone with a discrepancy or injury. I showed him my previous heel wedge and he says it wasn’t helping help me because it was to small. He says although the back is cut to 0.5cm your supposed to measure from the middle of the wedge and it looks to be about 0.3mm only. Plus the wedge lifts only the back of my heel causing my pelvis to shift forward. Full leg lifts is definitely what he recommends. The 3-D gait analysis is scheduled for 1 month. He will test my gait prior to the leg lift, then he will also make me a few full length foot lifts that I can take. He will then do another 3-D gait analysis a few months after (I think he said 1-2 moths) to see the changes. Hes mostly focusing on the pelvis and knee kinematics. 

      FMS (Functional Movement Screen) Results: So although someone did the FMS testing back in October. I asked for the results via email a few days ago and I got them back:

      Here are Tommy’s assessment results – it’s nothing groundbreaking but it’s good to have all the info you can:

      Dave, here is the assessment Report

      Moves extremely well in patterned motions. Far better than expected, almost flawless

      Standard Squat- Pass
      Heels Up Squat- Pass, but still with knee soreness
      Overhead Squat- Pass

      All done with full range and excellent posture

      Ankle Flexion- Excellent. Even and large range.

      Single Leg Strength- Full easy pistol on both sides with good posture

      Glute activation- a little unstable, but activation in extension/abduction is obvious

      Hamstring Mobility- Very good, although lots of quad cramping with quad activation

      Anterior Hip- The only place I found obvious issue. Both anterior hips (deep) were tight, and in knee flexion there was obvious internal rotation to compensate. Right side is worse than left.

      Did a Klatt’s test but it didn’t show anything obvious.

      My conclusion

      Very strong, very mobile- not your obvious issues you associate with knee pain

      However, I am assuming that in deep squatting and knee flexion the tight anterior hip is forcing internal rotation. Not with an obvious collapse at the knee but deep inside right in the hip capsule. If this is indeed the case his knee caps will be shifting and not gliding correctly- leading to knee pain. It also fits with his symptoms

      Right knee pain constantly, left knee pain when squatting

      Right is worse than left, but both increase in soreness with flexion

      Go over this with him and let me know what your thoughts are after session 1.

      I would say with some good smashing and band capsule stretching this should clear up over time.

      — 
      Tommy Caldwell

      Performance Coach and Consultant
      Founder and Head Coach- Hybrid Training System
      Founder and CEO- Hybrid Fitness Centres
      Founder- HTS Hockey
    • #74195
      AvatarPawan Lalwani
      Participant

      Thanks for posting that Kefu. Gives some othets some additional things to look at if they aren’t getting results.

      Followed my plan to continue with my strength plan and add in more mobility work this week, mostly focused on the quads for now. Felt pretty good during the week, no real knee pain, maybe some twinges. Went backcountry skiing today and felt my hip flecked, IT band, and lateral quad start to tense up, didn’t cause pain, more of an irritated feeling.

      Got home and decided to really focus on smashing my quadriceps on the affected leg. Using a 30lb kettlebell I moved it up and down my quads until I found the tender spots. Worst spot is on the vastus lateralis right near where it attaches to the patella. Since I started working that spot it’s become very tender and formed a more noticeable knot, is that normal? I feel like the wall stretch isn’t really hitting my vastus lateralis. I feel it a lot in the rectus femoris and hip flexors. Is there a specifc way to target the vastus lateralis with a stretch after a smashing session?

      I feel like I’m zeroing in on what is causing my issues. I feel like the following are my main issues. Tight overactive quads, tight and shortened hip flexors which are both pulling me into anterior tilt, which I feel like are inhibiting my glutes, this creates even more work for the hip flexors and tightens up my IT Band, also contributing to the lateral pull on my kneecap. My weak hamstrings and core aren’t strong enough to keep me in a neutral position. Muscles in the front are currently winning.

    • #74196
      AvatarRyan Cloutier

      My issues seem very similar to yours:

      1) Overactive/dominant/tight quads – slightly pulling the patella up and laterally, also contributing to anterior pelvic tilt. 
      2) Overactive/dominant/tight hip flexors – inhibiting the glutes, contributing to tightness in IT band and lateral pull on patella. They were being overactive by prolonged sitting among other things. Also contributing to internal rotation of my femur during knee flexion without an obvious valgus. 
      3) Weak/inhibited Glutes – at least relative to my other muscle groups, they were being inhibited by prolonged sitting. Also, hard to activate/strengthen them if hip flexors were overactive. Can’t get full hip extension for full glute activation unless hip flexors loosen up. Also contributing to anterior pelvic tilt and internal rotation of femur during knee flexion. Also hamstrings would preferentially activate during glute activation exercises as I noticed my hamstrings would fatigue during hip thrusts/glute bridges. 
      4) Tight IT band – I have no idea why it gets triggered to become tight so easily. My overactive hip flexors and weaker glutes are most definitely contributing to this problem. Perhaps my leg length discrepancy is also playing some role causing my right pelvis to shift forward and somehow leading to excess IT band tightness and knee pain… this is purely speculative,,
      5) Anatomical Leg length discrepancy – might be playing some role in my slow recovery from this injury. My right leg is shorter by 1.1 cm which is causing my right pelvis to shift forward. How is this causing or contributing to my tight IT band and patella femoral pain I have no idea.
      6) Loading the knee/patella during squat movements – overactive quads and hip flexors, with weaker glutes and hamstrings, and anterior pelvic tilt is contributing to preferential activation of quads during squats or closed chained knee flexion.
      7) Anterior Pelvic Tilt – Quad,hip flexors dominance, and weaker glutes and core contributing to anterior pelvic tilt. Which might be promoting internal rotation of femur and stressing the patellofemoral joint during squatting patterns.
      Things that seem to be helping:
      1) Physio exercises to strengthen glutes (maximus, and medius) also some hamstring activation. Trying to minimize quad activation but at the same time trying to do functional exercises such as squats, single leg squats, split squats/lunges. While also doing exercises such as hip thrusts/glute bridges, side lying leg lifts against wall, x-band walks, front and side lying planks
      2) Doing the mobs 2x a day targetting hip flexor, quads, IT band, (and sometimes calves, adductors, piriformis). Mostly rolling with the lacrosse ball and rumble roller. With stretches at the end.
      3) Voodoo band squats with band around the bottom of knees (2x a day usually)
      4) Rolling out the hip flexors prior to glute activation exercises. This has given me more sore glutes than previously. Also noticing less activation with hamstrings probably because I can get into a further range of motion and full hip extension. 
      5) Avoiding sitting. This has probably contributed to me being able to get full hip extension during glute activation workouts. 
      6) Doing capsule stretching/band distraction roughly once a day after my mobs. Targeting the hip capsule.
      7) Suction cupping and electro-accupuncture has been able to reduce muscle tension a lot. Don’t do these as often as the mobs however but seem to be really effective when I do them. No permanent changes however. 
      Note:
      1) Ankle range of motions is good with good dorsiflexion
      2) VMO doesnt seem weak as their is easy contraction/activation when I contract my quads. Also its of decent size. Perhaps their is slight earlier firing of the vastus lateralis and delayed firing of the VMO tho. Will try to get EMG to know for sure
      3) Foot Arch is of decent size. 
      4) No obvious valgus during knee flexion
      5) Mobility seems good
      6) toes point out 5-10 degrees usually which is good
      7) gait analysis seems good. 3-D gait analysis will show it in more detail once I get it.
      It seems like I have it all figured out and I know my issues. But the problem is I have been doing everything to correct the problem for awhile now with only mild improvements. The biggest improvements have come since January were I made some changes to my routine since following mobilitywod which has been of great help. Especially thanks to Kaitlin and others who have contributed their advice. My IT band has seemed pretty loose for awhile until recently I triggered it to become really tense and painfull again doing some physical activity during daily life involving an open chain knee flexion (just as tense as it used to be). This might be indicating that nothing really has changed except for me masking my symptoms with all the mobs and self-myofascial release. I hope this is not the case.
      Next step: See a legit well recognized physiotherapist who will confirm what I speculate are my issues during his assessment. Hopefully he will make alterations to my regime to improve my routine. Also, get advice from him in regards to the leg length discrepancy and pelvic tilt contribution to my injury. Also, looking to go see someone to get electro-accupuncture done on my hip flexors so I can get into more hip extension and better activate my glutes. This will give me the window of opportunity to strengthen my glutes in ranges I wouldn’t normally be able to go in.
    • #74197
      AvatarRyan Cloutier

      Jtrue 

      Perhaps the squats are causing tightness because you are loading your patella. Are you squating with your hips or your quads? Try squatting as if your sitting back with emphasize on glute/hamstring activation. Make sure youre knees dont come past your toes. Open up your hips during the squat as shown in some of the mobility wod videos. Then roll out your quads/IT band after the squats. Also maybe get some glute activation warm up before doing the squats, like clamshells or x-band walks or side lying leg raises against wall. This will help activate the glutes during the squats. 
      Also if you can squat with a band around your knees this will emphasize the glute medius. The band will try pulling the knees in while you use your glute medius to push your knees out to prevent that from happening during the squat. Its essentially cueing those stabalizing muscles to prevent any knee collapse or valgus. 
      Also, are you going parallel or below parallel. Have you seen a good physiotherapist or other health practitioner specializing in mobility and biomechanics that can fully assess your issue and if the squats are in a good form?
    • #74199
      AvatarRyan Cloutier
      Next step: 
      1) See a legit well recognized physiotherapist who will confirm what I speculate are my issues during his assessment. Hopefully he will make alterations to my regime to improve my routine. Also, get advice from him in regards to the leg length discrepancy and pelvic tilt contribution to my injury. 
      2) Also, looking to go see someone to get electro-accupuncture done on my hip flexors so I can get into more hip extension and better activate my glutes. This will give me the window of opportunity to strengthen my glutes in ranges I wouldn’t normally be able to go in.
      3) Get my full length foot lift and 3-d gait analysis in 1 months time
      4) Keep seeing Osteopath
      5) See a physiatrist/PM&R doctor specializing in sports medicine for his assessment, input and hopefully EMG analysis on: VMO to VL activation patterns, quads to hamstrings activation patterns, and glute to hamstring activation patt erns. This will give me a better idea of what is exactly going on. Perhaps also help me decide if I would benefit from botox into either the hip flexors or vastus lateralis.
      6) If I dont see large improvements within 2-3 months. I will consider flying from my location (Toronto/London Ontario to Los angeles) to see world renowned leader in Patellofemoral Pain and Glute/hip activation Chris Powers and his staff at the movement performance institute. The facility is highly sophisticated. Heres a link: http://movementpi.com/about-mpi/
      7) If all else fails will consider botox for hip flexors or vastus lateralis.
    • #74218
      AvatarERIC HOPKINS
      Participant

      google doug kelsey PhD, PT about ‘runners knee’. its quite unique and physiologically sound.
      the issue is the PF joint surface itself may be weak and needs to be toughened. you need to heal the joint itself first, not muscle/tendon, etc. They all have different load capacities. And even though the MRI is ‘normal’ does not mean the cartilage hasn’t softened.

    • #74239
      AvatarRyan Cloutier

      Thanks Ken Katz I will look into that

    • #74240
      AvatarRyan Cloutier
      I went to see a very good physiotherapist in my area he noticed a few things:

      1) Weak Hamstrings – even weaker than my glute maximus, which he said they should be, however the glute maximus is weak as well (posterior chain is weak–>leading to anterior pelvic tilt–>putting the hips in constant flexion–>leading to weaker glutes, stronger and tighter hip flexors and quads–>leading to IT band tightness–>leading to a lateral and upward pull on the patella during flexion–>leading patellofemoral pain. 
      Fix–>Strengthen hamstrings – he suggests strengthening the hamstrings with supine bridge curl, stiff leg deadlift, narrow stance squat (kicking the but back without having the knees track over the toes, kind of like a good morning)

      2) Right glute medius doesn’t fire at all – He looked at my clamshell very closely and noticed that I cant isolate my glute medius and they werent firing at all during the exercise. He said I am doing a number of things to compensate for it such as activating other muscles (my low back, hip flexors) and rotating my pelvis. This is contributing to a dysfunctional right side kinetic chain. My previous glute medius isolation efforts have not been effective because I was compensating with other muscles and a faulty motor pattern. 
      Fix –>Isolate and activate the glute medius – he suggests isolating the glute medius doing clamshells but with a very conscious effort on form and minimizing compensations (not shifting pelvis at all). He said I should only be feeling it in the glutes. He said this exercise is going to be the most annoying and hardest for me because I am focusing and re-learning a motor pattern which can get frustrating as I might not be able to isolate the glute medius easily at first. He said after I am able to isolate the glute medius and strengthen it, we will integrate the new motor pattern and strength to functional exercises. During my functional exercises he things they aren’t being activated. To help with glute medius activation during the clamshell he suggests to put a pillow between my legs focusing on a neutral pelvis with no rotation at all and to have my lower glutes (left glutes) against the wall, while the higher glutes (the right glutes) are slightly forward away from the wall. He said to have my hands behind my higher glutes (hand should not be touching the glute) to ensure that they dont move closer to my hand (indicating that my pelvis isn’t rotating to compensate)

      3) Limited Range of Motion for Hip External Rotation 
      The right side (side with knee pain) is worse than the left. It seems to be caused my tight/restricted joint capsule, deep internal hip muscles, and TFL pulling/rotating my hip/femur internal and making it hard to externally rotate the femur/hip. May also be contributing to reciprocal inhibition of glute medius: The tight internal rotators are preventing full range of motion for external rotation, thus preventing activation of glute medius on the right side. 
      Fix –> Smash and stretch hip flexors/internal rotators: This is were some mobilitywod work will help. Will have to look into videos to decide what are the best mobs for tight hip internal rotators (to improve hip external rotation). Banded distraction/capsule stretching, and smashing the hip region (TFL, psoas), hip opener stretches.

      One possible explanation of the cycle that is happening with me is this:

      Hamstring weakness
      1) Weak hamstrings* + sitting to much+ tight hip flexors + tight quads + quad dominant + weak glutes and core–> leading to anterior pelvic tilt
      2) Anterior pelvic tilt –> glutes are inactivated because I am always in slight hip flexion due to the anterior pelvic tilt
      3) Glute inactivation –> leads to a compensatory increase in hip flexor activation and tightness and also IT band tightness** 
      4) IT band tightness –> leading to a lateral pull on the knee (especially during knee flexion), also hip flexor tightness may be leading to internal rotation of femur relative to the patella during knee flexion (all tho not in an obvious knee collapse)

      Glute medius weakness:
      1) Glute medius is not firing –> leading to compensatory increase in hip flexor and IT band tightness
      2) IT band tightness –> leading to patella tilt

      I will do what my physiotherapist suggests along with what I have already been doing and update my progress.
    • #74241
      AvatarPawan Lalwani
      Participant

      Hope you’re seeing some results Kefu.  I am slightly better since trying to do mobility work daily, my strength regimen 3 days a week, and doing some bodyweight exercises that fire up the glutes, core, and hamstrings more often.  I went ski touring in Jackson this weekend, did about 20 miles and
      12,000 vert with some deep trailbreaking over 2 days which is a big effort compared to normal day
      tours.  Felt slight twinges in my lateral knee, but better than before.  Need to commit to more wall and couch stretching, only doing about 2 minutes per day for each leg.

       Also paying more attention to posture while standing, contracting core and glutes every so often.  Sleeping on my stomach with a pillow under my hips also seems to hips.  I think I mentioned that already.  Also using an exercise ball and doing a lunge to stretch my hip flexors while standing and working, adductors that lead into my affected left hip flexors are noticeably tight as well.  I recently noticed a slight bump in my left hipflexor area, not sure what it is.  Wondering if I possibly have a sports hernia, going to get it checked out this week.  Heard something like that could contribute to guarding that area creating similar issues to what I’ve been seeing.

    • #74260
      AvatarRyan Cloutier

      To early to tell for the results all tho I do seem optimistic as I have moments of very little pain and only mild discomfort. But then other moments come with more severe pain reminding me that I am still far from correcting my issue.

      I also forgot to add in my previous post that I the physiotherapist noticed very limited range of motion in my right hip external rotation (the side of my knee pain). He noticed worse hip external rotation on my right than on my left. I also notice a lot of tightness (around the joint capsule and TFL) when putting my right hip into external rotation.The tightness makes it hard for me to sit cross legged. 
      Tight Hip Internal rotators (Limited hip external rotation ROM): (2 ways it may contribute to my PFPS)
      1) Tight hip internal rotators–>pulling femur into internal rotation–>femur is in internal rotation relative to patella (not in an obvious valgus collapse but deep inside right in the hip capsule) –> patella not gliding correctly/patella tilt –> knee pain and IT band tightness
      2) Tight hip internal rotators–> preventing full range of motion of glute medius during external rotation (i.e., in exercise such as clamshells) –> leading to reciprocal inhibition of glute medius–>preventing full activation of glute medius–>glute medius weakness–>IT band tightness and poor hip control–>knee pain

      I need some good mobs to help address this 
    • #74262
      AvatarRyan Cloutier
    • #74263
      AvatarRyan Cloutier
    • #74264
      AvatarRyan Cloutier
    • #74267
      AvatarRyan Cloutier
      Updated Daily Mobility/Rehab Routine:
      1) Morning Routine: aprx 45 mins
      1) Warm up (aprx 2 mins): skipping, leg swings etc..
      Inhibit and Lengthen Tight/Overactive Areas:
      2) SMR hip flexors, quads (10 mins)
      3) Capsule stretch/banded distraction: Hip external rotators, Ant hip capsule (5 mins)
      3) Couch Stretch PNF: Rectus femoris (3 mins)
      Activate/strengthen weak areas:
      1) Clamshell (3 sets)
      2) Supine single leg bridge (3 sets)
      3) Front plank (2 sets)
      4) Voodoo band squats (20 reps)
      2) Night Routine: aprx 50 mins
      1) Warm up (aprx 2 mins): skipping, leg swings etc..
      Inhibit and Lengthen Tight/Overactive Areas:
      2) SMR hip flexors, quads (10 mins)
      3) Capsule stretch/banded distraction: Hip external rotators, Ant hip capsule (5 mins)
      3) Couch Stretch PNF: Rectus femoris (3 mins)
      Activate/strengthen weak areas:
      1) Clamshell (3 sets)
      2) Supine single leg bridge (3 sets)
      3) Front plank (2 sets)
      4) Voodoo band squats (20 reps)
      SMR
      1) IT band, calves, hamstrings, adductors
    • #74268
      AvatarRyan Cloutier

      Strengthening/corrective exercises routine to address muscular imbalances (2-3x a week): 
      total time: 1 hr 30 mins- 2 hours 

      Warm Up: (5 minutes) 
      1) Skip (aprx 2 mins), leg swings 

      Inhibit and Lengthen Tight/Overactive Areas: (15-20 mins) 
      2) SMR hip flexors, quads (10 mins) 
      3) Capsule stretch/banded distraction: Hip external rotators, Ant hip capsule (5 mins) 
      3) Couch Stretch PNF: Rectus femoris (3 mins) 

      My strengthening Routine: aprx 45 minutes 
      1) Clamshells: Glute medius/max 
      2) Supine single leg glute bridge: Glute medius/max 

      3) Single leg squats: functional, glutes, hams, quads 
      4) Stiff Leg Deadlift (SLD) /Romanian Deadlift (RDL): hamstrings, glutes 

      5) Side plank: core, glute 
      6) Supine bridge curl: hamstrings 

      Post strengthening Self-Myofascial Release: (10 mins) 
      1) IT band, gastroc, ant tibialis, hamstring, adductors 

      Suction Cupping – 15 minutes 
      -hip flexors, quads, IT band, hamstrings 
      -sometimes adductors, gastroc, ant tibialis

    • #74269
      AvatarRyan Cloutier
      Routine is based on advice from multiple physiotherapist and a recently visited good experienced physiotherapist. Also, readings from published research studies, online readings, exceptional recommendations online by Chris Powers, and online articles written by guys like Bret Contreras, Mike reinold, mike robertson, mike boyle, eric cressey, and chad waterbury.

