Medial knee pain in a skier.   Considering an orthotic?  You had better know what you are doing! 

Can you guess why this gal has pain in both knees? Especially when skinning up a hill and skiing down? 

 Take a close look at the photos above and notice the orientation of her knee with her foot. Now look at you tuberosity and drop a line straight downward.  This line should pass through or slightly lateral to the second metatarsal shaft. Can you see how it falls to the outside of this? Perhaps even between the third and fourth metatarsal?

This gal has bilateral internal tibial torsion.  When she wears a standard foot bed (creates a level surface for the right for the foot) or an orthotic without appropriate posting, it pushes her knee outside of the saggital plane. This creates abnormal patellofemoral tracking  and appears to be a major contributor to her pain. 

 You will notice that we placed a valgus post under the orthotic(  a post that is canted from lateral to medial) which pushes her knee to the midline as the first ray descends.  You can see her alignment is better with her boots on and the changes. 

 The bottom line? Know your torsions and versions.  Posting a patient like this incorrectly could result in a meniscal disaster!

Lower limb muscle strategies in low back pain patients.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. It is possible that your client may be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired. This problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges.

So you have sporadic low back pain and knee pain. Could they be linked ?

It has been a long believed rule that it is “all about the core”.  We have learned in recent years that this should be a very loosely accepted rule. 

In an old blog post (link) we stated some deeper truths:

Dr. McGill discusses the basic tenet that the hips and shoulders are used for power production and that the spine and core are used for creating stiffness and stability for the ultimate power transmission through the limb.  He makes it clear that if power is generated from the spine, it will suffer.  As gait experts, you should never forget this principle, if the spine and lumbopelvic interval is not strong/stiff and stable enough, the limbs can over power them and thus your gait, your running, your sport, could be causing you pain as the forces are poorly managed as they attempt to traverse the spine. 

Here we find a study referenced below that suggests that when the lumbopelvic interval is fatigued, that the lower limb muscles may step up activity.  This is a neat concept, not earth shaking by any means, but it nice to have studies that help solidify knowledge of compensation strategies.

“Individuals with low back pain (LBP) have been shown to demonstrate decreased quadriceps activation following lumbar paraspinal fatigue. The response of other lower extremity muscles is unknown. The purpose of this study was to determine changes in motoneuron pool excitability of the vastus medialis, fibularis longus, and soleus following lumbar paraspinal fatigue in individuals with and without a history of LBP.” 

What this study attempted to do was perform a controlled laboratory study designed to compare motoneuron pool excitability before and after a lumbar paraspinal fatiguing exercise. Twenty individuals (10 with history of low back pain) performed isometric lumbar paraspinal exercise until a 25% shift in paraspinal muscle surface electromyography median frequency occurred. 

What they discovered was that the soleus motoneuron pool excitability increased following lumbar paraspinal fatigue independent of group allocation and occurred in the absence of changes in vastus medialis or fibularis longus muscles. 

The authors propose that “increased soleus motoneuron pool excitability may be a postural response to preserve lower extremity function”.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. They very well could be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired.The problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges. 

Dr. Shawn Allen, one of the gait guys.


J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain.Bunn EA1, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.

What have we listened to lately? Patello Femoral Pain!

The David pope Physioedge PODcast with  Dr Micheal Rathleff talking about adolescent patellofemoral knee pain, which has a prevalence of 6 to 7%. 

Here is our summary: 

Two thirds of the population do sports five times per week and often do the sports with pain. This group (adolescents) has usually been doing one sport their entire life and has had pain on and off. The other third of the population are adolescents who do not play sports at all. This group often are going from primary secondary school and encounter a lot of stairs or increased amounts of activity which is believed to contribute to the condition. So the majority are increased intensity or frequency of load whereas the other one is increased load only.

For the first group, playing in identifying with the sport is part of their social network and they would rather play with pain than be excluded.

One of the questions was “is there a different treatment protocol for each group”? 

The short answer is no. Many times and adolescent in the “overuse” group is given additional exercises. Often this just contributes to increasing load. Education appears to be key in the rehab process. Males with the shortest duration of pain and lowest intensity seem to be the best responders to this program. Females with longest duration and highest intensity of pain seem to respond the least.

Not surprisingly, compliance with treatment protocol can be difficult with a teenager. In a recent RCT that they performed, 55% of folks that did their exercises three times per week were recovered in one year whereas those that did less were at 20%.  These statistics are often put on the chart, laminatedand shown to the patients. This seems to improve compliance.

Another chart is made with these bullet points: 

  • Low hip strength
  • low quadricep strength
  • different movement pattern. 

The anatomy is then shown and explained to the patient and an attempt is made to tie it all together.

