"Combined with an exercise-based rehabilitation program, a single injection of LR-PRP or LP-PRP was no more effective than saline for the improvement of patellar tendinopathy symptoms.:"
*this is the First randomized controlled trial comparing PRP (platelet-rich plasma) injection to saline, for patellar tendinopathy.
*in the video, watch the left knee
Hopefully this video and post will make you think deeper about patellofemoral tracking, runners knee, meniscal issues and anterior knee pain syndromes as a whole.
This is subtle, but in this case, this is relevant to the LEFT knee complaints of this client.
When the foot complex is a little weak, the arch can collapse more than it should, rendering too much pronation, this means the talus will adduct, plantarflex and medially rotate more than it should. Since the tibia sits on top of this talus it must follow. This will allow more internal tibia spin (medial rotation) and this will drag the knee medially (it appears in the video to be a valgus load but it is more internal/medial rotation than valgus).
So, what the foot-ankle complex does, the knee follows. Conversely, when the knee moves medially or valgus because of a hip weakness (poor external rotation control) the foot will move medially.
So, are you going to "fix" this with an orthotic ? A stability shoe? Or are you going to actually help the client gain better control ?
You can see that our "raise the toes, to raise the arch" helps the client find the more appropriate arch posture with the help of more anterior compartment engagement and windlass effect at the 1st MPT-hallux joint. This is where our reteaching of the component parts via "motor chunking" via the Shuffle Walk (see our youtube channel) can help them control the rate and amount of arch "collapse" and thus control the rate of medial knee spin.
i say it on our podcast all the time, the knee is a simple sagittal hinge joint between 2 multiaxial joints. It is often a follower, not a leader.
Or you can bandaid this client with an expensive orthotic and never fix their problem. This keeps them coming back over and over for symptom management. It is a good business model (insert sarcasm), but helping this client learn and remedy their deficiency is a better one. Happy people talk to their friends, even strangers.
Shawn Allen, the other gait guy
#gait, #gaitproblems, #gaitanalysis, #ovepronation, #archcollapse, #valgusknee, #tibialspin, #internalhiprotation, #thegaitguys, #kneepain, #runnersknee, #patellapain, #anteriorkneepain
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:
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/
Anterior meniscofemoral impingement syndrome. Ever heard of it ? Probably not.
Here we have a case of a young fellow with knee pain immediately below the patellae. As you can see here there are a few issues, some of which he will likely grow out of and some of which he may not. Here we obvious see hyperextension of the knees and increased ankle plantarflexion posturing (I chose that word carefully) that obviously goes hand in hand with this retro-postured knees.
After a few more questions it was clear that the pain had been around for quite some time and was at a specific pencil eraser sized area above the anterior joint line, slightly medially to center and without question not at the joint line proper but directly on the medial femoral condyle. There was no swelling or fulness to suggest this was involvement of Hoffa’s fat pad. The patellar tendons were not thick. So, do you know what he has ? You should always suspect this in knees that hyperextend this far or in athlete that have sustained or repetitive hyperextension stressing:
This fella has several factors here.
So, clearly understanding these biomechanical factors and coupling a palpatory tenderness at the correct spot on the medial femoral condyle indicates that he has (the youngest we have ever seen)…….drum roll…….
Anterior meniscofemoral impingement syndrome. Ever heard of it ? Probably not. Why, because it was glazed over in school, and maybe not at all for many doctors to be honest. Go ahead, look it up under Pubmed and see how many referenced papers you find on it. I see it enough (albeit still rarely) to know that it is frequently diagnosed as a patellar tracking problem but those clients do not have the same risk and anatomy factors that I discussed above. I have had doctor referrals call me back saying they have never even heard of it, most have not to be honest. Bottom line, if you know your anatomy and your biomechanics you can figure out most things. If you are slim and skinny on either one you might be missing a few things. I do sometimes as well; we are all students.
Summary: When the knee hyperextends either too much, too long, or for too many repetitions either statically or in dynamic walking, running or in activity the leading upper edge of the medial meniscus can impinge repeatedly and forcefully into the soft medial femoral articular cartilage and over time create a softening of the cartilage (chondromalacia ). Do it long enough or enough times and you create an inflammatory reaction with a cartilagenous defect.
This poor little guy was hating walking. Interestingly, what do you think happened when we had him crouch walk (knees flexed)……yup…..no pain. He looked up at me in wonderment immediately and of course saw me smiling knowing very well he would be pain free.
Solution in a 4 year old. Slightly flex the knees and place a long strip of tape down the back side of the upper and lower leg. If he extends the knee he forces the tape taught and is instantly reminded (pseudo biofeedback if you will) that he is approaching the danger zone. As this case and many other find, after a few days the skin gets pretty irritated but that is time to take the tape off and let him go back to his old tricks……. trust us, it is only for a few hours until he will figure it out……meaning….. hyperextension is evil ! Teaching this little guy our now famous “Shuffle walks” (to drive ankle dorsiflexion strength in the tibialis anterior and toe extensors in a posture of knee flexion) was on the menu to improve ankle dorsiflexion and anterior compartment strength and we turned it into a fun game for him to play with mom and dad.
