Ep 30: Returning to running from a knee injury

Michael Dermansky:

Hi everyone and welcome to the show that helps you become more confident in your body so you can keep doing the things that you love. My name is Michael Dermansky, I’m the Senior Physiotherapist here at MD Health and I’ve got a very special guest today, it’s actually myself. Today I wanted to mix it up a little bit and try something we haven’t done before. I want to try some short sharp solo episodes, no guests, just me about the facts. Let me know what you think of this experiment, send me an email to admin@mdhealth.com.au if you like this format or you don’t like this format. I’d love to hear your suggestions of different topics that we can cover in the future or any particular guests you’d like to hear in the here and from our podcast in the future as well. Um, we’d love to share exactly what the client journeys are and where you can make the biggest impact on your life. 

So our topic today, we’re going to talk a more technical topic: returning to running from a knee injury. We do see a lot of this in our centre. So I wanted to discuss this in a bit more detail and where different steps come into it. 

So first of all question number one is knee injuries can vary. So what do we mean by knee injuries as well? Well there’s a few major types of knee injuries that we see and some come from more doing more activity and some come from what would be typically an injury as well. So we’re going to start with the most common one today that’s kneecap pain. So irritation of the kneecap from an increased load on the knee and so the kneecap runs a little groove in the middle of the thigh bone and its major role is to make your major thigh muscle, your quadriceps stronger, it makes the performance of that muscle work a lot better. But it runs in its groove and when those muscles around that area aren’t strong enough or the balance of those muscles isn’t right, it drags it a little bit over to the side. 

Now what that means is that it rubs against the side surface of the area. And there’s two parts of that joint that actually get irritated. It’s not the cartilage itself, that can wear and tear, but that doesn’t have a nerve supply so you can’t actually feel it. What does happen is it rubs along the side, little flakes of that cartilage break off and they lodge in the outside layers of that joint called the synovial lining. Now that area has a very rich nerve supply and a very rich blood supply and when that’s irritated that can cause pain in the area. 

The second part about the kneecap that causes pain is a small bit underneath it, there also to protect it called the fat pad. So its major role again is to protect the bottom part of the kneecap, but in itself can get irritated. And so when either of those parts get sore, that’s where people get the most common reason for kneecap knee pain. Now the tough thing about the kneecap as a major cause of knee injury, is that it can be the primary cause of knee pain but it can also be a secondary cause of knee pain associated with another injury. 

So for example if you have another cartilage damage inside the knee that can cause irritation around the area and as a result why we are wired this way I don’t always know but we are wired this way that when another part of the knee gets irritated it switches the muscles off a little bit to control the position of the kneecap and so even though the kneecap or the control of the kneecap may start off very well. As you develop another injury, the muscles in the area switch off and you lose that balance. So what may start off was a cartilage problem can easily end up as a kneecap problem a few weeks or a few months later. So it’s very, very important to come back to actually always look at that in the future when you’ve had another knee injury, even if it didn’t start off as a major problem at the start. 

One of the biggest causes of knee pain is kneecap irritation called PFJ pain. And so that’s one of the biggest things we look for and try to control with knee injuries as well. And again, talking about that too, the major cause of that is increased loading. So when you start to do more things that you have than you’ve done before, either more running or higher amounts of running or just a larger volume. So you used to be walking 15 minutes a day.

Now, so I’m going to start walking an hour a day because I’m going to get fit. The load on the area becomes higher. And so if the muscles can’t cope with that load, it starts to rub against the lining of the joint. And that’s when we start to see problems as well. The second type of injury that we see is very common is cartilage or meniscal injuries. So there’s two types of cartilage that line the joint. There’s what’s called a meniscus, which is like a cushion between the major bones of the knee and so that absorbs the shock and distributes some of the force. Now that has a very poor blood supply and is and is and is really achieves its nutrients through the movement of the knee joint as the as the fluid inside the knee moves around. So when there’s a tear in the area it can cause it can cause some pain.