Differentiation is made between: patellofemoral pain, Osgood-Schlatter’s disease, and patellar tendinopathy. The differentiating factors are with patellofemoral pain, the pain is diffuse; with Osgood-Schlatter’s it’s located over the tibial tuberosity and with patellar tendinopathy it is more at the inferior patellar pole.

Differentiation is always made between Sinding-Larsen-Johannsen disease and the others by the fact that this is mostly pain at the inferior patellar pole and relatively rare and adolescent population.

Differentiation between patellofemoral pain and Osgood-Schlatter’s disease usually involves the latter having locking in addition to pain. These conditions are usually confirmed with ultrasound or MRI.

There don’t appear to be specific reliable tests to rule in patellofemoral pain so the process becomes one of ruling out.

Palpation in the diagnostic process of course please large role. Also specific localization by the patient can be helpful. Dimension and “app” that the patient can draw on to show the examiner where the knee pain is. We really like this idea. 

Exclusionary tests include the patellar fat pad compression test, but it is emphasize that this is more generalized rather than specific to the Tele femoral pain and a brief discussion as to its anatomy ensues. 

Treatment includes 3 main steps

  1. patient education as to activity limitations. 
  2. Patient refrains from activities a check of the pain for approximately four weeks and then his gradually reintroduce as long as they can keep their VAS scores below three. 
  3. Exercise can begin at the four-week timeframe, again depending upon the patient’s symptoms. A gentle progression with pain as a guide is advised with a return to activity previous activity as early as 5 to 6 weeks. Frequency of training is increased first and then duration of training.

Exercise initially is confined to the more proximal joints such as the core and hips.  They begin with open chain, theraband exercises (which we do not necessarily agree with). They also do RM testing 10 to 12 reps.some standardization is done with regards to therapy and length and amount of travel.

Compliance is discussed as adolescence often have an extensive social network. Exercise in 15 minute intervals is encouraged. Prognostically it shows that patients that can control their loads earlier tend to do better longitudinally.

Foot orthoses are discussed but it is pointed out that there is not a lot of data and research on their efficacy in an adolescent population for the telephone real pain. He goes on to talk about how a foot orthoses “takes your brain out of the equation” and can provide some degree of increased compliance albeit, passive. The orthotics are left in until they are “worn out” (they use a great expression:”until the natural mortality of the orthotic runs its course” which we loved ! and then see how the patient does.

Hip strengthening is discussed. It appears that adolescents develop weaknesses after patellofemoral joint pain,  not as a result of it. 

Other treatment modalities included “fat pad unloading tape”. A “v”  pattern is done with crossing at the tibial tuberosity. The Chris Barstann method is given in a YouTube link is provided. Plane “white tape” can be utilized for adolescents who hyper extend their knees, with the tape running behind the knee a few hours at a time.David talks about an anchor above and below the knee with an X pattern crossing at the middle of the popliteal fossa and having the knee in slight flexion.

So after the progression of one activity modification, two taping three therapy and exercises they then move onto hip strengthening with close chain exercises such as squatting and lunches.backpacks with different amount of weight totaling there 10 or 12 RM are then employed. Care is exercised to keep them in a pain-free range. When they can accomplish this then they move onto one legged work

Stretching was deemphasized because of the increased compression at the patellofemoral joint.

Guidance as to speed, frequency and ranges of motion of exercise are carefully given to each patient. Eight seconds of time under tension for each repetition using a thorough band (three second concentric, two second isometric hold, three second eccentric) adding up to 80 seconds for each 10 repetitions. This allows good proprioceptive control because of the long contraction and increased exercise dose. They often use a “smart phone” to video the exercise for the patient (with the doing this for years and it’s a great way to assist in compliance; a person may lose a sheet of paper or their keys but they will not lose their phone).

All in all, an informative PODcast for those who have a deeper interest in treating PFP in the adolescent population.

The Gait Guys

link to PODcast:

Heat Exertion and Gait Decline

Changes in gait characteristics are found when exertional heat stress is experienced during prolonged load carriage.  As heat stress increased, step width decreased while percent crossover steps increased. Reduced stance time variability, step width variability, and percent crossover step were observed.  These are frontal plane gait parameters for the most part. 

Think about these things during your long summer run or as you go deeper into those last miles of your long run.  Simple muscular fatigue in the frontal plane hip-pelvis stabilizers are going to render the same results.  This is quite possibly why many problems and injuries crop up in the latter miles of your run. 


Gait Posture.

2016 Jan;43:17-23. doi: 10.1016/j.gaitpost.2015.10.010. Epub 2015 Oct 23.Using gait parameters to detect fatigue and responses to ice slurry during prolonged load carriage. Tay CSLee JKTeo YSQ Z Foo PTan PMKong PW

We had a great PODcast in the studio last Friday, talking about tendon vascularity and compression vs tension therapies for tendinopathies.

