So here is somewhat of a controversial subject.

Perhaps, though not discussed in this article, activating more axial extensors (vestbulospinal pathways, things like your erector spinae) could be somewhat protective, in that it could, at least theoretically, help to normalize flexor/extensor ratios in the lower extremity. 

We see flexor dominance (increased corticospinal activity) in many cases of lower extremity problems causing an imbalance. Perhaps activating extensors the lower extremity (tibialis interior, extensor digitorum longest, etc.) could explain, in part, some of these (controversial) results.

We’re not recommending or condoning taking up smoking to preserve your knees. This is merely food for thought in the ever-changing landscape of clinical application.

Holy twisted tibias Batman! What is going here in this R sided knee pain patient?

In the 1st picture note this patient is in a neutral posture. Note how far externally rotated her right foot is compared to the left. Note that when you drop a plumbline down from the tibial tuberosity it does not pass-through or between the second and third metatarsals. Also note the incident left short leg
In the next picture both of the patients legs are fully externally rotated. Note the large disparity from right to left. Because of the limited extra rotation of the right hip this patient most likely has femoral retro torsion. This means that the angle of her femoral head is at a greater than 12° angle. We would normally expect approximately 40° of external Rotation. 4 to 6° is requisite for normal gait and supination.

In the next picture the patients knees are fully internally rotated you can see that she has an excessive amount of internal rotation on the right compare to left, confirming her femoral antetorsion.

When this patient puts her feet straight (last picture), her knees point to the inside causing the patello femoral dysfunction right greater than left. No wonder she has right-sided knee pain!

Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).

a note on tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°). more cool stuff on torsions here

Wow, cool stuff, eh?

What are we listening to this week? 

The Physio edge podcast with David pope. This week they interview Kurt Lisle about anterior knee pain. Here is our synopsis:

One of the things they empahasized right off the bat was that patellofemoral pain not only refers about the knee but also below or most importantly posterior to the knee. The fat pad had a tendency to refer more locally where is other structures can refer to other areas.

Aggravating factors for patello femoral dysfunctional pain tends to be flexion or activities involving flexion as well as compression of the knee and rest is in alleviating factor.

The fat pad pain tends to be to either side of the patellar tendon and sometimes directly under it. This can be aggravated by standing, particularly with the knee and hyperextension, which compresses the fat pad.

Patellar tendon pain tends to remain at the inferior pole of the patella on the tendon whereas patellofemoral pain has a tendency to refer more.

Physical examination pearls:

  • Patellar tendonopathy alone generally does not have effusion present where as the patellofemoral or fat pad injury may.
  • Is there pain in passive hyperextension? This generally can mean fat pad injury or potential he ligamentous injury.
  • Visually you may palpate a thickened fat pad, particularly in females.
  • Pain with passive motions generally points away from patellar tendon.
  • Dialing in as to where and when they are having their pain is an important part of the functional evaluation.

Kurt likes to do a table top examination first to ensure functional integrity of the knee before jumping right to functional tasks. His concerns are (which are valid) is the knee up to the task you’re about to ask it to do? Good advice here.
He emphasizes the need to be systematic and consistent in your examination, no matter how you examine them. Develop a routine that you follow each and every time. He recommends passively looking at the knee in extension and 90° flexion.

There is a discussion on functional movement about the hip and pelvis, knee, and foot and ankle. Emphasis is made, for example at the knee, as to “is the knee moving medially and laterally or are the femur and tibia rotating mediately or laterally” in which is precipitating the pain?

“Catching” of the patella is often due to patellofemoral pathology such as a subchondral defect, slap tear of the chondral surface, or abnormalities of the trochlea of the femur.

Advanced imaging strategies are also discussed with a brief overview of some of the things to look for.

Finally treatment strategies were discussed. It is emphasized that identifying the specific activity or change activities that’s causing any pain he’s made as well as activity modification. We were happy to hear that footwear and its role in knee as well as hepatology was discussed as well as looking at occupational contributions to the pain.

There was emphasis on exercise specificity particularly with respect to if the problem was unilateral not giving “blanket” exercises for both knees but rather concentrating on the symptomatic side.

A discussion on the use of EMG and activation patterns was also entertained with some good clinical pearls here. More marked rather than subtle changes and activation side to side seem to be more clinically significant. In other words, with respect training, can they achieve similar levels of activation on each side with a similar activity (for example isometric knee extension with the leg bent 60°).

The judicious use of tape from a functional testing standpoint was interesting. Emphasis was made that tape is not a cure and will merely a tool.

All in all and informative, concise podcast with some great clinical pearls and a nice review of the knee and patellofemoral pain.

link to PODcast:

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!

