Category Archives for "Knee Injuries, Pain, acl"

Running Gait Analysis with Iyad Salloum

Mark: Hi, it's Mark from TLR. I'm here with Iyad Salloum. He's the clinical director of Insync Physio in Burnaby, British Columbia, Canada. And today we're going to talk about running gait analysis. What's this all about Iyad? 

Iyad: Yeah, we see a lot of runners and some who are very into it and some who are just the weekend warriors and some people kind of want to take it to the next level. We have some very keen people who want to know how they're doing, how their form looks. So we would put them on a treadmill and take them through an assessment to see what things they could improve on from a form point of view and running economy point of view. Things like that.

And then you get also the people who are repetitively injured. Despite doing tons and tons of rehab. And they're like, well, what's going on here? And even when you try to manage how much running they're doing and the whole load management piece, they can still kind of keep cropping up with these random injuries. Like shin splint, hip pain, knee pain. And those are people who would also benefit probably from having their gait looked at or their running analyzed I guess. 

Mark: So what would be, what are some of the causes I guess of, before we get into actually talking about how you do this, what are some of the causes of somebody having kind of a not pure running style?

Iyad: I guess it's good to say that nobody, very few people have a very perfect, where we consider perfect running style. And I guess that's really important to normalize it because if you've adapted to your running form, there's really no need to change it. Now it's the people who, for example, the people I've seen mostly, have read something on a magazine, for example, that says you have to switch your running style from a hind foot strike, do a forefoot strike, where you kind of hit more with your toe than with your heel.

And that's a shock to the system, because imagine if you're running, like I think of a marathon training program and they're running between 40 to 50 kilometres a week. That's kind of on average. And then it kind of sometimes can go a bit more closer to competition time. They're trying to run up their volume. So imagine if you suddenly switch your running form. 

Well, that could change the demands on your body quite significantly. It'll change a lot of things. For example, like the length of your stride, which muscles are kind of going to hit the ground first and absorb more. Even stresses on our bones and ligaments. The average kind of like person never thinks about like, oh, I'm loading my bones when I run. And kind of also putting forces through these structures, but they are things that need to also adapt to tension and pressure. And this is kind of where having things done in a graded way is usually the best way to do it.

But then most people who like you're talking about with what happens is it tends to either be people who do too much too soon, and then they start running differently to avoid their pain, or you get the person who thinks they should run a certain way and tries to force their body to do something that maybe it hasn't been used to for 20 years plus of running.

You know, it's like since we're kids, we're just used to running a certain way and those people, if they just continue doing what they're doing, they were probably would have been okay. But now that they've kind of changed this, they got an injury and they can't seem to figure out what's the best way for them to run. So those are the people who would really benefit from kind of having that piece looked at. 

Mark: So this, if I'm to maybe, shortcut and jump through this, like the root, what we're looking at here is really the root cause of how to make your running form more efficient or less stressful and it's going to be possibly, or probably more effective than changing your running shoes or, you know, the stylish shorts you wear.

Iyad: Yeah, absolutely. So like, you know, the people we're talking about, we're not talking that like, the Eliud Kipchoge level, you know, or trying to shave off a millisecond off their marathon time. We're talking about, just you know, like recreational runners or even like serious runners who are not at the elite level.

Yeah like, definitely if you have old shoes, you should probably have that looked at. But most people do that first. Most people assume, oh my knees hurt, the shoes. Or maybe I should change something, maybe my socks are slipping. They literally change all of these things before they start to consider some of the things like, maybe it's just the way they're running.

And we tend to see these things where, it's really interesting, some people were like, well, I've been doing this all my life. How come? Well, things change depending on the stresses we put our bodies. So maybe people used to be more regularly active. And now they're going into periods where they're working all week and then trying to hit it hard on the weekend.

And those are kind of people who might benefit from having their running form maybe addressed better. Because now they're getting all of that training volume in a short period of time, and it's not leaving them with enough time to kind of cope or adjust to that. So for the most part, those are the people who would really benefit from having that looked at. But again, not every imperfect run needs to be changed because if you've adapted to it over time, you're good. 

Mark: Yeah. So before we get into the actual mechanics of what you're analyzing, you're also looking at what kind of volume they're doing? You're investigating what's their typical pattern. What's their history. How are their shoes? All of that is kind of the starting place before you get into, okay here's how the biomechanics are working. Is that right? 

Iyad: Absolutely. It's a great question Mark. The gait analysis is only a piece of this whole thing. So ultimately, even if you have the perfect running form, if I start throwing a hundred kilometres more out of you per week than you're used to, your body's going to react one way or another.

So we'd look at, we would do usually in the clinic, a good history. We'll do a training history. A specific injury history. We'll scan them, let's do a bed type exam. Or if their knees hurt, we'll check that out obviously. We'll check out how they move in like easy planes and movements like front, back and side.

And then we would want to look at them running too. Because you'll have a lot of people who have specific pains at certain distances of running. So even when that happens, we'll get people for example, to come into the clinic after they've run their 10 K and they're starting to feel soreness.

So we get to really see what they look like when they're kind of in that zone of fatigue. Maybe that's where things are starting to go poorly for them. And it really helps us identify deficits. So sometimes it's a purely strength issue. Your muscles are just not coping with with that kind of level of impact or volume. So we would kind of help them shore up up, I guess, wherever they need to strengthen. But yes, it's a total picture. It's never just a standalone piece. It has to be part of a more comprehensive exam. 

Mark: So what's involved in the actual gate analysis. Let's have a look at that. 

Iyad: Yeah, so I'll just do a quick screen share here so we can have a look. This is one of our colleagues here in the clinic when we were kind of playing around with this. So we would just kind of get somebody on the treadmill. We'd get them to run for a few minutes to kind of get used to the feel of the treadmill. And then we'd just look at basic things. 

We don't need to quantify angles and degrees to such an extent that's used in research studies primarily, but it's not going to change our clinical outcome. Because there's so much variation between people. So we look at things like how they're striking, how level they can maintain during a run.

We look at, for example, like if they're crossing over too much we tend to look at it from multiple views. So we'll do a side view. We want to see how far forward are they. For example, relative to their centre of mass. And then what we'll do from there is we will come up with a running program to kind of help supplement that and maybe help them retrain that. Sometimes it's just this small, simple cues of changing their step rate.

