Why Do Stairs and Squats Hurt My Knees?

Squatting and going up and down stairs are some of the most common irritants of knee pain. Have you ever wondered why? Is there anything you can do to ease the pain? To really understand this, we must first understand some anatomy and biomechanics. 

First, the anatomy: The knee cap is a bone called the patella. It is embedded within the quadriceps tendon. The quadriceps attach to the front of your pelvis and upper femur (thigh bone). It then runs down the femur, over the front of the knee joint (where the patella is located), and finally attaches to the front part of the upper tibia (shin bone). The patella is located where it is in order to protect the quad tendon from damage or tearing as it is compressed into the knee joint when the quad is stretched and knee is flexed/bent. The patella sits in a groove between the medial and lateral condyles of the lower femur to help stabilize it. 

Next, the biomechanics: Muscles connect two bones and move them. During a concentric contraction, the muscle shortens and the two bone move closer together. An eccentric contraction allows the muscle to lengthen slowly and allow the bones to move father apart with control. An example of these two contractions is a basic bicep curl. During the concentric contraction, your bicep pulls your lower arm and hand closer to your shoulder. The eccentric contraction is essential to slowly lower your hand back toward the floor. If we weren’t able to eccentrically contract our muscle, our hand would simply fall to the floor and we would develop an injury as a result. 

Squatting requires the quadriceps muscle to eccentrically contract as we lower ourselves to the floor (knees are bending) and concentrically contract to lift ourselves back up (knees are straightening). As we climb stairs, we use our quads concentrically to push ourselves up the stairs. Descending the stairs requires eccentric quad control to slowly allow our knees to bend with control and bring us down to the stair below us. Both of these activities are particularly challenging due to the amount of weight we are moving with each motion. 

In order for these motions to happen correctly, it is essential to have our weight in the correct place on our feet with these activities. 

When it comes to stairs, we typically have the weight mostly on the balls of our feet. This can be due to wearing heels, short stairs versus a long foot, needing to hurry up/down the stairs, etc. In order to go up the steps correctly and avoid knee pain, we need to place as much of our foot on the step as possible to allow our heels to get on the step or as close to it as possible. Then we need to push up the stair by pressing through the middle and back of our foot. If we push up through the ball of our foot, the quad has more load on it during the activity and presses the knee cap into our knee joint very hard. Going up the steps pushing through our heels also helps us use our gluts to push us up the step and not our lower backs!

To go down the stairs, we need to keep our weight on our heels as long as possible. For instance, if you are using your right leg to support you while your left leg is lowered down to the step below, you need to keep your weight on your right heel as long as possible. The second our weight transitions forward onto the ball of our foot, our quad turns on. If our quad is on, it cannot eccentrically lengthen and allow us to descend in a biomechanically correct way. If this is the case, you will simply press your kneecap into your knee joint as you essentially fall to the stair below you. If you start with irritated knees, it won’t take many steps for this to become really painful. 

We encounter essentially the same problem with squats, but luckily it is much easier to correct! Typically people will transition onto the balls of their feet when beginning to stand up straight. Keep your weight through your heels for the duration of the exercise and you should notice a dramatic improvement in your tolerance!

Written by Lesley Callaham, MPT, PRC on February 20, 2019

Why Your Orthotics Don't Work

Many of us have had some experience with orthotics. Most of us have purchased a cheap, off the shelf variety that we purchased on a whim or were suggested to us by a shoe salesman. Others of us have purchased the expensive, over the counter, "customizable" variety that you heat up in the oven and step onto as they cool, making a mold around your foot. No matter what route you took to get there, I'm guessing that your symptoms either worsened, lessened temporarily, or moved to another place in your body. 

Why? All of those orthotics are simply putting a band-aid on the problem and may not be any better for your body than if you were walking around barefoot all day. Any time you chose a shoe and what may be going inside of it, your anatomy, your compensatory patterns, and your pain need to be taken into account. Otherwise you're either putting your foot in a different, but still not properly aligned position. This will either increase pain immediately or after some time as your body adjusts its compensatory pattern and develops breakdown.