      Some changes made:
      1) Took out 90/90 split squat –> to much activation of TFL might be counterproductive, also single leg squat work glutes more
      2) Side lying leg abduction–>to much activation of TFL might be counterproductive, clamshells or X-band walks are much better at preferentially targeting glutes
      3) Stretch/SMR tight antagonist muscle areas prior to strengthening weak areas–>to get more ROM and activation of weak areas
      4) Focus on capsule stretching/banded distraction especially for external hip rotation
      5)Do activation exercises twice a day (morning and night do clam shells and supine single leg bridge)–>before I was not doing this.
    • #74270

      Kefu,

      You are sharing lots of information.  I really appreciate it.  
      1.) I thought 90/90 split squat was a hip flexor mob? Kefu, can you flex your glute at all?  When I do clamshells I do feel it in my glutes.  I am asking because I feel like I may have anterior tilt considering that I am finding my quads seem to be always tight. And I am wondering because I think my glutes might be weak.  I am thinking that I can activate them, but they just may be weaker.
      2.) To determine your external hip rotation — I am guessing you can’t pigeon pose?  Is a pigeon pose a good test to see external rotation limitation?
      3.) Is there a way to do a supine single leg bridge without a ball?
    • #74275
      AvatarRyan Cloutier
      Daniel

      1) Lunge actually does more TFL activation than glute medius or maximus (Power, 2013), which was shown by EMG assessment in published research study. Their are many better exercises to choose from if you have a muscular imbalance involving the TFL and glutes. I am thinking 90/90 split squat will show similar activities as the movement pattern is very similar. I dont know why the TFL activation is high perhaps its because its an eccentric contraction of the TFL during the downward movement. 

      I can flex my glutes. For example I stand here writing this I can contract my glutes easily. Even rhythmically to the beat of a song. However, my physiotherapist said I was not contracting my glute medius at all during the clamshell when he evaluated me. It could be due to weakness or just dysfunctional motor pattern. However, I have been doing the clamshells at home for almost a week now, and I feel activation and eventually a burn in my glutes now. It is certainly possible your glutes are weak if your quads are always tight. Also, weak hamstrings might also be contributing.

      2) Regarding the pigeon pose-  No and Yes – I can pigeon pose with good warm up, smashing, and stretching and easing into the position. Its pretty painful tho and I dont think I am doing it fully correctly in terms of body alignment and posture (I might be cheating, but no way of knowing unless someone watches me). The physiotherapist used a different test were I was lying down back against a table. I had my femur up with tibia bent 90 degrees. He would bend it in internal and external rotation and compare both sides. He noticed my right is a lot worse than my left in terms of external rotation ROM. 

      3) Yes. Their are 2 effective ways
      1) Position yourself similar to a piriformis stretch to add a hip opener/external rotation mob component. Perform a hip thrust holding the pirformis stretch. Hold position at top for 3 seconds. Go back down slowly. Thats 1 rep
      2) Performing it while holding knee to chest in the leg your not thrusting with to limit lumber extension and to better isolate the glutes.


      I am doing the plank in my routine but I dont know if it is an effective exercise as it also activates TFL and quadriceps. I might also consider adding box squats to target my posterior chain and to help learn squatting motor pattern. 

    • #74282

      supine single leg bridge with knee to chest version gives a knot/spasm feeling in my hammy — I have to abort the exercise when I feel it.


      I was doing it with foot on ground — not sure if on heel is better — I imagine not.
    • #74284
      AvatarPawan Lalwani
      Participant

      Kefu, I’ve noticed a couple of the same things you have in regards to TFL activation.  When doing side lying abduction exercises with my knee straight and doing an isometric hold of an exercise ball against the wall I noticed TFL started firing a bunch once I got fatigued.  Have recently switched to side lying abduction with knee bent, seems not to recruit the TFL as much or X-Band walks. 

      I am mostly pain free and IT band tightness has been much better for the last week after focusing on smashing lower body, but TFLs are both still very tight most of the time.  I’m also getting slight twinges of medial knee pain, which is new.  Think this might have to do with tight/weak adductors.  I’ve always felt my adductors have been tight so I just recently started focusing some more time on them, either foam rolling or lightly smashing, as they are pretty tender.  They are also the first muscle group that cramps up on me during or after a hard effort on the bike.  Smashing I have been focusing on vastus lateralis, rectus femoris, and anterior tibialis.  Need to start looking at the calves as well.  Have been leaving out squats for now as those seemed to irritate my lateral knee. 

      I’ve also started adding some more core work in as I was only doing side planks previously.  Throwing a 12 lb ball against the wall then catching it in a situp position seems to really fire up the main core muscles/stabilizers.  Feel like I am making progress, but also finding other areas I need to work on as I go. 

      https://www.youtube.com/watch?v=Qa0SHHIOyyg

    • #74297
      AvatarRyan Cloutier

      Daniel

      Same thing happened to me initially. My hamstrings would tense. This is most likely due to preferentially activation of hamstrings over your glutes. Your hamstrings are doing all the work and your glutes are inactive. Its a muscular imbalance issue. Try smashing and stretching the hip flexors first prior to the exercise (this will allow you more hip extension). Then when you perform the exerciser try pushing through your heels, and focusing on lifting with your glutes. Focus on contract the glutes while performing the exercise. It may take awhile before your motor patterns are corrected.
    • #74298
      AvatarRyan Cloutier

      jtrue

      I dont think the medicine ball sit up is the best exercise for our situation as it also works out the hip flexors. For core I would work on planks and their variations. Also, glute bridges target the core as well. Even chin ups/pull ups work the core intensely if you have access to a chin up bar. Try to find exercise which dont involve hip flexion for core activation. 
      You mention squats cause you pain. Try doing wide stance box squats. Its a very good exercise for posterior chain. It targets the Glutes, and hamstrings heavily and helps teach proper squatting form. It will make the transition into normal squats a lot more easier. It will teach you how to squat using your hips, glutes and hamstrings rather than your quads. After, when you progress to normal squats, focus on preventing the knees from tracking over the toes. Use your hips, glutes, and hamstrings rather than your quads to squat down. Pushing your knees out during the squat helps keep your knees from tracking over the toes. If your knees track over the toes it puts a lot of stress on the quads and patella.
    • #74299
      AvatarRyan Cloutier

      Update:

      1) Got MRI done on my proximal tibia-fibular joint. Will review results with sports-medicine physician in a week or two
      2) Osteopath appointment set up for next week. I will talk to her about what she thinks is going on. 
      3) 3-D Gait analysis, and full length foot lift (on my right foot). I have an appointment scheduled in two weeks.
      4) Physiotherapy: Had an appointment today. He mentioned the biggest difference he notices between my two sides is the difference in external rotation (he thinks this might be the biggest contributor in terms of my right patellofemoral pain). My right leg (side of painful knee) has limited external rotation ROM and also experiences discomfort deep in the hip capsule during external rotation. He says it doesn’t have the same “give” when he compares the 2 legs, and he says its not a muscle tension issue, rather its tight hip capsule on the right side (meaning the connective tissue and ligamants deep inside the joint). He wants me to focus on external rotation ROM stretches (along with my physiotherapy routine) for 2 weeks before I see him again. He wants to know if I can gain ROM in external rotation and if that will correlate with symptom relief. He is able to increase my external ROM during the physiotherapy session when he performs manipulations/stretches after a glute activation warm up. My symptoms do feel better today. But it could also be due to: him taping my knee, or because I have been generally having better symptoms each day since I had a flare up of IT band tightness and knee pain last week due to prolonged sitting, or maybe its just placebo.
      Dont stretch over pain threshold: I asked him about doing capsule stretching using a band (banded distractions). He says its perfectly fine, and it should also help and that he is familiar with mobilitywod and kelly starret. One thing he mentioned is to not perform the stretch to the point that one is having pain during the stretch. I was always stretching pretty hard before and experienced discomfort during the stretches almost like a little pin in the capsule (like a pain due to a stretch). He said that I have to avoid that and stretch the ROM right before you experience that. Because the pain can be counterproductive as it can cause more tightness due to a guarding reflex. After my banded distraction capsule stretch for hip external rotations it would be hard for me to walk and I would have a temporary limp that I have to walk off for a few minutes, just because of the long, intense capsule stretch. Is that to much?

      I dont feel a stretch however If i dont stretch to the point of a discomfort level. It feels like I am not stretching at all using his advice. What is mobilitywods view on this topic? I might start a new thread asking this question. 

      He mentions that stretching the ligaments can be done due to a phenomenon called creep. So I will begin doing some research on stretching ligaments and creep. Heres a a link I found on the topic just for starters:
       
    • #74302

      Kefu,

      What about couch stretch for tight quads?

      I think of hip flexor as really high region of the quads.

    • #74354
      AvatarPawan Lalwani
      Participant

      Good luck Kefu.  Still seeing tightness in hip flexors and IT band.  Lateral knee pain hasn’t popped up since I started smashing lateral quad and tibialis anterior.  Smashing of the tibialis anterior seems to make the biggest difference when I start feeling the sensation I feel before the lateral kneecap pain sets in.  After my strengthening routine my hip flexors don’t seem as tight and the tighntess in my IT band and lateral quad seems to go down.  However, it’s a temporary fix.  If I miss a day or push too hard ski touring the tightness pops back up.

      I’m still missing something.  I feel like standing in the same position all day at work is contributing somehow as well.  Heading to Alaska for a 3 week trip, getting dropped off on a glacier via bush plane and camping/ski touring expedition for 2 of those weeks.  Hoping that getting out of the office and changing up my routine for a while will help.  Will be bringing the softball to do soft tissue work on down days in the tent.  Maybe one of the small travel foam rollers as well.  Wish me luck.

      Before work this morning

    • #74389
      AvatarRyan Cloutier

      Dan 

      Yes I do couch stretches for tight quads and hip flexors as part of my routine twice a day. Hasn’t made any significant impact on my tightness. All the mobs help manage my tightness but nothing has been permanent. I had to sit for extended periods of time for 2 days last weekend and my tightness seemed to return rather quickly to painful levels.
    • #74390
      AvatarRyan Cloutier

      Jtrue

      That sounds exciting. I hope the best. 
      Interesting that you say smashing your tibialis anterior has given you the biggest difference. I might have to start smashing my tibialis anterior more often. 
    • #74391
      AvatarRyan Cloutier

      Update: 

      I have been seeing my new physiotherapist for 3 weeks now (2 visits), and have been doing my updated routine for 3 weeks now. Also, been seeing 2nd osteopath twice in 3 weeks. Knee pain has pretty much stayed the same. Quad and IT band tightness is manageable with rigorous mobs, physiotherapy, and standing more often. But with a day or 2 off the routine tightness reaches painful levels and knee pain increases. However knee pain persists even when doing mobs, and physiotherapy. Loosing hope that my situation will get better and been feeling slightly depressed last few days.

      My glutes have been firing during my clamshells, x-band walks, and hip/glute bridges. Been feeling my glute medius best with clamshells, and have upgraded to doing them with a resistance band last week. Overall tho I feel my entire glutes (mostly glute max) being worked a lot doing the x-band walks. I am still having difficulty mobilizing my right hip external rotation. I have been doing banded distractions to get a capsule stretch twice a day for my right hip capsule. 

      On the brighter side I have an appointment for a 3-D gait analyst and for a full length foot lift tomorrow. I am hoping that a full length foot lift of 0.5cm to address my anatomical leg length discrepancy of 1.1 cm is the missing piece to my patellofemoral pain situation. However, when thinking rationally I cant see how it can have a significant impact on my situation (and neither does my physiotherapist) so I dont expect it to be a miracle. I was really hoping that activating my glute medius and increasing my external range of motion on my right hip would decrease my symptoms . The fact that it hasn’t so far in 3 weeks is a major blow. I will keep at my routine for now, I will also have to make a 3rd appointment with the physiotherapist soon to re-analyze me and to get new progressions for the exercises.that are becoming to easy. 
    • #74396
      AvatarRyan Cloutier

      3-D gait analyses:
      The biggest issue was found in my hip:

      1) My left leg has an excessive pelvic drop (trendelenburgs sign):
      -which means my right glute medius (the side with my knee pain) isnt being activated to prevent the pelvic drop on the left leg (meaning that during my right legs stance phase of gait my left pelvis is dropping because glutes arent firing properly)
      -funny enough its only my left leg with the excessive pelvic drop, my right leg actually has a reduced pelvic drop, meaning that the glutes are firing enough on my left leg during its stance phase of gait which prevents my right leg from dropping.
      -But the experienced and highly regarded pedorthist said this is also adding to the asymmetry because the right side has reduced pelvic drop while the left side has excessive pelvic drop

    • #74398
      AvatarRyan Cloutier

      Possible conclusion that can be made: The right glute medius isn’t being activated or firing properly thus explains why I have knee pain symptoms on my right knee only. 
      Solution: 
      1) Learn to activate my right glute medius
      2) strengthen the right glute medius, 
      3) and then integrate the new found strength into functional activities.

      I am focusing on 2 major exercises to address this issue (I am still doing my routine but with a focus on the 2 exercises below):
      1) Clam shells (focus on right side)
      2) X-band walks
      3) Increase hip external range of motion on right side (Capsule stretching doing banded distractions, hip openers)

      Since I have been doing the clamshells I have feel my right glute medius being worked so I know I can activate it. I guess its just a matter of keep working those exercises until I can strengthen it a sufficient amount and then finally integrate the new found strength and learn to activate it during functional exercises (squats, single leg squats, lunges, walking, running etc..)

      I will keep with the routine and additionally focus more on the above exercises for 1-2 months. After 1-2 months I will get the 3-D gait analyses re-tested to see if their has been improvements made. If their hasn’t been major improvements in both the gait pattern and/or my symptoms I will look into getting a full length foot lift on my shorter leg.

    • #74403

      Kefu,

      Can you say a word or two about internal rotation banded distractions?  I am finding that external rotation is impacted by internal rotation as well.  When I internally rotate my leg while sitting I can feel a nice pull on my IT band (quads).  I get instant glute activation as well.  
      Banded distraction wise I am interested to know where you feel the most stiffness.  Again, when I do an internal rotation distraction I feel a lot of activation and room for improvement.  Are you getting that feeling from any of the mobs?
    • #74435
      AvatarRyan Cloutier

      My physiotherapist assessed my internal rotation and he said its fine. If you think you have a problem with internal or external rotation go see a qualified physiotherapist to assess you just to make sure, so you know what to focus your mobs on. 

      That is true that one of glute medius actions is internal rotation (medial rotation of thigh), but I think the TFL is predominant muscle responsible for internal rotation (correct me if I am wrong tho). In cases of patellofemoral pain, and anterior pelvic tilt one would want to avoid TFL activation as much as possible. So i wouldn’t focus on internal rotation workouts, plus it teaches the incorrect/faulty motor patterns in terms of caving your knee in and the tracking of your patella relative to the femur. I am going to avoid internal rotation movements unless someone shows me evidence of its effectiveness. 
      When doing banded distractions while performing external rotations mostly by these 2 stretches:
      1)  in a lunge position with the front leg externally rotated, trying variations in the position and trying to work my way to a pigeon pose ( I cant get the pigeon pose)
      2)  or on my back with one leg crossed–>piriformis stretch
      I definitely feel very stiff in my right hip capsule (the ligaments surrounding the hip joint) doing the 2 mobs mentioned above. Their is a discomfort feeling of stiffness and slight pain in in hip capsule.
      But apparently ligaments can be stretched through a process called creep deformation. This is the same process why your muscles get lengthened by performing stretches for extended periods of time. Thats why Kelly always says spend atleast 2 minutes a piece on a muscle. Soft tissues are viscoelastic in that if they are subject to a stretch they will shorten back to their original length, however if they are stretched for an extended period of time you overcome the elastic properties of the tissue and you get some deformation. Most of the tissue length will return close to the original length after a certain period of time after you exposed it to the stretch, but some deformation (or permanent elongation) remains. 
      Again, this is the same reason why people get rounded upper back and anterior pelvic tilt. They round their upper back throughout the day. The tissue gets permanently deformed into its new position. So only way to reverse that is to start stretching the tissue the opposite way numerous times a day and avoid rounding your back throughout the day. 
      In terms of how/why rolling on a lacrosse ball or rumble roller, and massage helps in terms of fixing soft tissue length and tightness issues I dont know. I dont even know if it helps as I have not seen any evidence. However, if someone would post some evidence to show that it works that would be great. The bro science theory is that it removes adhesions by ungluing the fascia between your muscles. So  the compression and shear forces causes the fascia (connective tissue) to break apart. I havent seen any evidence for this idea. Connective tissue is very strong and I doubt that the rolling can break apart the fascia. 
    • #74436
      AvatarRyan Cloutier

      On another note I just ordered the battlestar today. Will let you know on its effectiveness when it comes.

    • #74440

      hmm.  So if your internal rotation is good, then when you perform a internal rotation banded distraction you don’t feel muscle tightness…?  Are you just going by the word of your physician? 

      Can internal rotation be good and still feel muscle tightness in the mob?  Would an effective way of finding out your issue be to go through all the mobs and find the one that causes positive change?
    • #74442
      AvatarRyan Cloutier

      I havent performed internal rotation banded distractions, so I cant tell you if I feel tightness. Maybe I should try?

      I am going by the word of my physiotherapist and a FMS certified specialist, and their testing which I saw with my eyes. It was evident that I had a significant difference only in my external rotation range of motion (my right side having much less). My internal rotation was fine. Also, I feel it myself that their is a large restriction on my right side doing external rotation work (this was even before going to my last physiotherapist). 
      Another point is that limited external rotation would be more logical in terms of why it may be contributing to the patellofemoral pain: Limited external range of motion on right side–>limited glute activation on right side–>tight IT band and/or knee valgus–>lateral pull on knee–>knee pain 
      For my case the knee valgus isn’t as a big of an issue  at least based on: 3-D gait analysis, and physiotherapist examination, and FMS examination. None of which could find any significant knee valgus or differences between both of my legs
      I dont see how limited internal range of motion would be related to knee pain. Maybe something I can bring up with my physiotherapist. 
    • #74443
      AvatarRyan Cloutier
      I dont think an effective way of finding out my issue is to go through all the mobs and find the one that makes positive change. That seems like the most inefficient, and may lead to no answer. For example I can go through all the mobs but I will probably still see no positive change. It is not a very systematic approach and doing a lot of mobs means less time is spent on a particular area. So instead of focusing the efforts at the problem areas, you are spreading out your efforts in a lot of area but with less emphasize on the problem areas. Another analogy is like what one of the first physiotherapist told me to do. She just went by the book and told me: I have patellofemoral pain so I need to strengthen this, this, this, this, etc…. and stretch this, this this this etc… Basically just like an atomic bomb and do everything even tho it might not help me. This approach was not effective and I did not see any improvements. Partly because she did not effectively evaluate me. Not all patellofemoral pain are caused by the same things. And some exercises that may have been important I was not doing them enough because I had to do all the other exercises that she prescribed which may have been less important. Not to mention I was probably doing them with incorrect form, or doing them with what seemed correct form but not engaging the correct muscles. 
      I have already done a lot of mobs and at one point was doing tons of mob work (except I didnt do internal rotation, and only did upper body sometimes), and and have narrowed it down to whats most important in terms of my tightness areas. I do feel like I am beginning to have some success especially since seeing my new physiotherapist since 1 month ago. However, the change does seem slow. And at times it feel like I have made a lot of progress and that I will be healed soon, until the pain and tightness returns after doing something such as: cleaning, dancing, skipping mobs and sitting for extended periods of time, and sexual intercourse (basically anything with knees bent between below 90 degrees like quarter squat positions). If knees are bent between 0-90 degrees (quarter squat position) under load that triggers a return of painful symptoms for the following week. 
      You seemed to have some success with internal rotation mobs. Would you recommend trying it? If so why?
    • #74444
      AvatarRyan Cloutier

      Another thing to consider for my case is that my symptoms are unilateral. My knee pain is on one side. Its on my right side. The only thing different between my 2 sides found so far is:

      1) My right glute medius is weaker and/or isnt being activated (whereas my left glute medius is being activated)–> positive trendelenburg sign during 3-D gait analysis, their was a pelvic drove only on my left side indicating right glute medius isnt firing. Also during assesment from physiotherapist he noticed my right glute medius wasn’t firing when performing the clamshell and that I was compesating
      2) I got a tight right hip capsule with limited external range of motion (my left hip capsule isn’t tight and my external ROM is fine on my left)
      3) I have an anatomical leg length discrepancy (right leg is shorter than left by 1.1 cm)–>confirmed via x-ray. 
      4) Pelvic rotation with the right side tilted anteriorally–>adaptation to the leg length discrepancy
      Note:  Tight IT band is on both sides (but I think its tighter on my right side)

      My physiotherapist thinks by addressing the first 2 points will help resolve my case. Whereas my osteopath thinks I also need to address the 3rd point (the leg length discrepancy). She even went so far in saying that she thinks I can fix my case just by addressing the 3rd point. She said if I put a full length foot lift, my body will rebalance itself. She thinks that my right glute is weak because my right leg is shorter causing my knee pain. And by adding the lift, my glute will start to fire again, and my knee pain will go away. 

