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: http://physioedge.com.au/pe-029-acute-knee-injuries-with-kurt-lisle/

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!

Change the foot, change the knee (and vice versa). A video case of External Tibial Torsion.

Here is a perfect example of external tibial torsion. Are you treating and training people and messing with their orthotics, squat knee-foot posturing or making gait/running/jumping changes or recommendations? If you are doing all of this and you do not know about tibial torsions, then shame on you, go apologize to these people right now. You could be causing them mechanical grief. Go buy them ice cream (even if they are “paleo”), that fixes most unintentional human mistakes. 

This is a classic presentation of external tibial torsion. This is an anatomic problem, you cannot fix this intrinsically, but you can help extrinsically. You teach these people about this issue and why the foot and the knee cannot cooperate. You teach them why their feet are spun out (increased foot progression angle) while their knee tracks straight forward sagittally. You teach them why they might heel strike far laterally and why their pronation phase might be abrupt. As in this video, you teach them why they might fashionably choose to narrow the foot progression angle (foot turned in) while at the same time having to bear weight on the lateral foot (in supination to externally spin the tibia) to keep the knee tracking sagittally. You teach them why this will be impossible to do in pumps (inversion sprain ouch) and why over time this will anger many joints and tendons. You teach them that without this accommodation they will track the knee inside the sagittal plane (as seen in the video).  You teach them why they might be at greater risk of having foot prontation issue pathologies, why they might have limited internal hip rotation, why orthotics likely do not do much for them (yes, there are exceptions), why certain shoes are a challenge for them while others are magical and why over time their once beautiful arch has begun to “fall” and be less prominent as they attenuate the plantar tissues.  

As you get good with this gait and biomechanics stuff, you should readily see and understand all of the issues discussed here today in a mere flash of instant brilliance so you know what to offer your client, in understanding and remedy options. As you have seen in this video, when left to their own devices, they naturally allow the knee to find the sagittal plane in a nice forward hinge. In this posture the foot is excessively progressed outward. Again, this is because of the tibial long bone torsion. This is their anatomy, this is not functional in this case. You cannot fix this, you help them manage this, first with their awareness, then with your brilliance.  You may implement exercises and gait strategies to help them become aware of mechanical issues and how to protect the foot-ankle, the knee and the hip. You teach them why they might have a tendency towards anterior pelvis posturing or sway back type postures. You teach them why, in some cases, they choose knee hyperextension as a comfortable yet lazy stance postural habit. You teach them why some shoes are “happy” shoes for them, and why others are pure evil.

A foundational principle we teach here at The Gait Guys is that the knee is a simple hinge between two multiaxial joints on either side of the knee, the hip and the foot-ankle complex. The knee really can only flex and extend, and when the mechanics above and below are challenged the knee has little depth to its abilities to tolerate much of anything except simple sagittal hinging. You can see that the foot posturing and tibial torsion rule the roost here in this video. You should learn in time that managing this case above and below the knee is where the pot of gold is found. You will learn in time that taping the knee is often futile, yet a worthy experiment both for you and the client in the discovery process, but that a life time of taping is not logical. External tibial torsion, although affording the knee that sagittal hinge plane, can narrow its range of safe sagittal mechanics and it is up to you to  help them learn and discover that razor’s edge safely and effectively when the torsion is large.  You should also discuss with them that as they plastically tissue adapt over the years (ie. pronate more and lose more arch integrity), this razor’s edge may widen or narrow for the knee mechanics as well as the hip and foot-ankle complex.  

For your reading pleasure, a classic example of how to interrogate a safe sagittal knee progression was discussed in this blog video piece we wrote recently, linked here.

Look and you shall find, but only if you know what you are looking for.

* Please now know that you should never off the cuff tell someone to turn inwards their outwardly spun foot. But if you do, have ice cream on hand, just in case.

Need more to spin your head ? Think about whether their IT band complex is going to be functioning normally.  Oy, where is that ice cream !