Sometimes it's getting their arms swinging more. And sometimes we just look at that and we're like, that looks good. It's just the volume issue. We're going to have to address that because if it ain't broke, don't fix it. 

Mark: On this idea of strengthening, how often is that a component of the analysis or the prescription that you provide?

Iyad: Prescription, almost always. And it tends to be the one area that runners don't like to really focus on. Runners love to run. We know that and they're really good at that. The way we think about this is it helps keep them running versus make them stop. Because that's the last thing I'd ever want to do is to tell them to the rest, for example.

That tends to be a bit of a last resort for us, if there's a serious issue, like a stress fracture or something like that. But yeah, strengthening tends to be a big component of this because it allows us to build capacity in some of these areas that are going to be effected or maybe need to be absorbing more of that force.

So a common example would be for example, the person who just switched their running style. Well they probably should have addressed also that maybe if I switched to my forefoot strike my calfs are going to be loaded more and my achilles tendon might need a bit more. And then their hips and quads might also need to work differently.

So those are kind of things that we want to address too. And it's always important to look at the overall picture. It doesn't need to just look pretty. It also has to be gradual. Because that's a fundamental piece where all of us get into trouble, on the non elite level at least. 

Mark: And the kind of strength training we're talking about, it's not, let's go do some curls. It's more of endurance strength training. How would you describe that? 

Iyad: It would be actually sometimes a mix of that, like where we're just getting them to just go heavy. Because sometimes they just need to get the muscles tolerant. And sometimes we will need to work on like, you know, maybe a smaller, finer movements. But there's no such thing as bad strength training. This is kind of one of the biggest myths that people think we have to do, plyometric only to get running better, actually like barbell training can be very helpful. Dumbbell training could be helpful. 

We use whatever resistance tool we think is going to help them address the deficit. So if the barbell is the best way to do it, we do a barbell. If it's the dumbbells, and it also depends on what they have access to. We get creative sometimes the equipment that they have access to.

If somebody doesn't live near a gym and doesn't want to go, especially nowadays with COVID and all that stuff. We'll try to kind of work within whatever they have at home to allow them to kind of build up that capacity that we need them to be able to run. If that's their goals around run, we kind of work with them with whatever way they have to kind of build up that program for them.

Mark: So the typical course of treatment or length of treatment to get changes so people feel a little bit better about their running. What would that be? 

Iyad: Yeah, that's a good question. So there's lots of research on this and it varies between person to person, but the average is between six to nine training sessions that they'd have to do. We give them some certain cues. Sometimes it's auditory cues. They follow a metronome with the step rate that we find works best for them. And sometimes it's to focus for a few minutes at a time on, for example, swinging their arms a bit more, being chest up a bit more. Some people's knees cave in too much when they run.

So we kind of try to give them some cues to do that. So we'll try to get them to practice that over a while. And this happens in a mix between home treatment and also in clinic treatment because we can't see them every day here. So we're aware of that and we try to give them as much to work with at home.

And yeah, it can take anywhere from six to nine training sessions for people to kind of get used to this new style of running, but it doesn't really affect their efficiency from any point of view, like in the long-term. It's a short-term dip as they get used to this new style, but as they going to work through it, people just kind of pick it up again, and it becomes a new norm for a short period of time sometimes. And yeah, most of the time it's a good way just to kind of keep people running despite the injury. That's also another use for it. So it doesn't have to be, this is going to be your new, permanent thing for life. It could just be a nice tool for us to play with their symptoms and keep them active while they're rehabbing their injuries.

Mark: If you want some expert analysis of your running gait, if you're having issues with your knees. If you're having issues with whatever you want to try something new, get expert analysis at Insync Physio. You can reach them and book at on their website. Or you can call them in Vancouver 604-566-9716 or in North Burnaby 604-298-4878. Willingdon and Hastings. Lots of parking, especially in North Burnaby. They will look after you and they're experts in this stuff. Thanks Iyad. 

Iyad: Thanks Mark.

Traumatic Knee Pain with Wil Seto

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver and North Burnaby. Multi time winners of best physiotherapists in Vancouver and Burnaby. And we're going to talk about traumatic knee pain. What do you mean by traumatic? I'm traumatized. Just hearing that already.

Wil: Yeah. So traumatic knee pain is when you have an injury to your knee because you know, there's been like an event or something happened where you fell and you hit or you know, something happened to it. Like there was a clear thing that happened. It may not even be from falling. Maybe you twisted it. But there's a clear event. 

Mark: So it could be a hit from someone like if you're in a contact sport, it could be from cutting really hard say, in soccer, football, whatever, basketball, hockey. It could be all those kinds of things where you've moved the knee joint in a way that it really shouldn't be moving. 

Wil: Shouldn't be moving. Or got hit in the knee in the way that it shouldn't got hit. Exactly. 

Mark: So the cause is pretty obvious something's happened that's, it could be a fall. It could be that twist, even just gardening, just the wrong with weight, you've twisted the wrong way and suddenly there's pain. So how do you go about diagnosing this, what's happened and what needs to be done?

Wil: Yeah. So I talk to my physio group all the time. It's interesting because the biggest thing that I hear, clients come back in to see our physios, is their worry is that they've done something really bad to their knee. And so when we assess it, we want to basically rule out or determine whether or not if it's one of these bigger injuries. Or if it's not. Like it could be a smaller injury or it could be a bigger injury. And so that's our job. 

So I'll give you an example, we had a client who came in to see one of our physios and they had this outside knee pain. And they had basically been playing, I think it was actually rock climbing or something like that. And they had done something and they twisted their knee and basically heard a pop or a clunk. And then got some swelling and pain immediately. And immediately the brains go into like the worst case scenario. And I think that's human nature. I think we think, oh my gosh, what did I do in my knee? And especially when it swells up. 

And so you know, you got a rule out all these big things. Fortunately for this person, it was just like a minor, it was interesting because of the way that they put the knee, the positioning of it, they twisted it and ended up spraining a ligament on the outside of their knee. That was totally healable. And it could have been a lot worse. Could've been like other structures in the knee that would take longer to heal. Or a bigger, more major ligament like the ACL. But in this case it was the LCL, which is the outside of the ligament. And so the typical timeframe for something like this, we can predict and project and then help the clients understand what to expect in terms of how long it's going to take the full heal. And how long it take it easy for kind of thing, because that's also another thing that you'll want to also respect. There's a healing timeframe for these kinds of things when it's traumatic. 