      Is their any evidence, articles, or links that may suggest that a short leg can lead to glute medius weakness?
    • #74445

      I was curious about internal rotation because I am experimenting with the idea that you have to at the very least “clean up” the areas.  However, if you have a leg length difference then I am sure no matter how much you clean up it will go back to how it was.  But…by cleaning up the area you can also see what that new range feels like.  

      Anatomical means that you have a leg length difference because thats how long your femurs are.  Not because you have tight muscles and the femur is sucked up into your pelvis.  
      Kefu,  do you notice how you stand around?  Are you leaning toward one side a lot?  
    • #74446
      AvatarRyan Cloutier

      Their is also the possibility of me having both an anatomical leg length discrepancy as well as a functional one. So my right leg is anatomically shorter than my left and its also sucked up into the pelvis due to the tight hip capsule. 

      In regards to standing around. I dont notice myself leaning to a particular side. Also, during assessments from the various health practitioners they havent noticed that either. Perhaps I can ask my physiotherapist to check for this. 
      Wouldn’t a short leg cause a person to lean towards the short leg?
    • #74448
      AvatarNathan Richer
      Participant

      Hey Kefu,

      First I wanted to congratulate you for forming what must be the longest thread ever LOL.
      A short leg may not cause a person to lean. it can cause the pelvis to tilt lower on the short leg to make it touch the ground. what that also means is that the junction between the pelvis and lumbar spine is not flat, which can cause the lumbar spine to tilt to one side also.  neither condition is desirable from a performance standpoint.  
      i don’t have anatomically different leg lengths, but i had one leg shorter than the other when i first went to a PT after i began training for triathlons. he x-rayed me and showed me the pelvis tilt to one side, and the lumbar spine’s curve to accomodate! the fix back then was orthotics, but it wasn’t a fix as much as a crutch.  now i  know there are root causes to be addressed and i can manage it now, even though i still have uneven leg lengths occasionally.
      i’m curious – what were you scores in the FMS? also did he give you any corrective exercises? i’m not sure clam shells are optimal. Xband walks are better, but there may be more effective things you can do to help activate your weak side.
    • #74450
      AvatarRyan Cloutier

      Hahah thanks. Hopefully I will heal soon so this thread wont get to much longer. 

      Why would you say X-band walks are better?
      From my understanding clamshells are better initially and then x-band walks are the progression. Meaning the person does not want to be doing clamshells forever as X-band walks are more functional. However the clamshells do serve their purpose in that its more controlled and their is higher glute medius activation relative to the TFL when compared to the x-band walks. Chris powers is the one that did the study. Hes the world leader in patellofemoral pain syndrome and first one to prove their is a link between hip mechanics and knee pain. He also recommends starting with clamshells at phase 1 of the physiotherapy. Although he does some variations of it as well. But I also do x-band walks just not as often as the clamshells right now.
      In regards to the FMS, I will copy and paste the email I got of the results. In summary tho the biggest finding was tight hip capsule on my right side. 
    • #74451
      AvatarRyan Cloutier

      FMS REPORT:

      Moves extremely well in patterned motions. Far better than expected,
      almost flawless

      Standard Squat- Pass

      Heels Up Squat- Pass, but still with knee soreness

      Overhead Squat- Pass

       All done with full range and excellent posture

       Ankle Flexion- Excellent. Even and large range.

       Single Leg Strength- Full easy pistol on both sides with good posture

      Glute activation- a little unstable, but activation in
      extension/abduction is obvious

       Hamstring Mobility- Very good, although lots of quad cramping with quad
      activation

       Anterior Hip- The only place I found obvious issue. Both anterior hips
      (deep) were tight, and in knee flexion there was obvious internal rotation to
      compensate. Right side is worse than left.

       Did a Klatt’s test but it didn’t show anything obvious.

       My conclusion

       Very strong, very mobile- not your obvious issues you associate with
      knee pain

       However, I am assuming that in deep squatting and knee flexion the tight
      anterior hip is forcing internal rotation. Not with an obvious collapse at the
      knee but deep inside right in the hip capsule. If this is indeed the case his
      knee caps will be shifting and not gliding correctly- leading to knee pain. It
      also fits with his symptoms

       Right knee pain constantly, left knee pain when squatting

       Right is worse than left, but both increase in soreness with flexion

       I would say with some good smashing and band capsule stretching this
      should clear up over time.

    • #74452
      AvatarNathan Richer
      Participant

      re: FMS – i saw that in a previous post. what i was wondering about was the actual scores you got. Or did he not score you in the traditional FMS way?  These would be a score of 0 to 3 for every one of the 7 tests. some of the screens have both left and right components.

      re: X band vs. clamshells. Everything works to some degree. Clamshells just tend to be isolated in its effect. Generally the world is moving to not prescribing isolated muscle group exercises when you reach the pain free stage.  I think you see more of it when you are trying to get from pain to no pain.
      But i guess since i admit not reading every post in this thread, do you have pain now or are you pain free?
      As you say things like X band walks are more functional and tend towards reactive neural training (RNT) style of exercises. with RNT, you want to have something pulling a joint into a bad position and your job is to perform movement attempting to keep the joint in the correct position.  Then when you take the pulling away, your body tends to remember to keep the joint in the right position afterwards, activating the correct muscles, etc. during that movement. 
      So for X band walks, the RNT tries to push your legs together. You are forced to use the correct muscles to keep the legs straight in the right positions for walking.  Then you take away the X bands and your muscles should be slowly learning how to fire even without them.

    • #74458
      AvatarRyan Cloutier

      Thanks for the input

      I dont think he scored me in the traditional FMS way. However he did mention I did really well during the assessment which is unusual as I have knee pain and from the report he gave it seems like I did well on mostly everything (hip capsule being the only noticeable thing). All tho 3-D gait analysis showed trendelenburgs sign with a left pelvic drop. So my right glute medius isn’t firing atleast when performing functional activities because I do feel it firing during the clamshells. 
      Holding the clamshells (isometric) and preventing the leg for adducting can accomplish some of the reactive neural training. But I do agree X-band walks are better for this purpose. Another good one is squats with band around the knees trying to push the knees in while you maintain an external rotated position activating the glutes to prevent your knees from collapsing.
      I do have pain still.
    • #74481
      AvatarPawan Lalwani
      Participant

      Quick update after my trip. As strange as it seems I had no noticeable pain during an 11 day ski expedition. Skiing every day except for one, big days with a lot of mileage(~10-15/day), vert, and steep bootpacking(kicking steps up couloirs) A little tightness, but nothing too noticeable.

      Within a couple days of flying back to Anchorage and relaxing I started feeling tightness in my IT Band and slight lateral knee cap pain. Seems like when I am constantly moving it stops things from tightneing up, but as soon as I settle back into weekend warrior status the pain and tightness comes back. I feel like I am slowly getting better and learning how to manage it. But I am missing something that causes some pain and tightness to reoccur.

      The pain is more of an annoyance now than being debilitating and stopping me from participating in the sports I’m passionate about. However, I’d like to fix it before it does any permanent damage.

    • #74485
      AvatarRyan Cloutier

      Nice to hear your well on your way to recovery. Keep up with the glute medius strengthening. Its hard to tell whats exactly the cause of your pain and tightness return. Perhaps cross- country skiing is good for you tight IT bands and lateral knee pain as its one of the few sports that use lots of glutes? 

    • #74486
      AvatarRyan Cloutier

      Battlestar Review/Update:

      I got the battlestar on Monday and have used it every day so far. I would say its an upgraded version of the PVC pipe.Its similar to a barbell but a lot more practical and easier to manipulate. I wouldnt say its better than the rumble roller or lacrosse ball tho just different. A good analogy I have is comparing the tools to what part of the arm a massage therapist uses:
      Battlestar –> Forearm
      Lacross Ball –> Elbow
      Rumble roller–> Thumbs and Fingers
      I actually prefer the rumble roller and lacross ball over the battlestar although I will continue to use the battlestar as its still pretty good and works in somewhat different ways. 
    • #74488

      Kefu,

      It is crazy to know that you have great range of motion in your joints and yet you still experience pain.  I would think that because your glute is not activating that you wouldn’t be able to get in some of the shapes like a pistol or a squat.  
    • #74492
      AvatarRyan Cloutier

      Dan

      I think i am compensating with other muscles in order to perform the function such as for single leg squats using TFL, quads, low back and a little bit of hamstrings and glute max. This is something I will bring up with my physiotherapist on Monday tho.
    • #74493
      AvatarRyan Cloutier

      Update:


      Symptoms/Pain
       I dont want to speak to soon, but I am feeling some progress. Symptoms are a lot better, tightness has decreased, and knee pain is better. However, it still doesnt feel right, patella still feels compressed and tilted still gives me pain going down stairs. Not much pain at all when walking, or standing mostly just discomfort. Also, it feels like the tightness and knee pain can return to high levels anytime if triggered so I must be cautious all the time and avoid doing a lot of things. 


      Exercises/Glute medius
      Glute medius feels like its firing when doing clamshells. I have also been doing a lot of x-band walks and voodoo band squats with resistance band around knees pulling knees in (while I try to push knees out). Also been doing a lot of single leg glute bridges/hip thrusts. 

      Banded distractions/External ROM
      Banded distractions for my right hip capsule doesnt feel like its working to increase my external range of motion for my right hip/femur. It still very limited in external range of motion.

      I am going to see physiotherapist on Monday.
    • #74510
      AvatarPawan Lalwani
      Participant

      Good to hear you are seeing some progress Kefu!  Sounds like all your work is paying off.  Have you tried smashing the tibialis anterior yet?  I feel like it was contributing the pressure I was feeling.  Just like you on the affected side my glute doesn’t seem to be firing as strongly as it should, notice it especially when doing one leg deadlifts. 

      Went to the gym for the first time since I got back from AK, and I could tell my quads were tight when doing a couch stretch.  However, the tone in my TFLs seems greatly decreased after the trip. 

      I’ve been trying to get out of my habit of standing at my desk all day without walking around, other than hitting the gym.  I’ve been using an exercise ball with a stool behind me to do a standing couch stretch.  Placing my knee on the exercise ball, with my foot resting on the stool that is placed behind the ball.  Feel better so far, but only been back at work for 3 full days now.  Anyone have any tips on making sure the tibialis anterior is working as it should? 

    • #74562
      AvatarRyan Cloutier

      My symptoms are improving slightly, however it seems to be taking way to long. The physio had me do a lunge variation to try to emphasize glute medius activation, however my IT band flared up and knee pain came back really harshly for a few days. It took some smashing/rolling, stretching, E-stimed dry needling, and glute medius activation at home for a couple days to get back to normal. However, after the lunges my glutes were really sore indicating perhaps I was activating the glutes in a way I wasn’t before. But then why the IT band flare and knee pain? Maybe my knees tracking near my toes during the lunge had a role in the flare of symptoms. I have my next physio appointment on Thursday, I will discuss with him in regards to what the lunges did. He is trying to integrate my new glute medius strength that I have gained (from doing isolated and non-functional exercises) into a functional exercises thats why he had me do the modified lunges. I started to do 1 leg stance hip hikes tho as an alternate to the lunges (seems to work the glute medius in a similar way and is somewhat functional). Perhaps the lunges can be the progression after the 1 leg stance hip hikes get easy.

      Interesting that you say after smashing your tib anterior your symptoms are better. Seems almost to easy/good to be true that such a problem is fixed so easily with a seemingly unrelated muscle group. I guess I have to give smashing the tib anterior a longer and more consistent try. Perhaps its also playing a role in my symptoms (although I doubt it).

    • #74576
      AvatarRyan Cloutier

      Update:


      Went to physiotherapy. I told him that the lunges resulted in a flare in symptoms. I also told him that I have been doing hip hikes instead. He said thats an excellent exercise to transition into the lunge eventually. He also showed me the correct way to do the lunges and this time around I did not get any knee pain after. He had me do a number of new exercises as well. My glutes were definitely being worked in the exercises he had me do, I was feeling the burn. I have listed 3 of the main exercises he had me doing with descriptions of each.
      New exercises:
      1) Modified lunge
      2) Modified single leg deadlift (with hip external rotation)
      3) Modified hip hip hike/step up
      1) Modified lunge (Skater squat/King deadlift):
      -done facing the wall with hands on wall for more control
      -almost all the load should be on the front leg through the heel, back leg should be on floor but with no weight/load on it (so if you wanted to lift it off the ground you can easily do so)
      -chest leaned forward but with a straight posture so center of mass is balanced (if your not leaning forward you will fall backwards, and you would also be putting more weight on your back leg which you dont want)
      -hips squared
      -your not moving your front knee forward rather your bending your front knee down (very similar to single leg squat)
      -your using your glute medius on your front (loaded) leg to perform the lunge and to hip hike the opposite hip to keep the hips leveled in height
      -focus on small movements first
      -make sure front leg does not collapse in at the knee
      2) Modified single leg deadlift 
      -perform the single leg deadlift 
      -hold something for more control (i.e., 2 poles, 2 chairs, etc..)
      -keep hips squared/parallel to the floor with back straight and one leg straight back parallel to the floor at the bottom position
      -once at the bottom position, rotate your hips and shoulders while keeping your back and shoulders aligned with your hips, thus externally rotating the hips and the leg that is straight back parallel to the floor.
      -when externally rotating the glutes should be working. 
      -I was unable to perform this without the holding unto 2 poles (similar to ski poles). Motor control and balance was difficult. 
      3) Modified hip hike/step up (this one is hard to describe)
      -standing with one leg on an elevated platform facing wall
      -put the opposite leg behind you, crossing the elevated leg
      -all load should be on the elevated leg on the heel
      -straighten the leg thats on the platfoorm, lifting the leg behind you, swing it  towards the elevated platform away from your front leg (similar to the modified lunge, single leg squat, and hip hike)
      -glute medius should be used when lifting the front leg (similar to single leg squat or modified lunge, and hip hike) and maintaining balance while swinging the back leg towards the platform.
      The physiotherapist told me that since the lunges were to hard I should focus on the following progressions in the order listed. Once the first exercise listed gets easy I will move unto the next etc..
      1) Hip hikes – increase reps as it gets easy, and then start doing modified hip hike/step ups
      2) Modified hip hike/step ups – increase reps as it gets easy, and then start doing modified single leg deadlifts
      3) Modified single leg deadlift (holding both arms on something for control) – increase reps as it gets easy
      4) Modified single leg deadlift (holding 1 arm on something for control) – increase reps as it gets easy
      5) Modified single leg deadlift (holding on nothing) – increase reps as it gets easy
      6) Modified lunge (using the wall to help with control) – increase reps as it gets easy
      While implementing the progressions above, I will still continue to keep doing:
      1) clamshells using higher reps and holding for longer,
      2) x-band walks doing more reps
      3) Modified single leg glute bridge with external rotation 
      4) Stiff leg deadlifts with 40 lb dumbells (80 lbs total)
      5) Voodoo band squats with resistance band around knee 
      I will also add supine leg curls on yoga ball (without hip extension, and with toes pointed forward) to workout the hamstrings. I was reluctant to do this before despite my physiotherapists recommendations as it was also activating my hip flexors. However, I tried them again and it seemed to work my hamstrings a lot with minimal hip flexor activation. So it might be a good exercises in addition to the stiff leg deadlift to help address the quad/hamstring imbalance. I will also continue to smash/roll out my leg, and do hip flexor/quad stretch, and hip external rotation banded distractions twice a day.
      Next physiotherapy appointment is in 2 weeks. Wish me luck on my progress.
    • #74627
      AvatarRyan Cloutier

      Heres a routine I came up with for glute strengthening, pelvic stability and patellofemoral pain syndrome from the vast amount of research I have done and from my own physiotherapy experience. 

      8 levels:
      1 – Posterolateral hip (glute) muscle isolation (non-weightbearing, activation)
      2 – double limb support (static, activation)
      3 – single limb support (static, activation) 
      4 – double limb support (dynamic, strength) 
      5 – single limb support (dynamic, strength)
      6 – double limb support (ballistic, movement re-education)
      7 – single limb support (ballistic, movement re-education)
      8 – sports specific

      1 – Posterolateral hip (glute) muscle isolation (non-weightbearing, activation)

      Exercises
      1. Clamshells 
      • neutral pelvis
      • bi-planar motion
      • use resistance band, progress to stronger band and 60 second hold
      2. Firehydrant 
      • lift leg to side and slightly back
      • maintain neutral pelvis
      • tri-planar motion
      • use resistance band, progress to stronger band and 60 second hold 
      3. Sidelying plank/clam shell hybrid 
      • perform clamshell while in side plank position
      • dont roll hips back
      • engages core

      Progression criteria: hold each exercises for 60 seconds bi-laterally

      Level 2 – double limb support (static, activation)

      Exercises
      1. Static squat with hip bias
      • hold squat position at aprx 80-90 degrees
      • knees slightly greater than shoulder width apart
      • use resistance band around knees
      • externally rotate knees
      • lean forward with torso
      • keep torso neutral
      2. Static sumo squat
      • hold sumo squat position at aprx 90-90 degrees
      • lean slightly forward
      • toes pointing out

      Level 3 – single limb support (static, activation) 

      Exercises
      1. Hip hike
      • single leg stance
      • raise pelvis on one side
      • hold position 
      2. Bent over hip hike
      • same as above except bend over by hip hinging and leaning forward
      3. Standing firehydrant
      • similar to above 
      4. Wall stance
      • one leg stance with side against wall
      • leg against wall is lifted at aprx 90 degrees
      • push against wall with the stance leg while lifting pelvis (hip hiking)
      • hold position

      4 – double limb support (dynamic, strength) 

      Exercises
      1. Squat with hip bias
      • lean forward with torso
      • weight on heels
      • push butt back
      • resistance band around knees
      • externally rotate knees
      • knees slightly greater than shoulder width apart
      • dont track knees over toes
      • progress towards weights
      2. Sumo squat
      3. Lunge with hip bias
      • similar to a skater squat or king deadlift 
      • perform lunge motion
      • lean forward
      • weight on front leg and heels
      • dont track knee over toes
      • keep pelvis neutral (by hip hiking the pelvis on the opposite side as the front leg)
      • use something to hold unto for better control, progress towards holding unto nothing and weights

      5 – single limb support (dynamic, strength)

      Exercises
      1. Bulgarian split squat with hip bias
      2. standing birdogs
      3. Single leg deadlifts
      4. Standing firehydrants
      5. Hip Hike
      6. Bent over hip hike
      7. Step ups
      8. Step downs
      9. Single leg squats

    • #74683
      AvatarRyan Cloutier

      Update:

      Good news. I have been seeing progress. IT band hasn’t flared up but I have been cautious not to aggravate it. Knee feels a lot better but still not nearly 100% With the exercises I have progressed to single leg support static but I continue to do double leg support static and isolation exercises with higher reps. Smashing and rolling out my muscles was just hiding the symptoms. My issue seems to be a muscular imbalance and motor control problem. Even my pelvis is out of alignment (especially for dynamic exercises) because of asymmetrical glute medius weakness. When doing a dynamic exercises the pelvis shifts asymmetrically. I have to learn how to control my pelvis and keep it neutral.  
    • #74690
      AvatarAnonymous

      Great to hear you are seeing improvements with the work you are doing.
      Identifying the cause is key and sounds like you have.
      Yes, it can take time for an issue that is not a new one.
      Keep chipping away at it.

    • #74692
      AvatarPawan Lalwani
      Participant

      Good to hear Kefu!  I’ve been fairly pain free the last couple weeks but have been on a regimen of stretching and smashing along with my exercise routine.  One legged deadlifts, hamstring curls, x-band walks,some light core exercises, along with smashing the lateral quad and tibialis anterior seem to help the most.  I feel ok as long as I continue the regimen, once I stop the issue seems to reappear.  I went ski mountaineering this past weekend and started to get some lateral knee pain on the descent when we had to hike down a trail with skis on our back.  I’ve noticed some tightness in my adductors, and they are also the first muscle group to start cramping after a hard effort.  Is it possible that the adductors are weak/tight and strengthening them could lengthen them, creating more balance between that group and the glutes.  Seems counter intuitive that strengthening the adductors would help?