But often bits of that sort of this lodge irritate around the area too. And that can be one of the newer causes of knee pain as well. The other cause of knee pain is the lining of the joint, which is also called cartilage. So from, without doing an MRI, it’s very, very hard to tell the difference when someone’s got a meniscal injury or the lining of the joint. They’re very, very similar for what they have they present in the clinic as well. So as a clinician, it’s very hard to tell whether someone’s got a meniscal injury or a lining of the cartilage tear, you often need to have an MRI to find that out. Not that it actually matters that much because the management of it isn’t that different. 

So just because you’ve had a meniscal injury, so you were running or you were walking and you twisted your knee and showed this sharp pain on the inside of the outside of your knee, it can often be quite debilitating at that period of time, but most of those injuries will settle. So whether you have treatment on them or you don’t have treatment on them, they will often settle by themselves. And and the time frame can vary – you can be a week and could be two weeks, can be three weeks, it can be a few months, but they will settle. 

Rarely – very rarely – do you need any kind of operation on these as well. Sometimes if you have a particular type of those and your health practitioner can talk to you about this as well, they may – and I’m talking very rarely – may need an operation to get that cut out if it’s really locking the joint but most of them will settle by themselves. 

The biggest problem with meniscal injuries or cartilage injuries or so forth is that the effect they have on the kneecap. So when you irritate that area it causes the sudden pain in the area, the muscles in the area switch off and so you start doing less and it hurts to do so. We get that mechanism we talked about before as the area starts to switch off. We want it working and the muscles in the area start to switch off.

And so you get this secondary kneecap pain at the front of the knee happening a week or two, three weeks, a month later, it becomes a major source of problems. So even though the cartilage problem can settle down, what we are dealing with often is a secondary consequence of that – making the control of the kneecap better. 

The third type of problem is actually recovering from surgery. So when you have had an operation, for example, very major one called knee reconstruction, where you’ve torn one of the major ligaments inside the knee called a cruciate ligament, and that has to have a reconstruction. So what a reconstruction is, is that because that ligament is torn, I would say up until about six months ago, it’s very rare for that ligament to re-heal, but there is evidence coming out that those ligaments may heal with some people and there’s some new protocols coming out about cross bracing. It’s a very new thing that there are very exciting things happening that there may be ways of these ligaments actually healing as well, but it’s extremely new. It’s quite, you know, there’s still very early days before we get too excited about these things as well. 

But when you do have reconstruction, the surgeons utilise either the hamstrings or the front of the patellar tendon to recreate that ligament and it takes about 12 months to recover for that too. So it’s quite a long recovery process as well and the criteria for coming back for running from those injuries has to be very strict. Because you’re replacing the ligament in the area which is a major stabilizing around the knee joint you can’t just say I feel like I have to start to run; you really have to make sure the knee is very stable because that graft is quite vulnerable for over around 12 months and so you have to make sure it’s protected. 

So we have very strict criteria for when we tell someone it’s okay to start running again so you want to see you be able to be able to have good knee control when you step down so that puts a little load on the kneecap and so if you can’t control that movement you’re more likely to have that knee buckle and put pressure on that on the graft. You need to be able to lift your bottom up and control that position. So when particularly there’s a hamstring graft, there is a weakness in the area too. So you’ve stripped part of that muscle off. 

So the other parts of the muscle has to compensate for a part that’s now missing. And so one of the most common problems with the reconstruction with the graft of the hamstrings is that you don’t get full strength to the back of the hamstrings, even at the end of the rehabilitation process as well.

So it’s super important that muscle has a certain quality of strength and is almost about 90% of the strength of the other leg before you start going back to running. The second one you need good control around the kneecap and that means being able to do single leg squats with good control, speed, coordination and again similar strength as the other side as well. 

And then the calf strength as well. So a large proportion of propulsion when you run comes from the calf muscles. So when you push off, it is a big part of that job. And so if your calf muscles isn’t strong, you can’t do a certain amount of good quality calf raises. It puts more load on the hamstrings, on the quadriceps, on the hips to do more of the work and again, it makes you vulnerable as well. 

