Tuesday, 2 September 2014

Knee Injuries

Now, with knee injuries in rock climbing, there are no specific injuries that climbers get due to our sport – we get “normal” knee injuries, such as meniscus problems and ACL ruptures. The only thing that differs is the mechanism of injury, such as falls from doing an “Egyptian” or heel hooks, phrases your standard doctor or sports physiotherapist may not understand!

But first, as always, to discuss the anatomy of the knee, to aid your understanding of what's going on in your joint:

Knee anatomy

Now, the knee is a lot simpler to understand compared to those joints with more movement such as the shoulder, as it predominantly is a hinge joint, so moves forwards and backwards only.
However, there is a slight degree of rotation and translation (moving forwards and backwards of the bones without gross movement of the leg), and it's mainly these movements that cause damage to the structures of the knee.

Bones




Ligaments

Within the knee, there are 4 main ligaments, two on the outside edge of the knee called the collateral ligaments, and two on the inside of the knee called the cruciates; and two sections of cartilage called the menisci.




Muscles

The muscles of the knee provide the gross flexion / extension movements, which is provided by the hamstrings for flexion, and the quadriceps to extend the knee.





Movements

As previously discussed, the gross movement of the knee is flexion and extension of the knee, however there is a degree of lateral translation of the knee and some rotation.






Cause for injuries

Eqyptian / Drop Knee



These moves tend to stress the hamstrings and therefore can cause muscle strains or tears. They also put pressure on menisci and ACL/MCL which, in conjuction with a fall from these moves, can cause rupture and injury due to the unusual orientation of the knee.
This is caused by passively ‘sitting’ on the medial collateral ligament (MCL) that runs down the inner side of the knee.

Heel hooks



Falls

Especially when bouldering, falls onto an uneven surface can cuase damage and rupture to ligaments and muscles around the knee. This can even cause a cascade effect when one ligament fails, it shock loads the next and causes multiple injuries.

Common injuries

Common climbing injuries related to the above movements, as already mentioned, are:

Meniscal tears




Anterior Cruciate Ligament / Medial Collateral Ligament





Patella Dislocation






Hamstring and other muscular tears




I could go into much more detail, but then this post would turn into an essay and you'd be asleep by about....now! Further information on any specific injury can be provided, or as future posts.


Symptoms

Symptoms of a knee injury will depend on the degree of damage and the structure damaged, however, you will tend to find one or more of the following symptoms:
  • Locking of the knee
  • Localised swelling/tenderness/pain
  • Inability or difficulty in weightbearing
  • Clicking/grinding
Symptoms of an injured muscle will be the following:
  • Tightness
  • Swelling/Bruising/Redness
  • Weakness
  • Pain
  •  Inability to fully stretch

Treatment

The treatment to a specific knee injury depends on the injury, the extent of it, and whether a surgical intervention is required. However, much of the rehab will focus on training those muscles around the knee, so below are some sample exercises discussed.

Exercises: open and closed exercises


Simulated loading cases: A, closed kinetic chain
or squatting (WB, body weight). B, open kinetic chain leg
extension (WT, tibia weight). C, open kinetic chain loaded
(WT, tibial weight; M, external moment on tibia)


In a closed chain the end of the chain farthest from the body is fixed, such as a squat where your feet are fixed and the rest of the leg chain moves. In open chains the end is free, such as in a seated leg extension - See more at: http://www.afpafitness.com/research-articles/closed-chain-exercise-for-legs-and-knees/#sthash.pEvSRn4h.dpuf
In a closed chain the end of the chain farthest from the body is fixed, such as a squat where your feet are fixed and the rest of the leg chain moves. In open chains the end is free, such as in a seated leg extension
Closed chain exercises are better, as they provide more stability to the joint, less shearing forces therefore less chance of injury, increase stability, engages more muscles, and are more functional.
Some evidence says closed improve strength, however open chain exercises maybe nessecary if you are unable to weight bear on the injured knee.
To increase difficulty of these exercises, fix proximal point on unstable surface e.g. stand on a gym ball to increase stability and control

See some more sample exercises listed below.

Swimming and/or cycling are good later stage activities - non-weight bearing strengthening


Prevention

Again, much of the prevention work for knee injuries is strengthening of the muscles around the knee, and below is a sample of exercises from Climbing.com. Much of the other preventative work is repetitive information, but again is listed!

1. Strengthening work


Three Exercises That Protect Your Knees
Note: Ramp up gradually — building connective tissue can take two years.
1. Hamstring Curl on a Physioball
How: Lie on your back with heels on the ball, knees straight. Tighten your abdominals and bridge your hips up, and then bend your knees to roll the ball toward you. Try two sets of eight reps with good form; work up to three sets of 15. Advanced challenge: single leg atop the ball!
Why: The ACL prevents forward movement of the tibia. Your hamstrings assist in preventing that motion (particularly in this exercise).
2. Floor Touches
How: Stand on one foot with your knee slightly bent. With the opposite hand, touch the ground outside your standing foot. Keep your back straight. Repeat on the other leg. If tight hamstrings restrict your reach (and your lower back rounds), bend your knee more and reach only halfway. Begin with two sets of 12 slow, controlled reps, and work up to holding a three-to-10-pound weight in the hand reaching the fl oor. Advanced options: reach to the front, then inside your standing foot.
Why: Multi-joint proprioception and eccentric hip control. This exercise enhances the body’s positional awareness, to improve protective reflexes, and strengthens the hip muscles that maintain knee alignment.
3. Sidestepping with a Theraband
How: Place both feet atop a Theraband and hold opposite handles, with your arms crossed. Slightly bend your hips and knees, and then step left with your left foot, stretching the band. Lift (don’t drag) the right foot, and then step it left to narrow your stance slightly, keeping your feet greater than hip width apart — use core muscles to steady your shoulders, with your feet forward. Begin with 15 to 30 steps in each direction (depending on the band’s tension) and work up to 100.
Why: ACL injury can also occur when the knee is forced into a valgus (knock-kneed) position; your hip abductors and external rotators can minimize this vulnerability. Traditional exercises and day-to-day activities don’t strengthen these muscles, making the ACL injury-prone in certain climbing positions.

