Bookmark and Share
logo

Call us now at: 02 9922 6806

appointment times

Knee problems whilst skiing

Everyone knows that skiing requires strong control of the knee through the thighs. Frequently, people equate knee control with quadriceps strength and balance. Importantly, this balance isn't just the balance between inside (vastus medialis) and outside (vastus lateralis) strength, but also the balance between the hamstrings and quadriceps. 

The bending and straightening component of the knee is certainly under the control of the hamstrings and quadriceps, however, the medial and lateral control of the knee is controlled by the muscles around the hip and foot. As such, the muscles around the hip and talo-navicular joints perform the function of multidimensional stability.

Clearly, the femur affects knee positioning and the position of the ilium/hip will affect timing of the muscles around the hip-thigh. Any anterior ilial rotation generally makes it difficult for the gluteus maximus to fire before or simultaneously with the hamstring muscles. Tightness of the adductor muscle can cause an 'inflare' of the ilium, potentially placing adverse tension on the ischiococcygeal and sacrotuberal ligaments. Moreover, this adverse tension of the adductors could affect the knee through the phylogenetic link of these muscles with the medial collateral ligament and hence medial meniscus. Any adverse function of the iliopsoas can affect femoral blood flow which is likely to affect slow twitch, stabilising, endurance muscles more than fast twitch, glycolitic, ballistic muscles. Hence, as the duration of activity increases, movement stability may break down, leading to 'poor form' and potential injury.

link to explanation in Shoulder section

Motor learning theory devised by Bernstein suggests that the body will use the momentum of the limbs to optimize the degrees of freedom in the system. Similar to a mass-spring analogy where the perturbations of the mass will be dependent on the damping characteristics of the spring, the brain will introduce muscle tone to dampen the angular velocity and hence acceleration of the system. Therefore, instead of the muscles of the leg lifting the limb, the antagonistic muscles are decelerating the limb towards the end of trajectory. Moreover, by using eccentric (muscle lengthening and contracting) muscle contractions the system becomes efficient through these decelerating movements through the central nervous system enhanced visco-elastic rebound as well as the conservation of momentum. Hence, mogul skiing would need to generate this elastic rebound

see Motor Learning section for further explanations

Knee assessment and treatment using a motor control approach

The subjective examination should include aspects of the stage, stability, irritability and severity of the disorder.

link to further explanation

Hence the physical examination should include analysis ofgait

squat

  • pelvc symmetry
  • lumbo-pelvic dynamics
  • femoral pulse
  • inferior lateral movements of the T/S and lateral diaphragm control over Psoas Major function

  • foot dynamics (esp. pronation supination) - although the foot is in a boot during skiing, orthotic prescription for the boot may be advisable

  • muscle timing and duration of contribution between Vastus Medialis and Vastus Lateralis, Gluteus Maximus and Hamstrings, Gluteus Medius and Adductor synergy, deep hip rotator endurance and strength.
  • go to foot - orthotics section for further details

  • Relationship between the deep and superficial abdominal muscles and their affect on pelvic symmetry and lumbopelvic rhythm.ROM's of the hip, knee, foot and L/S, medial stability of the knee can be assessed and treated using the following exercise

 

 

Rehabilitation through exercise

Lumbo-pelvic and hip dynamics can be assessed and treated using Muscle energy techniques

Cycling can be used to build up the muscles of the thigh and butt through optimal Cycling Kinematics

  • Bike Seat Position

- anterior (front) knee pain : raise seat slightly (unless grossly malpositioned generally the changes are in the order of 2-3mm)

- posterior (back) knee pain : lower the seat slightly and/or move it forwards for butt tightness

- lateral (outside) knee pain : lower the seat and/or move it backwards

- inside knee pain : cleat and ankle position, symphasis pubis and adductor strain - seat may be too high, forefoot varus may require the insertion of a pedal wedge (Lemond LeWedges)

  • Pedal Position

- moving the foot forward on the pedaal creates increases in quadriceps power, however it also increases the loading of the patello-femoral joint

- moving the foot back on the pedal engages the hamstrings and gluteal muscles to provide synergistic extensor power to the quadriceps

 

 

  • Abdominal and Gluteal Strengthening

Knee Muscle representaion in the brain changes after injury

The representation of the knee muscles in the brain 

Transcortical muscle stimulation activity (Abrahao Fontes Baptista 2014)

  • Motor learning using Quadriceps VMO training

additionally, EMG can be used in combination with transverse abdominis, gluteus medius, medial calf muscles and VMO

  • Gluteal lengthening, combined quads/abdominal strengthening

  • Lumbo-pelvic dynamic stretching a la Krause

Patella treatment using tape

Taping or other aids can also be used around the hip/buttocks to prevent femur internal rotation thereby reducing the relative lateral alignment of the patella w.r.t the femur.

Patella Tendonosis using an eccentric loading program

 

In conclusion, the examination and treatment of the knee for skiing should include assessment of all the structures which can affect knee function. Prior to the physical examination, a thorough subjective examination should be conduct to enable the client and the therapist to engage in the clinical reasoning process. Interested readers should look at the Instructional Design section of this website.

Last update : 17 June 2014


 

Trending @ Back in B Physio

  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More
  • Mon 07 Nov 2016

    Pilates – with Brunna Cardoso

    Pilates – with Brunna Cardoso Martin is pleased to welcome the bubbly Brunna Cardoso to Back in Business Physiotherapy for Pilates Classes in February 2017.  Brunno is an experienced pilates instructor and has had several years experience training with pilates instructors in Brazil. Read more Read More

Funding, Advertising and Linking Policy

This site is set up as a free of charge service to the community. Back in Business Physiotherapy pays for all aspects of this website and does not endorse any paid advertising on this site. Back in Business Physiotherapy does have an affiliate program with Lunar pages who host this website. Additionally, the links to Human Kinetics and Amazon may result in Back in Business Physiotherapy receiving a small commission for precisely those books if purchased on those sites. Links to other sites are based on the relevance of that sites information to the principles of this websites desire to enhance the standards of Physiotherapy. Unless I am the author of the content of a linked site, these links are not based on reciprocal agreements. No banner adds or pop-ups should appear on your browser as a result of browsing this website. However, if you leave this website to a related one, Back in Business Physiotherapy cannot accept responsibility for neither changes in their contents nor their advertising or privacy policies.

image removed

Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected