Coach Needs Help 001

Posted on July 31, 2009 by CoachJay

I’ve received several emails this summer asking my opinion on topics that I either know nothing about or know very little about. But the readership of the blog is diverse and well informed and the comments section below could be used to assist the coach asking the question. Just because I don’t know the answer (or know where to begin) should prevent a coach from getting their question answered. I will make this a regular series under the title, “Coach Needs Help.” Thanks in advance for your help and thanks to Phil for taking the time to email me.

Hello Jay

In your experiences with young college runners do any of them still experience Vastus Medialis Oblique (VMO) problems or patella pain? If so, do you have any suggestions to strengthen their quadricep strength. We are using the LL and LM as our warm-up with my high school cc team. If you would pass this question on to some of the other respected high school coaches that our your acquaintances I would appreciate it. Thanks for all your time on your website.

Phil

Disclaimer: Obviously the views and the opinions expressed below are not mine and I will delete any comments that are obviously incorrect or off-topic.

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  • melissadonais

    I'm a post-collegiate distance runner (5k/10k currently, aspirations for 2012 trials in 10k/marathon), I ran division 1 in college, and I've had issues with weakness in my VMO causing pain in my knee. I'm not sure what Coach Jay thinks of this, but I've had Boston-area physical therapists and doctors prescribe two exercises that have helped me tremendously: one is a straight leg raise with an ankle weight (I use a 5lb ankle weight). I lay on my back, propped up on my elbows, bend the knee of the non-exercising leg and place that foot on the floor. The exercising leg is straight with the toe turned out (to focus the work on the VMO). I do 3 sets of twelve raises, lifting the leg to the top of the other knee.
    The second exercise is the knee extension machine at the gym. I know the machine is controversial among coaches (my high school coaches told me never to use it), but for this purpose you do one leg at a time and again turn the leg out to focus the work on the VMO. 3 sets of 12.

    I do the above two exercises mostly if I have flare-ups of knee pain and the exercises seem to help within a week. I also do Coach Jay's LM and LL before every run and I really think its helped, not only with my quad strength but also my leg strength in general.

    Hope that helps. I have to say I love the sharing of information on this site. Its helped me so much with my running and coaching. A great resource!!!

  • http://karlstutelberg.blogspot.com/ Karl

    Melissa, you are correct…but not the way you are thinking. You cannot isolate VMO and I would be almost 90% certain that your quad is not your problem at all, it is your hip. So the reason you are getting better is not because of your straight leg raises or knee extensions, it is because you start doing the lunges! You probably also decrease your mileage a bit when you are hurting which helps. Work all the gluts (minimus, medius, maximus) and get on a good core program, and I bet you would have less frequent knee pain, if any at all. The posterior chain is what propels us forward, the quad helps to slow us down.
    Coach Phil, make sure you are watching your athletes during lunges and that they are using proper form. If you don't know what to look for watch some of Coach Jay's videos! Good luck to you all.

  • http://coachjayjohnson.com CoachJay

    Thanks for posting, especially since you've had VMO issues and you can speak directly to Phil's question.

    I will post my own comment below regarding the specifics of your comment, but just wanted to say thanks.

  • http://coachjayjohnson.com CoachJay

    First, we are all in indebted to Melissadonais and Karl for their comments – thanks to you both.

    My first thought when I read Phil's email was, “Well, even though the area seems to be VMO, I wonder what the other weaknesses and a-symmetries are for the athlete?” Now, let's be clear about something – I'm not a PT or a Chiropractor or a Physiothrapist and therefore I don't have years of working with athletes to know what can and should be done for a specific problem area. But as a coach and as a former competitive runner and now a baby jogger running father, I know some simple principles, such as the fact that my left “butt cheek” is always tight and when I have lower leg problems they're on my right side (right gastroc, right Achilles). That's really general and somewhat vague (is the issue my gluteus maximus or gluteus medius or is it the TFL?) but I know that big movement, such as the movements in the Lunge Matrix or Cannonball cool down, that ask many muscle groups to get involved before and after a run is a good thing.

    Does this mean that a leg raise with weight on the ankle is bad? Not at all. I ask athletes to do 24 leg lifts (8 x 3 different foot positions) as part of the Cannonball and Grant Green cool downs.

