My Foot Hurts!

September 2009 Issue

My foot hurts!
Causes and prevention of foot & ankle conditions associated with running

By Tracy D. Harper PT, DPT, ATC
Guest Writer for Running Illustrated

Recreational and competitive runners are used to pain.  We often train through chronic, overuse conditions such as sesamoiditis or metatarsalgia (injuries associated with a pain in the ball of the foot or toes), stress fractures, plantar fasciitis, Achilles tendonitis, and painful bunions. Those nagging pains can eventually become severe enough, however, that we must alter or even cease training.  Some injuries, if not treated properly, can come right back when we resume running. And sometimes runners sustain traumatic injuries such as sudden sprains and strains of the foot and/or ankle during training can curb training all together.

The general causative factors of foot and ankle injuries can usually be blamed on a combination of things ranging from fatigue, poorly-fitted shoes, old shoes, and over training to body make up, weight and other factors which are listed below.

Common Factors Contributing to Foot/Ankle Conditions

Other more familiar factors contributing to foot/ankle conditions include:

• training errors
  - excess training on hills
  - ramping up your pace or distance too quickly
  - insufficient rest
• improper footwear
  - running in other than running shoes
  - trying to get too much mileage out of a single pair
  - too much or too little shock absorption for your foot or body type
  - too much or too little pronation control features for your tendencies
• shortened calf (Achilles) and/or hamstring length
  - perhaps congenital, perhaps as a result of training
• possible weakness of muscles that reinforce the arch
  - may relate back to training errors that overly fatigue the posterior tibialis muscle
  - incomplete rehabilitation after a traumatic injury
• excessive body weight
• eating disorders that have lead to bone density loss
  - See:   http://www.femaleathletetriad.org

Runners Are Predisposed to Certain Conditions

 Hypermobility

Some runners have a genetic predisposition to loose ligaments and tendons – allowing excessive joint mobility. Depending upon the work load placed upon these tissues, this tendency can lead to tendonitis, fasciitis, or even progressive alteration of joint structure – such as in (acquired) flat foot. Tendonitis may occur in the loose jointed runner since the tendons are working overtime to stabilize the foot/ankle while also trying to propel you forward. The demands upon the tendon may be too great for it to handle, so breakdown (and eventually pain) occurs. The loose jointed (or hypermobile) individual usually needs more time to ramp up their training, more support from a running shoe, and can take longer than usual to heal if they do sustain an injury.  See:  http://www.hypermobility.org/

Structural or bony alignment issues

Similarly, you can be born with certain structural features affecting the bony alignment of the foot such as a 2^nd toe lengthier than the 1^st, an “equinus foot” that restricts the degree your ankle bends, a high rigid arch, or a relatively flattened arch. You may also be born with a bone/joint structure that gives you the tendency to over- or under-pronate when you run. Your bone/joint structure can even change as you age, usually in response to the stresses placed upon it, but also due to injury or disease processes. These bone/joint aberrations change how your foot accepts weight when it strikes the ground and propels you forward during your stride.

Common Foot/Ankle Region Conditions

Sesamoiditis: Sesamoid bones are small pea-shaped bones located under the joint at the ball of your foot and are important attachment sites for many soft tissues of the foot. They help to maintain the right alignment of tendons as well as to absorb pressures as you push off. This region can become inflamed due to various compensatory foot motions that occur as a result of structural problems with the foot, including hypermobility of the forefoot especially. Sometimes the sesamoids can be subjected to extra pressure in those who have thinning of the usual fat pads that help cushion bony prominences of the sole of the foot. Continued stress without treatment can sometimes lead to stress fracture of a sesamoid bone. Source: http://www.foot.com/info/cond_sesamoiditis.jsp.

Stress fractures: As mentioned above, sesamoid bones can fracture with repeated, unmanaged stress. However you may be more familiar with the more common type of stress fractures in runners which occur to the long bones of the forefoot called the metatarsals. Usually the second or third metatarsals are involved, and sometimes the 5^th. Stress fractures may result due to a combination of factors including structural (bone density, excess weight, structural foot abnormalities, tight Achilles) and those such as poor shoe wear and/or poor training habits. Pain is usually on the top of the forefoot. It can be quite dull at first, and then become sharp each time you try to push off.

Plantar fasciitis: The plantar fascia is a rather dense tissue – sort of like your ligaments – that begins at the heel and spans most of the bottom of your foot. It helps to absorb shock and to add structural stability to your foot. Many of the same factors responsible for stress fractures can create inflammation and pain of this tissue. With plantar fasciitis, you often have pain that is worse in the morning when you try to take that first step after getting out of bed. As you warm up and stretch a bit you may have less pain. The longer you stand or the longer you run, the pain begins to intensify. Some people describe it as an ache while others experience a burning sensation. Some have more pain in the heel area while others have pain more so in the arch, or even the whole length of the underside of the foot. Even when diagnosed with plantar fasciitis, other tissues may be involved such as nerve tissue – hence the variability of symptoms.

Achilles tendonitis: Most runners are familiar with the Achilles tendon since, hopefully, you do spend at least some time trying to stretch it before a training session. The Achilles tendon is a rather dense tissue that attaches 2 major calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). When repeatedly overstressed, it can become inflamed and eventually even damaged with small tears. The tendon can be overstressed by excessive tension such as when the tendon is shortened (tight) but the demands for lengthening are high, or when there is compensatory motions at the ankle that cause a twisting of the tendon where it receives the least amount of circulation. Pain can be at the site where the tendon attaches to the heel bone or even a short distance above this site. Like plantar fasciitis, this condition can be most painful upon getting out of bed in the morning or any time you have been sitting a long period and then take that first step. Of course, this pain is also felt during running, often as you push off. It may cause you to shorten your stride such that you could continue running with less pain.

Metatarsalgia: This is a blanket terms for pain under the ball of your foot, usually in the area just before your 2^nd and 3^rd toes. It usually hurts there mostly when you are bearing weight over this area, and especially as you push off. Calluses may form as the body’s way of reducing stress here. Pain can originate from too much stress to the soft tissue forming the joints in the area, or even due to compression of the small nerves that run between the bones called you metatarsals. Pain may start in the foot and even radiate into the 2^nd and 3^rd toes. People with this condition often have a second toe that is longer than the 3^rd, but other factors can lead to this condition as well.

Bunions: A bunion is actually a change in the bony alignment of the bones forming the inside part of the forefoot and big toe which occurs as tendon slide out of their desired alignment. The forefoot will actually appear wider over time than it once was, and may occur with both feet – but often unequally. This change in alignment due to abnormal stresses to the foot affects the structure and function of what is called your 1^st metatarsal-phalangeal joint. The joint can become quite prominent in severe cases, often laying down extra bone material such that it projects even further inward (toward the other foot). Sometimes this prominence rubs against the shoe or sneakers – which are now too narrow – creating painful calluses. The change in the joint alignment can eventually lead to restricted motion of your big toe joint, which then changes how you walk or run. Pain can therefore occur at the affected joint or elsewhere.

Prevention

Dr. Benjamin Overley, DPM of the Sports Medicine Institute (www.sportsmedinstitute.com) of Pottstown, PA reminds runners to honestly consider how their bodies’ are feeling before increasing training intensity and mileage.

“A reasonable training schedule plus the appropriate running sneaker type for the intended mileage are the best defenses against overuse injuries.”

An avid runner and foot/ankle specialist surgeon, Dr. Overely suggests to consider the time and training needed for to adequately prepare for a race, and that is perhaps lengthier than you are accustomed.  

Preventing common foot injuries is easy – it just takes paying some time an attention to your feet.

• Address training errors! Perhaps you need a coach to design a training schedule that meets your goals yet minimizes the chance of injury. There are many resources available to assist the novice runner in judicious training for an event. When your training is too rigorous for your fitness level or even your joint structure (remember loose jointed people?), breakdown in the body’s tissues can occur – even before you begin to experience pain. All those endorphins that kick in during a long run tend to mask the pain that otherwise would occur with tissue breakdown. If experiencing pain when you run, you can try to modify the workout by changing the mileage, velocity, intensity, running surface, and incline as well as adding rest days or cross training.
• Go to a reputable running store for advice regarding which brand and style are best for you. Usually, a good running store will have someone watch you run and then offer suggestions. Runners training over 25 miles/wk usually need to replace their shoes every 3-4 months.
• Stretch those heel cords and hamstrings! Tight musculature alters how you run. When your ankle cannot bend easily due to tight heel cords, you tend to move excessively at joints not meant to do so. If you tend to position your toes pointing outward when you run, you may need advice as to whether this is due to tight muscle/tendon or caused by something structural you cannot change. Running with a toe-out gait also stresses joints improperly.
• Consult a physical therapist (with foot/ankle expertise) for advice regarding specific strengthening of foot/ankle muscles if you think weakness is an issue. If your foot tends to “wobble” a lot when balancing on one leg, you may have weakness that should be addressed.
• Consider Orthotics: If you think that you may be loose jointed you may benefit from orthotic shoe inserts, and definitely from a running shoe recommended by an expert. You may have the tendency to overpronate. See: http://www.youtube.com/watch?v=pODcT55_7zA

Runners With Injuries We Can Relate To

The following case studies describe three runners with common foot injuries.

CASE #1 – The 45-Year-Old Female 5K Competetor

A runner, lets call her “Karen,” is a health care worker who runs 30 miles a week. She has been doing this mileage for many years and while she runs on many different types of surface, mostly, she is running along the side of road facing traffic.

Karen was complaining about a dull achilles tendon pain just above the heels of both feet where her right foot experienced worse than her left. She felt a very sharp in the morning or trying to take a stride after her long commute to work.  Before she went to a physical therapist, she used to have pain at the beginning of the run and would get better as she warmed up. Karen did notice that the pain she felt upon getting out of bed got better with stretching as well as taking small steps at first.  After three months experiencing this pain, Karen realized the pain in her feet was getting worse; she experienced it walking and that the pain did not get better after her warm up.  

Karen saw podiatrist who recommended consultation with physical therapist (PT).

The PT diagnosed Karen with plantar fasciitis in her right foot and suggested Karen use cold packs after every run. She shortened her training distance, avoided hill work, and changed her running shoe.  As part of her therapy, Karen did the following:

1. Modified Achilles’ stretch – wall push type stretch with foot straight ahead, although with weight more to the outside of the foot. Lean forward at the hips without allowing foot to “roll” inward (keep weight on outside of foot).
2. Small heel lift added to both orthotic shoe inserts (Karen had to purchase a running shoe with a deeper heel seat to accommodate for the extra height of the insert). Another alternative, since both feet were affected, would have been to add a lift to the heel aspect of the sneaker soles. This would usually be done at a shoe repair facility or by a pedorthotist (practitioner who specializes in shoe accommodations for foot problems).
3. Saw a PT. Her physical therapist performed manual techniques to increase the mobility of both ankle joint and the potential scar region within the tendon, stretches for the hip to help correct the toe-out style running and walking that had developed, and strengthening of the muscles that bend the ankle (toes/forefoot move up).
4. Continued use of cold packs after work, and stretching throughout the day (especially in the morning).
5. Ceased running until walking was pain free. Using the advise of her PT, Karen could start training only when walking was pain free, and then she could begin a light jog of 1 – 2 miles, and then slowly increase mileage if she had no pain during, after, or in the morning. When she could jog 5 miles pain free,  only then, could the she increase her speed.
6. Karen’s PT advised her to run on level surfaces that do not create unequal footing since she agreed that she was running mostly on a road in which the slope caused her right leg to be slightly elevated versus the left.
7. Corrected her running gait. Once appropriate heel lift was added, KBV was trained in correcting her toe-out gait.

After going through this program, Karen was able to return to running her usual mileage and running speed in 6 weeks.

CASE #2 – 40-Year-Old Male Attorney; Running for Fitness and Weight Loss

“Steve” had gained 20 pounds. His wife had kindly urged that he lose weight. Steve had adopted the traditional American diet of high fat foods. To loose the weight he took to running. He grabbed a pair of running shoes from the back of his closed and started to run on the wooded trails near his home.

Steve got up to running 10 miles per week but was experiencing heel and arch pain in his left foot. Steve’s symptoms were worse in the morning, after running, and if standing long periods. 

Steve called an uncle, a physical therapist who lived 3 hours away. His uncle recommended he consult a known, reputable pedorthotist near Steve’s office and faxed him a series of Achilles stretches. Steve’s uncle also advised him to stop running until he saw the doctor.

Steve saw the podiatrist who quickly saw the problem, first of which was that Steve’s running shoes were two years old.  Steve was diagnosed with “compensated forefoot varus” which begins as a structural alignment “deformity” in which the forefoot has to move excessively just to get the sole of the foot firmly onto the ground with each step. This appears as overpronation or prolonged pronation of the foot, often leading to excessive mobility of the forefoot. This places extra stress on the plantar fascia, and eventual pain and tissue breakdown. The same condition – combined with being overweight and/or overtraining – can cause painful bunion formation, metatarsalgia, stress fractures, Achilles’ strains, and even symptoms at the knee (predisposition to ACL injury).

Steve was told to stretch his Achilles’ at least two times a day and to buy new running shoes. The podiatrist fit Steve with custom made orthotic inserts, specifically constructed with what is termed medial posting. Once Steve started his treatment, we has able to get back into running after a three short weeks.

News and Notes – Grand Opening of PR Running Store

Store associate helps new customer

On Saturday, August 22, 2009 I attended the grand opening of the Potomac River Running Store; a chain of running stores in the Washington, D.C. area. This store, located near Tysons Corner was once Metro Sports – the very store where I was introduced to the Asics 2100 running series. Four years later, here I am, running in the 2140 series.

Runner Signs in for a raffle

So it seemed appropriate for me to return to the store. I will admit I had an alterior motive – Mizuno reps were there and in the morning there was a fun run where people got to test drive new Mizunos. I arrived and put on a test pair comperable to the Asics shoe I currently wear.

I was either the Wave Expire or the Elixer that I tried on. The shoe was light – so light it felt like a sock.  I went about 5 miles in the shoe. After returning to the store I did a foot analysis; which showed I needed a support shoe.  A running analysis proved even better. As the store associate watched me run he was talking so fast I could barely understand him – but MetroSport had pointed me in the right direction. “Don’t fix what ain’t broke,” the associate said. “If your Asics are working for you, stay in them. The Mizuno support shoe is comperable and if you want to switch brands, go for it.”

Treadmill w/TV

The reason I went to the PR Running Store was because of the treadmill. The Georgetown Running Company has one of these treadmills set up in their store. I was going to go over there to make sure I was in the right shoe when the press release for this store was emailed to me. 

The trip to the store was worth it. A few years ago I went to MetroSports and tried on all the stability shoes they had. In the end, I went back to my Asics.  I did the same last Saturday and was glad I did.

Cindy and Tim

Thank you to Cindy and Tim, who let me tag along during the fun run!

Women Athletes and Post Partum/Past Baby Knee Injuries

Women Athletes and Post Partum/Past Baby Knee Injuries
Injury Prevention for Moms!

 By Alix J. Shutello

Esther Prins and Christine Saxon both injured their knees in two separate incidents. Esther, a new mother, ran through her pregnancy, Christine, a mother of three, was bed-ridden with her twins during her pregnancy. Each became injured post partum; one while just getting back in shape, the other while training for triathlons. 

Esther Prins was running uphill on the paved and gravel trails not far from the campus where she taught along the foothills of State College, PA when early into her run it she felt a sharp pain in her knee.  Over the past few months, the pain became more on her runs as she started out; but the pain was short-lived.

“I only occasionally felt my knee running up a hill near my house and on various other hills around town, but it would usually go away after no more than 25-50 meters or even a few steps,” she said.

It was only a few months after giving birth to Lily, her first daughter, when her knee started to bother her.   Esther was fortunate to be able to train through her pregnancy.  She stopped running only for six weeks after giving birth to recover from her C-section.  Once the pain in her knee became more persistent Esther didn’t hesitate; she went to the doctor to have it examined.

Christine Saxon of Philadelphia, PA, on the other hand, had a completely different pregnancy. After being relegated to bed rest for complications during her pregnancy with her twins, Christine had to go through months of therapy just to walk again. When she started training, it was exhausting at first but soon she was back in the groove. It was about 18 months before she was able to train again, and now she was tempted to be a triathelete.

That was in January of this year. In May, Christine was on a long distance run in and around Philadelphia when it felt like someone had hit her in the knee with a baseball bat.

“I was about twenty-five minutes into a run and I felt this stabbing pain in my knee. I had to just stop running,” she noted. “I had to walk back.”

Where Do Injuries Originate?

Julie Everett, PT, DPT, a physical therapist at Excel Physical Therapy and Fitness in Philadelphia, PA is a specialist in knee injuries. A runner herself who has had numerous knee operations, she understands not only the physiological issues of knee injuries but the emotional and mental drives of athletes; runners in particular. 

“The issue with any injury is that it almost impossible to know exactly what went wrong first. A weakness in one part of our body can lead to an injury somewhere else.  A micro tear in a muscle can seem minimal until scar tissue fills those tears. Then you have a real injury that needs massage, strengthening, and rest, in order to heal. Runners in particular need to be patient or they’ll fail to heal properly.”