No matter where your pain is, the position and function of your entire body needs to be assessed to see where the breakdown in your movement is. The site of pain is not always the site of the dysfunction. For example, someone may be experiencing neck pain and headaches because they keep all of their weight on their toes and lock their knees. This moves their center of gravity forward causing their hips to move forward while their shoulders lean back to rebalance themselves. The head will then move forward so that they can see the world in front of them. This places excessive stress on the neck muscles and will lead to pain. 

One major theme to proper position and mechanics of the entire body is the ability to sense and feel where we are in space. Our body must be able to feel where the weight is in our foot in order to tell us where our body is on the ground. Proper positioning of the ankle joint is also essential so that our proprioceptors can tell us, again, where we are on the ground and how we are moving on it as we walk. If we cannot accurately sense and feel where our body and feet are, we develop compensatory movement strategies which eventually lead to pain. 

Cheap, over the counter orthotics are a "shot in the dark." The chance that the amount of arch support that is built into the orthotic is actually the amount we need is unlikely. The "customizable" over the counter orthotics that are heated in the oven simply support your foot in it's improper position. This is also how corkbedded shoes work. They are typically very comfortable, but as they support you in your dysfunction, your compensatory pattern will only worsen and you will eventually experience you pain again. Rigid orthotics do not work because they do not allow your foot to change from a "loose bag of bones" that is needed when your heel first strikes the ground (this is needed for your leg to appropriately absorb the force the ground exerts on you leg at initial impact) to a rigid lever that is needed when you're pushing off of your toe of your back foot. It also doesn't allow your foot to feel and sense and change in pressure as your weight moves in your foot. 

What your body needs is to sense and feel the floor. The first line of attack to achieving this goal is to be sure that you are wearing the approparite shoes for your feet. Some people need more guidance for their foot while others need the motion of their foot to be controlled as they walk. If appropriate footwear will not solve the entire problem (likely to due a structural change in the foot or ankle from surgery, fractures, arthritis, etc), orthotics may be appropriate.

The orthotics made at Integrate 360 are made of a dense foam and are customized to each of your feet. We take measurements of the foot and ankle, pictures of the alignment of the foot in relation to the lower leg, and impressions of your feet. The orthotics are made by Dr. Paul Coffin with respect to your PRI rehabilitation goals. Once you receive your orthotics, they will have been made to support your foot/ankle where they need some assistance and, more importantly, allow you to sense and feel certain areas of your foot as you walk. This is essential as your brain needs to sense where you are on the ground to activate your muscles appropariately. This allows your underactive muscles to turn on, while keeping overactive muscles off. From here, your therapist now has a "blank slate" to help teach your body to use these cues appropriately, strengthen "weak" muscles, and help your body to learn to move in a balanced way again. 

Just by changing either your footwear or orthotic, your body is now able to regain proper joint/muscle position and restore reciprocal movement allowing for perfected mechanics versus putting a band-aid on their symptom. 

Interesting in an assessment to see what will fit your needs? Call Integrate 360 Physical Therapy at 314-733-5000 or email Lesley@Integrate360PT.com or Nancy@Integrate360PT.com

How to Correctly Wear a Backpack

It's that time of year - back to school! Getting back into an academic routine can be really fun, but whether you're walking across your college campus or up the stairs at your high school, your backpack can be damaging your posture and causing a lot of pain. Here are some pointers to lessen the negative effects a backpack can cause.

1) Tighten the straps. Whenever you are carrying a heavy weight (be it a backpack, laundry basket, or groceries), it's the easiest on your body when you carry it as close as possible to your center of gravity. For us, that happens to be at belly button level in the center of our bodies. So for a backpack, you want it as flush to your back (the center of it around belly button level). Most people tend to wear their straps loosely so there's a visible gap between their lower back and the bag itself. Go ahead and tighten up the straps and feel the difference. If your backpack also has a belt that can go around your waist, that will also help to distribute the load appropriately. 