    • #74764
      AvatarPawan Lalwani
      Participant

      Since you haven’t posted in a bit I’ll assume things are going well for you Kefu.  Have had some good results lately with some changes I’ve made to my bike fit and pedal stroke.  I noticed my affected knee was flaring out a bit at the top of my pedal stroke, so I’ve started to concentrate on keeping the knee tracking straight up and down during the rotation.  I also widened my q-factor a bit by moving my bike cleats in, which effectively moves my foot away from the centerline of the bike.  I also added some adduction to my strength routine, considering my knee was flaring out, it seems like adduction might help balance things and smooth out my pedal stroke.  On the seated hip abduction/adduction machine I can easily max out the stack for abduction(~200lbs, 3 sets of 5), but adduction I can only comfortably lift 120lbs(3 sets of 5).  Is there an agreed upon ratio of abductor to adductor strength?

      I know that the other strengthening and mobility exercises I’ve done have contributed greatly as well, so I’ll continue to do those.
    • #74814
      AvatarRyan Cloutier

      jtrue funny enough my physiotherapist brought up the point that I have slightly weaker adductors on the effected side (side with knee pain and glute medius weakness). He says we want to strengthen the adductors but not so much that they are compensating for the glute medius. He says functional exercises will strengthen the adductors effectively while also strengthening the glute medius. 

      Kaitlin thanks for all the help thus far

      Update: I feel like my progress is stagnating. I have been able to decrease my knee pain and IT band tightness dramatically but this was only for a few days after which I caused them to flare during a physiotherapy session without rolling them out extensively and perhaps doing to much exercises I was not ready for.The IT band and knee pain returned to similar levels experienced months earlier and since then I have not been able to bring it down to the levels before the flare. I feel like my symptoms are easily triggered because underlying issue is still not fixed. 
      Glute strengthening:
      I have progressed in my glute strengthening regime. I am using stronger bands, using higher reps, and feeling my glute fire. This is still not translating to improvements in symptoms however. I am doing a lot of single leg work. A variation and progression of the hip hike the single leg stance bentover firehydrants seems to burn the glutes the most at this point. 
      Self-myofascial release:
      I am still smashing/rolling my hips and legs with rumble roller, battlerstar, and lacross ball. Doing the couch stretch and banded distractions. My external rotation has improved (as noted by myself and my physiotherapist). I can sit cross legged now without getting pinching feeling in hips.
      Motor control:
      I have improved in motor control, but the pelvis still seems to move asymmetrically during functional exercises (such as squat) unless I have a mirror and I consciously try to shift pelivs. Also, just standing on both legs my pelvis is shifted with the right side (side of effected knee and glute medius weakness) rotated forward, 
      Next physiotherapy appointment:
      Physiotherapist has given me over 2 weeks from today to keep doing the exercises. If I dont seem to get an improvement in symptoms, I will have to discuss with him other possible options such as EMG to look at muscle firing/activation. Maybe that information will help pinpoint more accurately what is going on. I would be interested in seeing the EMG activity of my right and left glute medius during different exercises and compare them, as well as EMG activity of hamstring and glute max during various exercises such as glute bridge to see how they are co-contracting. Also, interested in comparing quad contraction of both legs and quad to hamstring/glute ratio. Also, check to see if hip flexors are overactive and check adductor firing relative to other muscle groups and compare them on both sides. Their is a PM&R sports medicine physician that might be able to do these EMG recordings.
      E-stimed trigger point dry needling
      Doing this in different areas of my quad and IT band for 4 days in a row seemed to make huge improvements in my symptoms of both my IT band tightness and my knee pain (knee felt like it was less compressed and tracking a lot better). However, when I went to physiotherapy and he made me do some new functional excercise, my symptoms flared and returned to previous levels. I am assuming that the trigger point dry needling was just addresing the symptoms rather than the cause. It released my IT band tightness, however the weak glute medius is still their so the IT band would tense up eventually especially if triggered through physical activity. 
    • #74817
      AvatarPawan Lalwani
      Participant

      Hey Kefu, I think you’re on the right track. Keep testing what works and change as needed to get results. After a couple sessions of doing some adductor strengthening I am feeling pretty good day to day. Tightness of my it band and lateral quad is no longer noticeable most of the time. I literally feel a release of tightness after I do some adduction, sort of like after a long stretch. I’ve been able to ride 20 miles with 3500 feet of climbing a couple times now without any pain after, the tightness returns just so I notice it, but goes away as soon as I start working my adductors. For me it makes sense that my adductors are much weaker. Skiing and racing a single speed mountain bike are all quad dominant activites. I overtrained on the single speed and it set off years worth of issues stemming from this imbalance. Not going to say I’m fixed yet, but pretty confident this may be a very big part of the puzzle. I was so focused on what everyone and the research was pointing to that I totally dismissed the thought of adding adduction.

    • #74935
      AvatarRyan Cloutier

      Jtrue:

      Glad to hear your progressing very well. You wouldnt think strengthening the adductors would play such a significant role especially since they can compensate for weak glute medius. Thats interesting that its been able to help you tho.
      Update:
      I feel I have not made any progress. If anything my knee pain and symptoms have slightly gone worse (perhaps due to triggering the symptoms through inappropriate activity one time). The next time I see my physiotherapist is 3 weeks from now. Thats more than enough time to see any progress. If there is no progress, I will ask for an appointment with a PM&R sports medicine physician to get a another opinion/assesment and do EMG analysis. I would hope to get EMG analysis done on:
      1) VMO to VL activation ratio and timing
      2) quad to hamstring activation ratio and timing
      3) hamstring to glute activation ratio and timing
      4) TFL to glute medius activation and timing
      Furthermore, I am considering seeing another physiotherapy clinic with a physiotherapist that is an olympic athlete, with 12 years of experience and certified pilates instructor. She does a lot of postural work. Also, the clinic offers IMS (intramuscular stimulation). 

      Glute strengthening
      Glute seems to be firing as I feel the burn during exercises. The standing firehydrant still seems to be activating it the most, also X-band walks seems to give a nice burn.

      Self-myofascial release
      The IT band seems to be tight now (it got triggered easily through light activity that involved bending the knees and hip) even tho I have been doing e-stimed dry needling and smashing/rolling on rumble roller and lacross ball. 

      Motor control
      There still seems to be pelvic misalignment with the hips leaning towards my right side (perhaps due to glute medius weakness on the right side leading to pelvic drop on left side). During a squat its hard to perform it symmetrically and maintain neutral pelvis, the pelvis seems to shift out of alignment and lean towards the right side pretty easily even with conscious effort in front of mirror.

    • #74950
      AvatarPawan Lalwani
      Participant

      Sorry to hear you’ve had a setback Kefu. I’m glad you’re still searching for answers, you will figure it out, but I’m guessing it’s a combination of things like it has been for me. I feel like my movement patterns were so jacked that it will take quite a while for me to get back to normal. It seems like I’ve been compensating for injuries I’ve had over the last 3-4 years. Strengthening my posterior chain has seeemed to be a huge help.

      The lateral tightness and pain hasn’t come back since I started adding adduction and modifying my pedal stroke, however the medial knee irritation I was feeling a couple years ago came back. Adduction seems to set it off, it feels like it tightens up my vmo and pulls on my medial knee. Not sure if I have an osteophyte or something but it feels like once it tightens up there is some friction right at the medial knee, I’ll feel a pin prick sensation where the vmo attaches. KT Tape seems to help it from getting too aggravated, and smashing the top of my vmo literally stops the irritation from occuring. Also stopped adducting my leg during my pedal stroke and just try to make my knee track as straight as possible throughput the pedal stroke. Frustrating since I solved one issue mostly, but this new issue popped up.

      Going to do very light adduction going forward, continue my strength regimen for glutes/hams and core and make sure I’m doing mobility work to address the areas that need it.

    • #74995
      AvatarRyan Cloutier
      Jtrue
      Maybe look into seeing a  physiotherapist whose a pilates instructor or postural restorative certified. Perhaps your lumbo-pelvic complex is unstable and you have poor motor control leading to excessive motion of pelvis and femur, thus leading to knee pain.


      Update:
      So there has been very little progress in the last 1-2 months. I feel like my progress has stagnated and my symptoms arent improving noticeably. I still get a return of symptoms (tight IT band, and painfully achy knees right around the patellafemoral joint) when I load the knee, and avoid doing mobility/foam rolling/stretching/myofascial release. I still cant do any physical activity without intense flare of symptoms. I just recently seen my physiotherapist, and he says we are going to need to take a new approach. He looked at my hamstring tightness while keeping a lumbar curvature (not letting my lower back round). Apparently he found that my hamstrings are completely restricted. In order to get full range of motion for my hamstrings I move my lumber spine to much. He then tried getting me to stretch my hamstrings while preventing my lumbar spine from rounding. This was very difficult to do and co-ordinate. He then had me lay supine with my feet flat on the table and knees up with a blood pressure cuff on my lumbar spine. He had me raise one of my legs while telling me to not move my lumbar spine as indicated by the pressure changes in the pressure gauge. I found it nearly impossible to not move my lumbar spine while lifting my leg. He said that my lumbar spine and deep core muscles are unstable and move around to much leading to lots of pelvic and hip motion, which leads to excessive motion of my femur during dynamic tasks, leading to my patellofemoral symptoms. He then tried to teach my to activate my transversus abdominis, diaphraghm, and pelvic floor by just doing breathing exercises. He noticed I was breathing through my chest and not through my diaphragm. He said my deep core muscles arent being activated thus leading to lumbo-pelvic instability. He said I have poor motor control and I have to learn how to activate my deep core muscles to prevent excessive motion of my lumbo-pelvic complex. 

      Glute strengthening
      He said continue doing the glute strengthening exercises. I do feel the glutes working when doing the single leg squat/lunge against wall, x-band/lateral side walks, one leg standing fire-hydrants, and clamshells.

      Self-myofascial release
      Still seem to have tightness in IT band, hamstrings, quads, etc.. Smashing/rolling on lacross ball and rumble roller seem to be temporary solutions and only help a little. Also, been doing E-stimed trigger point dry needling everyday for 15 minutes.

      Deep core, transverse abdominis, diaphragm, pelvic floor and lumbo-pelvic stability
      He gave me a few exercises to work on for this that I am still confused about. The most important he said is just getting the diaphragm to work for breathing. He said breath with your stomach/diaphragm area rather then chest. Also something about decreasing the belt line (space between belt line on pants and stomach). He said as I get better start contracting my pelvic floor muscles slightly during the breathing exercise. The 2nd exercise is lying supine with knees bent and raising one leg without moving the lumbar spine/lower back. 

      Hamstring tightness
      The 3rd exercises is doing a straight leg deadlift to help lengthen the hamstrings.

      Future:
      I made an appointment in a few days with an experienced physiotherapist whose also a pilates instructor and an olympic athlete. She should be able to help with my lumbo-pelvic instability issue and deep core muscle strengthening.

    • #74999
      AvatarPawan Lalwani
      Participant

      Yeah, seems like I need to take a slightly different approach as well. Lateral quad, itb tightness, and slight pain returned. I can keep it at bay by smashing, light adduction, and posterior strength exercises(one legged dls, hamstring curls, x-band walks, etc. I haven’t been focusing on my core much at all besides the dls and some isometric side planks every couple workouts.

      Are you doing something like this:
      http://m.youtube.com/watch?v=ONSH_vwvI50

    • #75001
      AvatarRyan Cloutier

      Yes thats the exercise. I cant do it. My lower back arches and moves, and I have poor motor control. He then told me to work on deep breathing exercises first as they are easier, then progress towards breathing with contracting my pelvic floor muscles. After I am able to do that, he said I progress towards the exercise in that youtube video. 

      The reason I am going to see another physiotherapist is because I want someone who specializes in this area to help me go through the exercises properly. My current physiotherapist while being very good doesnt specialize in deep core muscles. He also operates multiple patients at the same time, so he can only help me go through the exercises and watch my form in a given amount of time that is relatively short. On the other hand the other physiotherapist that I am going to see does 1 on 1 sessions, and specializes in pilates, core muscles, etc.. So i feel I can benefit a lot from it. Also, since my progress is stagnating I can always use another opinion on what is going on for my case and perhaps make adjustments to my current regime. 
      My current physiotherapist thinks the deep core muscle weakness, lumbar spine instability and poor motor control are the missing pieces to my puzzle, (the previous piece being glute medius weakness, and pelvic instability).  I hope he is accurate so I can finally get this situation handled for good. 
      Theoretically it is very plausible indeed that deep core muscle weakness is having a major impact on my physiotherapy progress. Around the time I got my patellofemoral syndrome I also strained my lower deep abdominal/groin area. I thought I got a sports hernia because it would not recover. Eventually when I quite sports the pain/symptoms disapeared. Perhaps the abdominal strain had led to lumbo-pelvic instability and an exacerbation of my glute medius weakness leading to a severe and complicated case patellofemoral pain that was not able to be fixed by conventional physiotherapy protocols. Also I do have an anterior pelvic tilt which can be due to not only my quadricep dominance, but also deep core muscle weakness. 
      Jtrue do you have bilateral knee pain? I wonder if indeed the deep core muscle weakness, poor motor control, and lumbo-pelvic instability may also be why you continue to struggle to progress. 
    • #75002
      AvatarRyan Cloutier

      Also just came by this exercise which looks pretty insane,and looks a lot like what I imagine clinical pilates to be:

      It looks like you trains everything I need: glute max, glute medius, external rotators, lumbo-pelvic stability, deep core muscles/transverse abdominis, and motor control. Im not at the level to be doing such an exercise tho if I cant even activate my transverse abdominis. 
    • #75003
      AvatarRyan Cloutier

      The hamstring range of motion test my physiotherapist did was similar to the one in this video:

      What my physiotherapist found was that it seemed I had good hamstring range of motion. But he then had me not move my lumbar spine at all during the test. When I tried to do this I had very little hamstring range of motion, and I would start to move my lumbar spine. 
    • #75011
      AvatarPawan Lalwani
      Participant

      Hey Kefu, I did have bilateral pain and tightness at one point. Lately it seems like its mostly my left leg. Which happens to be the side that my glutes feel a little weaker/inhibited on. I think I already mentioned this but after a couple PT visits I asked my PT to check my pelvis, sure enough my right side was posteriorly rotated, a quick adjustment and most of the itb tightness disappeared. Plus a functional leg length discrepancy was resolved. Right leg being shorter than the left. Granted that didn’t last, I came out of alignmemt and it came back until I started hitting the gym.

      A bunch of people have mentioned to look at the psoas as well, but haven’t noticed that its weak or tight, maybe I don’t know what those muscles are supposed to feel like as I admit my core is probably very weak compared to the rest of my body.

      Thanks for the thoughts and videos, keeps me motivated to find a fix. I know you know better than anyone, but after a while it’s hard to stay motivated and stick with a program if you aren’t getting results. 

    • #75033
      AvatarDorina Gulyas
      Participant

      Hey Kefu,

      You need to look into the work of PRI (Postural Restoration Institute). with out assessing you i would say you are a typical Left AIC. your leg discrepancy along your “tight” IT band and patellofemoral pain are typical in this pattern.

      clearly you have tried about every modality there is. if this doesnt fix you I would be very surprised.

      here is some info on it.
      http://chadwaterbury.com/align-your-pelvis-to-reduce-pain/
      https://www.posturalrestoration.com/

    • #75055
      AvatarRyan Cloutier
      Hey Dvirkus


      Thanks for the info. I have been advised to check out someone certified in PRI by numerous people on forum. Right now I am seeing a new physiotherapist who is an olympic athlete and member of the Canadian Physiotherapy Association and is STOTT PILATES Certified Rehab Instructor.  In addition, she is trained in the Integrated Systems Model of Physiotherapy assessment and treatment. She specializes in integrating Clinical Pilates stabilization principles and exercises to rehabilitation. Hopefully she will get me on the right track.


      As for the left AIC pattern. I am not rotated toward the right, rather my hip is rotated toward the left. So I have an atypical right AIC. 
    • #75056
      AvatarRyan Cloutier

      Things to work on:

      1) Activate my deep core muscles (diaphragm, pelvic floor, TVA)

      Since glute strengthening has only helped somewhat previous physiotherapist thinks weak, inactive deep core muscles is leading to poor stabilization of the lumbo-pelvic-femoral complex and leading to poor motor control and inappropriate movement of legs during functional activity leading to associated IT band tightness and knee pain
      1) Diaphragmatic breathing – deep breathing using diaphragm rather than chest. Breath in as stomach expands. Breath out as stomach gets drawn back in.
      2) Pelvic Floor activation – activate pelvic floor during deep breathing by imagining as if you are holding in your piss or lifting your testicles up. Should be completed when breathing out (stomach getting drawn in). When breathing in (stomach expanding) eccentrically activate pelvic floor by imagining as if you are pissing and forcing a piss out.
      3) Transverse abdominis (TVA) activation – when breathing out (stomach getting drawn in) imagine drawing in your navel and belly button closer to your spine.
      Note: When breathing in activate diaphragm. When breathing out activate pelvic floor and TVA.
      2) Posture / lumbo-pelvic-femural symmetry
      Release the deep gluteal muscles on the right side that might be causing my right femur to be more externally rotated relative the left. My right thigh muscle is normally more externally rotated during rest and functional activity when compared to left. This is a noticeable asymmetry that my new physiotherapist thinks might be leading to the tight IT band and knee pain. GUNS IMS will be completed to relax my deep gluteal muscles (piriformis, gemellus, obturator internus, quadratus femoris). Also, advised to perform stretches and smash this area with lacrosse ball.
      Body alignment
      Physiotherapist brought up rolfing as a possibility to re-establish body alignment. She said we need to get the body algined properly prior to physiotherapy exercises because without the proper alignment any exercises we do will reinforce the misalignment. She wants me to discontinue any exercises prescribed by my previous physiotherapist and focus re-aligning the body first. She said we will slowly start adding exercises in as the body becomes properly aligned
    • #75072
      AvatarRyan Cloutier

      Goals:

      1) Body aligned
      2) Activate Core, posture
      3) Integrate Core activation with glute activation
      4) Integrate core activation and glute activation with functional movements
      1) Body aligned
      Re-establish aligned body by getting 10 session series done by a Rolfer. I have only read good things about rolfing and my physiotherapist brought it up. I think this may help align my body and release knotted tissues. Stretches at home, and self-myofascial release can help it remained aligned between sessions.
      2) Activate Core, posture
      Activate my deep core muscles (TVA, pelvic floor, and diaphragm). This will help make sure I will be activating my core during functional exercises which will allow for better motor control and better posture and alignment. Physiotherapist whose a clinical pilates instructor will help accomplish this. 
      3) Integrate core-activation with glute activation
      Physiotherapist will help accomplish this. This is the progression towards functional exercises. This will help me keep my newly establish alignment from Rolfing and make it permanent.
      4) Integrate core-activation and glute activation with functional exercises
      Physiotherapist will help accomplish this. This is the final progression. Key emphasize placed on proper form, body alignment, posture, motor control while using the core and glutes to perform exercises. This will reinforce proper body alignment.
      5) Maintenance
      Continue doing Rolfing less often on a maintenance basis. Also, continue doing key physio exercises, stretches and self-myofascial release to prevent regression. 
    • #75154
      AvatarPawan Lalwani
      Participant

      Since you posted about the deep core muscles and posture I’ve been trying to pay more attention to it.  In the past I was mostly doing side lying planks with a isometric holds, 1 minute on 15 seconds rest, 4 times on each side.  I’ve started adding some more front planks with my arms out further than in the past.  I’ve also started to work on releasing my psoas, laying on a lacrosse or softball and breathing, bringing my leg up then straightening while pinning the psoas down.  After releasing the psoas I feel a release that flows down to my SI joint and down to the lateral quads.  On the bike I’ve been paying attention to engaging my core during my pedal stroke.  It’s easiest on the road bike, as soon as I suck in and engage my core I feel I can apply more power to the pedals and my knees seem happier.  Only been trying this for a couple rides, but I think neglecting my deep abdominals was playing into the screwed up movement patterns I am stuck in.  It’s hard because I feel like I start focusing on one thing that seemingly helps but then neglect some other piece that is key to getting better.  So far the exercises or movements that have helped the most:

      • RDL(both one legged and two legged)
      • Hamstring Curls(one legged, high weight low reps)
      • X-Band Walks(progression from clamshells, and holding an exercise ball against the wall with one leg while in a side-lying position)
      • One Legged Glute Bridge
      • Smashing Lateral Quad and ITB with Kettlebell(only masks symptoms, but helps get me through the day)
      • Psoas Release
      • Engaging Core during movements
      Hope you are seeing some improvement!
    • #75173
      AvatarRyan Cloutier

      This is one the progressions my phyiostherapist has me doing to engage the core and to gain proper motor control of the deep core muscles.

