Boots, shoes, and knee support

[Harrison Carpenter]

I've a quick question for all you kinesiologists. Do boots, with their ankle support, also support one's knees?

I wonder about this today, with my second case of runners' knee flaming in my left leg. This is the second time my knees have suffered towards the end of a moderate hike (in this case, a 16-mile day on rolling terrain); both times I wore my trail runner shoes. I've never had this problem with my old-fashioned boots. Ergo, curiosity is setting in.

[Jake D]

I find the opposite. Having my ankles stablilized in boots causes my knees to take the wobble associated with uneven trails and makes them hurt more.

Your ankle is designed to move a lot side to side to absorb that motion.. your knee is designed to be a hinge and nothing else.

I'm guessing something else was different.. either the terrain, intensity, lack of stretching? Could be less fit than before?

[Greg Mihalik]

Muscles support knees.

Often when a knee "flares" the vastus medialis (inside and just above the knee) drops out resulting in poor petellar tracking. Sit on the floor with your legs extended. Tense the muscles in the affected leg, watching your kneecap. It should travel Straight up the leg. If it is moving to the outside you need to start some medialis specific strengthening.

Make sure everything is working together.

Then look at the external components.

….stepping down off the soapbox, carefully ;-)

[Jennifer Mitol]

Sorry Greg,
The VMO (vastus medialis) theory was long ago debunked. You cannot selectively train the medial portion of your quad, nor does it selectively atrophy. There are many neurophysiological reasons for this, but I won't go into that unless you would like me to. The primary culprit of poor patellar tracking actually comes from weak HIP muscles: the patella is embedded in the belly of the quad and does not really go anywhere. The issue is that with poor performance of the abductors and external rotators of the hip, your femur actually internally rotates UNDER the patella and causes a relative lateral tracking of the patella and the condyles of the femur. This is a major cause of ITB syndrome, overpronation of the foot, "hip bursitis," and patellofemoral pain syndrome.

I started a blog that I never learned how to work, but there is actually a single PT post there that has some of this info, good pictures, and a demo of nice hip strengthening exercises (by the way, if anyone wants to help me figure out how to make a blog work, ill provide free PT care!)
backpackerPT.com

Now, on to your boot question…

It turns out that taller, stiffer boots actually transfer a great deal of unwanted forces to both the hip and the knee. Under normal conditions the very mobile foot and ankle compensate for uneven surfaces, as well as flexing your leg over your foot during walking (called dorsiflexion). If you wear higher boots you limit your ability to dorsiflex, thus tranferring all that force through the knee and the hip. So…in a "normal" condition, the higher boot actually causes more trouble than it helps. If, however (there are tons of ifs in orthopedics), you do have some underlying condition anywhere along the kinetic chain (back, hip, knee, ankle, foot) then you may need something different. But no one can tell you that through a forum.

But first, I'd give the hip strengthening exercises a try. Most hikers should do these anyway, as most of us are weak here and this is a major component of so, so many lower extremity and back pain problems.

[Dustin Short]

Probably the best explanation I've heard for joints (in general) is to look that the two joints above and below an affected joint and see what type they are and how they are behaving.

So for knees, the knee itself is a hinge joint designed to work in one plane of motion. The hip and ankle are ball joints that move in many directions. So I've found that by "supporting" my ankles I restrict movement in them and that causes my knees to over compensate and try to move in less than ideal ways. So from a pure biomechanical stand point I never support my ankles anymore if I can avoid it (very heavy packs or cold weather being some notable exceptions).

That said, this works with well developed and balanced muscles. Greg is right on the money. Most knee issues come from some form of muscle weakness or imbalance. The stiff ankled boots may have just been masking/compensating for muscle problems (and that is a ticking time bomb for injury).

So work on the muscles and your ankle support (or lack thereof) shouldn't affect your knees.

[Andrew Zajac]

What hip exercises would you suggest?

[BlackHatGuy]

"But first, I'd give the hip strengthening exercises a try."

I've just started reading "Foundation" by Dr. Eric Goodman and Peter Park. Interesting so far – they talk about strengthening your 'real' core (not the abs, they say, but instead building a strong posterior chain [neck, back, butt, hamstrings, heels]). The book/training seems to be mostly targeted at people with chronic back pain, but it seems useful in many areas.

Jennifer, if you've heard of this book/training and have an opinion I'd love to hear it — good, bad, or indifferent!

[Jake D]

Andrew.. from her blog.

http://backpackerpt.com/2012/06/27/backpacking-with-knee-pain/

[Jennifer Mitol]

I can't say I'm familiar with that book in particular, but sounds like they are right on the money in terms of the muscles to be worked. One of the reasons I try to debunk a lot of advice about strengthening your quadriceps is because for the vast majority of us our front thigh muscles are quite strong, but our hamstrings and gluteals are decidedly NOT. Greg and the other poster were right about muscle imbalances, but the imbalance is usually on the part of the gluteals and hamstrings. (An aside: This is actually the prevailing theory as to why some people tear their ACLs.)

Look at any older man (sorry guys….but you are SO obvious sometimes) with a bit of a belly and no butt. Classic example of too much up front, nothing in the back (meaning no butt and hamstrings…keep your jokes to yourselves…)

Our eyes are in the front of our heads, we work with our arms in front, we stoop over benches or computers, etc. So over time we get these forward shoulders, forward heads, flat butts and no hamstrings: way too front-dominant and not nearly enough strength in the posterior parts of our bodies to counter that. Then we go and hike 20 miles (or canoe for 3 days, or play a game of football in the back yard, or chop wood…) and wonder why our knees or our backs or our necks hurt. So yes, I frequently get my patients to stop doing exercises that strengthen anything in the front of the body and instead work the sides and the back of it.

Now obviously everyone is different, and just because this is the most common presentation doesn't at all mean that it applies to you personally. But for most folks it's a good place to start before you end up spending cash and time on imaging studies you don't need and orthopedic surgeons who make money by cutting you open (sorry to all the orthopods out there. I really do love you…honest.)

[Roger Caffin]

Hi Jennifer

Your contributions are much appreciated.
Thank you.

Cheers

[Harrison Carpenter]

Thanks, all (especially Jennifer for your detailed insight). This all suggests to me that I may need to modify my training somewhat; I suppose it's time to talk to someone, eh?

[HkNewman]

Do those foam rollers really work? Mostly to Jennifer but also anyone with any sort of exp -pro or con.

Add that may make a good dual use pillow

[HkNewman]

Depends on the individual I guess. I had a bunch of PT problems hit and civilian/ military docs couldn't figure it out (running in those Vietnam-era flak vests pre-Iraq probably didn't help the quad/ham coordination. It took an military PT to torture … make that treat me and give me a regimen that got my hams back in order. PTherapy ain't fun and is no massage. Still can't wear ankle high boots for any length of time though, but had to figure that out myself.

[Hoot Filsinger]

If anyone needs pics of "a bit of a belly and no butt" let me know and I will PIF.

[Jennifer Mitol]

Oh yeah, those foam rollers are awesome.

Use it to roll out your ITB, any muscle, stretch your back, lay on it lengthwise (butt and head on the roll, arms out to the side like a snow angel), roll it up and down your spine sideways (who needs a chiro? Just do that to crack yourself!)

And cheap, too. Shouldn't be more than $20 for a full length one. No real need for the bumps and such on it, but some people think it feels better. So that is a personal preference thing.

[Jennifer Mitol]

Well…maybe, maybe not.

A couple of questions (and these are good for anyone in similar situations, too):
1) how new are you to trail runners? Are you a recent convert from the boots? Do you get the knee pain every time you try the trail runners, or was there something particular about the times you did get the knee pain?

2) are they supportive enough/too supportive? I always strongly recommend to runners and hikers transitioning to trail runners that they should have their gait analyzed before buying shoes. Good running stores will do this for free and usually you just need to go once to get an idea of how supportive your footwear should be. If you have high, stiff arches you need more cushioning; flat floppy feet need motion control; then there's everyone in between. A podiatrist will always always give you orthotics…but really not everyone needs them.

3) any back pain ever? Low back pain is a common cause of weakness in the hips and sometimes you need to address that too

Give the hip exercises from my feeble blog attempt a try…I can also help out with some other recommendations, too if you PM me (we can address your case a little more specifically). Most knee pain gets quite a bit better by strengthening the gluteals and the hamstrings regardless of the cause, so it's a great place to start.

A quick soapbox, if I may:
I will say this again, knowing that I'm speaking against my profession here. There is A LOT of bad PT out there. No one should waste your clinic time with hot packs, ultrasound, electrical stimulation, iontophoresis, etc. Your PT should put their hands on you a lot (no, not massage…for manual therapy and joint mobilizations), you should be doing exercises with someone watching you, and have small home program, too. If this is not the case, please go somewhere else. PT can be very effective if done correctly, but wow can it waste your time and money.

[Travis Leanna]

Jennifer,
Just saw your blog. Very helpful for people who don't know where to start concerning hiking healthy.

On one of our first backpacking trips, my wife and I hiked the Superstition Mountains. About the middle of the second day my wife was complaining out loud of knee pain and by the end of the third day she was in tears. I ended up carrying both our packs. Luckily we were near a trailhead and were driven by good samaritans back to a place where we could be picked up by family.

She's quite small, and I have no doubt that her body just wasn't ready for the terrain. It took a long time for that knee to heal, but so far so good with all subsequent trips. However, With an upcoming trip that will require long distances and possibly lots of water weight in the packs, we're both looking for a little extra insurance against a crippling instance like Arizona.

She's excited to try out some of those exercises on your blog, as am I. Thanks!

[Jake D]

HK.. Foam roller is pretty good for IT band and many other lower body and even upper body massaging. I don't have the discipline to do it enough myself but I do use The Stick on my quads, hams and calfs after riding and day hikes.

[Jeremy G]

My feedback from my PTs and Chiropractor / exercise physiologists matches up with Jennifer's advice. Especially for those of us that sit behind a desk all day, muscle imbalances and weaknesses seem inevitable. The hamstrings are in a shortened position all day while the quads are in an extended position, meanwhile the gluteus are relaxed and unused. Poor posture stresses the back and shoulders which causes more issues down the posterior chain.

Solution? Stop sitting down all day. Get a different job or get a standing desk. Studies show that even a lot of correction or exercise cannot offset the 8+ hours of sitting in a chair.

The one thing I would challenge Jennifer on is the shoes. The one thing I really appreciate about good PTs and Chiropractors is that they are really working at getting the body to work as it is intended to…. Fixing muscle imbalances, structural alignments, strengthening weaknesses, recommending ergonomics in the work environment, good posture, etc. in my opinion, the one thing they miss out on is the feet. They seem to be really quick to push orthotics and corrective shoes which is basically a cast for your foot. They all know to well what a cast does to the rest of the body in terms of atrophy and yet seem okay with putting a lot of structure around the foot. The feet have the most intricate and amazing muscular and physiological structure of the body and yet it seems to be left out when it comes to treatment and therapy. I just don't understand the push to put more structure to something that has its own internal structure. Instead, start doing foot strengthening exercises, SLOWLY transition into minimalist footwear for both work and play, go barefoot as much as possible. Experiment with it and see what happens.

It worked for me to fix my Patellarfemoral Syndrome, runners knee and hip issues. It also relieved a lot of my back problems. I used to wear orthotics and after transitioning into minimalist foot wear, I can't stand the feel of any structure or support under or around my feet.

[Leigh Baker]

Someone please help Jennifer with her blog :-), I'd love to see some more exercises and I think many of us could benefit. I've had less than stellar pt for my knee issues and what she mentions makes a lot of sense. Nice to see others concur as well. I've been focusing on the quads all this time with little success (although I recently did add some "core" exercises focusing on the hams and gluts.) I'm going to give these exercises a try. I'm one of those unfortunate desk dwellers, but I got a cheap adjustable hospital bed table, and use it to stand at work.( I once heard it said that sitting all day will literally kill you.) Thanks for your insight Jennifer!

[Jennifer Mitol]

Perhaps it didn't come off as I intended, but I was actually criticizing all the orthotics floating around out there. Yes, there certainly are some people whose feet are just soooo floppy no amount of strengthening and stabilization is going to help.

But for the vast majority of people the orthotic just allows your foot to be lazy…and get lazier. Our bodies are inherently lazy, and will do the absolute minimum amount of work required of it (thus so many compensations in so many parts of our bodies that can end up causing injury). If your intrinsic foot muscles and the lower leg muscle that supports your arch don't have to work, they won't, and will just get weaker and weaker.

Leigh…thanks for the plug!! I'm very good at orthopedics, but wow am I computer stupid. I'm kind of impressed I can even post to this forum.

[Jeremy G]

Jennifer, that's great to hear! From my experience, you are not the norm, so it is very encouraging….. Yes, get your blog going and start influencing other PTs and Chiros!

BPL has had some great articles on minimalist footwear and Staff Member Damian Tougas is a great advocate. See Toesalad.com for more info.

[Tony Campana]

A comment on orthotics for consideration:

I agree that orthotics are a "crutch" in most cases, and over-prescribed. But every case is different.

I had significant forefoot pain I was dealing with when walking. I tried minimalist footwear and that hurt just as much as regular shoes. I went to an podiatrist and I found out that my big toe had some arthritis in the joint and did not carry all the load it was supposed to carry when I walked. This overstressed my toes and caused the forefoot pain.

I was not enthused when the podiatrist prescribed orthotics for the various reasons mentioned in this thread. But I had run out of options so I gave them a try.

In about two weeks the pain went away, so in my case they worked. I also realized that if I did not continue to wear them the pain returned. (I was ill for a few days and walked barefoot around the house, and the pain returned.)

So in my individual case they work as a crutch, relieving my symptoms. Until I find another remedy I'll take the orthotics to continue walking pain-free.

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