And so if it's a bigger ligament thing versus like maybe the spongy part of the knee called the meniscus versus the LCL, and depending on how serious that injury is as well, will determine the amount of time that you gotta to take it easier versus the amount of time that you can start to like then, okay I can actually start training harder now. They're going back to climbing harder now versus, okay you know what? Four to six weeks or six to eight or maybe within two weeks. So it all really depends. 

Mark: So when you've diagnosed it, you've determined exactly what the extent of the injury is and where it is. What's a typical course of treatment look like. I imagine getting the swelling down is probably the first layer. 

Wil: Yeah, that's the most important thing. If there's any swelling, you want to take that down. But at the same time, you know, if you want to be able to start to be able to put weight on the knee, retrain what's called your balance and your strength in your balance and sort of weighting it. And that's actually really important. And you need to do specific things to start to reactivate the muscles. That's super important. And so we want to look at the things that have been affected. You know, that's interesting, because we talked about in a previous podcast, about A-traumatic or non-traumatic knee pain.

So you can develop a lot of things that are kind then similar to things where you get tightnesses here and tightnesses there and weaknesses here. Because when you have a traumatic incident or a traumatic injury, then certain muscles will shut off and other muscles will just take over to protect. And now you develop this certain pattern of basically muscle activation. And a lot of that is just to keep you functioning. That's the miracle of the body. The amazing feature of the body is that it just will do that. 

So then what we want to try and do is we want to try and start to, you know, normalize the movement. You want to try and optimize the movement and be able to get you put weight on it. And it may not feel intuitive, or may not feel natural, or like you really want to do that. But the key is also, you don't want to do anything when you have that traumatic injury where you're getting that bad pain.

Mark: Yeah. Pain to be avoided. So if you could grade it, I guess, you know, a minor sort of thing is going to take two to three weeks. A major thing could be six months. 

Wil: A minor thing you can take up to four to six weeks depending on what it is. So if it's like the spongy part of the knee and the meniscus, I mean, it's hard to say if it's a you know, minor thing could take longer than that. But if it's like the ligament on the outside called the lateral collateral ligament, then that could take, four to six weeks or it could take longer, depending on if there's other stuff involved too. 

So if it's very simple and it just really never is, you know, four to six weeks is the healing timeframe. So you have to respect that. And then sometimes it can be extended, it can go six to eight. And then if it's like looking at major ligaments in the knee, then there's other things that we want to look at where, potentially having other interventions involved like with the major ligaments of the knee. And then that can be a full several months, maybe up to a year long process. And then also, depending on the sports that you're doing, if you're just an amateur, trying to get back into doing things, it can take several months still. But if you're professional, then we can speed things up a little bit, but then also looking at what we need to help you actually regain, in terms of your functionality. 

Mark: If you want expert help with any kind of knee injuries that you might or might not have, hopefully none. Well, I wish you that never get a knee injury, but if you get one, the guys to see are Insync Physio. You can book online at or you can call the office in Vancouver, (604) 566-971 6 or in North Burnaby, (604) 298-4878. You have to call and book ahead. They're always busy. Insync Physio. If you want your knees strong, healthy and feeling really good, right until you're old and decrepit like me. Thanks Wil.

Wil: You're not old Mark. But thanks, take care.

Non-Traumatic Knee Pain with Wil Seto

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver, many time winners of best physiotherapists in Vancouver. And we're going to talk about knee pain. Specifically, non-traumatic knee pain. What's non-traumatic knee pain Wil?  

Wil: Hi Mark, thanks. Yeah so non-traumatic knee pain is basically the type of pain that you get in your knee when it's not something that you can recall. Like one incident happening. And sometimes you're a little bit fuzzy about it. And it may be like repetitive thing that happened, like maybe you started up running and cycling or you've increased your training load a little bit more. And so there isn't like a collision or direct contact or something specific that happened to it. And the onset of that pain can be gradual. 

Mark: So basically it started hurting and it wasn't so bad and you kept going and it got worse and worse and worse. Yeah. Is that accurate symptom? 

Wil: Yeah, that's a very common thing where, you know, someone comes in with you know, I just started getting some soreness after a training session. I just thought it was just regular soreness that, you know, from training a little harder, that you get after a hard work. 

Mark: And so what's the cause of this? What are the possible causes involved? 

Wil: So there's there's many different things, but you know, I'll talk briefly about some of the main things that we've seen as a physio group at our clinics. And when you look at non traumatic type of knee pain, you can have stuff where, you know, it's usually an imbalance issue. So an imbalance issue in the muscles, so you'll have certain muscle groups that are just tighter because you're always using them or maybe you're doing desk work where you're sitting down all day long and your hip flexors get really tight.

And then that pulls on certain structures called your IT band, which is basically a connective tissue all along the outside of your thigh that connects down to your knee. And that can start to get little tighter. And then when you take up running or get a little bit more mileage in and try to increase your training, then that starts to get irritated down in that area. Because it gets a little tighter. 

So these muscle imbalances are pretty prominent. And on the assessment of what's causing it and it's with everyone it can be different. So it could be like a different part of the hip flexor. It could be maybe the part of the hip flexor that's more around the front of the thigh. Which is part of the quad. Or maybe part of the hip flexor, that's kind of attached directly to this connective tissue that I was just talking about, the IT band. So those are the things that we do in terms of assessing to really determine what are the imbalances? So that's the big one. Is the muscle imbalances.

And so in addition to that, then you're looking at the weaknesses. So you're going to look at what is not activating to support the proper mechanics. To support the proper movement of that whole chain. So when I say the whole chain, I mean, like not just the knee movement but also what's going on in the hip. And then from the hip down in the knee to the ankle, is functioning properly or not. 

Mark: So once you've gone through the diagnosis and you've identified the possible causes, what's a typical course of treatment? 