What were they thinking? Oh, they weren’t thinking…

Here is a simple case of knowing your anatomy. 

make sure to use the toggle bar to the right and left of the picture to see all the pictures : )

This woman came in with right sided lateral knee pain with hiking and skiing; worse with fatigue, better with rest. The pain was localized at the lateral joint line and at the tibial fibular joint. 

She had been previously been diagnosed with tibial fibular hypermobility and subsequently had an arthrodesis (fusion) performed at that joint for knee pain. The surgery helped for a short time and a newer, slightly different pain developed. 

Yes, she has a moderate genu valgus, R > L. Yes, she has a left, anatomically short (tibial) Left leg. Yes, she has has NO MOBILITY at the tib/fib articulation and the focus of pain is just above at the joint line and at the lateral aspect of the patello femoral joint. 

The tibial fibular joint is a syndesmosis (not a true synovial or diarthrodial joint) that is supposed to have a a superio/inferior gliding motion (see diagram) with ankle dorsiflexion, due to the wedge shape of the talar dome and talo crural articulation. It also is supposed to have an anterior/posterior gliding movement at the superior aspect of the joint and a reciprocal movement in the opposite direction at the ankle (see diagram).

Whenever we take away movement in one area, it needs to occur somewhere else; in this case, at the femoral tibial joint and patello femoral joints.

Does it make sense that her left sided leg would cause hypermobility on the right side with a supinatory moment of the foot on the left to attempt to lengthen the leg and a pronatory movement of the foot on the right, in addition to valgus angulation of the joint on the right to attempt to “shorten” that extremity? Would this increased valgus angluation of the knee, in turn, cause abnormal, lateral, tracking of the patella? Wouldn’t the increased pronatory moment cause a more supple foot on that side with increased requirements for “push off” on that side with increased calf recruitment? Do you think that may impair proprioception on that side?

What if you put a sole lift in the left shoe (like we did) to help to alleviate some of the discrepancy and gave her some anterior compartment exercises (toes up walking, lift/spread/reach exercises, heel walking, simple balance on 1 leg exercises? Her world becomes a much better place to live in and she can return to the activities she loves to do with her 65 year old friends, like hiking 14′ers, skiing and mountain biking,

What we do to one joint affects all the others. You cannot make one change without expecting others. Be on the lookout and know your anatomy! This case was relatively straight forward. Many are not. Do a thorough exam and expect the unexpected. 

Now THERE”S some internal tibial torsion!

So, this gent came in to see us with L sided knee pain after it collapsed with an audible “pop” during a baseball game. He has +1/+2 laxity in his ACL on that side. He has subpatellar and joint line pain on full flexion, which is limited slightly to 130 (compared to 145 right)

 We know he has internal torsion because a line drawn from the tibial tuberosity dropped inferiorly does not pass through or near the plane of the 2nd metatarsal (more on tibial torsions here)

What would you do? Here’s what we did:

  • acupuncture to reduce swelling
  • took him out of his motion control shoes (which pitch him further outside the saggital plane)
  • gave him propriosensory exercises (1 leg balance: eyes open/ eyes closed; 1 legged mini squats, BOSU ball standing: eyes open/eyes closed)
  • potty squats in a pain free range
  • ice prn
  • asked him to avoid full flexion

Is it any wonder he injured his knee? Imagine placing the FOOT in the saggital plane, which places the knee FAR outside it; now load the joint an twist, OUCH!

L sided medial knee pain in a TKR patient

So, why does this gals L knee hurt, posterior and medial on the left?

  • L total knee replacement 6 years ago; she thinks they used too large a size, we would have to agree.
  • occassional peripatellar discomfort
  • current pain descending hills and stairs, posterior and medial on the left

Physical findings

  • tenderness at posterior, medial aspect of knee at the top of the tibial plateau
  • positive anterior and posterior drawer +2
  • McMurrays for clicking with valgus and varus stresses
  • negative valgus/varus stress
  • all muscles test strong except for one, which one is it?

Read on…

Here is our theory:

This particular muscle fires at heel strike and again from loading response until toe off (you can look at the diagram above if needed). It also acts as an acessory posterior cruciate ligament (PCL).

Think about the forces on the knee while descending hills or stairs. The momentum will carry the femur forward (or anteriorly). There needs to be something to reststrain this; enter the PCL.

Because of the laxity (and instability), the poplitues needs to fire to take up the slack. Palpation confirmed it being tender throughout its course, with most at the tibial attachment. The attachment is largest here, so that makes sense. The muscle also tested weak.

We gave her popliteus and 1 leg balancing exercises in addition to doing acupuncture (origin/insertion work) as pictured. 5 days later she was 60% improved. She may need to return to her ortho, depending on her response to additional care.

Think about the popliteus the next time someone has posterior medial knee pain, especially when descending.