patellofemoral tracking discorder

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

http://www.cnbc.com/id/102088318

Video case: The King’s Preference: Short and Sweet. A quick and easy case demonstrating the patellar tracking struggles with external tibial torsion.

Our favorite functional evaluation piece of equipment as well as our favorite piece of therapy equipment is the Total Gym. Here we clearly demonstrate, to us and the client, in partial weight bearing load, the effects of external tibial torsion.

Remember, the knee is sort of the King of all joints when it comes to the lower extremity. The knee is a sagittal plane hinge, and so all it wants to do is hinge forward, freely without binding from deficits at the hip or knee. But we cannot ignore the simple fact that pre-pubescent kids the long bone derotation process is still undergoing, and in adults the process may have been corrupted or insufficient.

In this case it should be obvious that the knee is sagittal and free to hinge when the foot is at a large foot progression angle. This allows the knee to hinge cleanly. But when the foot is corrected to the sagittal plane, as you see in the second half of the video, the knee tracks inward and this can cause patellofemoral pain syndromes, swelling, challenges to the menisci (and possible eventual tears) and challenges to the ACL and other accessory restraints. Additionally, this medial drift is a longer and more difficult challenge to the eccentric phase external rotators such as the gluteus maximius not to mention many of the other muscles and their optimal function.

So, the next time you see a large foot progression angle in a client or in their walk (duck footed if you will) try to resist the natural urge to tell them to corrrect the foot angle. They are likely doing it to keep the King happy. And furthermore, be careful on your coaching recommendations during squats, olympic lifts, lunges and running. Just because you do not like the way the foot looks doesn’t mean you should antagonize the King of joints.

External tibial torsion, its not something you want to see, but when you do see it, you have to know its degree, its effects at the knee, hip and foot as well as how it might impact hip extension, pelvic neutrality, foot strike, foot type, toe off and so many other aspects.

Whoever said gait analysis was easy was a liar. And if all they use is a video camera and fancy analysis software they have show up with only part of the team. And if they said they were an expert in gait only a few years into practice, you had better also look for a jester’s hat somewhere hiding in the corner. After all, the King would want to know !

Shawn and Ivo, your court jesters for the last 3+ years. Maybe we will get a promotion from the King someday soon !

More Proof that the Cross Over Gait has Pathologic Issues for Runners / Athletes.

We have referenced below yet another article in our 2 year long soap box rant that the cross over gait has many negatives to it. Two weeks ago we discussed the issues in greater depth in podcast # 23 (link: http://thegaitguys.tumblr.com/post/43424418001/podcast-23-neurology-of-walking-babies-dialogues-on) and further in a most recent blog post here (link: http://thegaitguys.tumblr.com/post/44060333371/step-width-alters-iliotibial-band-strain-during).

By this point pretty much everyone should be aware that pelvis width and femoral shaft angle orientation (Q-angle) parlays consistently into knee posturing and thus patellar tracking. Loosely it goes to say a wider pelvis often makes for a knee tracking challenged environment. But today’s reference article takes this a little deeper.

Running mechanics always have to be approached from above the knee and below. If the foot collapses too far inwards the internal spin put on the tibia will drag the knee inwards and generate a mal-tracking environment. And from above, if the gluteal muscles are underperforming they cannot assist in holding the femur in sufficient abduction and external rotation to prevent excessive internal spin from above, thus also enabling a mal-tracking environment from developing. These are well established theories with plenty of research and years to back them up. The verbiage “proximal control for distal control” holds. Or, “proximal stability for (proper) distal mobility” also holds true but one needs to never forget about the critical importance of the far distal (foot/ankle) foundational support.

In today’s study from 2012 there is really nothing earth shatterning to most of our readers but we wanted to again bring these thoughts are results to you and keep the cross over gait in your ever-present mind. The conclusions of this Harvard study were predictable, that being:

“the finding of greater hip adduction in female runners who develop PFP is in agreement with previous cross sectional studies. These results suggest that runners who develop PFP utilize a different proximal neuromuscular control strategy than those who remain healthy. Injury prevention and treatment strategies should consider addressing these altered hip mechanics.”