Wil: Yeah, so depending on what we find. We have a physio group that basically, you know, we share our case histories to help each other to learn. And it's very typical. This one physio has a client that basically has this lateral knee pain and it's non traumatic knee pain. And as we went over it, your classic tightness into the hip flexors and weakness into the glutes that are not stabilizing the pelvis, which is causing all this non-optimal movement of the whole chain, as I was saying. And so the physio addressed those specific issues. So this person was a runner, and started increasing your training load. And then also the person, his work was getting busier and they're doing a lot of stuff in front of the computer. And so they're in a lot of sitting. And so things are getting tighter and tighter. And then their training load was getting a little bit heavier because they wanted to do a couple of races that had come up recently. 

And so they needed to address those imbalances that were actually causing this. Because the actual issue, like of the pain, yeah you look at it and you there's certain tests. He said, yeah, that's tight. So we want to work that out and we want to try and relieve that pain and that tightness in that area in the knee. But then you also got to figure out what's causing that. And so for this physio to really address that, this person actually had, it was really cool because she was saying that, this person that she was treating basically had almost 85% pain relief after the first session from doing releases. But then it came back because she wasn't really dedicated and doing her strengthening. And then when she realized that strengthening was really important. And then the physio also can do a lot of manual stuff to release, to help facilitate that cycle. 

Now that's a really good example of someone, you know, they come in the second time, they're like, oh, the pain came back. And then the physio did the manual stuff and released it. And then got them to progress with more strengthening. Came back a third time and the pain relief was gone and they increased the training load again. So it was like significantly better. And then they basically, I think was all healed in four or five sessions kind of thing. 

Mark: So when you say lateral knee pain, you're talking about pain that's either on the sides of the knee, not front or back, on the sides inside or outside?

Wil: Yeah. And there's other things that could possibly happen, but I'm just describing like the most common thing, which is just lateral knee pain on the outside of the knee. And it's not like on the knee cap. And it's not like inside the knee. So it's actually on the outside of the knee. And that's where your connective tissue attaches and you have all the muscles that can attach onto that that can pull on the knee structure and effect the movement of it right. 

Mark: If you've got some knee pain, you need to get it looked after, basically. If you want to increase your load, if you want to get back active, if you want something expert diagnosis to identify what needs to be fixed. What you could do to actually repair, allow your body to repair itself. The guys to see are Insync Physio. You can book online at, for either office. They have an office in North Burnaby and in Vancouver. You can call Vancouver 604-566-9716 to book or North Burnaby, 604-298-4878. You got to call and book ahead. They're always busy. Get yourself some help so that you feel better and get back moving well. Thanks Wil. 

Wil: Thank you, Mark.

Growth Spurt Injuries, Part1 with Wil Seto

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver. Multiple time winners of best physiotherapists in Vancouver. And we're talking about growth spurt injuries today. How are you doing Wil? 

Wil: I'm doing great. Thanks Mark. 

Mark: So you had given me some fancy names, Osgood-Schlatter syndrome. What the heck is this? 

Wil: Yeah, so, basically it happens in mostly the athletic population, in younger people. So these are the younger people who are basically going through growth spurts. And that's usually the important factor there, is that there's a larger amount of load. So with training, so in sports and being more repetitive and increasing that load, and then the growth spurt. 

So Osgood's what that is, is basically the attachment point of where your quadriceps muscle, the tendon, attaches down, like just below the kneecap. And so it's basically a pulling away of that attachment point because that bone and all that area is still immature.

And so the big, fancy name is Apophysitis. So basically it's the pulling away at that attachment point of the tendon on the bone.

Mark: So what kind of symptoms would someone, how would this show up for a kid? 

Wil: Yeah, so they would start to get some knee pain there right in that attachment point. And then the classic thing, especially if it's been going on for a little bit where they're still playing, they might start to get a little bit of a bony bump. And then essentially that's there for life because, you know, it's the protuberance or the attachment point of that tendon pulls away. And it essentially is a permanent bump. But in terms of long-term effects, if you manage this correctly and that's the key, is managing it correctly, and knowing what to do and knowing what not to do. And in terms of sport, gradual return to sport is really huge. 

Mark: So, how do you go about diagnosing this?

Wil: Yeah, so like I was saying that the biggest factor is you know, the load and also looking at the growth spurt because it happens in younger kids or kids between the ages of like, it could be as young as 8 to even like 14 or 15. And basically they get tenderness on palpation maybe swelling, you know, if it's really, really bad, just on that attachment point of that tendon, where the quads attaches just below the kneecap.

And so basically in really worst case scenarios, which I'm thinking about a kid that we saw, you know not too long ago in the clinic, one of our therapists, basically the kid had trouble walking. Woke up the next day, like had a hard training session, and it's obviously been developing for a while and he was pushing through the pain. But then it was just the last straw, that last training session.

And he was a competitive soccer player. And then woke up the next day and then just was limping. And normally in terms of the referral and the medical system, they would go see the family doctor, you know, like, oh, what's going on. And then they would probably refer over to what's called a pediatric specialist, which is basically a doctor that specializes in seeing kids.

And they may do some tests and scans, but usually when you look at it, you can see it. And a lot of it is proper physiotherapy management, and there's a lot of research that's showing, it's very dependent on where they are and their growth spurt. So if they're having a huge growth spurt in addition to that training load, then there's a certain amount of graduated return to sport that you want to take them in terms of intensity.

Mark: And what's the typical course of treatment? 

Wil: Yeah. So you really got to give them a chance to settle down and you really want to just take off the load. So if this was a mature, like adult, where the bones are all developed and the tendons are all developed now, then it present more as a tendonopathy or tendonitis. So then protocol would be much different. When you have something like this with an immature adult, with this kind of condition, you really got to take the load off.

And that's huge. It's not about, okay. Yeah, we've got to strengthen this and we got to stretch this. I mean, that's not the case. You don't really want to be doing too much of that. There are some things that you don't want to do because when they start to develop this and what we want to also look for is all the compensation patterns they might develop. Because then you don't want them to start that, because they're growing, not just in that, obviously in that area of their body, their whole body is growing. 

And you know, you look at some athletes that may have, you know, maybe oh, two inches in the year, or maybe a whole 12 inches in the last year. So depending on how big that growth spurt is, then you've got to look at, okay, let's see what's happening in the back. Let's see what's happening in the hip, you know, and in the compensation patterns that are going on there, because then they can start to have issues that can come back to haunt them.

Mark: So there you go. If your kid is having some issues with pains that are getting worse as the training load in their sport is going up, the guys to see are Insync Physio. You can reach them in Vancouver at 604-566-9716 or in Burnaby 604-298-4878. Or of course you can book online at Get them in there, get this treated right so they don't have long-term injuries. Thanks. Wil. 

Wil: Thanks Mark.

Knee Ligament Injuries ACL

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver, multiple time winners, their whole crew of best physiotherapists in Vancouver and in North Burnaby, they have two offices. And we're going to talk about things that break in your body. How are you doing Wil?  

Wil: I'm doing great. 

Mark: This isn't so much a break, this is more of a tear kind of a thing. The knee ligament injuries. What kind of symptoms that people have when they come in with knee ligament problems? 

Wil: Well, what I wanted to actually discuss a little bit more today was major ligament in the knee, called the ACL. Now the ACL stands for anterior cruciate ligament, and the whole purpose of the ACL is that it's actually the main stabilizer in terms of ligament in the knee.

So you have several ligaments in the knee. You have your ACL, your PCL, and your LCL and you MCL. And so with the ACL quite often you also injure it in conjunction with a couple of other structures in the knee. So with your MCL, which is your medial collateral ligament, and then also your medial meniscus.

So quite often with the three injury, they call it the evil triad, so to speak. So quite often with sports, it's very, very common, you know, when you have like a sport that involves running with cutting and a lot of fast changing directions.

Particularly hockey, any kind of field sports, like football, soccer, ultimate Frisbee and rugby. Even like, believe it or not like tennis and squash. Anything that involves like fast changes in movement, but particularly the other ones that I mentioned because they involve contact. So you can kind of add that factor into it. 

Quite often, what happens is if you have contact, then you have sort of this initiation of force on the knee, and so this is where it involves all three parts. Like I called the evil triad. Where you can injure the ACL, MCL and the meniscus where you get this blunt force on the outside of the knee where it causes it to buckle and also hyperextend. And that's where you get the injury to all three. 

Now in another case where you can get just the ACL isolated, it could just be like a hyperextension type of injury, because the main function of the ACL is it actually stops like, so your knee, if you think of your knee is a hinge joint. And so the purpose of that ligament is, so say this is your lower leg and then this is your femur or your thighbone, so when you go to extend your lower leg or your knee, it actually prevents it from hyperextending or straightening out beyond what should be. And that's the protective, normal check and balance for protecting the knee.

 And so what ends up happening too is you've got a lot of nerve endings in that ligament, that basically when that happens, muscles will kick in and stop, like your hamstring is the biggest one. And so when you hyperextend it, and especially if you have your foot planted, then that can cause a tear in that ACL. 

And there's different degrees of tearing. So there's basically three classifications. So they have a grade one, grade two and grade three, and those are the three classifications.

And in grade one, it's a very mild injury to the ACL where basically you still have a good portion of the ACL, but it's either been slightly torn or stretched. And when you assess it and you diagnose it and you feel for it, and there's a battery of different tests that you want to do to kind of test it. But a couple of main ones and you can still feel that there's still ligament there intact. 

And a second degree, that's where you feel like a lot more give and it feels, it definitely has more of this like unstable kind of feeling, but it still has a little bit of that ligament left where, you know, it's still kind of holding it in place.

Whereas a grade three tear classification is that, that ligament is completely torn. And when you do specific tests on it, then that's not holding at all. And it's just basically, you know, pretty unhinged.

Mark: So how would, other than pain, swelling, what other symptoms would people have? Is it more about how it feels, whether how stable that knee feels for certain actions or you're just not capable of doing those actions anymore? What am I going to notice if I have a tear? 

Wil: So well, first off, if it's an acute injury or a trauma, there's going to be swelling right off the bat. Particularly because there's the way the blood supply is and how it connects and everything like that, then you're going to know right away that you've injured most likely your ACL, if you've done those sort of directions of movement that may cause the injury. The swelling happens automatic, like pretty instant.

And so the other thing to also consider too, is like, what I was talking about in terms of the movement is that you're going to have this feeling unstable. So your knee will feel like it gives up because it's just basically, especially with a grade three tear, you know, like I said before now it's like unhinged. I mean, it's got a bit of a weird term, but like the stability in your knee is no longer as good.

And so when you walk, you're going to feel like it gives out. And so that's a big problem. Like your knee will literally give up. Like it'll feel like it sort of just like glides out of joint and out of place. So that that's another thing to look for.

Now is you have other things that are happening, like if it locks, then it could be a meniscal injury as well. So when I talked a little bit earlier about how it could be this triad, this evil triad, and you have a bit of meniscal stuff going on, then that could be a part of it too. So you want to get it properly diagnosed to see if it's just the ACL, if it's possibly, you know, two or all three of them.

Mark: So where's the line between rehab and the knife? 

Wil: That's a really great question. Now it's kind of interesting because prior to 2019 and 2018 if you were a very active individual and especially if you were involved in athletics and sports and you had a complete tear, then the rule of thumb was to get that reconstruction and get that repaired.

But they have done a lot of research and they came out with a consensus and a study. Some studies done in 2019 and they presented it at sport physiotherapy in the sports medicine conference, world congress in 2019, showing that it's actually 50-50. And so in other words, with a complete rupture of your ACL, there've been people that have had athletes, so this is going back to the athletic population, and were very active and depending on that stability. That if they've gone under the knife and they had the reconstruction done, they've done really well in terms of rehab. But then they've also seen half of that study group not do well. 

But then they took another group where they had individuals not do any surgery. And they did really well. They just did very specific rehab that was geared towards what they needed to get back to playing sport. And they were actually back playing competitive sports at the level that they could play with the full rehab, with a fully torn ACL.

So this has been interesting. So that's kind of where we stand now more recently in the last couple of years and that's kind of the direction that we're going. But either way, the rehab component of strengthening and really being sport-specific or activity specific dependent is a huge factor. So you always want to make sure that you're addressing whatever deficits are needed. Because that's ultimately the key to successfully return to sport or a successfully returned activity, whatever that is. 

Mark: Okay. I really don't want this ever. How do I prevent it? What are the actions I can take to help prevent other than a blunt force to the front of the knee kind of thing, that hyperextends it, what could I do to strengthen it? 

Wil: There's some specific things that you can do. Like you want to strengthen up your quadriceps. You want to strengthen up the hams, like all those muscles around the knee. And there's some specific exercises that you can do. We actually have a YouTube channel with a specific list of ACL prevention exercises.

So there's about seven to 10 exercises that you can do, but there's more. But those are the basics that you can start with. And then obviously as you get into like specific sports, like if its Ultimate Frisbee, even rock climbing, you want to do some specific things to work on strengthening the knee.

So that is very important because what you're doing is you're developing the what's called the muscle activation pattern, that will stop your knee from going beyond the range that it should be. Because I mentioned before that your ACL has nerve receptors. And so when it goes to the end range of extension, as it goes just even a little bit past that end range, your nerve receptors kick in right away. Now, if your muscles are trained and strong and you've been, and you've been really focusing on having a good sort of sense of muscle activation patterns with respect to also your balance and all that stuff and how everything activates properly, then that's a really great way of preventing injury.

Mark: Depends on the grade of injury, but what's a typical course of treatment? 

Wil: Yeah. So it can take anywhere from up to six to eight weeks for really, really mild someone that's just sprained it very, very gently. Where they're back on track and they're doing their sports to as long as a year. And the other interesting thing about that is that you're asking, you know, your actions, I never want this injury. Well I didn't mention that this injury can be something that can happen that you might not even be aware of. And then maybe because you're very active, I'll give you an example. 

One of our therapists is treating someone else right now who does not do any contact sports or running sports or whatever, but he is an avid golfer. Like super avid golfer. And he was complaining of like weakness and loss of range in like his hip and other areas. And he's like complaining about his golf game. And so the physiotherapists on our team assessed his knee and found that, well, this is the cause of your hip tightness and why you're compensating because you have, you have this deficient ACL and the best way to actually ascertain that is to compare that knee in question with the other knee. So you always want to do what's called a bilateral comparison. And so she found out that he had a total grade three ACL tear. And so they'd been doing rehab, working on it, and he's been doing simple things and he's like a very avid golfer. 

He's been really getting out there on the greens, but he's been like hitting balls and playing all summer long and his and his hip just started getting tight. So these compensation patterns started happening. His knee started feeling weird. But he didn't know why. And for life of our physio, who's been working with him you know, like there has been no trauma. So that's really interesting. So we think that it's his compensation pattern and he's been over stretching and over stretching and over stretching. 

So his timeframe for rehab you know, let's go back to your question, might take a little longer, because he's developed all these muscle patterns in his hip, in his back because of that ACL. And he didn't even know he had an ACL injury. 

Mark: Yeah, complicated. If you want help with your knees, the guys to see are Insync Physio. You can reach them at their website to book, Both offices you can book there. It's really easy to use, or you can call them in Vancouver 604-566-9716. Or in North Burnaby, 604-298-4878. Get professional help. Keep going with your sports. Thanks. Wil.

Wil: You're welcome Mark.

Knee Osteoarthritis with Simon Kelly

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly of Insync Physio in Vancouver. We're going to talk about osteoarthritis. Something that's probably rampant in the population. Something that has, I get more grey hairs, I start to wonder about things around this particular subject. So Simon, tell me what's the deal with osteoarthritis.

Simon: Thanks for having me. Absolutely, like osteoarthritis, a lot of people are well aware or have heard the term arthritis any way for sure and osteoarthritis is more, to be honest, it's sometimes healthy, not healthy, but we all get a bit older and sort of, we do develop some wash terminology can be like degenerative, osteoarthritis, wear and tear. They all kind of mean the same thing, but I think sometimes our terminology can get a bit out of hand as well. So it is just wear and tear and break down of cartilage. 

Now, one thing I like to let people know is that once the cartilage is worn out, they know physio can really get it back, which you can really increase the longevity of your joint by increasing the muscles around that joint and maybe the joint evolve. I'll speak about the knee in this video just for simplistic reasons. So like the real hard part about osteo, so that's osteoarthritis sorry. And it's not to be confused with rheumatoid arthritis, which are autoimmune diseases and that's kind of the body attacking instead of a little bit. So it's  a little bit different from that. 

Osteoarthritis generally, you know, it usually affects the older population. It's rare that, you know,  it would present gradually. People will come in and say, Oh, I just suddenly have pain in my knee. And generally they're pointing to the inside of their knee because that compartment gets loaded more than the outside compartment of the knee. Some people do complain about pain behind the knee cap as well. That can be put in with patellofemoral pain syndrome, but usually it's a bit of wear to the cartilage behind a knee cap as well. And some people would present with the three different components. The inside of the knee, the outside and  behind the kneecap. 

But anyway, it would be gradual in onset. People would be like I can't remember doing anything, no specific event. And it usually points to the inside of the knee. So usually what we do is when they come into clinic, first of all, we do take a history. We look at the age of the person. Could be mid fifties sometimes, maybe late fifties and onwards. What's important to know osteoarthritis is it is painful. But not all the pain is bad in that it's okay what I said to have 2 out of 10 pain are 3 out of 10 pain when you're doing your activities. 

I had a guy in recently, actually, I kind of link it to this case study. He was a 58 year old man loves his tennis and obviously quite worried about like is his joint degenerating? What can he do moving forward and wanted to be proactive. So I told him, look, it has a bit of wear on the joint, not to be worried about the terminology. But you can also settle, pain isn't always linked to the where prior to the joint, it can be linked to just a bit of over activity. He was doing a bit of tennis in his case, so maybe more higher impact then just normal squats or when your foot is fixed on the floor.

So, and, but he was also doing like, again, it's nice weather now at the moment here in Vancouver. And he went from like zero to like hero of like five days in a row of tennis and Vancouverites love the outdoors. Just like a woman in the previous videos. So they love to run a lot and get out a lot and I don't blame them in the pandemic.

Like if he came in with a very swollen knee in his case, I asked him what he was doing. And he told me he was playing tennis five times a week and cycling two or three times a week. So really had to address the load his knee was on. Obviously he was 58 years old. He had a previous MCL injury, which is the ligament on the inside your knee. So he was wearing a big brace with two metal bars down, either side of his knee, which is good for MCL strain or injury. It prevents the knee from kind of going from side to side. But Ironically, he thought it was still an MCL injury, but I tested him in clinic, we do a few tests and his MCL was pretty good.