Shawn Allen, one of the gait guys

Patello femoral pain? Thinking weak VMO? Think again…

“Atrophy of all portions of the quadriceps muscles is present in the affected limb of people with unilateral PFP. There wasn’t any atrophy of the quadriceps in individuals with PFP compared to those without pathology. Selective atrophy of the VMO relative to the vastus lateralis wasn’t identified in persons with PFP.”

http://www.physiospot.com/research/atrophy-of-the-quadriceps-is-not-isolated-to-the-vastus-medialis-oblique-in-individuals-with-patellofemoral-pain/

Folks with patellofemoarl pain move differently. But they don’t necessarily engage their trunk differntly. We think we all knew this, but here is a study that looks at it. 

“Compared with the control group, the PFP group demonstrated increased ipsilateral trunk lean, hip adduction and knee abduction (p = 0.02-0.04) during single-leg squat accompanied with decreased trunk isometric strength (p = < 0.001-0.009). There was no between-group difference in trunk muscle activation. Only in the control group, ipsilateral trunk lean was significantly correlated with hip adduction (r = -0.66) and knee abduction (r = 0.49); also, the side bridge test correlated with knee abduction (r = -0.51). Differences in trunk, hip and knee biomechanics were found in people with PFP. No relationship among trunk, hip and knee biomechanics was found in the PFP group, suggesting that people with PFP show different movement patterns compared to the control group.”

Man Ther. 2015 Feb;20(1):189-93. doi: 10.1016/j.math.2014.08.013. Epub 2014 Sep 9.Trunk biomechanics and its association with hip and knee kinematics in patients with and without patellofemoral pain.Nakagawa TH1, Maciel CD2, Serrão FV3.

Foot orthoses and patellofemoral pain: frontal plane effects during running | Lower Extremity Review Magazine

We all see people with patellofemoral pain. Some of those cases may have responded to orthotic therapy. Some studies show that the effects on frontal plane kinematics are minimal (1 degree); this doesn’t mean it didn’t work, or this amount is not clinically significant. So why do they help? Perhaps it is a “timing” issue and the knee abduction moment.

“Our results are consistent with a 2003 study by Mundermann et al that compared the effects of custom orthoses (with posting, molding, or a combination of both) to flat inserts. For each orthotic condition, these authors reported a significant delay in the timing of the peak knee abduction moment. This finding may be related to the aforementioned clinical effects, as delaying the peak knee abduction moment would effectively decrease the rate of loading at the knee joint. The rate of loading has been previously implicated as a possible contributing factor in running-related overuse injuries, as runners with a history of injury have demonstrated a higher rate of loading of the vertical ground reaction force than runners with no history of running-related injury.”

This is an interesting take. If you have a few moments, give it a read:

Foot orthoses and patellofemoral pain: frontal plane effects during running | Lower Extremity Review Magazine

Podcast 81: Gait, critical, pure and essential principles

This week’s show sponsors: 

www.newbalancechicago.com

www.lemsshoes.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_81f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-81-gait-critical-pure-and-essential-principles

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Show Sponsors:
 

* Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

* Other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

 
Show Notes and links:
 
Forget Cheetah Blades. This Prosthetic Socket Is a Real Breakthrough
http://www.wired.com/2014/10/forget-cheetah-blades-prosthetic-socket-real-breakthrough
 
Rebuilding and Regenerating Damaged Knees: The Future Has Arrived!
http://www.huffingtonpost.com/nicholas-dinubile-md/rebuilding-and-regenerati_b_6043374.html
 
the foot gym:
 
From a reader:
Thanks for sharing all the great information over the years. I would like to pose to you some simple questions. How do you decide what area/s are relevant to the issue a patient presents? How do you decide what is “normal” given anatomical variations, history of injuries, torsion’s, etc., and if pain is present, why would you address biomechanics, since pain is a neurological phenomenon not a biomechanical phenomenon?
This may not be that simple but would like to hear what you have to say on these topics.
Thank you,
Joe 
 
COMPARISON OF ISOMETRIC ANKLE STRENGTH BETWEEN FEMALES WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196327/

 
the drawbacks of technology