2) Use BOTH straps. It's easy to swing that bag up over just one shoulder, especially if you're in a hurry. But having this heavy weight just on one side of your body will typically cause you to lean away from the bag and forward. This causes a lot of stress on your lower back as well as makes your to contort your neck to see the world in front of you. This excess neck strain can lead to tension headaches. 

3) Don't carry so much. Easier said than done, we know, but making more frequent trips to your locker, car, or apartment so that you're carrying a lighter load will put much less strain on your body. It'll help you get to your 10,000 steps a day goal too!

4) Be careful how you lift it. As we've previously inferred, backpacks can be tremendously heavy. Therefore, it's important that you use good body mechanics when picking up your bag. If it's on the floor, remember to squat or lunge down to the bag. Then, pull it close to your body near your belly button. Next, stand up keeping that bag at belly button level. Once you're up you can move the backpack onto your shoulders. 

5) Choose the right bag. Backpacks can come in different sizes. There's also options like messenger bags and roller bags. Choose one that will be the most convenient for you understanding that, from a musculoskeletal health perspective, the best bag is a rolling one, followed by a standard two strap backpack, with the worst option being the messenger bag. If you do decide to use a messenger bag, wear it across your body so that the load is more evenly distributed across your body and not all on one side. 

Have a great year!

Pregnancy and Pain: How Physical Therapy Can Help

Pregnancy is a journey and as time passes, you'll likely experience some sort of musculoskeletal pain. Additionally, that pain is likely to evolve and change as your pregnancy progresses. Some common complaints women have during pregnancy are low back pain, pubalgia (pain in the pubic bone right behind your zipper), sciatica (pain into the buttock and/or leg), rib pain, and pelvic pain. Although these issues arise as your body changes from the pregnancy, there's no reason to wait it out - nine months is a long time to hurt! There are many ways in which physical therapy can help.

Let's start with discussing how the body changes during pregnancy. As the baby grows, so does your stomach. As it grows further outward, your center of mass shifts forward and your pelvis widens. To compensate for this we tend to bear more weight through our toes, lean back, and let our legs rotate outward. These compensations cause us to overutilize our piriformis muscle and other hip rotators, lower back extensors, and calves. Leaning backward will also close the facet joints in our lumbar spines (lower backs) and can cause nerve entrapment and pain. These postural changes and the weight of the baby itself will cause our pelvic floor to work harder which can cause muscle spasm and more nerve entrapment. On top of all of this, ligaments in our bodies naturally become more lax as pregnancy progresses so that the baby can move easily through the pelvis. This is good news during delivery, but can cause skeletal malalignments and additional pain. 

Postural Restoration Institute-based physical therapy can help ease this pain as our interventions address all of these issues at one time. PRI focuses on flexing the lumbar spine and moving the center of gravity as far backward to its normal position as possible. This opens the lumbar facet joints and can relieve a great deal or lower back and/or leg pain. As our lumbar spines return to a more normal position, our legs will also return to a more normal rotational angle. This takes a great deal of strain off of the hip rotators that may be causing pain in the buttock region, but those muscles may also be compressing the sciatic nerve causing leg pain. Lastly, when our center of gravity moves backward, we can bear more weight through our heels as intended which will alleviate calf or foot pain. 

How does this happen? We utilize many positions in which to exercise to achieve maximum results. We tend to gravitate toward activities that involve lying on your side or on your hands and your knees as those allow us to isolate areas of the body and specifics muscles that we want to effect. This also unweights your pelvis and allows areas like your pelvic floor to relax for a bit. To make things more functional, we will reposition and strengthen in standing as well as long as our patient can tolerate it. Additionally, we do have modalities and various manual therapies to help us along in our goal of reducing your pain that can be utilized as needed. 

Think pregnancy-related issues stop once the baby is born? Unfortunately no, there are a multitude of problems that can arise aftward as well. Stay tuned as we discuss this topic in next week's blog post. 

Want to address your pregnancy-related pain? Call Integrate 360 Physical Therapy and 314-733-5000 or email lesley@integrate360pt.com or nancy@integrate360pt.com