      There called pelvic clocks. Here is a good video:
    • #75353
      AvatarRobert Behnke
      Participant

      Kefu,

      First of all calm down. Just to let you know you are not the only one going through this nightmare. Especially when you thought you had done everything under the sun and nothing seemed to really help or help long enough. The pain and tightness always comes back. First you have to understand that the hip/leg area consists of many muscles/tendons/fascia etc. bone alignment. One would normally start with the orthopaedic doctor and slow go off to more alternative forms of treatment. Well that is good for a start. Many things are too simplified and many things were also hypothesized wrongly even by master therapists. I can tell you for sure it is not as simple as lifting the heel or lengthening the heels. The cause of the problem is normally way higher up. You have an injury that caused some muscle imbalance which had altered your body and hence the ITB appeared to be short. I may have shorten a little on its own as well but it did not start with that. The shortening came in later. Don’t waste too much money on nutrition or muscle relaxant. Anti-imflamatory or supplement type anti-inflamatory is fine. Do bear in mind those are way too mild to have a long lasting effect. You question therefor would be. “I had done every theraphy available out there and why I can’t cure myself?” Simple, the root of the problem was not identified correctly. Many times, the symptoms were wrongly identified as the source of the problem or rather the main or primary cause were never addressed. You must understand all these therapies are regulated and no therapy is allowed or trained to provide a working force or technique that could alter the physical state of the Fascia. In fact the fascia is badly misunderstood by the therapist community. Anything not done right or incomplete will be pushed to blaming the fascia. You will need a person who totally understand how these muscle works, joins and finally a technique so powerful yet simple. It can cure you in one session. Long session perhaps. If you do the RIGHT THINGS RIGHT, it will be solved. You just haven’t found it. No mainstream therapy I know off is able to “cure” you. Yet,many people like yourself and worse re being cured everyday. 
      1. Accupuncture will only give temporary relief.
      2. Trigger Point Therapy will only give some relief, it is too mild. 
      3. Massages will practically be useless it is the Advanced Tuina, which will help to some degree but the tightness will return because Tuina masters are weak in 
          complete system diagnosis.
      4. Cupping will give some temporary relief IF ONLY DONE ON CORRECT POINTS. Under the hands of a Grandmaster hybrid Cupping Manipulation(A Very Highly 
          Effective Therapy but only available in certain countries
      5. T.E.NS and F.E.S is only for some comfort. Nothing more
      6. Deep muscular accupuncture is good for starter but again not available in western countries. These are not the average accupunturist. They are the neuroi-
         muscular/bone experts who also do manipulation and joint mobilation.
      7. The Heel Raise will only give you a See-Saw effect and a thigh muscle strain
      8. Chiro? Not the standard ones of course. The average ones would probably do GONSTEAD and provide some short-term relief
      I am trying to tell you that, the direction you are going is not right. DO NOT OVERLY STRETCH ON YOUR I.T.B etc. or else later when the problem is addressed alter, you would have a second problem the later being a overly laxed etc. DO NOT FORCE OR APPLY GREAT FORCE IF YOU ARE NOT 100% SURE THAT IS THE ROOT OF THE PROBLEM. 
      In my country, this is easily fixed. Something we see everyday. If you a professional sports person, chances are that you have been seen by your sports rehab specialist. The VOODOO Band is doing a Compression on the Fascia but that is still mild and it will not have a lasting effect. When it is in place, sure it feels good. 
      Rolling on the side is too tedious and has to be done a few times a day. I think you are thinking of getting rid of the problem permanently or at least for a few years.
      Yes, but these are all proprietary and non mainstream techniques. Some are very simple but is so powerful it will out do hundreds or stretching sessions. All thiose things you mentioned are just basics of manual Medicine and sports therapy. All these EMG and advanced technology and still not much result todate –  how strange. As for your comment – “Thats weird that your a bit bow-legged because that should put you at more risk for medial knee pain rather than lateral knee pain”. Not necessarily, commonly but not always the case. Sometimes bow legged and rotated and sometimes translated. Sports medicine is not very complete in terms of it’s coverage. Even Flossing is relatively mild compared to what we have. I showed the VOODOO Band to some of the our practitioners and they were laughing at it as they had been doing these since 50-70 years back. Leave alone the price and effectiveness and for all that trouble. Things are overly commercialised in the western countries. Maybe you should try manipulation under anaesthesia(Just a Joke).  Even the the science behind the VOODOO Band is misunderstood. I am glad you realised that the VOODOO BAND AT IT’S recommended strength is not helping. So you are basically using it “off-label”. It is not the compression that is helping you. I am trained in all the therapies you listed and more and I can safely say they will not be able to “cure” you. You guys are so steadfastly following a science that is so shallow as to the degrees etc. Good for basics only. Can’t spill the beans but aren’t you glad if you can the whole piece of tendon/fascia/muscle out and stretch them out, measure them and put them back so they will work perfectly. Hmm..we can do that but close enough. An Important Question – Why is your leg shorter on one side and what had caused it? If someone gives you an answer, are you 100% sure he is right or you think he is right because he is qualified or certified.  Things, that takes too many sessions to get little results or less than ideal results simply means it is not entirely correct. Good Luck!
    • #75354
      AvatarRobert Behnke
      Participant

      Jtrue, Why would you want to do a PSOAS Release? IS he walking bending over or to the front or have some gait problem? Many of the suggestions here are mostly theoritical and on a should-work basis. have you ever wondered if many sports therapist or rather the fielf of sports therapy had made several wrong assumptions. If they had been correct, this poor guy had long been pain-free. Some of the exercise you guys recommended will aggraviate the condition. Sorry I did not read the later part. Your later therapist is smarter but not entire correct. Loosing up the Pelvic Floor with so much effort? It is not weak, just tight. Rolfing will not work either. What maintenance. In our place, the problem is entirely eradicted once and for all. If you know what you are doing and really sure what is wrong, you just fix it. No Excuse and can do without the needless dozens of technical jargons and all that complexity. Here we do it 30-60 minute session and everything is fixed. At most, we will ask you to return after a week to see how the correction is holding up and if the whole body had harmonised with the new structural dynamics. Once a while we do make our clients wear a a hip customised support. All in all you got some things right but you did not have the best treatment modality hence SO MUCH FOR SO LITTLE.(So much hassle, time, money, worry, so little progess). Fanciful but ineffective. Again, get the most advanced or best Chiro/Therapist you can find because the standard one will only be guessing. What you are having is a compedium of issues normally left untreated in most therapist since the do not know the issue well. Find one that will list down all the issues and who is able to peel the mater layer by later and walk you through what causes what and which comes first and to reverse the problem stage by stage. A complete reversal is possible if the only the diagnosis is correct. When more excuses than results are given, then it’s time to go to another therapist.

    • #75366
      AvatarRyan Cloutier

      Thanks for the tips therapist. I would be interested. I sent you a PM.

    • #75437
      AvatarRyan Cloutier
      My progress is still up and down but my knee pain and IT band tightness is still improving:

      1) 4 treatments of Rolfing – I am doing weekly visits all the way to 10 treatments. It has helped my posture and tension of my muscles/fascia considerably
      2) Physiotherapy visits every 2 weeks for 2 months now – Seeing a PT who specializes in clinical pilates, deep core musculature with over 10 years of experience and an olympic athletes. 
      3) At home physio exercises everyday – foam rolling, stretches, diaphragmatic breathing, deep core musculature exercises, pelvic clocks, glute medius exercises (side lying clamshell with plank position)


      Changes:

      1) My PT has given me numerous progressions to the exercises I have been doing over 2 months ago. I am no doing similar exercises but while lying on a foam roller for extra stability work as well as single leg balance work. Eventually I will progress to doing standing single leg clamshells (motion: rotate hip and leg while hips are flexed)

      2) I have also changed my approach to foam rolling and stretching by utilizing a more softer and gentle approach that elicits no pain and a much slower approach. The rationale behind this is that pain triggers the sympathetic nervous system to tighten your muscles and fascia. If you want to decrease muscle tension you have to trigger the parasympathetic nervous system. Muscle tone is not decreased by the amount of force you apply on your tissue rather its decreased by stimulating the nervous system in a specific way. 

      Note: Symptoms are still easily flared and triggered when performing most functional movements especially those involving bending of knees and movements of hips. 
    • #75465
      AvatarPawan Lalwani
      Participant

      Was wondering how you were doing Kefu, glad to hear you’ve made some progress!  I’ve had my ups and downs, work has been crazy lately which hasn’t allowed me to get out and ride much.  Seems like sitting around makes things worse, so I’ve tried to stay active just taking my dog for a walk, going on short hikes, etc. A month ago I started back with my PT and right away asked him to check my pelvis. Appeared that on my affected side my si joint was “stuck”. He did a chiropractic adjustment and pushed that side down, which clunked back into place. A day later I was getting up off the couch and heard the other side clunk, it was out again.  Followed up my PT appt with another bike fit, this time with slow motion cameras and stick on sensors that measure angles between two different poimts. Most telling thing we saw was that on my affected side(tight it band, lateral knee pain) my so joint wasn’t moving freely like the other side. One side was moving 3.5 degrees up/down other side was moving less than 1 degree during my pedal stroke. Took that feedback and started hitting the core exercises, didn’t seem to help.  Went back and he did another full evaluation, re-adjusted my pelvis back to nuetral. We noticed that on my affected side my vmo was firing late and was much smaller than my other side.  He also continued to state that even though my glutes were relatively strong, they were weak compared to other muscles, quads, hamstrings, mostly.  I’ve only recently strengthened my hamstrings, they were weak as hell when I first started training them 4-5 months ago.  I started with some double leg squats with a band around my knees and have progressed to single leg squats, with a band around the inside of my knee pulling it laterally.  I think these are helping me the most as of late.  I feel like I can get my vmo firing and my knee feels more stable, I’m sure it’s helping my glutes as well.  I’ve gone on a couple quick rides and the tightness hasn’t come back like it has most other times.  I’ve also been massaging my psoas, iliacus, and ql which all seem to help.  I’m optimistic if I keep on my regimen of single leg squats, one legged rdls, hamstring curls, and core work that I’ll get back to 100%.  

      Good luck Kefu, keep posting updates and don’t give up no matter how many setbacks you have.  I know how hard it is to go from being a semi-elite athlete to not even being able to go for a walk, crushes you.  But something is creating all this pain/tightness, just need to try every avenue and figure out what the right fixes are to put you back together.
    • #75467
      AvatarHelen Seville
      Participant

    • #75504
      AvatarRyan Cloutier
      My posture has improved and so has my TMJ problems. But right knee pain with IT band tightness hasnt improved in last month.

      1) 8 treatments of Rolfing – I am doing weekly visits all the way to 10 treatments. It has helped my posture and tension of my muscles/fascia considerably. My anterior pelvic tilt is almost normal so is my lordosis. Also, I had TMJ problems that seem to have almost gone away. 2 more sessions to go. The pelvis is still twisted but to lesser extent. Right side with anatomically shorter leg has pelvis rotated anterior and left side with longer leg has pelvis rotated posterior. Also there still seems to be a noticeable pelvic drop on the longer leg (contrary to whats supposed to happen – pelvic drop is usually on the side of the shorter leg to compensate for difference in leg length –>this is all paradoxical). One might suggest adding a full length foot lift on shorter leg but this would only exacerbate the pelvic asymmetry by creating a larger pelvic drop on right side and clearly causing my right hip to hike dramatically. I am disappointing with the Rolfing treatments as the rolfer said my issue would resolve after the 10 treatments. So far there are no signs pointing to my problem of correcting anytime soon.
       
      2) Physiotherapy visits 4 months now – Seeing a PT who specializes in clinical pilates, deep core musculature with over 10 years of experience and an olympic athletes. 
      3) At home physio exercises everyday – added some progressions from previous exercises such as performing them on foam roller for more core engagement and doing higher reps. still keeping up with foam rolling, stretches, diaphragmatic breathing, deep core musculature exercises, pelvic clocks, glute medius exercises: 1) side lying clamshell with plank position and 2) single leg standing clamshells/firehydrants
    • #75505
      AvatarRyan Cloutier

      Unknown user:

      Thanks for the video.Very interesting. So according to the video a lack of transverse plane movement causes excessive frontal plane (swaying of the hips from side to side) and excessive sagittal plane movement (lordosis and kyphosis, anterior pelvic tilt) leading to IT band tightness and then knee pain. He brings up the point of doing SMR on IT band (without causing pain and discomforrt because this would trigger your kinetic chain to tense up and you wouldnt get effective release but also suggests that foam roller isnt enough) to help resolve the issue which I have been doing, and so far it hasnt resolved my issue. I have been rolling with foam rolling lately perhaps i switch to PVC pipe and lacrosse ball again.
      Would exercise that activate and strengthen transverse plan movements address the cause? He makes it sound like that in the video.
    • #75506
      Joshua A bradleyJoshua A bradley
      Participant

      Wow guys, this is one heck of a series of posts.  I’m floored by how much effort you’ve put into this.  I’m not nearly on your level but perhaps my experience can shed some light.  My quick background is that I’ve had patellofemoral knee pain for 7 yrs now, and over the last 3 years it’s significantly affected my quality of life.  No sports, no jogging/running, no sitting with my knees at 90 degrees for more than a few mins at a time, not able to walk down stairs at all.  I haven’t gone the extreme lengths you guys have to fix it, but I’ve gone to 4 different physical therapists for months at a time.  They all recommended a variety of the same thing… strengthening quads, hips, vmo, and rolling out IT band.  Everything seemed to marginally help, but nothing fixed it.  Over time it grew worse.  I began to fear taking flights (due to the long sit times), and I could no longer sit in an office chair at work, had to stand.  Inactivity made my knees worse, very quickly.  Walking for up to 30mins at a time always helped.  I’m writing because as of recently I’ve gotten a lot better.  I’m hoping it sticks and that i’m not posting this prematurely, but I feel ya’lls pain and wanted to share some of the things I’ve learned which have helped:  

      • Despite all my strengthening with PTs, none of them focused on my hamstrings.  Hamstrings don’t tie directly into the patella, so they’ve been mostly ignored.  I went to the gym a few weeks ago and thought I’d give the hamstring curl machine a try for the first time in years. Turns out I had trouble curling 20 pounds!  And when I did, I noticed my calf muscles would quickly kick in to help.  Having trouble with 20 pounds was a huge red flag obviously, and I’ve spent the last 2 weeks just focusing on that.  Within a couple weeks my pain started to reduce.  This whole F’ing time that was my main problem!  I see red just thinking about it.  So basically I was told by my PTs that I would need to continue doing the straight leg 4 ways and all the exercises they gave me for 30 minutes a day for the next year and then I’d finally be cured.  Which is what ya’ll have been doing.  But my experience shows that continuing what’s not working isn’t the answer.   The 3 months I did those exercises every day were some of the most depressing of my life.  To put in all that work and make little to no progress is extremely frustrating, as you know.  Instead, I found a muscle that had no strength whatsoever and within a couple weeks of training the problem was sorted.  I realize that something as obvious as a weak hamstring likely isn’t ya’lls problem, I just write all this to caution you away from strengthening the same 4 muscles over and over again, because that is likely not the answer.   Instead, work out your core, your back, calves, adductors, etc, and try to find something that might be weak and that you were missing.  
      Other observations over the last few years:
      • Foam rolling is great.  But it’s like taking a drug.   It’s a temporary fix and then you need the next fix to be even stronger.  So I upgraded from a foam roller to pvc to a black rumble roller.  What’s next, metal spikes?  I think rolling is good to continue, but I don’t think it’s the answer
      • After 4 PTs and 2 sports medicine docs and 2 orthopaedists, I finally figured out my problem without them.  The internet is great too for anecdotal evidence.  But the takeaway is that doctors and PTs only know so much.  They rely on studies that apply to problems large groups of people face, not unique problems like Kefu has with one leg shorter than the other.  Also we know our bodies best, so we can’t rely completely on someone else to fix us.
      • Where’s your pain? If it’s to the right or left of the patella it could indicate the problem is from a muscle connected at the sides, like the IT band.  If the pain is above or below, it could indicate a hamstring or quad issue  
      I think that’s all I’ve got.  Best of luck to you guys
    • #75510
      AvatarRyan Cloutier

      djrachman

      Interesting. This is something ill bring up with my physiotherapist. I will ask her to check my hamstring strength to see if there is any imbalance. My previous physiotherapist had told me my hamstrings were weak. Maybe its something to focus on by strengthening it and see if there is any progress. 
      Was your issue only in 1 knee? Cause I have a hard time imagining how a hamstring weakness will cause unilateral knee pain unless the hamstring weakness is on one side. 
    • #75511
      Joshua A bradleyJoshua A bradley
      Participant

      Both knees were weak, but 90% of the pain came from my left knee.  My left knee has a patella tracking issue which my right knee doesn’t.  I suspect this additional underlying issue made my left knee more susceptible to patellofemoral pain, although i know that thoughtful doctors such as Scott Dye have refuted patella-tracking PFPS hypothesis.  

    • #75519
      AvatarPawan Lalwani
      Participant

      djrachman, sounds pretty similar to what I have going on.  Like you I started out where I could barely lift 2 plates on the hamstring curl machine single legged.  I’m now up to 10 plates singled legged 3×5, trying to build strength with high weight, low reps.  It does seem to help, but only for a day or two.  In general tightening up my posterior chain helps but isn’t a lasting fix, maybe my quads are still dominating my hamstrings?  Maybe I need to focus on my back?  I’ve found that just staying active helps me, it doesn’t allow my hip flexors to tighten up. When I go out for a big effort on the bike or ski touring and sit around after everything tightens up.  If I stay active and do some mobility work I am much better off.  Maybe that’s why walking is helping you?  I don’t think I walk enough, I do other sports instead.  Walking seems like such a fundamental movement, it’s probably not a bad idea to increase my mileage.

      Went and got dry needled for the first time, it just became legal for PTs to perform dry needling in UT.  Before performing the work she did an assessment and noticed a pretty noticeable leg length discrepancy on my affected side(functional).  She also noticed limited external rotation in my affected leg.  I also have limited dorsiflexion of that ankle due to breaking my calcaneus years back.  She had me squat like I was doing a goblet squat, then squat with my arms above my head.  When squatting with my arms above my head it was much harder for me to go deep and my knees wanted to come in.  She mentioned tight lats can affect that and gave me a couple stretches to try. 
      She worked on my affected side, needling the vastus lateralis, calf, and tfl.  Got some twitch reactions from my vastus lateralis and a really big one from my calf.  The TFL didn’t seem to react at all, she thought maybe it’s because I have such a chronic issue.  However. the tfl did feel pretty sore after.  I’ve started religiously flossing my tfl and practicing squats.  I do feel less impingement in the front of the hip.  Probably just a temporary fix, but hoping it helps reinforce good movement patterns while the tfl has less tone.
    • #75520
      AvatarRyan Cloutier

      I asked my physiotherapist to check for hamstring weakness. She did notice a slight weakness but she noticed that the glutes are even weaker and thats the bigger issue. She said I should focus on strengthening glutes rather than hamstrings because most of the glute exercises will also strengthen hamstrings anyways and she said I dont want to be hamstring dominant.

      One of the new exercises she has me doing is the Romanian deadlift (straight leg deadlift). This is an exercise I was also told to do by my previous physiotherapist but my current physiotherapist said I wasnt ready for it until now since ive improved my posture. Focus on hip hinging and sitting back with your glutes, My lumbar spine is pretty straight when doing it. There is no “butt wink” (lumbar spine flexion), which is good form. I feel my glutes and hamstrings working. The hamstrings also get a good functional stretch. She said Im more ready to perform the movement than I was before because my posture has improved. My anterior pelvic tilt is minimal now, so proper muscle recruitment is occuring. The exercise also helps reinforce the good posture I have gotten from rolfing and helps reinforce good motor patterning during daily movements. I feel like im engaging my glutes and hamstrings more especially when I bend over.I perform the bend similarly to how I would perform the romanian deadlift and feel my glutes and hamstrings working. I have only done the exercises twice tho since beginning physio with my new physiotherapist. 
      One concern I had with performing the excersise is the assymetry in my pelvic alignment. Left side being different than the right. As I perform the movement there is assymetry from left and right side because of the misaligned pelvis. The physiotherapist said my pelvic assymetry is much improved since the rolfing and the previous physio exercises and that any differences between the 2 sides is subtle. She still recommends performing the romanian deadlift. 
      Jtrue
      Perhaps you should try taking a similar approach by correcting overall posture first. Then performing physio exercises to facilitate permanent change in the new posture and good motor patterns and proper functional movements. The new posture will allow you to perform the exercises properly. The exercises will re-wire your muscles and brain to proper muscle balance and movement. 
    • #75521
      AvatarHelen Seville
      Participant

      Its not about treating one area its about looking at the whole body
      remember muscles don’t work in isolation, so its best to train them as you move in reality

      To be honest functional patterns is making a change for the better in the fitness industry.. they are years ahead of the current fitness industry..

      https://www.facebook.com/FunctionalPatterns?sk=wall

      http://www.functionalpatterns.com/

      https://www.youtube.com/watch?v=-MIweO9f23A

    • #75522
      AvatarHelen Seville
      Participant
    • #75525
      AvatarPawan Lalwani
      Participant

      Kefu, what exercises were you doing beside pelvic clocks to help with posture?