So when we’re looking at people coming back for running, it really matters about what kind of injury you have. So when you have a kneecap problems, it usually doesn’t mean you can’t run, the muscles around it stronger to cope with the load that you’re asking it to do. So if you’ve gone from a short amount of walking running and you’ve increased that load, you need to make sure your strength can match what you’ve asked your body to do to be able to go back to running. When you’ve got a cartilage injury, often the time is variable. It’s probably a faster recovery because that will settle down. So this new injury, this irritation, although it could be quite severe at the start, it often settles down faster.

It’s probably the kneecap issues that you have to look for later down the track that will be the limiting factor if you’re going back to running. And a good quality health practitioner will be able to look at where you’re at, how much load you can take in the knee and say, yes, you can start going back to running, but I want you to do this amount. I want you to start back to walking for 15 minutes at this pace, see how your body copes and then start going back to a running routine. So doing it hand in hand with a health practitioner makes a big difference of being able to cope with load or going back in the same cycle, you’re not getting better. 

A different criteria is when you come back from surgery and then you have to be a lot more stricter with the protocols. So you might feel like your leg is okay, but if you haven’t matched the criteria of being able to control your step downs, being able to have good control of your hamstrings, getting a good control of your hips, your hip control of your glutes, being able to do singular squats with good strength and control, having good calf strength, you’re not ready to go back to running and that makes you very, very vulnerable to injury. 

So just because you’ve passed a certain period of time and you feel okay and you’ve had a knee reconstruction is not a good one to try this out on your own. You do really wanna get a good conversation and clearance with your health practitioner like a physio, exoskeptical, osteopath to make sure that you’re ready to go back to running. 

So one of the interesting paradoxes is that if you wanna be a good runner, you need good strength. And so most runners, hopefully learning these days, if you wanna be a good runner, you need to have good strength. Why is it important to have good strength in running? You’re doing it running, doesn’t that make you stronger? Unfortunately, the answer is running is not enough. So when you start to walk and start to run, you do get a little bit of increased strength. But because it’s a repetitive activity, with a relatively even load, that strength gains plateau extremely fast. 

And so the strength you require for the muscles that allow you to have good control of your hips, knees, ankles and make a good runner. Running alone isn’t enough. You have to independently make those stronger to actually have that, to become a good runner and improve your performance. So runners have started to hopefully learn after now that if you want to be a great runner, you have to do deliberate strength work just like everyone else in other sports.

The strong recommendation I have is if you’re going to be a great runner, strength training twice a week, working on the major propulsion muscles around the body. So if you’re going to work on your lower half of your body, you need good strength around your core stabilisers, your abdominals and your small muscle around your lower back. That creates a foundation for your back muscles to stay stable. You need extremely good strength around your hips and glutes. So your gluteal muscles – your gluteus maximus, medius, minimus muscles – are all major stabilisers around the hips of pelvis and so when you go running the major propulsion when you push forward should come from your glute muscles as well. If they aren’t strong enough it puts much more load on your knees and your calves and you just don’t get the push off that you require. 

In addition those muscles are the major power muscles around the lower back, much more load on the structure around your lower back like your discs and are asked to stabilise around your lower back to do a lot more work. So your core stabilises provide control around your lower back. 

Unfortunately that’s not enough. You need power too or you need strength too and so your glutes should provide that strength so that the stabiliser can do their job of creating stability and the power should come from these muscles. If that balance isn’t right, that’s where problems start to occur.

The next group is your quadriceps, the obvious ones as well. So these are the major ones that control position in the kneecap as well. And so if those muscles aren’t strong, it puts a lot more load on the kneecap and it starts to irritate the lining of the cinevular lining of the joint. And that’s where you start to see these kneecap and knee problems. It also makes your cartilage is more vulnerable to injury because the muscles aren’t taking the load. It makes the pressure on those joints a lot more. And so you’re more likely to injure that area. It doesn’t mean you will, but you’re more likely to. So having good strength around those muscles makes a massive difference. 

