A Coach with Anterior knee pain:  About as common a problem as finding dirt on a child.

We get emails like this all the time. Here is one from a coach with a problem.

Hi Gait Guys,

I was just found your blog visiting one of the running sites I like coachjayjohnson.com. I’m a high school xc/track coach and a former runner myself. I say former because I dug a nice hole in my cartilage in the lateral trochlear groove about 4 years ago from running. This actually happened 3 months after I stopped wearing the custom orthotics i had been wearing for about 8 years. What a mistake that was, but the biggest mistake might have been getting them in the first place.

Anyways, 3 months ago I had a procedure done to regrow the cartilage. this was done at the stone clinic in San Francisco. The doctor said I should wait a year before I attempt to run again. I’m fine with that but sometime next year once my knee is feeling good enough I’d like to come see you guys before I start running again so that you can help analyze everything and get me out there running again with good form and in the correct shoes etc. Where are you guys located? Also, are you going to come out with some new DVDs?

Thanks,
(name removed)

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What The Gait Guys have to say …

Dear Coach:

(Links in our discussion have been embedded for you and other readers and we have included a picture above so everyone else will know where your problem was.)

Anterior knee pain in runners is about as common a problem as finding dirt on a child. You have described the all to common, osteochondral defect. IT is a defect of bone and cartilage quite often from blunt or repetitive trauma.

Knee joint anterior malalignment is multivariably associated with patellofemoral osteoarthritis (study). Alignment issues at the knee can be driven by variations of the optimal anatomy (versions and torsions, see a post on this from ~3 weeks ago) but in our opinion they are often driven from other factors most notably improper biomechanics driven by muscle weaknesses-tighness. However, other factors can come into play to complicate the scenario, such as poorly selected footwear for a foot type. Alignment at the knee is subservient to the mechanics at the hip and foot. Both the hip and foot are multiaxial  joints, whereas the knee in its healthy state and most basic description, a sagittal hinge joint (sure, miniscule rotation). When the hip or foot are prostituted and some of the availability of their normal motion is lost or changed (as is possibly the case of an orthotic as you eluded to, however in the hands of a skilled practictioner the orthotic can help positively restore compromised function, if they understand and assess whole limb kinetic function) the knee joint can often find itself in the middle of altered biomechanical force streams. This all to often can lead to anterior knee pain, compromised function of the patellofemoral joint.  This, as in your suspected case, can lead to abnormal cartilage wear at the interface of the two bones.

In one article it was proposed that physical activity may modify the association between joint incongruity and cartilage loss, and can be further affected by subject characteristics such as gender. It must be part of the thought process that rather than it being the activity, is more likely to suspect altered biomechanics during said activity as being the culprit.  Understanding these complex interactions will help optimize strategies to maintain patellofemoral joint health. However, this study found that for every one-degree increase in the proximal trochlear groove angle at baseline, there was an associated 1.12 mm  increase in the annual rate of patella cartilage volume loss. This brings a person’s given anatomy, perhaps suboptimal anatomy, into play and thus adds one’s risk factors. There was a trend for this effect to occur for males, as well as people participating in vigorous physical activity. Males who exercised vigorously were more adversely affected.

In conclusion, this study showed that in vivo engineered cartilage was remodeled when implanted; however, its extent to maturity varied with cultivation period. The results showed that the more matured the engineered cartilage was, the better repaired the osteochondral defect was, highlighting the importance of the in vitro cultivation period.

There are many surgical interventions out there for anterior knee pain, such as tuberosity transfers, retinacular releases, injections, and God forbid patellectomies among others (yes, we have clients who decades ago had this done, imagine that! Thankfully this radical move is no longer done !). Most people simply need a well versed biomechanist who understands the whole kinetic chain, understands the force streams, can assess for the limitations and reduce them to restore the previous normal mechanics.  Sadly, sometimes interventions are not optimal or precise and folks end up like you coach. And then surgery is your only option.  Thanks for sharing your story and reaching out to us. Sharing your anonymous story may help others avoid your painful journey. We would be happy to see you, we are getting more and more letters like yours both here in the home land and internationally. Hopefully, our mission will help reduce these problems, if at least just a little. (PS: yes, our 3 part Shoe Fit / Biomechanics & Functional Anatomy DVD and online program should launch in February. Information about the launch will be right about the time phase 2 of the website will lauch www.thegaitguys.com).

Best to you.

Shawn and Ivo, The Gait Guys