    Cannonball
    http://www.coachjayjohnson.com/2009/06/summer-g…

    Grant Green
    http://www.coachjayjohnson.com/2009/08/summer-g…

    I hope this does not come across as “Jay thinks if you do three or four of his routines you'll never be injured.” Injuries are the most challenging part of being a runner and I don't take injuries lightly, yet I do think that doing more work in the warm-up and more work in the cool down, especially when you're building your running volume and when you starting to introduce more intensity into your training, is important.

    Thanks to both Melissa and Karl and if you will both email me your mailing address and shirt sizes to coachjayjohnson@gmail.com I want to send something to you both for taking the time to comment.

  • melissadonais

    Just wanted to clarify…the knee issues I had that were directly related to the VMO according to my sports medicine doctor were “lateral tracking” issues of the patella (when severe my doctor and physical therapist would tape the knee by bringing the patella over medially which provided much relief). I've had this problem off and on since high school and the exercises I've described have always helped. I didn't begin doing Coach Jay's LM and LL until after college and I've noticed that his exercises help strengthen my entire leg and I find myself having to do the aforementioned “rehab” exercises a lot less frequently.

    Of course many runners have issues with their hip strength and flexibility. I've been no different, and in my case I've had IT band problems, and a whole set of “rehab” exercises for that as well, but those exercises line up well with the Myrtle routine so now I just do Myrtle a few days a week.

  • Rhymenocerous

    Karl, you said, “You cannot isolate VMO.”
    Are you sure?

    In my experience, which sounds pretty similar to Melissa's, I've been able to.
    Early on in HS I'd occasionally get a spot of tendonitis. Whenever this happened, I'd go to the weight room every day for a week or so and do single-leg leg extensions, very little weight (~25 lbs.), turning my foot out a bit to isolate the vastus medialis – at least that's what I thought I was doing. Since I was in high school, and thus an idiot, I didn't run less or anything like that, just did the leg extensions every day and took a lot of ibuprofen. It seemed to me that I was isolating the vastus medialis, as that was the only thing that got tired, and my knee usually got better pretty quickly, though perhaps the eccentric loading helped as well.
    Around my junior year I think we watched 'Vision Quest' or something and got really into wall sits. After that, nobody had any knee problems.

  • http://karlstutelberg.blogspot.com/ Karl

    Coach Jay, you are right there are no wrong exercises, just more appropriate ones. The reason I said you cannot isolate VMO is that it does not have its own nerve supply. It has been shown in studies that doing leg extension or leg raises (even with toe out) activates just as much VLO as VMO. There may be a late VMO activation when compared to VL, but again quad strengthening in WB would be more appropriate. Rhymenocerous, your wall sits were good but lunges are even better. Check out some good peer reviewed journal abstracts on the topic here:

    http://www.ncbi.nlm.nih.gov/pubmed/9934418?ordi…

    http://www.ncbi.nlm.nih.gov/pubmed/7644571?ordi…

    http://www.ncbi.nlm.nih.gov/pubmed/18436468?ord…

    The take home on all this is lets all get a little stronger and more “athletic”. Overall leg and core strengthening will improve form when running and prevent overuse injuries due to less stress on tendon and ligaments. I would argue that running does not make us “athletic”, I would actually say the reverse happens and we become less “athletic” becuase we only run in a straight line or in circles over and over. One main reason why runners get hurt is that they are inherently very weak. Strength training when done appropriately will allow you to run farther and faster without getting hurt. Coach Jay has some great routines on his site. Pick a few and get started. Lunge matrix and pedistal are my favorites.

    Keep the discussions going. We can all benefit.

    Karl Stutelberg, PT

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  • pointzone

    Thank you all for your informative answers to my question. It seems the 14 – 15 year old girls that are having issues with their knees are experiencing discomfort due to the tracking of the their patella. Would the lack of strength to the posterior be a contributor to this? If not what then?

  • KP

    I'm with Karl on this one: can't isolate the VMO, and if the patella is tracking laterally that could be as much a result of a tight lateral retinaculum, tight IT band, tight biceps femoris along with weak/not firing correctly glutes. Patellar taping can provide great kinesthetic feedback to the athlete as they train, but that won't address the underlying issue. The lunge matrix, leg circuits, and the other functional strengthening stuff Jay has here on the website is a great place to start. Just my $0.02 but while sometimes necessary (as in post-surgical rehabs) lying on your back doing a leg raise ain't functiona.

  • mgooch

    I would like to echo the sentiments of other posters above in saying that this is developing into a great forum…and there have been some very intuitive answers to this question so far. Keep it up Jay, your efforts are paying off. Also, Phil is a friend of mine and is doing a great job in his first couple of years coaching high school.

    Phil, when I read your question, my thought process also went to other inflexibilities/weaknesses that might be contributing the issues your girls are having. While I'm sure that Karl S. would be better able to address this that I would, here are my thoughts…

    While I would say that Vastus Medialis weakness (and of course specifically a weakness of the oblique section) is the classic contributing factor of PFP syndrome… I would also encourage you to look to a few other areas since you are covering the general strengthening with the LM (among other closed chain exercises).

    Specifically, I would wonder how the flexibility in their hamstrings, gastroc and IT band are…especially on the affected side. I would also have the girls really focus on flexibility the rest of the summer in these areas after practice and hopefully the combination of strengthening and increased flexibility will help ease their problems.

    Also, if they have some excessive pronation (~80% of the population does) this can lead to a increase in internal tibial torsion…which over time can be a factor in PFP. Pronation issues can usually be helped by properly fit shoes and biomechanically sound orthotic.

    A lack of posterior chain strength and flexibility tends to be an issue for distance runners. As Karl S mentioned, because of the dramatic amount time spent moving forward in the sagital plane…distance runners are at greater risk of becoming less athletic. Depending on what research you read, many over-use injuries in distance runners can be indirectly linked back to weakness/inflexibility of the gluteus medius. It has a significant role in decelerating your pelvis as you run… if it is weak… other structures must compensate for that. This can lead to over use and injury. (Orthotics have been shown to increase both gluteus medius activity as well as vastus medialis activity… so they may also help here)

    So this got so long everybody…

    Matt Gooch C.Ped, CSCS

  • http://coachjayjohnson.com CoachJay

    My guess – and it's just that, a guess – is that girls are really bad in the the frontal plane and transverse plane.

    Have you done the LL warm-up after the LM? I bring this up because the single leg squat as the third exercise in the LL (and the eighth exercise if you did the LM and then the LL) you'll see a lot of kids who struggle and my thought is that a single leg squat is a realistic exercise for any human who wants to run 1-2 miles or more. Video of LL below, but I will edit a stand alone video soon.

    http://www.runnerspace.com/profile.php?do=video…

    I bring up the LL WU because I think it combines elements of the two views on this issue. One view is that isolating VMO is helpful and to me, a single leg squat does that, yet the single leg squat also forces the athlete to be athletic, to use other muscles and to use their general preconception to execute the exercise.

    …I guess my point is that in the midst of any functional exercise you could take still frame photo and find one muscle group doing the majority of the work (making Mellis and Rhymeno correct) yet if you look at the gestalt of the exercise there is dozens of muscles and thousands of motor units involved (leading creedence to Karl and KP's stance….get it, stance…sorry, it's late).

    Okay, off to bed, but please know how much I appreciate everyone's input.

  • karlstutelbergpt

    Wow…some great comments here people. Patellofemoral Pain Syndrome is a complex problem with many different causes. It requires a thorough evaluation by an orthopedic MD and/or a physical therapist to properly diagnose and determine cause and treatment. For example weakness in quads, glut medius/minimus, glut maximus, hamstrings, and core; tighness in quads, hamstrings, TFL (IT Band), and calf. Some of use are hypermobile and hyperextend at the knee. Others excessively pronate causing increased rotation at the knee and hip. Some have patellas that just don't sit straight in the patellofemoral groove and can be rotated and tilted. Some of us had hip problems at birth that can cause a whole host of other problems. My point is that these runners need to be properly assessed to determine where their deficiencies are now so that the don't have repeated problems. An orthopedist and a sports PT are your best bet. Strength training is great and helps many runners but as Gray Cook, PT says, “You can't build fitness (strength) on top of dysfunction.” It won't solve the whole problem.

  • karlstutelbergpt

    Hey, I was just reading some abstracts posted on runnersworld.com and they were discussing VMO too! The article correlates VMO cross sectional area with benefits in patellofemoral joint health and reduce the long-term risk of patellofemoral pathology in a pain free population. Just another interesting study to read and log.
    http://www.ncbi.nlm.nih.gov/pubmed/19077298

    You can always tell someone who was well toned quads by the nice tear drop look of the VMO.