In our discussions about Esther and Christine, one commonality became clear. “When people feel something like a pencil stabbing them in the knee, a sharp pain, or something similar, this can happen from a weakness in our quads,” Julie Everett comments.  “For women who don’t have the quad strength to prevent over use of the hamstring, a lot of us suffer from tight hamstrings. We also suffer from tight quads that get balled up and can weaken from over exertion.”

And these weaknesses can lead to disorders – particularly in the tendons in and around the knee.

Esther and Christine were diagnosed with completely different knee injuries; both of which can be categorized as severe, needed physical therapy and a dedication to doing what was necessary to heal – including not running. Both have surgery as an option conservative management – rest, therapy, time, and patience are the recommended therapies for both women. 

This approach is supported by other sports physicians, surgeons, and other health care professionals who see overuse injuries in athletes all the time.  “Conservative management,” according to a paper by Rees et. al, is about rest, exercise, training modification, non-inflammatory drugs like Ibuprofen and sometimes steroid injections. Exercise, particularly in patellar injuries (in particular eccentric training), produced good results in patients.

But during pregnancy and after, it is impossible to know how women will respond to training. Rees, et. al suggests that the sports medicine community does not know exact dynamic can lead to these injuries – but usally assumes over use being the main problem; “the exact mechanism by which this [injury] occurs remains uncertain.”

Challenges of Women During Pregnancy

“A lot happens to women when they are pregnant,” Julie said   “There are more than the physical changes to our bodies. There are hormonal changes that also affect our running both during and after the pregnancy.”And after pregnancy things are not back to normal right away.

According to Finding Fitness After Baby:

“The knee, hip, and back are particularly susceptible to injury during and after pregnancy, and if you are predisposed to patellar (kneecap) problems, this may be a time when you could cause serious injury or inflammation. 

Running on hard surfaces, like pavement, are not recommended and the return to a regular schedule must be gradual.”

And it is these things, including vascular, mechanical, neural, skeletal and genetic variables, which play a part in injury.  Pregnant women and women post partum need to pay special attention during training. Fatigue, change in body composition, gait, weight during pregnancy, c-sections, and all of these other factors can make injury more prominent in new mothers. 

The good news, however, is that  many people react well to conservative management – and it is my belief that if runners can utilize conservative management in their training, we may even prevent the injury from happening.

Esther’s Knee Edema

Like many runners, Esther had a problem with tight hamstrings before she got pregnant. She had seen a physical therapist that referred to pain to tightness in her glutes.  During her pregnancy, however, “the only thing that really bugged me were my shins” she told me.  “It felt like they were working hard.” Aside from that, there were no complaints or issues. 

“This is because of a change to her center of gravity,” Julie reported. “The ligaments and tendons loosen up or merely function differently during pregnancy and because you are leaning forward more because that is where your center of gravity is, you change your gait and most likely, are running more on your toes, hence sometimes pregnant runners have tight calves or shins.”

And the long-term ramifications of running slightly forward for months probably put stress and weight on the knees and potentially stressing the quads.  This can have a damaging effect over time. Increased weight from pregnancy can also put undo pressure on the knees – causing the tissue to break down and for the bones to “bruise.”

The prognosis of Esther’s injury was that there was fluid in the knee and in the lower tip of the femur– clinically called Bone Marrow Edema (BME) which is described as increased free water or edema within the normal fatty marrow of the proximal femur – or in English, according to About.com, swelling in the knee which is indicative of injury to an area, and in some cases what may be seen within a bone (a “bone bruise”) or within the soft-tissues. Many times, knee edemas are associated with arthritis in the knee according to my research.

Studies have shown that there is no diagnosable reason for BME and it is referred to in the literature as “transient” bone marrow edema. One study suggested, interestingly, that transient bone marrow edema has been described in association with a number of conditions including arthritis or osteoporosis among other things.

What was interesting is that this condition can be related to pregnancy. According to the literature:

“Transient osteoporosis is one of several related conditions that have in common the development of self-limited pain and radiographic osteopenia affecting one or several joints, most commonly the hip. Transient osteoporosis of the hip was first described in the American literature in 1959 by Curtiss and Kincaid, who reported the condition intwo women, both of whom were in the third trimester of pregnancy.”