      Edit: Seems like a good article to start with http://deansomerset.com/si-joint-dysfunctions/
    • #75526
      Joshua A bradleyJoshua A bradley
      Participant

      My knee pain improved from the hamstring work, but after walking down a staircase last week the pain came right back.  Either the hamstrings are not the ultimate solution, or I’ve now fixed the imbalance but years of damage are not so easily undone.  

      F this shit, long term joint issues are absolutely depressing.  I’m hoping you guys figure this out soon so I can piggyback on your success.
    • #75527
      Joshua A bradleyJoshua A bradley
      Participant

      jtrue – when lifting weights, i’d avoid the high weight / low rep approach which is designed to build bulk muscle.  It often promotes bad form and it always places a lot of stress on the joints.  My personal trainer has me lift heavy sometimes, and it seems to result in more clicking and popping.  So I try to avoid that.  What works well for me is doug mcguff’s super slow lifting method.  What he believes in is 4-8 reps and 8-10 seconds in each direction with the weights.  By the end of that 2 minute set you should be completely at failure.   The benefits are that you won’t need multiple sets, 1 is enough.  By going to fatigue you’ll have made deep inroads in your muscles and you’ll gain strength similar to if you had lifted much heavier weight.  And the slow, controlled motion with the lighter weight puts the least amount of stress on the joint.  

      Second thing is I’ve recently stopped working out with headphones on.  My knees click and pop in certain positions and I try to stay tuned into that when I hear/feel popping, I can adjust my form or reduce my ROM to prevent it from happening as much.
    • #75530
      AvatarRyan Cloutier

      Jtrue 

      The article you posted focuses on SI joint pain but there is some overlap in concepts. The core exercsise they show is not one that my physiotherapist had me doing. She says abdominal hollowing is an old concept and is outdated. When performing deep core exercises you should be contracted your deep core muscles only 20-30%. Its more of control. 
      This video in that article:
      Thats the form I perform the Romanian deadlifts. I use 25 pound dumbells on each arm however.
    • #75531
      AvatarRyan Cloutier

      heres some pelvic clocks: https://www.youtube.com/watch?v=UfTf6FdJ2Ao

    • #75532
      AvatarRyan Cloutier

      Heres a good article that talks about a weak core leading to stiffening in limbs and gives a good exercises which my physiotherapist has me doing something similar (the leg raise on the stability ball): http://chadwaterbury.com/strengthen-your-core-and-loosen-your-hamstrings/

    • #75533
      AvatarPawan Lalwani
      Participant

      Thanks Kefu, I thought the article on SI joint dysfunction was relevant seeing as how my pelvis is tilted anteriorly on my affected side, keeping my tfl tight.  Which seems to lead to my functional leg length discrepancy and tight it band.  I’ve been performing one legged rdls for a while now, they do seem to help but still missing something.  I’ll take a look at the videos you posted and start incorporating into the routine.

    • #75534
      AvatarRyan Cloutier

      Stuart McGill is the field leader on spinal stability heres a video: https://www.youtube.com/watch?v=qsup3ZvzAjU

    • #75535
      AvatarHelen Seville
      Participant

      Kefu, Stuart is quite a bit behind on human biology now

    • #75536
      AvatarRyan Cloutier

      Unkown please tell me what Dr. Stuart McGill is teaching that is incorrect or wrong. I would like to read it, and post it right here. I can say the same thing about functional patterns. Naudi aguilar in his “how to correct knee imbalance” video was teaching  myofascial release incorrectly as he was demonstrating quick movements of the quadriceps over a medicine ball. Quick movements should be avoided when performing SMR. 

    • #75537
      AvatarHelen Seville
      Participant

      Follow his page and his personal account on facebook and you will understand functional patterns. You will learn why deadlifts, crossfit is all irrelevant etc

    • #75538
      AvatarPawan Lalwani
      Participant

      Kefu or djrachman have you noticed any tightness or restriction in your external obliques or QL?


    • #75539
      AvatarHelen Seville
      Participant

    • #75540
      AvatarRyan Cloutier

      I am following functional patterns. I have some of there products. Nothing against Functional Patterns but also dont see how Dr. stuart mcgill is behind. He doesnt teach cross fit or deadlifts. So i dont see  how your remarks on cross fit or deadlifts relates to dr stuart mcgill

    • #75541
      Joshua A bradleyJoshua A bradley
      Participant

      Maybe a little oblique tightness but not much.  Kefu and Jtrue, do ya’ll have forward head / thoracic kyphosis / computer guy posture?

    • #75546
      AvatarPawan Lalwani
      Participant

      Yeah, I do tend to slouch forward when sitting. Standing I feel like I tend to stand up much straighter. Been trying to pay better attention at all times. I have a standing desk at work. Been doing pelvic clocks the last couple days and do feel more in tune with how my pelvis is sitting. Just can’t seem to keep my tfl from tightening up, very frustrating.

    • #75549
      AvatarRyan Cloutier

      Yeh i got forward head posture (kypthosis/ventral drag). Its improved since rolfing. I currently finished my tenth session of rolfin (last session). My posture and overall body alignment has improved. Anterior pelvic tilt has improved. Also, my pelvis isnt as assymterical. Rolfer finds it weird im experiencing lots of patellofemoral pain and tight IT band/quads still. 

      I have been looking more into functional patterns now. I have there products purchased and will go over certain exercises Naudi Aguilar recommends to my physiotherapist. I am starting to be convinced that lack of transverse plan motion (rotational movement of the trunk during various functional activities) might be a key player in my dysfunction. Naudi Aguilar talks about this a lot and how this can lead to assymetrical pelvis and weight shifts, and excessive motion in the sagittal plane (anterior pelvic tilt) and frontal plane (pelvic sway and trendelenburg sign). I just skimmed the abstracts of many studies that confirm that trunk stiffness is associated with low back pain and knee osteoarthritis. Nothing on patellofemoral pain syndrome tho. He also talks a lot about hip hinging (trunk flexion) as a good motor pattern to have during various activities. I also skimmed some studies talking about the benefits of trunk flexion during running and jump landing leading to less knee force loads and less quadricep activation (more activation of glutes). I am going to see my physiotherapist tomorrow. Changes need to be made as I am not seeing any progress with patellofemoral pain and IT band/quad tightness.
      Things to consider:
      1) Transverse plane motion (rotational movements – mostly about the trunk)
      -need to go over exercises for this and to see if I have dysfunction
      -it activates the anterior oblique system (AOS)
      2) Trunk flexion (hip hinging, activating glutes, less quad activation)
      -emphasize this during daily activities and exercises
    • #75550
      AvatarPAul Evans
      Participant

      Do you have a video of yourself walking/running? that might give some evidence what is going on..

    • #75553
      AvatarSarah Thompson
      Participant

      I have not read the entire thread, but so far I have the basics about your runners knee/ITBS/leg length discrepancy.

      I am a massage therapist with athletic experience as a professional modern dancer. I primarily use deep tissue, neuromuscular, and assisted isolated stretching techniques and specialize in diaphragmatic disorders, pelvic function (sacroiliac joint disfunction, piriformis syndrome), cervical spine, and TMJ.

      First, I would like to address the “hip flexor”, which is the iliopsoas (or illiacus plus psoas major). It should not be considered part of the quadriceps. Many therapists are of that perspective, but I whole heartedly disagree.

      Your iliopsoas is better seen as part of the diaphragm. Where one ends the other nearly seamlessly begins.

      Diaphragmatic disorders can most commonly result in sacroiliac joint disfunction, thoracic outlet syndrome, piriformis syndrome, ITBD, pain throughout the hips, low back, spine, and ribcage. The reasoning behind why the diaphragm should be considered part of a whole body system of its own, instead of a piece of the muscular system, takes an entire paper to explain, but that concept is very important. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731110/ 

      I saw many times repeated by folks here, “It’s like you’re missing the problem”, “the work I’m doing in my glutes, quads, etc… …only last for a little while before everything tightens back up”, “my foot tracks to the outside”, “my hips are rotating laterally and anteriorly”, “try to do the exercises in a way that does not activate your hip flexor”, “I do tend to slouch when sitting”.

      An illustration:

      The psoas connects on the lesser trochanter where some of the adductors attach. Tightness in the psoas will result in tipping the bowl of the pelvis forward to the trochanter, straining hamstrings, glutes, and rotating the femur so that the lesser trochanter presents forward and your toes point outward, which allows tightening in all of the deep hip rotators and glutes. Your upper chest will droop/slouch forward as it is pulled down by the psoas/diaphragm tightness.

      Your psoas will tighten if you are chest breathing instead of breathing into the belly, stretching the transverse abdominis, and using the transverse ab. to compress the abdomen. The nerves which innervate the diaphragm will only activate and tell it to reset to its umbrella-like position if breathing is done correctly. Babies naturally belly breathe only. We learn to chest breathe in response to our need for fight or flight. The chest space opens to allow for more air, but if we do not return to the diaphragmatic breath (thanks to modern anxiety, stress, and sitting for too long), the transverse abdominis weakens, the diaphragm tips upward, cascading a shortness into the psoas which will in turn rotate and shorten the leg (usually left side, since the right side of the diaphragm has a 3lb liver holding it in place).

      What I recommend:

      Find a massage therapist who knows neuromuscular therapy and can release your diaphragm, your psoas major, and the illiacus. You can somewhat get at the illiacus on your own by touching the front of the hip (where it begins to point forward) and keeping your thumb on the bone slide down toward your spine so that you pinch the illiacus between your thumb and the interior of the hip bowl. However, it is better and safer to let an experienced practitioner release it for you to avoid organ and blood vessel trauma and the diaphragm release cannot be done on your own at all.

      Then find a PT who knows diaphragmatic strengthening exercises (may come as part of sacroiliac joint disfunction treatment or not). These exercises should include having you lay on your back, feet on a wall at 90 degrees, activating your hamstrings, and inflating a balloon using belly A.K.A. diaphragmatic breathing.

      You can smash the parts that hurt all you want, but if the pain you feel is a symptom instead of the source (likely), you will never improve for long. You may or may not have a leg length discrepancy. That is either caused by a diaphragmatic disorder or is exasperating and increasing the problem. I suggest wearing the taller heel wedge and getting the work I recommended for your diaphragm done. If things begin to clear up, try weaning off the heel wedge to see if symptoms return.
      Also, stretch your psoas major. http://stronglifts.com/the-psoas-is-it-killing-your-back/

    • #75556
      AvatarPawan Lalwani
      Participant

      Thanks cmillercmt, I think most everything you state above rings true, at least with the issues I’ve been experiencing.  I’ve only recently started belly breathing, definitely a work in progress.  I’ve also started doing some more core work, stirring the pot seems like it works well, also incorporating some pelvic clocks while breathing correctly.  Maybe I’m changing too many things up, but I’ve also been doing some isometric holds that Naudi Aguilar recommends in some of this videos, making sure I’m concentrating on a neutral pelvis while doing them.  I’ve said this before, but I’m seeing some improvement.  I’ve also been dry needling myself, mostly get a twitch response from the vastus lateralis and rectus femoris on the affected side.


      Over the last couple days I’ve been out ski touring and although I’ve had slight discomfort during the activity the tightness hasn’t returned like in the past.  Going to continue strengthening the posterior chain along with everything else I mentioned above.  What kind of practioners are usually trained in releasing the diaphragm?  Overall my psoas and illiacus don’t seem to be super tight, but I do feel some tightness while performing a side bend.  



      Isometric Holds are in this video, along with some more dynamic movements I hope to progress to.

    • #75586
      AvatarPawan Lalwani
      Participant

      Hope everyone had a great holiday, happy new year!  No real change after implementing the exercises above.  Just noticing some things that I need to seem to work on.  Lateral knee pain and tightness came back after two long days ski touring in deep snow.  When I’m doing stir the pot I usually try to do 3 sets, one set consists of stirring 5 times one way then 5 times the opposite way.  After 2 sets of these I find that my core shuts down and I start feeling it in my lower back.  As soon as I start to feel it in my lower back I stop the exercise.  Going in for an FMS screen just to see if they can point out something that I don’t know already.

      Is my strengthening program wrong?  I’m mostly doing lighter weight or bodyweight 3 sets x 8-10 reps.  Main exercises include stir the pot, x-band walks, one legged rdl(35lbs in opposite hand of stance leg), was doing them with up to 70 lbs in one hand, but thought I should concentrate on form vs heavy weight.  I needed something to balance against when doing it with high weight.  Hamstring curls, started off heavy trying to build muscle as I was very weak.  Originally doing 8-9 plates 3 x 5.  Now I’ve been trying to work on muscle endurance a little more and have been doing 6 plates, 3 x 10, but the last set I try to go til failure, which is usually about 15 reps.  Also all the myofascial release, couch stretch, dry needling, goblet squat hold to work on external rotation, banded distraction, etc.
      The TFL on my affected side seems to fire more when contracting my glutes than the unaffected side.  I can see how if this happens every step I take ski touring or revolution of the pedal when cycling it would lead to an overworked tfl that would tighten up.  I guess my main focus is going to be trying to inhibit the TFL while strengthening that glute.  Along with focusing on my core and gaining some endurance.  I also know I don’t walk enough, I literally stand for 15 hours of my day either at work or at home at a standing work station, I really need to change that.
      Some skiing from this weekend before my knee started acting up again.

        
    • #75605
      AvatarPawan Lalwani
      Participant

      Since I tend to have issues after squatting can someone critique my squat?  Knees tracking too far forward?  Ankle dorsiflexoin? I fractured my left calcaneus(affected leg)  which can lead to limited ankle mobility.


    • #75628
      Joshua A bradleyJoshua A bradley
      Participant

      JTrue- I’m no squat expert, but here are my 2 cents for what they’re worth.  

      First off, I get pain when I go down too low.  Even 90 degrees is slightly too far for me, and you’re way past 90 degrees.  I’d reduce that range of motion first.

      If your squat still hurts, adjust your stance until you find one that doesn’t.  Spread your legs further apart and point your toes either further outward or more towards the center.  Keep changing this up until you find a combination that causes no pain, then stick with it.  
      Once you find a squat position that works, give the 1 arm kettlebell swing a try.  It strengthens the whole posterior chain and I feel great the day after doing it.   https://www.youtube.com/watch?v=R8uI-EopErw    make sure to use your empty arm like a counterweight behind you, kinda like a cowboy on a rodeo horse.  Grab the weight in mid-air with the other arm to switch arms… no need to put the weight down.  GL
    • #75635
      AvatarPawan Lalwani
      Participant

      Thanks dj.  I usually don’t get pain upon squatting, but the tightness and pain return after.  I feel like maybe I’m compensating with some overactive muscles and then they tense up after.  I’ve been doing posterior and core strengthening the last couple days, seems to help, but always have that slight tightness that I know will come back once I stop.  I’ve wondered this before, but I’m really curious about a possible disc issue.  I don’t present with any back pain, although I’ve had a couple twinges here and there, never anything debilitating or something I thought I should have a doc check out.   I know most people have disc issues when they receive an MRI, but most have no symptoms.  I’m not sure an MRI would help anyways, am I going to have back surgery at this point, very unlikely. 

      Another thread I’ve had going for a bit, with some different perspectives, think there might be some useful info in it.

      http://www.tetongravity.com/forums/showthread.php/264615-ITB-Issues-What-Worked-for-You

    • #75640
      AvatarPawan Lalwani
      Participant

      Started incorporating controlled bodyweight back extensions into my workout, feel less tightness in the lateral knee than I have for a bit. Making sure not to hyper extend, but hitting a neutral.  Have an appt on Monday with a McKenzie diplomat that also backcountry skis and is an expert in biomechanics and how they affect sports performance.  Looking forward to meeting with her to see what her take is.

    • #75656
      AvatarPawan Lalwani
      Participant
      Went to see the McKenzie certified PT today. It’s a private cash only practice, but I paid less out of pocket then the out of network PT I was seeing. Funny how insurance works.
      Anyways, no smoking gun. Through all the tests there wasn’t one thing that stuck out to her. No reg flags while she put pressure on my lumbar spine. We went through my history, what I’ve been dealing with. What flares up my condition, what helps, etc. She said she deals with mostly athletes and that with a lot of them it’s hard to flush out the issue right away since most of them are strong and can compensate a number of different ways for any dysfunction. She mentioned if my quads were affected it could be an issue higher in the lumbar region which are sometimes harder to illicit a response from during a short period of time. Every sport I’m interested in is an endurance sport so I tend to be in the same position doing the same movement for long periods of time. 
      After talking with her about my lifestyle we did come to a conclusion, I appear to live in a way where I try to keep my back in extension as much as possible. I don’t sit unless I really have to, because I tend to slouch when I sit and this seems to tighten up my quads and IT Band. I have a standing desk at work and at home. When I watch tv or read I always try to lay on my stomach on my elbows, laying against a wall with a pillow behind me and my back in flexion seems to make my symptoms worse. I also sleep with a pillow under my pelvis/lumbar area which also seems to create less tension on the lateral side of my knee. 
      As a follow up we decided to tape my back to limit and remind me not to go into flexion, along with only doing McKenzie exercises over the next couple days. Nothing else that makes me feel better, like one legged rdls, etc. Just to see what happens. Since we couldn’t illicit any change in symptoms during a one hour visit I’m hoping we can flesh out some of the things that contribute to my pain/tightness over a couple days. If it makes no difference we can go from there, but it’s one avenue I haven’t gone done before, so it’s worth a shot.
    • #75686
      AvatarRyan Cloutier

      A few things ive noticed in that video as a critique:

      Looking from the side:
      1) Before you even squat I notice you are in anterior pelvic tilt. I notice lumbar curvature as the shirt sags.
      2) Your hip hinging seems fine as you kick back your glutes and draw the hips in for hip flexion. That is good.
      3) Your knees arent tracking over your toes and shin is approximately vertical which is also good
      4) Your pelvis starts to tuck under the deeper you go. Notice the point when your lower back is in extension and switches to flexion. You dont want to switch to flexion. Only do squats as deep as you can maintain that lowerback extension (neutral spine has the lumbar curvature in slight extension), So keep the spine neutral throughout the squat.
      5) When you get up from the bottom position you push through your heels but you lose slight balance and the toes lift off. You want to avoid the toes lifting up and you want to keep a strong base. A guideline to follow is 75% weight on heels and 25% on toes. 
      6) Your final position at the top of the squat you try to do hip extension but it cause you to sway your upper back behind the glutes and creating more lordosis. Instead dont exagerate the hip extension rather focus on posterior tilting the pelvis during the last phase. Naudi Aguilar talks about this. 
      Looking from the front:
      1) Even on the downward phase of the squat your toes lift off. Try keeping them down.
      2) You do seem to be symmetrically from left to right atleast through this video 
    • #75687
      AvatarRyan Cloutier

      I suggest you watch more of functional patterns videos (naudi aguilar). He seems to have a really good understanding of proper biomechanics and movement and his a good arsenal of exercises and progressions. You may need to purchase some of his video or book products as well. I will continue to watch and learn from him as well. I brought him up with my Physio and my physio agrees he has good exercises and suggestions but doesnt agree with everything he says. Also, doesnt think his posture is proper as it looks like hes sucking in his lower abdomens and his upper chest sticks out. Also, naudi thinks the plank is a good exercises if done properly. My physio thinks it isnt a good exercises and it teaches the wrong patters. 

    • #75688
      AvatarRyan Cloutier
    • #75689
      AvatarRyan Cloutier

      Its interesting. He says glute medius isn’t the culprit. Rather the core is.

