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