We also need to do the activity modification to give her time to get better and stronger. We are suggesting that she modify her training until her symptoms actually resolve. To move to three times a week, only one long run a week, and to be sure to include a pre-run stretch. We also are talking about five minutes of a walking warm-up for a musculoskeletal warm-up in her active muscles and also to choose run/walk intervals so that she doesn’t get into the pain cycle. We are also suggesting to her, anecdotally I might add, that she look for places that she can run and consider alternating right and left sides on the pitched running surface. People often do this as a way to use the surface to actually supinate the foot for most of the gait cycle. And people tell you that it’s effective for them. Also we will try to educate her so that she can develop some good self-management skills to replace her competitive athletic collegiate mind set of “no pain, no gain.”
We are going to do quad strengthening with this person and we know that quadriceps strengthening in patellofemoral pain is quite effective. They pretty much consistently show improvements in pain and function. Anything that interferes with complete extension of the knee does diminish the effectiveness of knee-strengthening exercises so things like an extensor lag, patellar shift, knee flexion contracture, or even very slight knee effusion definitely will get in the way of your efforts to strengthen the quadriceps. We are not exactly sure why strengthening the quadriceps works so consistently when so many people have different reasons for pain. Some of the speculations are that may actually alter the location of the patellar contact. You may actually redistribute the pressure of the patella, or that you are actually producing improved proprioception and neuromuscular control of knee activities.
The exercise program we are suggesting for her is: daily and pre-run stretches for the tight muscles, and three times a week strength training for her quadriceps, hamstrings and hip abductors – which we also found to be weak. It will be important for this person who is training for a fairly rigorous event that we help her develop a training regimen that will stimulate the quadriceps and the hamstrings to over 70% of their maximal voluntary contraction and keep up with her improvement. We need to get to that level of a stimulus before we know that we are recruiting fibers and we will get a new training adaptation then. So quad sets, isometrics are probably not going to be adequate for what this person needs. We will try to instruct her in a home or gym program and provide monthly follow-up.
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