Also, performing the moves will help train and strengthen the ligaments and joint in question, however start easy and simple and build up with repetition.


2. Correct any muscular imbalances

Personally, I know my hamstrings are quite strong, however this means my quads may not be as strong, therefore I perform cross-training, I run to ensure equal training of my lower limb muscles.

3. As always, improve technique to avoid falls and stressing your knee in strange positions because you have rubbish technique!

4. Down climbing to prevent falls / look at stable landings
Including using bouldering mats to protect landings.

5. Ensure good lower limb mobility
Make sure you have good range of movement at the ankle, knee and hip to limit damaging specific structures.

6. Stretching
Ensure muscles are correctly stretched, not overstretched, to aid performance at their optimal range

7. Listen to feedback from your knee
If it starts to hurt, or ache, or twinge, stop doing the move that's aggravating, or else something may well go pop!

8. Warm up!
Tendons and ligaments are stiff when cold, more elastic and better proprioception when warm.
Sample warm up for knees
 Try the following before climbing: •10 lunges on each leg, to open your hips and warm up your legs •10 floor touches (exercise No. 2 above) •Single-leg balance on the ground for 20 seconds — close your eyes •Two 30-second quad stretches (hold your foot in your hand and bend your knee, with your heel touching your behind)



COMING SOON: a post on lower limb amputations, as I'm currently treating a gentleman and learning lots in the process!
References

http://www.afpafitness.com/research-articles/closed-chain-exercise-for-legs-and-knees/#sthash.pEvSRn4h.dpuf

Jewell DV. Guide to evidence - based physical therapy practice: Jones & Bartlett Learning; 2008

Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D. Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med 2004;32:1122-30


Bakhtiary AH, Fatemi E. Open versus closed kinetic chain exercises for patellar chondromalacia. British Journal of Sports Medicine 2008;42:99-102


http://ptrehab.ucsf.edu/sites/ptrehab.ucsf.edu/files/documents/Open%20versus%20Closed%20Kinetic%20Chain%20Exercises%20for%20Patellofemoral%20Pain%20Syndrome_Tsai.pdf

Cohen, Hrvoje Roglic, Grelsamer, Henry, Levine, Mow, Ateshia 2001 Patellofemoral Stresses during Open and Closed Kinetic Chain Exercises An Analysis Using Computer Simulation Am J Sports Med vol. 29 no. 4 480-487 

Dave Macleod; Injury case study, knee ligament tear


Wednesday, 4 June 2014

Mirror Neurons: How we learn by watching

You here it all the time, don't you....


Watch better climbers and you'll learn to climb better

And it seems to work, we see someone shift there body position slightly, maybe twist into the wall a bit more, and can then reach that elusive hold. Then we can recreate it.



But how does it actually work?  

Well, I went to a very interesting lecture last week on mirror neurons, with the thoughts that there are a certain set of neurons within your brain that fire whilst you are doing a task, and whilst watching someone do the task, for instance, you reach for an object, XY and Z neurons fire. You watch someone else reach for the object, XY and Z neurons fire again.

This is a new concept, as previously it was thought that when learning (or relearning) a new task, the brain observes, analyses, breaks down step-by-step, then recreates the new task. 

But it's much more of an instinct as that.

With one provision:


There must be a goal, a purpose to the task

 If there is no goal, say, just a hand making a fist shape, then the mirror neurons get bored, and therefore don't fire. The task has to be purposeful, like reaching for food or an object (or climbing a route!)
The brain sees the initiation of the movement, understands the task in hand, and almost figures out the "filler" bit in the middle of how to achieve it. 

This helps us understand lots about how we learn new tasks, and can be used in a context of a child's learning, or in the re-learning of tasks, for instance, after an acute brain injury.
It also helps explain how we feel empathy, as when we watch someone fall off a problem, miss a hold, miss a penalty, whatever the analogy, then it's like we are the person doing it, the same neurons in the brain are firing.

The lecture I went into went into a lot more detail, however, I'm going to leave you here, further reading is available below, or some TED talks that are always worth a watch! 
Any questions, comment below!

References

Harriss JP 2014 Mirror Neurons. Presented at Annual Brain Lecture

Papers

Rizzolatti G 2008 Mirror neurons and their clinical relevance. Nature Clinical Practice Neurology


Further watching:

Ramachandran 2009 The Neurons that shaped civilization. TED Talks

And a heart warming story to end, to show that it does work:

R D'Angelo, F Fedeli 2013 In Our Baby's Illness: A Life Lesson. TED Talks