    • #75690
      AvatarPawan Lalwani
      Participant

      Thanks Kefu, very similar to the critique the mckenzie certified pt gave me, especially about the butt wink at the bottom.  Said that could be why squats seem to aggravate my condition.  Funny thing is that I have excellent hamstring mobility, so I’m missing it somewhere else.  I did purchase some of Naudi’s videos, just haven’t had a chance to watch them yet.

      This is what I posted in that other thread I have going on at tetongravity.com
      “Just wanted to report back, wore the tape since Wednesday, it definitely served to remind me when I was slouching. Did the McKenzie exercises daily and slept with a pillow under my lumbar spine. The tightness and irritation are basically non-existent when I really pay attention to posture. My IT band on the affected leg seems much looser than it’s been in quite some time. It feels un-natural how straight I have to stand up to stop the tightness and pain from coming back. I notice that when I’m standing my shoulders want to slouch forward if I don’t pay extremely close attention, this results in a slight rounding of my back. If I notice the tightness coming back I immediately go into standing back extension and it seems to help.

      I haven’t ridden my bike or gone touring while trying to ride or skin with improved posture, but that’s the next step. I’ve been told my posture on the bike needs improvement by one of the first bike fitters I went to, it’s very easy to get lazy and let your back round on the road or mountain bike when you get tired. I’m sure the same thing happens while I’m touring, leaning over slogging up a steep long slope allowing my back to round. Same thing with after I’m done with a long ride or tour, I am usually exhausted and my posture probably suffers for it. Have my next appointment on Wednesday, so I’ll be interested in what conclusions we come up with after this test. It appears that any exercise or posture that keeps me more upright and keeps the posterior chain tight helps my issue. Trick is going to be staying on top of myself and figuring out how to make some lasting changes.”
      I did go ski touring tonight, just up a local resort and paid very close attention to my posture.  I went pretty hard to see if I could keep my posture in check while exerting myself, it’s very hard to do once you’re winded and trying to run up the mountain on skis.  I didn’t pay attention to my breathing, which I really should have.   It seemed to help during the activity, feeling twinges now, but haven’t done any extension press-ups after the activity.  This last week the only things I’ve done are light one legged rdls, extenstion pressups(standing and lying) and some light foam rolling on the rectus femoris.  Tightness is so much better, but still comes back  if I’m not religious about the extension press ups.  Wondering if I actually have a back issue or if this is all posture related/core related.  I’ve been hitting the core pretty hard over the last couple weeks prior to just doing the extensions, but maybe not focusing on the right muscles. 
    • #75692
      AvatarPawan Lalwani
      Participant

      Went to go see the new PT again today, she thinks it’s an issue with discs near l1/l2.  The press-ups are definitely helping, if I feel tightness in my lateral knee I go do a pressup or standing back extension and am good to go for a bit.  My IT Band is the loosest it’s been in a long while when I palpate it.  She gave me some additional things to work on, including some movements to target right between the thoracic and lumbar spine.  Next step is to continue the pressups and other movements she gave me.  Trying to continue to stay out of flexion and the movements that are keeping my symptomatic.  She said if I can stay symptom free for a week we can start working on additional strengthening for my upper and lower back.  I never target the upper back.  But exercises that have targeted the lower back have seemed to help in the past.   She also had me practice keeping my transversus abdominis tight while doing bird dogs, which I don’t think I’ve done before. She taped my back again to remind me about posture.


      I spoke with her about how many patients she sees that don’t complain of back pain but have other chronic ailments that stem from the lumbar spine.  She mentioned about a 1/4 of the people she sees have little to no back pain, but have issues that stem from the spine.  Kefu, you should try some press-ups for a couple days and see if they help at all.

    • #75713
      AvatarMitch Rostad
      Participant

      Hey just found this post by fluke … I’m an avid runner and weight trainer and I have this exact same problem with leg length imbalance due to pelvic tilt …my hip is visibly lower than the other which in turn causes me a lot of pain … I have been dealing with this for over a year thinking of every cause under the sun … With no avail .. But recently I have discovered the relationship between my tight quad on the injured leg and the pelvic tilt . I never had pain in my quad , it was just always very tight . However after going to a therapist I began to realize I have literly a brick of muscle adhesions all through my quad hip flexor and it band which pill on the front of my hip dragging it down … This is why I cannot feel my glutes when squatting and why my hamstrings feel like they might snap … As I have been releasing my quad my hip levels have evened out and the pain is much less … I hope this may help you In Your journey I know as well as anyone how frustrating finding the answer to something like this is 🙂

    • #75714
      AvatarMitch Rostad
      Participant

      Hey just found this post by fluke … I’m an avid runner and weight trainer and I have this exact same problem with leg length imbalance due to pelvic tilt …my hip is visibly lower than the other which in turn causes me a lot of pain … I have been dealing with this for over a year thinking of every cause under the sun … With no avail .. But recently I have discovered the relationship between my tight quad on the injured leg and the pelvic tilt . I never had pain in my quad , it was just always very tight . However after going to a therapist I began to realize I have literly a brick of muscle adhesions all through my quad hip flexor and it band which pill on the front of my hip dragging it down … This is why I cannot feel my glutes when squatting and why my hamstrings feel like they might snap … As I have been releasing my quad my hip levels have evened out and the pain is much less … I hope this may help you In Your journey I know as well as anyone how frustrating finding the answer to something like this is 🙂

    • #75716
      AvatarRyan Cloutier

      Hey Nicole55

      You should still feel the glute during the squat during the eccentric phase if you hip hinge correctly and kick back your glutes keeping a focus on having your weight distributed mostly on heels with only some on your toes. Make sure your knees dont track to much forward keeping your shins as perpendicular to the ground as possible.
    • #75717
      AvatarRyan Cloutier

      90% SURE I FOUND WHATS CAUSING MY PROBLEM. NOW I NEED SOLUTION!:

      Right knee pain, IT band/quad tightness 
      So after watching plenty of functional patterns (Naudi Aguilars) videos, comments, blogs etc.. I think I figured out what is wrong. I think I figured out what is causing my tight quad/IT band leading to knee pain. 
      MY PROBLEM:
      —>Weak lower right inner core/abdominals, weak transverse abdominis (TVA) on the right side
      How did I figure this out: extensive research + trail and error + functional patterns (naudi aguilar)
      1) Strengthening the VMO did not help
      2) Strengthening VMO + Self Myofascial Release (SMR) –> did not help
      3) Glute strengthening + SMR + ART + massage + osteopath –> did not help
      4) Glute strengthening + deep core strengthening + SMR + Rolfing –>helped slightly
      From this we can deduce that:
      – VMO unlikely whats causing the problem and current literature supports this. Also, I am quad dominant. So strengthening VMO would strengthen the quads and cause even more imbalance and incorrect motor patterns.
      -Tight IT band/quads and hip flexors muscles is not whats causing my problem. It is a symptom of the real cause
      -Weak glutes is unlikely whats causing the problem as months of proper glute strengthening did not improve symptoms and Naudi Aguilar supports the fact the weak glute medius is probably not the cause.
      However, recall that 3-D gait analysis showed: 
      1) Pelvic drop on left side 
      -indicating the right glute medius is weak and cant support the one leg stance.
      BUT
      -This is incorrect. It wasn’t the right glute medius that was weak. It was the lower right deep abdominals (TVA)
      -When contracting and tightening the lower right abdominals my right pelvis dosnt shift laterally which prevents my left pelvis from dropping
      Posture:
      -I have anterior pelvic tilt (lordosis in lumbar spine, and kyphotic cervical spine)
      -Pelvis on right side: Is twisted forward and shifts laterally to the right.
      Why is posture like this:
      anterior pelvic tilt:
      1) tight  and dominant hipflexors/quads
      2) weak glutes
      3) incorrect motor pattern (quad dominant movements, inefficient hip hinging)
      4) weak core: not engaging the deep abdominal muscles***
      Lateral pelvic shift and anterior pelvic twist on right side:
      1) Weak core: not engaging the lower right deep abdominal muscles 
      How would a weak lower right deep abdominal muscle cause Tight IT band and Knee Pain:
      -Naudi Aguilar talks about the cause of knee pain/IT band tightness is probably not glute medius weakness and it probably is weak deep core muscles (TVA) leading to poor transverse rotation and pelvic instability in the frontal plane. 
      -Excessive pelvic motion in the frontal plane would cause incorrect biomechanical load transfer through the thigh/femur unto the knees causing tight IT bands and then lateral tracking of patella and knee pain.
      -My pelvis is shifted laterally on the right side. This causes my IT band to always feel tight and leads to the IT band pulling on the patella. When I consciously shift my pelvis more towards the left and try tightening my lower right abdominals the IT band loosens. This positioned cant be maintened however as it is artificially created my lots of effort. In my natural state my pelvis reverts back to shifting to the right side must likely caused by weak lower right abdominals.
      How to strengthen deep lower right abdominals?
      – Would anyone know how to do this? I dont know how to target the right side without getting the left.


    • #75718
      AvatarRyan Cloutier

      Why do I have weak deep lower right abdominals?:

      I injured my lower right abdominals (sports hernia/atheletic pubalgia) Just after I started getting my knee pains roughly 7 years ago from a twisting motion as I was playing soccer (goalie). I had pain in my deep lower abdominals for roughly 1 year until I stopped playing sports. Then it stopped.
    • #75722
      AvatarPawan Lalwani
      Participant

      Hey Kefu, I also noticed that on my affected side my deep abdominals didn’t seem to be firing as hard as my unaffected side.  Same thing for my glute med on the affected side.  My PT said that once I got the back issue under control the muscels should start firing again.  So far I’ve been pain free since starting the Mckenzie exercises, some tightness does comes back if I stay in flexion for too long, or slouch while standing during the day.  As soon as I notice it coming back I do some standing back extensions and it goes away in the next couple minutes.  The decreases in tightness seems to last longer each day as I continue to do the Mckenzie exercises and remind myself to stand with good posture at work.  Sitting is still tough for me and I have to overcompensate with a larger lumbar curve than natural.  I’m hoping this decreases as time goes on.  Not saying you definitely have the same issue, but since we seem to have similar symptoms I wouldn’t rule out the back.  Good luck and keep us updated.

    • #75728
      AvatarClemens Környefalvy
      Participant

      Hey guys, obviously a long convo but I tried to read as much of it as I could. I have some of the same issues, but also some differences, and am just looking for some feedback. In 7th grade I got oshgood schlatter in my left knee. At the time I was a very active kid. Football, basketball, baseball, soccer, sports all year. I kept doing all these sports and played through the knee pain, but over the course of the next year, I started to compensate for this pain. I got pinched nerves around my sacral bones, starting on the left side but moved to my right. I did not know at the time, but it’s bexause I was rotating my femoral heads (left to right) on an axis. I did this consciencly and subconscienly because I was trying to take weight off of my left knee w/ O.S. Another consequence was that my left femoral head dropped, and thus that left Sacal bone dropped with it. This is where the pinching came in on that left sacral bone. The pinched nerves were absolutely awful, and I had to stop playing sports because of it. In response to the pain, I started locking out the muscles in lower back and top of the hip (like a band that goes across/around Sacral bones from hip to hip). I basically put my lower back in flexion and, next year, in reponse, began to sit on my hip joints. When I say this, I mean I began to tighten those outside quad and anterior hip muscles because it gave me stability. I had none, no matter what I was doing, becuase the hip and lower back tightening that gave me no hop mobility meant that those lower glute muscles were doing no work. I could barely get them to turn on. This obviously gave a anterior pelvic tilt, and like most people with Anterior tilt, wasn’t using my Lower an muscles. To try to describe this to you, I have a huge mound/mass of muscle that sits on the front side of my greater trocanter. Like it literally sticks out. It is my entire stability. For example, if I do a leg lift, i don’t feel my abs or gluten active at all. My lower back tightens and that big clump of muscle just hulks up. It looks like Popeye after he eats his spinnage. To further progress this, my patella’s are very tight, because of that clump of muscle directly in front of my trochanter, My legs(and thus knees) are turned inward from the hip. My knees used to feel like I was going to tear my ACL whenever I cut(quick shifting) of did squats. In response, I have tightened my patellas because, again, it seems to give me stability. If you don’t have glute activation and you flex your lower back, chances are your knees will start to feel an inward pressure( you can try it for yourself) the glutes are the muscles that should give you stability when you cut squat etc, and since they are very unactive, I am forced to tighten my patellas, and they are on fire. I am just hoping to get any feedback from you guys. Maybe some of you can apply this to your own problems and I would appreciate any advice back. Have any of you guys made progress? If so I would really like to know what it is your doing so I can try some of it myself. Thanks!

    • #75740
      AvatarPawan Lalwani
      Participant

      Jake, you didn’t mention whether you’ve seen a good PT.  Not all are created equal, so make sure you research and try to find one that will try to come up with a diagnosis and treat the cause of your imbalances vs just treating the local issues.  Sounds like you have a lot of layers to peel back and try to fix. 


      I’m definitely not a PT, so I don’t want to give you the wrong advice, but if your glutes aren’t firing at all then that might be a first step, working on isometric holds doing a clamshel, and getting those glutes to fire.  You’ll want to progress very slowly.  If certain tissues are tight you should try to work on mobility of those tissues.  The nice thing about a PT is that they should be able to help you peel back the layers to try to find the underlying cause.  For myself, I had a bunch of different issues that were probably contributing to my tight lateral quads, it band, and resulting knee pain.  I believe it was a back issue that was keeping those structures tight, but there were areas that I needed to work on, like strengthening my glute med, hamstrings, and just my posterior chain in general.  Find what movements cause pain and what movements help, this can lead you in the right direction.
    • #75776
      AvatarRyan Cloutier

      Jake anderson

      here a couple of recommendations that you would need to do your own research on and consider:
      1) Rolfing/structural integration – considering seeing a rolfer or structural integration therapist
      2) Functional patterns (Naudi Aguilar) – watch all his videos. Pick out things he says and google search it for more in depth information – he will talk about important areas to focus your corrective areas on such as transverse abdominis, diaphragm, pelvic floor, internal obliques, anterior oblique system and posterior oblique system, fixing anterior pelvic tilt, strengthening core stability, preventing pelvic frontal and sagittal plane of motion. Working on transverse plane rotation exercises, self-myofascial release etc..
      3) Go see a good well qualified physiotherapist – look for ones with expertise in core stability, pilates, yoga, athletic experience, good credentials perhaps, lots of experience etc.. – mention funcitonal patterns to him and Naudi aguilar. Go over exercises from functional patterns with the physiotherapist making sure you are performing them in correct form and to choose the specific ones. He will help you choose the exercises that cater to your specific needs and weakness. A corrective exercises is only corrective if dont correctly and address the root cause of the issue. The physiotherapist will help you determine this. Most likely it begins from the core.
    • #75777
      AvatarRyan Cloutier

      Weakness on my right side of internal oblique and TVA is likely causing my right side pelvis to be unstable and move excessively in the frontal and sagital plane. This creates stress on the IT band quads and patella due to improper load transfer. I am looking for specific exercises to address this problem by strengthening the right internal oblique and TVA. One such exercise I have found from functional patterns Naudi Aguilar. The exercises is a staggered stance resistance band isometric hold focusing on antirotation (the resistance band goes across the body with the right leg planted infront and left leg behind in position similar to a lunge but more upright)
    • #75778
      AvatarRyan Cloutier

      Staggered transverse isometeric hold

    • #75891
      AvatarPawan Lalwani
      Participant

      How’s it coming Kefu? After focusing on my posture and staying out of flexion I’m 95% better. Just twinges here and there, but it’s a good reminder to pay attention to my posture and any tightness goes away. I’ve found that foam rolling my lumbar and thoracic spine also helps.

    • #75909
      Joshua A bradleyJoshua A bradley
      Participant

      I haven’t been following the thread.  I just wanted to jump in and say that my pain is completely under control now.  Unfortunately, I still can’t squat down or walk down stairs or the pain returns.  But this is probably because I let this problem fester for about 5 years.  But whenever the pain starts returning, I know exactly what to do to.  It’s not hours of leg exercises every day – which like you guys, i did religiously at one point.  All I have to do is one thing:  Strengthening hamstrings.  And I’ve found that this is my favorite way to do it.  short video… https://www.youtube.com/watch?v=oAYtwM95-ug    The hamstring machines at the gym are garbage.  This swiss ball method is pretty good.  I know I’ve mentioned hamstrings before and you guys indicated it’s not likely your issue.  But thought I’d post with this one last time.  GL

    • #75935
      AvatarRyan Cloutier

      djrachman 

      I was recommended that exercise before it didnt help me. Naudi Aguilar from functional patterns talks about that exercise as not being the best choice because it teaches you how to do hip extension and knee flexion at the same time (which are never done in the same time in real life). So it is teaching you the incorrect neural associations and patters. When doing knee flexions you should do hip flexion.
      A variation I have been doing of that exercise is instead of flexing the knees I do straight leg hip extension. It still hasn’t been much felp
    • #75936
      AvatarRyan Cloutier

      jtrue


      I still haven’t improved in terms of symptoms. My knee pain is still pretty bad. My posture has improved and my physio has said I am performing all the exercises better. I am still twisted in the pelvis but its subtle she said. Still have anterior pelvic tilt but much less. My knee’s dont track over toes when performing corrective exercises and im pretty much doing them in correct form. My IT band, and quads are still tight and painful. They flare when doing certain functional activities during the day. 
      I really started to progress with Naudi Aguilars exercises recently at functional patterns (in his knee, hip and gait foundational products). Its only been a 1 week of doing the progressions, so I am still going to give it a little bit of time.
      I am thinking of going to see another physiotherapist who specializes in running as running and gait are one of the most functional and important movement patterns to master. Insufficient gait patterns might be related to my problem.
    • #76006
      AvatarPawan Lalwani
      Participant

      djrachman, I’ve also found that hamstring work and posterior chain work in general helps my symptoms, but for me it seemed like it was a temporary fix.  So far doing the Mckenzie exercises seem to help the most, but aren’t a cure all.  I’ve been riding my mtn/road bike about 80 miles a week for the last couple weeks and my symptoms were under control, but a couple days back I did a 25 mile mountain bike ride with lots of vert and I started to get some lateral knee pain again.  I think I just overdid it and stayed in a position where my spine was in flexion for too long.  

      Lately, I’ve been trying to just focus on one muscle group every time I go to the gym and see what helps the most, then start working that into my routine with my mckenzie exercises.  My left VMO is smaller than my right and also fires later, I think this might have been caused by some medial knee pain that I had early on, which led to incorrect firing patterns and along with my back referring tightness to my IT band, is causing a whole host of issues.  Seems like I’ve got it mostly under control, but I’d like to get back to racing bikes and being competitive which I can’t be when things are flaring up every couple weeks.  I’m 90% better, but still have a ways to go figuring out how to get that last 10%.
    • #76033
      AvatarRyan Cloutier
      Naudi Aguilar from functional patterns is coming to Brandfort ontario to teach a course. Im going to go.


      https://www.youtube.com/watch?v=GedBR8ULqgM

    • #76043
      AvatarPawan Lalwani
      Participant

      Nice Kefu, how’d it go? AnAny insight gleaned from the seminar?

    • #76044
      AvatarRyan Cloutier

      The date is in October. Its an extensive 5 day course that includes one on one session, assessments, exercise prescription, and a bunch of other stuff. Its really expensive tho at 2.5 thousand dollars. 

    • #76059
      AvatarEric Robinson
      Participant

      For a fraction of that price you could fly out to see Bill Hartman and the ifast guys and not deal with someone spouting pseudoscience from a youtube page.

    • #76156
      AvatarNiko Korkalainen
      Participant

      Ok so reading through some of this and it seems this problem is still going on and it sounds like nothing is really helping. There is one thing that I think will help but it isn’t a quick fix its something that takes time and some dialing in. You most likely have some muscle imbalances that need correcting. Take a look at something called Muscle Activation Technique.  It is a great tool and there are so many checks and balances in there that you know it is something that helps. Here is the website find someone near you and give it a shot. Also give it time do not expect a quick fix because this has been a problem that has been going on for a while so it will take a while to fix. Hope this helps!!