The last muscle group is your calf muscles. So it is one of the most underestimated muscle groups. And so because a lot of the propulsion when you run happens from that area, you need good calf strength. So the whole lower limb really has to be stronger. 

Now the big surprising one is also upper body strength. Now a runner – why do I need upper body strength? Because the arm swing makes a difference in speed, it counterbalances the control around the hips and pelvis. And so in order to be a good runner, you actually need good strength and control around your arm swing. Now, if you’re not working on body strength, you actually can’t get that. So a great runner is going to have a really well structured strength program focusing on core stability, glutes and hamstrings, and upper body strength and you’ll see, you’ll be amazed how that improves your performance as a runner using that, doing strength training twice a week with a well structured program and then adding that on top of a well structured running program. 

Now this is an interesting one – one of the other things that’s important in improving running is that you can have good control, you may have no injuries, you may have good strength in the area too, but being psychologically ready to return to running is actually an important aspect. And so we need to test for that too. So if someone feels like they aren’t ready to go back to running because it doesn’t feel right, they’re actually not right to run. So you might find that the strength is great. You might find that every test you do comes back relatively normal. But if you’re not ready to come back to running, you’re not ready to come back to running and that will be a limiting factor. 

And so testing for ‘You know what? I feel okay. I’m ready for this,’ is actually a major part. So if you feel like, you know what, I’m not ready to run an hour yet to, I’m not just not ready for it. I’m happy with 30 minutes and I’m going to stop there. Then it’s okay to do that because that also has a major factor or whether you’re ready to, uh, you are going to likely to hurt yourself or not yourself from running. So being physically ready and being psychologically ready, both are important criteria for being ready to return back to running as well.

And the last bit is returning to training and competition. So if you play a sport like basketball or soccer or hockey or football, all those things require contact sport, you might be ready to go back to straight line running as well. So you pass all the criteria or step down is great. Your bridging is great. Your singular squats are great. Your calf’s right. Your balance is really good, but they’re not enough. When you go back to competition, it’s a more on training, they’re more unpredictable movements. And so you really have to get tested a little bit further to be able to say, you know what, I’m okay for you to start doing running, but I’m not okay for you to go back to competition yet too. 

So looking at jumping and speed and so forth, and other very particular agility tests as well are all important criteria to say, you know what, I think you’re ready for competition now too. And so looking in a little bit more depth, and that’s where again, a good health professional looks at those extra criteria. Are you ready to be back? Go back to competition. Um, um, those conversations are extremely important. And so knowing why you should or why you shouldn’t go back to running, or competition, are really good things to know and what you need to work on to get ready. So you might be able to really go back to straight line running, but you may not be ready to go back to training because your, your agility skills aren’t good enough yet.

And so incorporating that as part of your training before you go back to competition is probably the next step that you need to work on. So keep doing your strength work, keep doing your control exercises, but start adding in appropriate agility work that makes you ready for the competition and having those clear and clear and regular conversations with your health professionals is where you really need to need to go in order to be able to know you are now safe and ready to go back to training competition and really get the most of it and actually enjoy it and reduce your risk of further injuries rather than just go back and give it a gamble. 

There will always be a risk when you go back and we’re always making it a guesstimate based on the data we have. Are you ready or not? Are you not ready to go back to competition? But that’s, you know, having those honest and specific conversations is where you’ll be able to know ‘I’m ready’ or ‘I’m not ready to go back to competition’.

So this is the first solo episode, I hope you enjoyed it. These are my thoughts and this is what goes through my head when I see clients with knee injuries and ask myself are they ready or not ready to go back to running, to training, to competition. Thanks very much and we’ll see you next time. My aim next episode is to have a running coach talk about how non-runners can start running and get the most out of it too.

Talk to you soon.