So it was really just early onset osteoarthritis that we were dealing with. So he just had to, the plan for him was just to offload. Maybe again, don't play a tennis five days in a row. Even if the weather is good. I know you like the weather and we'll probably get some rain next week here. Well, like if you just went to like Monday and again, every Wednesday or Thursday, and they'll be cycled on the alternate days, his knee might not have swelled up at all.

So the real trick osteoarthritis, even if you are feeling a bit of pain with your activities like 3 out of 10 is okay, but like, I don't want his knee ballooning up swollen like he presented to me in clinic. That's just too much and that can really progress the disease that much quicker actually. So like, he'd be looking at a knee replacement like, I dunno exactly maybe three or five years, as opposed to maybe 10, 15 years. If he's to play tennis at that level, where his knee is swelling up, which is just not ideal.

However, too little load is also detrimental because I used the analogy like astronauts in space. You go up into space, like you just lose all your bone density. So like gravity and weight is actually quite important for new bone growth. Every 10 years, our body makes new bone growth until we die. You stop growing between the ages of 17 and 25, but they keep regenerating every 10 years.

So it's also not going to like, not load the joint at all. So the real trick is to load the joint pain, 2 or 3 out of 10 on a pain scale, 10 being excruciating pain and zero being no pain. And it's kind of what we're seeing in the research is okay without obviously ballooning up of the knee and obviously like not giving it kind of time to rest. So it really is getting that  happy medium again. 

No w in clinic obviously you have to assess all of that. And then we do a lot of exercises. A lot of the time it's actually the hip muscles that become weak that cause the knee to kind of turn inwards. That puts the load down through that kind of inside compartment of the knee.

That's why they point their finger to the inside of the knee. It's in your glute medius, it's the name of the muscle, we've all heard of the glutes and glute minimus. That keeps the pelvis level in single leg stance. It also pushes the knee back into neutral. Prevents a kind of caving inwards. So a lot of the exercises are geared towards the joint above because it's mostly weakness in the hip. And a little bit in the knee, but mostly in the hip that we need to kind of correct. 

So when someone comes in, we'll look at the biomechanics of the body. We'll sort of get the load more neutrally distributed down through the lower limb, and then we'd obviously allow the person, I like to get the person to do their activities. In his case, it is tennis. It was high impact. You know, he's only 58. I want him to have enjoyment out of tennis. So I'm not going to cut it out completely because I don't believe he needs to cut it out completely. He just needs to cut it down and drastically for a while initially. Like maybe once a week he could go twice a week and then his knee could last him 15, 20 years.

Mark: And what's the typical treatment protocol for him to get to a place where the pain is minimized, maybe not gone, but just minimized.

Simon:  Absolutely Mark. So, and you're right with the minimize there. A timeline, rough timeline it's not as long as the tendinopathy, mostly four to six weeks. All depends on how would a patient adheres to like the knowledge that you kind of pass on as well. If they really like in his case, actually, I saw him just during the week. He'd cut down his tennis. He'd done what I told him. And he had no swelling at all on the next visit. He'd stop wearing his knee brace because he doesn't need it to, because of the old ligament injury he thought he had. And he understood like, you know, a little bit of calm weight is important, but not to be ballooning up.

So you know, that was almost like a magic trick he felt, I felt it as well. It's almost like a magic trick, but just because he was loading it in such a different manner to like doing the weekend warrior stuff on it, you know? So I usually just treat that like four to six weeks, you could argue it is a bit of a lifestyle. He will need to monitor his knee from this point onwards. With or without me, you know, it has kind of reared its head. If he keeps continuing at that point, his knee will decline much quicker. But if you kind of just alters those few bits, his knee could last him like 10, 15, more years, maybe even longer. Obviously it depends on his activities and whether he wants to play a tennis in two or three years. And at that point you might want to look at maybe lower impact activities, more like biking. Also depending on how we would present maybe in three or four years time. 

Mark: And what would be the kind of typical hip exercises that you would prescribe? 

Simon: So yeah, we do a bit of single leg bridging again. I kind of spoke about it before. A lot of glute medius exercise, kind of like single leg stance. We call them hip hikes. So you're kind of standing on the edge of step and let your hip drop down and then you pull it back up. So this glute medius pulls this hip back into neutral. That's kind of what happens.

We call it a trendelenburg gait. Usually it's hard to see though the early stages of osteoarthritis, but you know, you're 80 year old women, you know, you really notice it.  They try to step on their pelvis, but their pelvis is dropping because it can't keep it level in order to take a step. If that makes sense, but we really want to prevent getting to that stage.

And obviously if it does get to that stage, you do have to get, like it's usually pain that people get a hip replacement for eventually. But that's maybe a conversation for another day, but at times, like it depends on your age. You probably don't want to get a hip replacement at 90, just because you might get an infection or something in clinic, so it's better to kind of choose. Usually have a 20 year life span. So a lot of people might get a knee or hip replacement around 65, 70, and that would probably do them their lifespan. As opposed to like maybe 88 and then, you know, because there's a bit more comorbidities. People are kind of struggling at that moment in time. So that's just something that you'd have to discuss with the individual, depending on how it presents.

 Mark: If you're noticing some pain in your knee, could it be osteoarthritis? Come and see Simon Kelly at Insync Physio. You can book an appointment at Easy one click, boom, boom. You can find the opening and where works for you get in there. Get to see him.  Get some treatment. Get the pain minimized or you can call to book at (604) 566-9716. Thanks Simon. 

Simon: Thank you Mark.

Knee ligament Injuries – Big Ball Curls

When you injure your knee ligaments an important part of the recovery process is to begin to strengthen it properly. Big Ball Curls do just that!

Lie down on the ground with your lower legs and the back of your calves and heels on a big ball. Keep your arms on the ground, knees straight and the inner core muscles for your lower back engaged so that your back stays in neutral.

Then lift your butt up off the ground while maintaining your balance and then curl the ball in towards your butt with your heels activating your hamstrings and posterior hip muscles. Hold this for a good second with the knees fully flexed and then slowly straighten the knees push the ball away from you.

Keep your butt off the ground the whole time for ten reps and then come down for a rest after one set of 10 reps. Do 3 sets of 10 in total.

This is a great exercise to build more functional core and knee strength after injuring it. If you have any problems or questions with this exercise consult your local Physiotherapist before continuing. 

