Everyday, patients get misdiagnosed. Unfortunately, this is equally true for the injured runner. Well meaning medical professionals with little to no running expertise make a diagnosis based simply on the runner pointing to an area of their body that hurts. For example, runners with complaints of knee pain are often hastily diagnosed with patellofemoral syndrome when the complaint given is that their knee hurts and the patient shares that they are a distance runner. In turn, many physical therapists, who do not work regularly with the running population, address the injury based on this inaccurate diagnosis without really uncovering the specific running impairment(s) at the core of the problem. “Runner’s knee” is more localized in its presentation and I want to share a recent case demonstrating how an inaccurate diagnosis and the wrong focus can get an injured runner way off the track to recovery. Treatment of the specific running-related dysfunction is paramount.
”Sean” is a runner who came to me after months of failed rehab at another clinic. Every time he gets 10 miles into his training, his knee blows up and he is unable to run. He even has trouble going up and down stairs for several days afterwards. Sean had previously gone to his physician and they diagnosed him with chondromalacia and a patellar tracking problem. The therapist told Sean his problem was due to weakness in his VMO muscle (i.e. the vastus medialis oblique muscle-a muscle on the inner side of the knee which is a part of the quadriceps (thigh) muscle). The therapist had taught Sean all about his VMO and he happily shared with me all of the information his previous therapist had given him. Sean was convinced that the weakness in his VMO was the root of all his running problems. He had spent weeks working with the therapist to get his VMO big and strong. Sean was diligent with his therapy where he also received electrical stimulation and biofeedback in addition to gym exercises. Sean even boasted that he spent extra time in the weight room after work doing his therapy exercises. Overall, Sean was now very proud of his big and strong VMO. So what’s the problem? Unfortunately, Sean was no more able to run with his newly developed VMO than before. His knee continues to blow up everytime he is deep into his training, and he is still left unable to negotiate stairs for several days afterwards. Essentially, nothing has changed except for his newly strengthened VMO-the dysfunction is still present.
When I examine Sean, I find tenderness and weakness lateral/inferior to his patella (knee cap). Sean’s problem isn’t chondromalacia with a tracking problem due to a weak VMO, but actually a lateral patellar tendonosis. Sean’s long term lateral patellar tendonosis had never been addressed, so every time he returned to running and his knee blew up, he then had lateral patellar tendonitis (“osis” refers to the condition (of a tendon problem), while “itis” refers more to an acute inflammation).
As with all running injuries, addressing Sean’s specific running-related impairments is critical, and his difficulty with stairs is a big clue. As I assess Sean on a step test and on the treadmill, Sean’s body isn’t balanced when he runs or steps and he has poor control of his knee movement through his range. Sean severely lacks body awareness and, despite his well developed VMO, is moving with very little lower extremity control.
I worked with Sean to teach him how to control his knee and balance it in relationship with the rest of his body. Once he was better able to control his knee and keep his body balanced for stepping, we transferred this concept into running. Sean had to once again learn how to properly run. He desperately needed increased body awareness and the ability to self correct his posture and mechanics, specifically related to his knee mechanics. By identifying Sean’s specific running dysfunction, it allowed us to properly address his training deficits, thereby allowing him to return to distance running.
In the end, it didn’t matter that Sean knew the name VMO or that it was big and strong. And it probably didn’t even matter that Sean understood the difference between a patellofemoral syndrome or a lateral patellar tendonosis. What matters is that Sean is a better runner now than before his injury. He knows how to control his knee and balance his body for stepping and running. The healthcare provider needs to correctly identify the injury/deficit and this is why it’s important for runners to seek help from medical professionals with running expertise. It’s very much about addressing the specific problems affecting your running. The Running Injury Recovery Program will help you decide if you chose healthcare professional that is qualified to help you with this disorder and give you guidelines to self manage your injury.
By Bruce Wilk & Annmarie Garis
This post is written in part by Bruce Wilk, author of the The Running Injury Recovery Program. Bruce is also a board certified physical therapist and the director of Orthopedic Rehabilitation Specialists, a private physical therapy practice located in Miami, FL, and the president of The Runner’s High, a specialty running store also located in Miami. He is also the RCAA certified head coach of the Miami Runners Club, and has completed multiple road races himself, including 26 full marathons and four Ironman races. For more information, please visit postinjuryrunning.com, and to purchase the Running Injury Recovery Program, please visit goneforarun.com