Here is a great FULL TEXT article on tendon vascularity that can serve as a catalyst for designing your treatment programs

Neovascularization is critical to tissue repair and wound healing. Therefore, strategies to enhance vascularization to promote regeneration are considered promising treatment modalities, i.e., the use of platelet rich plasma (PRP) to restore functional bone (Zhang et al., 2013) or skin (Kakudo et al., 2011). However, in acute or chronic tendon injuries hypervascularity often does not pave the way to functional recovery of the tissue. Therefore, to overcome the limited intrinsic regeneration capacity of tendon and to achieve scarless healing will most likely require a balanced manipulation of the angiogenic response in tendon tissue. For a variety of treatment methods, such as the use of PRP, the availability of clinical data is limited, due to heterogeneity in application (Khan and Bedi, 2015). In order to develop rational strategies to achieve a well-balanced angiogenic response following tendon injury, we need a thorough understanding of the molecular and cellular networks driving tendon vascularization and regeneration—a challenge for years to come.”

image from:

link to full text:

Ankle spains and hip abductors

We see it ALL THE TIME. But sometimes it is nice to point out the obvious, just in case you are not looking for it.
“Conclusions: Our subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar-flexion range of motion on the involved sides. Clinicians should consider exercises to increase hip abduction strength when developing rehabilitation programs for patients with ankle sprains.”-Friel et al
Dr. Allen: if the hip abductors are weak, the leg will posture more adducted (ie, cross over type pattern) and this places the foot more directly below the body midline plumb, this will posture the foot in inversion and thus at greater risk for future inversion sprains.  This sets up the vicious cycle of hip abductor weakness, frontal plane drift of pelvis, inversion of the foot and more ankle sprain risks/events.  The cycle must be broken. The hip must be addressed. That lateral chain must be restored all the way up from the foot.  All stuff you likely already know, but good to find another study to validate.

Dr. Allen

J Athl Train. 2006; 41(1): 74–78.PMCID: PMC1421486Ipsilateral Hip Abductor Weakness After Inversion Ankle SprainKaren Friel,Nancy McLean,Christine Myers, and Maria Caceres

Why don’t some folks pay attention to anatomy?

Movement isn’t important…until you can’t…

Grey Cook

Manipulation of a joint appears to change the instantaneous axis of rotation of that joint (1). It would stand to reason that this change would effect muscle activation patterns (2). Can this be applied to the lower extremity? Apparently so, at least according to this paper (3). 

“…The distal tibiofibular joint manipulation group demonstrated a significant increase (P<.05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention (P=.48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease (P<.05) from baseline values in fibularis longus (10-30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.”

So, what does this mean?

The peroneus longus contracts from just after midstance to pre swing to assist in descending the 1st ray and assist in supination. The soleus contracts from loading response (medial portion, eccentrically, to slow calcaneal eversion) until just after midstance (to assist in calcanel inversion and supination). 

The tibiofibular articulation is a dynamic structure during gait, and the fibula appears to move downward during the stance phase of gait (rather than upward, as previously thought from cadaver studies)(4), with the distal articulation having a rotational moment (5). 

Consider checking the integrity of these joints, and asuring their proper ranges of motion, particularly in patients with chronic ankle instability (6). A little joint motion can go a long way : ) 

1. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint LaxityCraig R. Denegar, Jay Hertel, Jose FonsecaJournal of Orthopaedic & Sports Physical Therapy 2002 32:4, 166-173 

2. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee painSuter, Esther et al.Journal of Manipulative & Physiological Therapeutics , Volume 22 , Issue 3 , 149 – 153

3. Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability.Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel JJ Electromyogr Kinesiol. 2011 Aug;21(4):652-8. doi: 10.1016/j.jelekin.2011.03.011. Epub 2011 May 4.

4.  Dynamic function of the human fibula. Weinert, C. R., McMaster, J. H. and Ferguson, R. J. (1973), Am. J. Anat., 138: 145–149. doi: 10.1002/aja.1001380202

5. Kinematics of the distal tibiofibular syndesmosisAnnechien Beumer , Edward R Valstar , Eric H Garling , Ruud Niesing , Jonas Ranstam , Richard Löfvenberg , Bart A Swierstra  Acta Orthopaedica Scandinavica  Vol. 74, Iss. 3, 2003

6. Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle InstabilityJames R. Beazell, Terry L. Grindstaff, Lindsay D. Sauer, Eric M. Magrum, Christopher D. Ingersoll, Jay HertelJournal of Orthopaedic & Sports Physical Therapy 2012 42:2, 125-134