Knee Pain – Heather Camenzind

Mark: Hi, it's Mark from Top Local. I'm here with Heather Camenzind and she's a physiotherapist at Insync Physio in Vancouver in the Cambie Street area. And we're going to talk about knee pain while running. How are you doing Heather? 

Heather: I'm good. Thanks for having me Mark. 

Mark: So knee pain from running. This is a new thing, or there's been an increase in it because of something. 

Heather: Yeah, it's not a new thing, treated a lot of it before. But I'm seeing an increase in the past year. I think with the current status of our globe and with the pandemic, we're seeing a lot of people that have taken up running as their form of exercise with the gym schedules being modified and closed. So I'm seeing an uptake in the clinic with knee pain. 

Mark: So is there specific things that cause knee pain from running? 

Heather: There's many different causes. But a lot of them that we're seeing is a breakdown for the underside of the knee cap. So it's basically, it's a rubbing on the underside of the kneecap on the end of the femur bone. And there can be different causes to why that breakdown is happening. And so that's why a physiotherapist can help with that. 

Mark: So what's the protocol. What does treatment look like when you're faced with a client coming in? 

Heather: Yeah, a typical treatment will start with a history of how long that they had the pain. Where does the pain, can they describe it? And you just have a good chat about that. And what are some factors that may be contributing to that? So changes in current training schedule, have they significantly increased how much they're running or the terrain that they're running on? 

Other things that can affect it are their footwear? Have they made a change to their shoes? Or lifestyle changes. So that's what we're seeing a lot of right now is the lifestyle changes. I think people are trying to be active, but we're also told to stay at home a lot right now. And so I think people are sitting more than they typically would in the past.

Mark: So give us a couple example things of how you would treat this. Couple of causes, a couple of treatments. 

Heather: Yeah, so different ways that we can treat it is sometimes it's just that the hip flexors and the quads are more tight. And so we have to release the tension through there. So the physio might work with some manual therapy on that, and then give you some exercises such as foam rolling, and some stretches to open up the quad and the hip flexors.

Another common thing that we're seeing is that people are weak in their glute muscles. So, especially their glute medius muscle. That's the muscle on the side of your hip that helps control the alignment of your knee. And a lot of just like leg lifts out to the side. Or like your figure four stretch is a very common stretch that people know, are ones that can help with that hip tightness that will help with the alignment of the knee.

Mark: And what's I know it's case dependent, of course, but what would be a more typical treatment program and what might it affect how effective it is? 

Heather: Yeah, so different things that can affect like how much progress you see is a, I counsel people on is kind of like, the more often you do your exercises and how frequent you do them, you'll get a better bang for your buck so to speak. If you're consistent with them, you'll notice progress sooner and faster. If you're maybe do them once a week, yeah, you may get there. It will improve. It'll probably just take a lot longer. So the more consistent that you are at home the better it is. You only really see your physio probably once a week maybe for maybe half an hour, 45 minutes an hour, if you're lucky. So there's so many more hours in the day that you can be working on things yourself. 

The other thing is just, can the physio diagnose and figure out what is the major contributing factor for you? Is it just a modification that needs to be done to your training program? Have you increased things too quickly? Or can they narrow in on the specific weaknesses that are contributing to your knee pain. Such as glute weakness, or maybe it's your running shoe? So it's proper diagnosis of what is the main cause. And then you'll start to see progress. Typically we see progress within six to eight weeks that you're seeing significant progress with it.

Mark: And I guess depends on how much the pain is and the cause whether somebody has to totally stop their running program in order to let the healing happen. How does that work? 

Heather: Exactly. So some people come in and they're, they're very flared up. Everything is hurting, just walking and it's very sore. Those people benefit from just allowing their nervous system, allowing their body, the inflammation that's there to calm down.

So we have to say, I'm sorry, you have to stop running right now. Others it's maybe their knee pain only comes in 45 minutes into their run or something. It comes on later and then their body tolerates it quite well. They don't really get too aggravated after. So those people we're able to work with them and just modify their running program and get them doing the right exercises. And then we're able to maintain their running. So it depends on the person. And sort of a case-by-case basis on what I typically recommend for them. 

Mark: So if you put the work in and you listen to your physio and have the right shoes and don't crank it up too much, within six weeks, eight weeks, you're probably back running as hard as ever and all the things you want to do without pain.

Heather: That's the hope. Yeah, definitely. 

Mark: So there you go. If you want some expert advice on how to deal with your knee pain while running, or any kind of knee pain or any kind of shoulder problems or neck or back, or you name it basically toes to the top of your head, this is a person to call. Heather Camenzind. You can reach her at Insync Physio to book an appointment. book online. You can see there, they've got both the Vancouver and Burnaby booking systems are hooked up. Very easy to use. Or call the office at 604-566-9716. Thanks Heather. 

Heather: Thank you very much. Bye.

Knee Ligament Sprain Injuries – Airplane Transitions

Start with one lower leg length away from the wall. Plant the foot on the ground with the standing leg. Hip hinge into the wall and make sure you hinge at the hip and not bending through the knee.

Keeping your pelvis, navel, and the centre of your chest in a straight line and pivot through the hip, turning your pelvis over the standing leg. You should be feeling it through the side of your hip, back of your gluteal muscles, and the upper part of your hamstring. 

This is a great exercise to build more core strength to help with the rehab of your knee ligament injuries. 

Knee Ligament Injuries – One-Legged Squats

This is a great exercise to rehab & strengthen your knee injury after you have sprained it. It works the muscles of the lower quadrant to help provide more dynamic stability.

Keep both sides of the pelvis level and squat down on one leg pushing your butt back like in a chair. Keep the knee over the ankle and aligned with your hip and second toe and prevent it from moving past the toes as you squat. You also want to reach both arms out in front of you to keep balanced and bend your hips so your chest comes forward. Your weight is on your entire foot as you come straight back up. Place the emphasis on pushing through the heel while squeezing your butt all the way back up. Repeat this for 10 repetitions doing 3 sets on each side.

Knee Ligament sprain injuries affect the optimal activation of what’s called proprioceptive strengthening, or rather the balancing muscles of the leg and hip. The gluteus medius is a muscle that is important in this function.

If you have any pain or problems doing this exercise consult a local physiotherapist before continuing.