So the study eludes to the fact that not only is it about the anatomy of the parts but also about the functional control of the parts. Without adequate control from above and support from below the knee, it will be difficult to control a largely uni-planar joint (the sagittal flexion/extension of the knee hinge) when the support of a multi-planar joint complex (foot/ankle) from below is insufficient and the control of a multi-planar joint complex above the knee (hip/pelvis) is insufficient. When one or especially both are compromised the knee will be compromised. It may take weeks or months or even longer for the process to render joint change or pain but without sufficient biomechanics the system is likely to fail. And further more, one needs to realize that shoes and orthotics often are an incomplete (and very often an insufficient and inadequate) remedy. One must “earn it to own it”.

If you find you are new to our work and want to catch up on the Cross Over gait topics we have covered previously, try starting here (link: http://thegaitguys.tumblr.com/search/cross+over) and here (link: http://thegaitguys.tumblr.com/search/cross+over+gait). We are likely to continue to build on this disfunctional paradigm.

Shawn and Ivo
The Gait Guys

Reference:

Med Sci Sports Exerc. 2012 Dec 27. [Epub ahead of print] Prospective Evidence for a Hip Etiology in Patellofemoral Pain. Noehren B, Hamill J, Davis I. Source

1Division of Physical Therapy, University of Kentucky, Lexington, KY 2Department of Exercise Science, University of Massachusetts, Amherst, MA 3Spaulding National Running Center, Harvard University, Cambridge, MA.

Abstract PURPOSE:

Patellofemoral pain (PFP) is the leading cause of knee pain in runners. Proximal and distal running mechanics have been linked to the development of PFP. However, the lack of prospective studies limits establishing a causal relationship of these mechanics to PFP. The purpose of this study was to prospectively compare running mechanics in a group of female runners who went on to develop PFP compared to healthy controls. It was hypothesized that runners who go on to develop PFP would exhibit greater hip adduction, hip internal rotation, and greater rear foot eversion.

CONCLUSIONS:

The finding of greater hip adduction in female runners who develop PFP is in agreement with previous cross sectional studies. These results suggest that runners who develop PFP utilize a different proximal neuromuscular control strategy than those who remain healthy. Injury prevention and treatment strategies should consider addressing these altered hip mechanics.

How to (and how not to) do a single leg squat, CORRECTLY !

Here Dr. Allen has one of his elite marathon and triathletes demonstrate how to correctly and incorrectly do a single leg squat. The single leg squat can show many of the pathologic movement patterns that occur in a lunge. The single leg squat is more difficult however because it requires balance and more strength. Many people do not do the single leg squat correctly as you will see in this video. Many drop the opposite hip which means that there is an inability to control the frontal plane pelvis via the stance leg gluteus medius and the entire orchestrated abdominal core. Most folks will drop the suspended hip and pelvis and thus collapse the stance phase knee medially. This can lead to medial knee pain (tracking disorder in the beginning) , a driving of the foot arch into collapse and impingement at the hip labrum. We know that when the knee moves medially that the foot arch is under duress. This problem is often the subliminal cause of all things foot arch collapse in nature, such as plantar fascitis to name a common one. Remember, optimal gluteus medius is necessary here. And the gluteus maximus is working to eccentrically lower the pelvis through hip flexion. So, if you do not consider the gluteus maximus a hip flexor then you are mistaken. Everyone thinks of it as a powerful hip extensor and external rotator. But do not be mistaken, in the closed chain it is a powerful eccentric controller of hip flexion and internal hip rotation.

Tomorrow we will look at this same case and look at her feet and discuss those as a problem, predictor and limiting factor to long term optimal function.

We are The Gait Guys,

Shawn and Ivo (visit our blog daily at www.thegaitguys.tumblr.com)

(Source: http://www.youtube.com/)

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