    • #76200
      AvatarChris McLaughlin
      Participant

      Hi Kefu,

      I apologise, I haven’t read your entire post or any of the comments on this thread. That being said, in response to:

      “My IT bands, quads, and hip flexors are really tight. Nothing seems to really loosen them, especially my IT band. I have tried physiotherapy from multiple physiotherapists, ART, electrically stimulated trigger point dry needling (PENS/electroacupuncture), acupuncture, massage therapy, foam rolling (lacross ball, PVC pipe, rumble roller), suction cupping, strengthing glute medius and maximus, VMO strengthening, core strengthening, balance work on wobble board, orthotics, intra-articular prolozone injections, joint supplements, heel wedge for leg length discrepency (my right leg is 1.1 cm shorter which was confirmed on an x-ray).”

      If you’re stretching a muscle and it’s not helping than that muscle isn’t the problem. Rolling, needling, massaging etc of your IT band is a waste of time. Trigger point your gluteals and you’re ITB will loosen up. That’s your short term fix, your long-term fix is to strengthen your gluteals.

      A muscle will get tight because it’s being overworked. This can be for a number of reasons, the ones likely applicable to you are that the muscle is weak and it’s being overworked or it’s compensating for a movement dysfunction/other weak area/weak synergist.

      The tricky part, without examining you, is what your movement dysfunction is. This will be a bit of a guessing game.

      Let’s start with VMO retraining. The research shows a correlation between decreased VMO bulk and knee valgus. Unfortunately, almost everyone in the health care field has taken this to mean weak VMO=knee pain/knee valgus/chondromalacia patella. Weak VMO is not a cause of knee valgus it’s a symptom. What is knee valgus? What movement is occuring at the knee joint when your knees move medially (valgus). There is no movement at the knee, the movement is occuring at the hip. When your knees medially deviate your hips are internally rotating; therefore, if you cant hold your knees neutral your hip external rotators are dysfunctional (weak).

      As for your hip flexor and quadriceps tightness this can be for several reasons. I’d sort out your weak external rotators first and see if this resolves your quads and hip F. I know you said you did clam shells but have you been doing them correctly? If your hips roll back your not doing anything. Are these the only gluteal exercises you’ve done? Are you only focusing on strength or have you done gluteal activation exercises?

      Tight quads can be a result of your hip extensors not working properly OR they can cause your hip extensors not to work properly. If you’re stretching your hip F and the problem is getting better than it’s probably the latter. Otherwise you knee to get your hip extensors working/activating again. This will most likely be your gluteals and in particular glut max. Weak hip extensors force you to rely on other muscles – quads and calves to compensate.

      Your anterior knee pain could also be patellar tendinopathy. I won’t go to much into this because it gets lengthy but if this is the case you need to start seriously rehabing it immediately.

      Hope that gives you somewhere to start.

    • #76201
      AvatarChris McLaughlin
      Participant

      Daniel Matrone:

      “Can you say a word or two about internal rotation banded distractions? I am finding that external rotation is impacted by internal rotation as well. When I internally rotate my leg while sitting I can feel a nice pull on my IT band (quads). I get instant glute activation as well. “

      Stretching a muscle is not the same as activating a muscle. When you internally rotate your hips in sitting this IS NOT activating your external rotators (glutes), this is stretching them.

    • #76267
      AvatarRafael Strobosch
      Participant

      Lots of good information in this thread. I read all 7 pages and I’ve been dealing with a similar issue. I’d be interested to hear what the outcome was from the people in this thread.

    • #76271
      AvatarPawan Lalwani
      Participant

      I’ve had some luck managing my symptoms, but haven’t gotten to the root cause. Main things I do to manage the tightness are mckenzie pressups, foam rolling lumbar and thoracic spine, releasing the psoas on my affected side, and dry needling the lateral quad. I’ve put a lot of work into my core, glutes, and hamstrings with limited results. Seems like some movements cause tightness while others help, I need to focus on what helps going forward. Wondering if I need to do more single leg exercises as I think this is mostly stemming from a muscle imbalance that I continue to perpetuate.

      Right now it feels like the psoas on my affected/tight side is getting overworked. I mostly notice it after completing an activity but sometimes during. It presents as a tight it band/lateral retinaculum and causes some lateral knee pain. I’m into endurance sports that involve lots of knee flexion, cycling and ski touring. I also feel like the glute on the affected side isn’t firing like it should because of the dysfunction so I’ve been trying to concentrate on it as well. Haven’t seen my PT in quite sometime as I wasn’t seeing results and it’s expensive, but might go back to have him check my leg length as I previously had a functionally shorter leg on my affected side.

      Just started incorporating some more upper body work like horizontal rows and scap push ups to see if it’s something further up the chain that might be contributing to a movement pattern affecting my gait. The activities I participate in push you for a couple hours on end, I feel as though as I start getting tired my form suffers causing other muscles to take over that shouldn’t.

    • #76301
      AvatarPawan Lalwani
      Participant

      Just found out I have celiac, was feeling tired and having GI issues. This has been going on for a while, just never put two and two together. Had the blood test and endoscopic biopsy to confirm. Very anemic, currently supplementing with iron, b12, vitamin c, vitamin d, etc. Wondering if this has anything to do with the constant tension in my muscles, possibly causing some of the symptoms I’ve been dealing with. Only time will tell.

    • #76382
      AvatarPawan Lalwani
      Participant

      As crazy as it seems most of the tightness has gone away since I’ve gone on a strict gluten free diet and my body started taking in all the nutrients and electrolytes I was missing. Still get some weird fasciculations, but hoping these go away with time. I’ve been going pretty hard ski touring and cycling and while I get a little tightness afterwards it doesn’t really bother me or cause me pain. Kefu, any updates on how you’re doing?

    • #76383
      AvatarPatrick Thomas
      Participant

      Yes, sitting for prolonged periods of time will negate the benefits of mobs, exercise you do.
      Break up your unnecessary sitting when possible. For example, every 30:00 takes a 2:00 break. Get up walk around the office or work place. Quick check in with a co-worker, deliver a message in person etc.

      Begin transitioning to a stand up desk if possible. This allows non exercise movement throughout the day. This helps improve focus, productivity, and counter act the negative effects of sitting.

      Create strategies for prioritizing mechanics when standing and sitting.
      Understanding how to organize& stabilize your body in a good position is key.

    • #76428
      AvatarGabriel Tudor
      Participant

      Having a hard time posting because I can’t get to a mobile friendly page.  Anyways, I had the same pain many times in the past.  I highly recommend 1.5 squats with very slow eccentric phases.  Use lighter weight like 135 max or even bodyweight.  Do a few sets of 15 about 2 or 3 times a week.  Also, afterwards while your quads are pumped, roll your quads with a hard roller, not one of those rinky dink ones.  Roll your groin and hams.  Lacrosse ball your hip flexors, piriformis, and gluteus medius/minimus.  Couch/ wall stretch the beck out of your quads, the lean forward and stretch the hip flexors.  Stretch the glutes.  Lay on your back, keep one leg on ground.  Swing other leg across your body to touch your outstretched arms.  Do this dynamically left right left right for maybe 20 or 30.  Good luck.

    • #76463
      AvatarLiz Becker
      Participant

      I think my situation is closest to jtrue, granted I didn’t read every post, but I am a Physical Therapist (a GOOD one) that works with professional athletes among other things, and I have anterior lateral/superior knee pain. I have had it since highschool, and it gradually got worse. Finally I started training as an athlete for my sport and decide I am going to fix this. I have never had a patient like me and I have never had a physician or clinician identify why. Knee flexion to 90 degrees in a squat is sometimes 8/10 pain, sometimes in both knees.

      The only medical findings: left knee Baker’s cyst, few calcium pyrophosphate crystals, no problem on right. Slight kyphosis. glute/hip weakness on affected side (left) because of pain with tone. Slightly reduced mobility on affected side for sacrum, ribs, thoracic spine, and shoulder, reduced spinal rotation away from affected side, no apparent calf tightness but reduced symptoms with stretch to reduce tone especially if it’s a self stretch by dorsiflexing foot. Hip adductor tightness Right>Left, quad tightness L>R, hip flexor tightness R>L.

      Pain is worse after a day of rest. If I wanted to set myself up for some seriously debilitating pain where I couldn’t walk down the stairs I would train hard one day, not stretch quads/hip flexors or hips afterwards, eat sugar/carbs/gluten (anything inflammatory) then rest a whole day, that night I would wake up in so much pain the sheets hurt me.

      The best I can figure out so far for this illusive pain and what helps me:

      1. Got MRI, finding something small/mechanical is chronically irritated at onset maybe, for me it’s the cyst, sight fluid increase puts pressure on site superior and lateral to patella.

      2. Rolling out my trigger points, I have one above the area of irritation, one on posterior boarder of middle ITB, one TP on distal 1/3 of vastus.

      3. Avoid all sugars, inflammatory foods and sometimes gluten/carbs as they increase my pain especially on bad days.

      4. Ice during flare-ups, take antiinflammatories if I have to perform.

      5. Stretch quads/hip flexors, hip external rotators, proximal hamstrings, gastrocs, deep pelvic muscles ONLY WHEN I AM MAXIMALLY WARMED UP, otherwise I only stretch structures involved with tone and other small micro injuries occur = more irritation. Best stretch for me to reduce pain is one that turns off the opposite muscle, example dorsiflexing foot to stretch gastroc, or better yet keeping the whole body engaged while stretching, example down dog or hanging on a deep lunge.

      6. Get mad, let it out. All the years of pain build up and take a toll, let my heart heal and feel the resolve to push through pain.

      7. Good posture. String pulls chest up, don’t let your hips posteriorly rotate especially while sitting.

      8. Do front squats for a while if I have to squat and keep chest up, stick butt out, knees out. If I can’t do it because it’s too painful I do a sumo squat and each rep I slowly inch my feet where they need to be for a regular squat until the tone changes.

      9. Warm up with dead lift, back extensions, posterior chain. Warm up gently and progress. Sometimes ankle alphabet. Engage affected side. Focus on warming up hips. Knees completely depend on mobile, strong skilled hips and ankles.

      10. On good knee days I push it as hard as I can. Hard strength training, sprinting, pushing my limits and the pain virtually disappears and lasts several days if I stretch right afterwards and watch my diet. Everything maximally engaged.

      These things have not completely taken away my symptoms because of the cyst, but as I get stronger and more mobile it’s getting better.

      I hope my experience helps, interested to see what else comes up.

    • #76496
      AvatarAlex Salomons
      Participant

      You may want to check out http://deepvibrationtechnique.com/. This is a great tool for any type of soft tissue adhesion.

    • #76517
      AvatarRobert Papson

      Hi Guys,
      I have a very similar issue with you.
      Starting when I run too much too soon 1 year ago, one day after I run I tried flex my knee and feel sharp pain my left knee.
      Got MRI and doctor said small lateral meniscus rupture and rupture of antero lateral ligament.
      Since then both my left and right ITB tighten up severely.
      I have a lot of adhesive knots or trigger point along my left ITB. I feel tingling sensation along my left ITB.
      My right ITB does not have muscle knots however it is very tight, much tighter than my left ITB. This affect my walking gait and recently I feel medial knee pain in my right knee due to this improper alignment.
      I feel my right pelvic is shifted anterior and my left pelvic posterior. And also a lateral pelvic tilt.
      Recently my shoes are all wearing out at the outside rear both left and right since this injury.
      I visited a PT and she did a deep tissue massage in my lower body that hurt like hell.
      Has anyone in here try Yoga?
      Similar with Kefu, I have tried many alternatives mentioned here but found no improvement.
      I will update more later.

    • #76547
      AvatarPawan Lalwani
      Participant

      Very interesting Heyo, sounds like a very similar problem. Since being diagnosed celiac and going gluten free I have had a reduction in my symptoms. Still have a flare up every now and then. For me it seems to be certain movement patterns that contribute to the issue and tighten my hip flexors. We just had our first snowfall in UT and I went ski touring, I had a flare up and my psoas got super tight. I haven’t been hitting the gym but I think with the reduced muscle tone I’ve felt after going gluten free I’ll be able to workout and fox some of the muscle imbalances I’m always fighting. In the past everything would tighten up and cause a whole host of issues.

    • #76566
      AvatarRobert Papson

      Does any of you guys have fascial adhesion along your IT Band?
      I could not remove this fascial adhesion or scar tissue.
      My pelvis is torqued.
      I feel my legs are at different length and it hurts my knee and ankle.

    • #76567
      AvatarPatrick Thomas
      Participant

      I’d recommend having Instrument Assisted Soft Tissue Mobilization done along your IT Band.
      This will break up the scar tissue, re establish sliding surfaces which allow your skin, muscles, and tissues to move independently of each other.
      You may need an adjustment to re align your pelvis.

    • #76569
      AvatarRobert Papson

      I have no access to graston in my country.
      The scar tissue along my IT band wont budge and seem pulling my TFL and rotate my pelvis.
      Is there any alternative beside Graston to remove the scar tissue along the IT Band?
      It feels like a bumpy road with gravels along my IT band. I tried massaging it with no success.

    • #76570
      AvatarPatrick Thomas
      Participant

      Graston is a company not a technique. Graston tools are one type of tool for IASTM.
      Message me the city, country you live may be able to connect you with a provider in your area.

      Do you have or have access to a supernovito (80mm supernova), supernova or gemini? (Included the Rogue Europe links)
      These are great tools that are much different from using a ball.

      Have you watched episodes which address the TFL, resetting the pelvis, or quad?
      Addressing areas up/down stream help feed slack to the area.

    • #76571
      AvatarPatrick Thomas
      Participant

      Check out Daily MIWOD Tuesday October 25th at the 4:00 mark Kelly talks about glute interface sucking up slack and being a big tentioner on the ITBand.
      Diagnosis Series: Runner’s Knee Part 2 – IT Band Syndrome

    • #76628
      AvatarRobert Papson

      Thank you Kaitlin.
      I feel my IT Band is stucked to my vastus lateralis. Seems like adhesion between them.
      Due to no graston provider, I tried doing it my self using metal spoon and oil. No progress so far.
      Should I stretch or smash to break down this adhesion?

    • #76636
      AvatarPatrick Thomas
      Participant

      Voodoo band it and perform squats.
      Smash it.
      On your side peel away using big battlestar, or small supernova.
      You can’t stretch the IT Band.
      Have you watched the IT Band episodes?
      How long are you working on it at a time?
      Are you addressing it more than once during the day?

    • #76652
      AvatarRobert Papson

      HI kaitlin, i already voodoo band my quad and do squat, but my left knee produce clicking sound when squatting.
      I think if i can get rid of scar tissues in my left IT band, I can solve my problem.
      But, the scar tissue wont disappear no matter how hard I smash them.
      Is scar tissue reversible?

    • #76655
      AvatarPatrick Thomas
      Participant

      Have you done your high hamstring?
      Adductors?
      Psoas? This can change the position of your pelvis.
      Have you worked up/downstream of the knee?

      Instrument Assisted Soft Tissue Mobilization is very effective with breaking up scar tissue.
      It is not a matter of how hard you are smashing. It is if you are effecting the targeted tissue?
      I’d recommend using the 80mm supernova. It creates higher global shear pressures.

      Yes, scar tissue can be broken up. I have an of incision which was opened twice and have no scar tissue in the area. Yes, I work on it regularly, however, this is what is required for it.
      It’s learning what methods, tools result in the best results for you.

      I work with a construction worker who has scar tissue along the IT Band area who has seen great results. I work on it weekly and it is progressing nicely. Starting at his hip and down the quad to the knee.

    • #76670
      AvatarRobert Papson

      Hi Kaitlyn,
      Thank you for responding.
      I did foam roll all below my hips front and back. I used a smooth normal density foam roller.

      I would love to try IASTM as you mentioned if there is provider in my area.
      Right now, all I can do about it is using metal spoon and try to do it myself.

      I did MRI of my thigh.
      The summary is:

      1)      Nodular surface of the distal ITB with few small nodules within the ITB substance, compatible with scarring/ fibrosis. This most likely corresponds to patient’s symptomps. The ITB remains intact and adherent to Gerdy’s tubercle.

      2)      Mild muscle strain involving distal vastus lateralis muscle as well as the muscle-tendon junction. The distal quadriceps tendon is intact.

      I can feel my tight ITB (the one with scar tissue all over it) pulling my hip and throw my pelvis out of balance.This is my issue. My ankle and my knee at opposite leg is painful due to wrong walking gait.

      I browse online and read somewhere that scar tissue once formed can only be excised surgically to remove it.
      This thing is also surprisingly not familiar among orthopedic doctor at least in my area.

      Regarding the construction worker you mentioned, what kind of treatments you provide to him? Anything other than IASTM?
      What happen to the scar tissue? Would it “dissolve”?

    • #76673
      AvatarPatrick Thomas
      Participant

      You are ready to change the tool that you are using to foam roll.
      PVC is a one option, supernova is a great option for hip, QL etc.

      You can learn to do IASTM to yourself.
      I work on myself using HawkGrips. I’ve taken a HawkGrips course which was excellent.
      The tools come with a cd and manual on how to use them. I can tell you more about them on email.
      The tools have different types of edges and using different type strokes allows for different angles and vectors to address the area. Much different from using a dull flat edge of a spoon.

      Having surgery to remove scar tissue creates more scare tissue from re opening the incision.
      I have an incision along my collar bone that was opened twice. I had it worked on shortly after the second time it was opened and its been great. No restrictions.  I check in with it often.

      You may have some tacked down skin as well.
      Do you have a voodoo band or voodoo x band?
      If not I recommend getting one.
      Wrapping your leg is performing squats and other movements that are restricted can have a big impact.
      Having someone move their hands in opposite directions (Indian sunburn) in the area frees up the tissue.

      We combine a few recovery protocols.
      I use mobility, IASTM, voodoo x band, estim depending on what we are addressing.
      Scar tissue can be broken up. Addressing up down stream of where you see the problem is an important aspect. Restoring sliding surfaces within the impacted area is key. This allows the skin to move independently of the muscles and tissues and vice versa.

    • #76682
      AvatarRobert Papson

      I think Jtrue already mentioned something similar, currently drinking electrolytes drink is the only thing that reduce my muscle tightness. My ITB, Quad, hip muscles feels a release soon after I drink the electrolytes. I feel the scar restrictions in my left ITB area are untangled. It is very hard to describe the nerve/muscle sensation. But I feel very loose after I drink it.

      But it is only momentary. The next day, I will feel the tightness comeback again and the scar tissue restriction is back also. The electrolytes is like “muscle relaxer” pill. But it is quite effective in treating the symptom.

    • #76683
      AvatarPatrick Thomas
      Participant

      If you are dehydrated (which it sounds like you are) the quality of your tissues are compromised.
      Connective tissue dehydration causes pain because
      connective tissue is the supportive scaffolding of the body; when
      dehydrated, it can’t support, protect or stabilize the body properly.

      Drinking electrolyte water is a band aid to the bigger issue of dehydration.
      I’d recommend getting The Right Stuff to address your hydration. It is a NASA developed electrolyte liquid concentrate drink additive.

      Restoring hydration and the balance of electrolytes allows tissues to move in the ways they were designed to move and support the body during movement. Once your hydration is back in check your body is able absorb the work you are doing on the areas that need attention.

    • #76688
      AvatarGopal Raghunath

      Psoas

    • #76689
      AvatarGopal Raghunath

      I’m old and an amateur. My occupation required years of sitting. I have a variation of the problems mentioned but without severe pain. I work all the way up my left side: foot, calf, quads, hams, etc. BUT release of the psoas is the absolute best. I need to work it several times a day. It’s not a one time deal. It took 40 years to get screwed up. So, I imagine it will take awhile to relax. As you know it’s big and powerful. That’s my 2 cents and that’s probably what it’s worth.

    • #76920
      AvatarHeidi Hutchison

      Wow, big thread, with just about every treatment imaginable.  

      What happened to Kefu? 
      The comment on page 6 by cmillerCMT, about the diaphragm possibly being the root cause of many issues, blew my mind.  It’s something I’ve never heard about in over 20 years of cycling with the occasional injury
    • #76948
      AvatarPawan Lalwani
      Participant

      Not sure, just sent Kefu a note. Still have occasional flare-ups and can’t seem to get to the root cause but hitting my psoas with a theracane whenever I feel myself tightening up works. I’m back to riding bikes about as fast as I was pre injury and ski touring without any issues.

    • #76992
      AvatarRobert Papson

      I have similar issue with Kefu and Jtrue.
      Recently, I have tried deep massaging my knee at the crossection between IT Band and Patellar tendon (Near IT Band insertion at the knee).
      And I got some improvement.
      I did it myself.
      I actually use a cupping cup to massage it but without vacuuming it.
      Just using it as a simple massaging tool, I find it effective at delivering pressure and shear to the area.
      Maybe you guys can try it.

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