Regardless, Esther has experienced a condition where the surface layer of cartilage breaks down and wears away  (some may also refer to this as wear-and-tear arthritis). The breakdown of cartilage causes the bones under the cartilage to rub together (bone-on-bone). This probably contributed to the edema (swelling).

Christine’s Micro tears

Christine was über fit herself before she got pregnant. A long distance runner who also did long distance bike-a-thons, Christine really felt benched when she had some complications when she got pregnant with her twins.

”I was having so many complications, including suffering from an acute liver problem, that I was put on bed rest for months. I had to be put in rehab just to walk again.”

Fortunately, Christine gave birth to two healthy babies in April 2007 but for months afterwards, everything hurt.

“My thing was that I wanted to get back into shape. I wanted my old life back to normal,” she said. For about 18 months, Christine was engaged in rehab and then ran just to keep in shape.

Finally in the fall of 2008, “someone talked me into doing triathlons,” she said. The next thing she knew, she started training in January 2009 and was slated to do three races this year until her running incident in May.

For Christine, the pain, much like Esther’s, festered before it became chronic.  As she ran longer distances, her knee would ache as she got into the run.  An MRI showed she had an undersurface tear of the posterior horn in her knee a tear in her quadriceps tendon.

“When we overexert or if the quad muscle is weak we get micro tears in the muscle fibers. This feels like a stabbing pain in the knee. Scar tissue eventually fills the tears, which allow us to keep running, but the scar tissue stretches and causes pain.” Julie said. This explains why Christine was able to run even after the injuries occurred.

In Christine’s case her doctor asked her – “do you ever want to run again?”  With races on the horizon, “no” was not an option and she agreed to go to rehab.  Christine had to ditch the 3-inch heels she wore to work, which put stress on the knees, and commit to a treatment plan that forbade any running.

“This is a case where massage to break down the scar tissue is important,” Julie said. “In time, the scar tissue is broken down and the injury heals. This is a long-term process and requires a commitment to the treatment, which also includes stretching and strength training.” Julie added.

“I’ll admit, I was cocky,” Christine said. “I thought, ‘what do they know!’ After my first session when I felt nothing in the way of pain relief I was going to ditch the rehab but something in me told me to go back.”

After a couple of sessions, Christine saw the importance of the rehab. She could feel improvements and the pain in her knee decreased significantly, but she wasn’t to run a step until told.

Despite this, Christine went ahead and ran anyway.

“I only ran a mile but my PTs were pissed,” Christine emphasized. “I didn’t do what I was told.  Finally, they let me run on a treadmill really slow.”

That pace, a 10-minute mile was all she was allowed. While her ego told her to go faster, she soon realized the importance of the slower pace. Better slowly, than not at all.

The Job of the PT

“We don’t know where an injury begins to manifest itself,” Julie said. “Our job is to determine a program of exercises, massage therapy, and rest to get a patience to heal properly.”

Esther’s physical therapist made sure she was doing strengthening exercises and utilizing conservative management in her healing. 

“I didn’t run at between early April and mid July.  On July 14 I saw my sports med doctor and when I told her that the pain had disappeared and swelling had diminished, she said I could try running (alternating with walking). If there was any problem (pain, excessive swelling), then I should stop & we would consider an arthroscopic procedure. If there wasn’t a problem, then I could continue slowly getting back into running. And that’s what I’m doing now! It doesn’t feel “normal” yet, but there’s no pain or no more swelling than I used to have pre-injury, even though I’m not doing any of the strength exercises or stretches anymore.”

Christine , who is a patient at Excel Physical Therapy, is also treating her knee through exercise including active movement and stretching. 

While neither may race in the immediate horizon; in time, they will regain their gift of running again but it will take time and patience to heal – but more time to spend with family.

Editor’s Note: I hope to meet Christine and the Nation’s Triathalon in DC on September 13!

Sources:

Anatomy of the Quad. http://www.fitstep.com/Advanced/Anatomy/Quadriceps.htm

Rees, et. al., Management of Tendinopathy,  The American Journal of Sports Medicine, Vol. XX, No. X, 2009.

Suggested Further Research and Articles: 

Is there evidence to support the use of eccentric strengthening exercises to decrease pain and increase function in patients with patellar tendinopathy? -

How do Eccentric Exercises Work in Tendinopathy

Knee Pain – I highly recommend this link to look at the types of knee injuries there are and what some contributing factors are.