    Karl Stutelberg, PT

  • http://coachjayjohnson.com CoachJay

    Matt -

    That's such a well thought out comment. Thank you!

    I want to quote from it:

    “Specifically, I would wonder how the flexibility in their hamstrings, gastroc and IT band are…especially on the affected side. I would also have the girls really focus on flexibility the rest of the summer in these areas after practice and hopefully the combination of strengthening and increased flexibility will help ease their problems.”

    I was on the phone with Mike Smith (Kansas State and RunningDVDs.com collaborator) a month or so ago and simply said, “My left butt/glut is always tight and that's why I think my right gastroc/achillies is acting up.” I share not because I was correct or I know what I'm talking about, but just to bring up the important idea that often the thing that is bothering you – in my case the calf/achillies – is likely “downstream” from the real problem. For the past two years every time I do both the iron cross (anterior chain) and scorpion (posterior chain) I can feel tightness in my left butt cheek.

    I can't add anything more than what Matt has added, but I just want to highlight his post. Also, Coach Mike Kerley of Strake Jesuit in Houston spent a lot of time at my camp educating me about proper sprint mechanics and he highlighted the importance of gluteus medius.

    …I've got a lot to learn.

    …and for those of you who've not heard this concept, muscles involved in deceleration, be it in running fast or pitching a baseball fast, are at higher risk for injury than muscles that accelerate the body…which I guess would lead the theory that eccentric exercises would strengthen the muscles that decelerate the body.

  • http://coachjayjohnson.com CoachJay

    Karl -

    I have Gray Cook's “Athletic Body in Balance” on my shelf but have not implemented his screening into my work with athletes (and to be honest, I've identified a PT in the Loveland/Ft. Collins area that I trust will do a good job and hope to simply “outsource” the screening to him) but if you've done that screening with athletes and would be willing to share I'd love to hear about it.

    Regardless, I love the quote, “You can't build fitness on top of dysfunction.” You have just captured at least half of the 140 kids that I saw at the Boulder Running Camps this summer. They are building bigger aerobic engines, which is good, but they have serious, fundamental movement issues that may eventually be the limiting factor in performance. Why? Not because of longer ground contact time or poor RE (running economy) but simply because they will be injured and unable to run. That's why the global issue of dysfunction is so important – not only does it look bad (these kids are easy to spot running by the 2 miles mark of a HS 5k XC race) but they may be on a collision course with career ending injuries that will not go away.

    Yes the body can learn to compensate and yes I agree with Vern Gambetta's recent post on symmetry (we don't need symmetrical robots as much as athletic kids) but if a kid looks really bad running by the 2 mile mark we should all ask the question, “Should they spend time on becoming a more functional athlete because they might not be able to run many more years if they don't.”

  • cdpatten

    I just attended the Functional Training Summit in Long Beach Calif. Lots of good speakers. Most all of the speakers agree when they tell me not to look at the knee for the problem of PFPS. The knee is especially prone to being caught in the middle of dysfunction that occurs at the hip and the ankle/foot.
    I like the comment Karl made from Gray Cook PT that you cannot build strength on top of dysfunction. I love the influence of Gary Gray PT throughout the Functional Training Summit. Coach Jay's videos are great. Have the problem checked out by a running physical therapist. Then try to make an athlete out of the runner.

  • cdpatten

    A running physical therapist is the key! I myself a PT could see 9 out of 10 PT's that would prescribe the same SLR, VMO, Taping etc etc that help temporarily. The problem often described as putting the train (patella) back on the track with ITB stretching, VMO training which is all good and nice but if you haven't fixed the track (foot and hip and core) the derailing will continue to occur. The only good way I have found of activating the VMO is through the Gluteal muscles and that occurs in standing.

  • rongallagher

    I was connected to this dialogue by Karl, PT as I am a PT. I would like say that one thing I think about a lot is that the knee joint is half femur. If the femur is rotating way too much then the patella will react to the femoral rotation. So the knee is very capable of “pronating” just like the foot if the hip cannot protect the femur. I think the knee or ITB is the pain generator but the hip is very often the culprit. Mr CDPatten is also right on the money when he said a running PT is the answer. The informed consumers get the best results. Make some phone calls, find a PT who runs and has experience with the endurance population. If the PT did not get you on the treadmill and analyze running, how can he/she help? you can stop by and ask the PT questions to get a feel of if they know what they are talking about. Awesome dialogue all. Happy running!

