Frontal Plane and Knee Pain: Tennis Player

             Your plane or mine?

Dysfunction is quite common in the frontal plane. Beyond uncontrolled or excessive valgus is a cornucopia of goodies to dig into. This image is perhaps a bit dated and myopic but serves it purpose. The key musculature responsible for providing frontal plane stability while on a single leg has been drawn in. 

I like how this second image expands the view further up and down the kinetic chain. One area that I think is often overlooked is inversion and eversion of the calcaneus. Another is the impact that the shoulder complex (or thoracic spine) can have down through the chain. You can take an even more complex look through the Thomas Myers Anatomy Trains lens as well. The lateral line, spiral line and arm lines can easily be added into the equation.
I have been working with a tennis player who has reported left knee pain, right shoulder pain/tightness, and left medial heel pain. Their left knee pain when they are playing singles and have to move quickly to the net, especially on hard courts, is their primary source of discomfort. They are right hand dominant and display many of the imbalances that you would expect from a tennis player. I have used; static postural analysis (standing-anterior, posterior and lateral views, seated-A,P,L views, supine and prone positions), the Functional Movement Screen, and NASM’s Overhead (regular and two modified versions) and Single Leg Squat assessments.  I performed goiniometric assessments on the major load bearing joints and manual muscle testing on some of the key players based on the results of her previous assessments. I also checked their sacroiliac joints and subtalor joints. Their thoracic rotation was limited when they rotated to the right (tried to look over their right shoulder for example). Unlinke the #3 picture above, this client did not have the thoracic mobility to reach over head in the frontal plane without causing disjointed pronation on the left and some excessive supination on the right.
In NASM nomenclature their right knee aBducted at the bottom of the Overhead Squat and left knee aDducted. There was more right knee aBduction than left knee aDduction. Their right shoulder did not maintain flexion as well as the left. There was an asymmetrical weight shift to the right at the bottom of the squat as well. When on a single leg this client demonstrated poor stability and their stance leg knee moved in excessively (aDducted) when standing on either leg. When standing on their left leg their trunk also moved inwards during the descent of the squat.
I released their; adductor complex (spent longer on the right adductor magnus than the left “flexor” adductors due to limited right hip internal rotation), TFL (right more than left due to limited hip extension on the right), right piriformis, right biceps femoris (both heads), right quadratus lumborum, right lat, right pec minor and both calves. I mobilized their right SIJ (which was restricted mildly in the sagital and frontal plane and moderately in transverse plane) and right illum (which was elevated and rotated anteriorly). Then assisted them in performing some thoracic mobilizations.  We then performed some activation techniques for their deep core stabilizers and  left glute maximus and minimums.
We then progressed to some additional correctives including; a 1/2 kneeling tubing chop (I used a Grey Cook purple tube), left VMO, left medial gastroc activation, left medial hamstring activation and split stance front foot elevated tubing (same tube) lift.  I have them repeating the SMR and corrective work 5-6 times per week in addition to their general warm up before workouts and tennis. Their workout consists mainly of corrective exercise and includes core stability training and total body/integration types of exercises designed to help them relearn common movement patterns. I only have the client perform exercises that they can control without repeating their movement faults observed during the assessment process. They also complete an SAQ and conditioning workout several times per week. No plyos at this time.
We also discussed their footwear. They wear pronation control running shoes (even though they don’t run for conditioning) when not on court and tennis shoes when on court. I recommended that they move away from the running shoe because of the elevated heel. They have higher arches so the support feels good for them when in the pronation control show so we went to a hiking/walking shoe that has a much lower heel but still had some support for the medial arch.  We also have discussed the importance of preparation and recovery from a movement and nutritional stand point. Specifically focusing on the odd stint of time away from the tennis court. It appears that travel plus 3 or more days out of their regular routine exacerbates old (or new) aches and pains. My recommendation was to enjoy the time away from the game, but to go through their corrective work, dynamic flexibility and light cardio (just enough to break a sweat) every day that they are away. This program would take 20-30 minutes and help them to recover “actively” while off away from the tennis court and ease their return a few days later. If they are feeling burnt out and can’t bear the sight of a roller, some tubing or a gym, then just get some body work while on the road at the very least.
Does any of this sound familiar?
Do you have clients with similar issues?
Anything else that you have grown in that has worked well?
Thanks for reading! And oh yeah….Happy New Year,
Eric Beard
Corrective Exercise Specialist
Integrated Manual Therapist
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