  • cdpatten

    I have never seen a nice looking VMO without a nicer looking Glut.

  • http://coachjayjohnson.com CoachJay

    I couldn't agree with the “if you haven't fixed the track (foot and hip and core) then derailing will continue to occur” statement more.

    The thing we all know intuitively but soon forget when an athlete comes to us at practice with something wrong is that the thing bothering them is usually not the real problem, but rather a symptom.

    That said, I think we also need to celebrate the simple fact that the younger the athlete is – i.e. middle school or high school vs. mid thirties like myself – the easier/quicker the body heals itself. So back to some of the early comments in this thread, maybe that is why a wall sit was helpful for a whole group of HS athletes – it was simple GS and it helped them globally. I flipping through the Bosch/Klomp biomechanics book “Running” and they have a great illustration of the TFl/Gluteal group, similar to the image below (but their illustration is much better)

    http://www.nasmpro.com/uploadedImages/Library/P…

    I share this because, in the spirit of Vern Gambetta's advice to “train movements, not muscles,” even a simple isometric exercise like a wall sit is going to involve more than one muscle.

    …just a thought and lets be honest – at this point this thread beyond my expertise, yet it's such a fun way to think about the Whys.

  • Rhymenocerous

    Your mention of the wall sits reminds me of all the other GS stuff we kind of accidentally did. During track, XC, and over the summer we were always doing stuff barefoot on the grass – drills, strides, cooling down after sessions/races, sneaking onto the golf course at 11pm for an easy run, etc. Clearly this helped keep the “track” in good shape so things wouldn't derail. There were also pushups, situps, pullups ad nauseum. Looking back, I can't help but think this was a huge reason we had essentially no injuries amongst a group of 5-6 guys who were really lashing it in training, especially by HS standards. Amongst the lower level guys on the team who weren't staying late after practice there were plenty of sore knees, 'shin splints', ITB problems, etc. Obviously I only have intimate knowledge of one HS program (mine) so maybe other teams were doing the same things as us but getting hurt because we were all freaks. I somehow doubt it though as none of us really went on to do anything so I don't think there was much inherent talent there.
    Showing up to a relatively large college program, I was really surprised that there was nothing in place that even remotely resembled my HS' ad hoc GS program. Nobody ever even told me what drills to do to warm up for a session, though I do think this changed later. Maybe I just wasn't paying attention.

  • http://coachjayjohnson.com CoachJay

    Well, I've held back on one issue…

    When I think about GS I think about compost. I don't know how compost works – I don't understand what micro-organisms are working, I don't really understand why the ratio of Green to Brown is important to keep it hot and I don't understand why the compost needs to be damp, but not wet – but I do know that compost makes our garden better. Basically, compost is magic.

    GS is magic too. The endocrine response to GS work can't be anything but good for an athlete. The “movements not muscles” directive given to us by Vern Gambetta is meet with most of the GS exercises I employ and that simply means that that you're targeting muscles – on the motor unit level but also on the macro (i.e. all the gluteal muscles, not just glut medius vs. glut maximus) – that the athlete may not have been using in their running training.

    I need some time to think this annalogy through, but my good friend who is the CU trainer has heard me say this for a couple of years and she agrees. Athletes who do lots of GS simply have fewer injuries…even when training at a high volume.

    …and and obvious thanks to Mike Smith (Kansas State Univ.) for introducing me to this idea 5-6 years ago.

  • http://hamiltontrack.blogspot.com hamiltontrack

    without a doubt my hardest working athtlets at practice (while not always the best performing) are ussually the least injured. Even though they are doing way more running and WAYYYY more strength work.

    Pull-ups will make you run faster.

    more GS work = a healthier more “tuned” body…

  • Grace

    Hello Mr. Johnson,
                     I am a middle school cross country runner and a trustworthy runner family friend, who is much more experienced than my team coach, recommended doing barefoot strides to help strengthen my feet and protect me from injury in my lower legs.   I was wondering if you think that the minimalist running shoes would be worth investing in just to wear around when not running. Would they be useful in ensuring that my feet go uninjured?  Thanks for your time, G

  • QuickChick