Anterior Meniscofemoral Impingement Syndrome. Say it 3 times fast with a mouthful of organic chunky peanut butter for fun.
Hope you never see it in a little one. if you do, smile and reach for some tape and put on some 70’s music and shuffle to some oldies.
Dr. Shawn Allen, one of the gait guys
1996 Dec;12(6):675-9.Meniscal impingement syndrome.
McGuire DA, Barber, Hendricks
.Plano Orthopedic and Sports Medicine Center, Texas, USA.
Abstract
The meniscal impingement syndrome consists of three elements: impaction on theanterior medial femoral condyle by the leading edge of the medial meniscus, articular cartilage damage of at least Outerbridge grade 3, and knee hyperextension of at least 5 degrees. This report reviews this condition in a series of seven knees with an average follow-up of 39 months. The time from the onset of symptoms until surgery averaged 45 months. Treatment consisted of a thorough arthroscopic knee evaluation and debridement of the articular cartilage fragmentation and any impinging synovitis. Postoperative rehabilitation includes extension block bracing, hamstring strengthening, and closed-chain exercise. With this regimen, there was improvement in the Tegner scores and a reduction in postoperative knee hyperextension. Identification of this uncommon condition requires a complete evaluation of the medial femoral condyle in patients with knee hyperextension.
After a few more questions it was clear that the pain had been around for quite some time and was at a specific pencil eraser sized area above the anterior joint line, slightly medially to center and without question not at the joint line proper but directly on the medial femoral condyle. So, do you know what he has ? You should always suspect this in knees that hyperextend this far or in athlete that have sustained or repetitive hyperextension stressing:
This little fella has the last 2 factors, BIG TIME !
So, clearly understanding these biomechanical factors and coupling a palpatory tenderness at the correct spot on the medial femoral condyle indicates that he has (the youngest we have ever seen)…….drum roll…….
Anterior meniscofemoral impingement syndrome. Never heard of it ? Probably not. Why, because it was glazed over in school, and maybe not at all for many doctors to be honest. Go ahead, look it up under Pubmed and see how many referenced papers you find on it. We see it enough to know that it is frequently diagnosed as a patellar tracking problem but those clients do not have the same risk and anatomy factors. We have had our doctor referrals call us back saying they have never even heard of it. Most have not to be honest. Bottom line, if you know your anatomy and your biomechanics you can figure out most things. If you are slim and skinny on either one you might be missing a few things. We do sometimes as well.
Summary: When the knee hyperextends either too much, too long, or for too many repetitions either statically or in dynamic walking, running or in activity the leading upper edge of the medial meniscus (see anatomy diagram above) can impinge repeatedly and forcefully into the soft medial femoral articular cartilage (see the colored purple area in the diagram) and over time create a softening of the cartilage (condromalacia as it is known). Do it long enough or enough times and you create an inflammatory reaction with a cartilagenous defect.
This poor little guy was hating walking. Interestingly, what do you think happened when we had him crouch walk (knees flexed)……yup…..no pain. He looked up at me in wonderment immediately and of course saw us smiling knowing very well he would be pain free.
Solution in a 4 year old. Slightly flex the knees and place a long strip of tape down the back side of the upper and lower leg. If he extends the knee he forces the tape taught and is instantly reminded (pseudo biofeedback if you will) that he is approaching the danger zone. As this case and many other find, after a few days the skin gets pretty irritated but that is time to take the tape off and let him go back to his old tricks……. trust us, it is only for a few hours until he will figure it out……meaning….. hyperextension is evil ! Teaching this little guy our now famous “Shuffle walks” (to drive ankle dorsiflexion strength in the tibialis anterior and toe extensors in a posture of knee flexion) was on the menu and we turned it into a fun game for him to play with mom and dad.
Anterior Meniscofemoral Impingement Syndrome. Say it 3 times fast with a mouthful of organic chunky peanut butter. We dare ya ! (Sounds like a whimpy frat house hazing technique if you as me.)
Hope you never see it in a little one. if you do, smile and reach for some tape and put on some 70’s music and shuffle to some oldies.
Shawn and Ivo……. yup, orthopedics is also in our soup of letters after our names. But it ain’t the letters that matter, it is what you do with them. Anyone up for Scrabble ?
* Oh, look, we found one journal article ……from 1996 ! Sad.
Plano Orthopedic and Sports Medicine Center, Texas, USA.
The meniscal impingement syndrome consists of three elements: impaction on the anterior medial femoral condyle by the leading edge of the medial meniscus, articular cartilage damage of at least Outerbridge grade 3, and knee hyperextension of at least 5 degrees. This report reviews this condition in a series of seven knees with an average follow-up of 39 months. The time from the onset of symptoms until surgery averaged 45 months. Treatment consisted of a thorough arthroscopic knee evaluation and debridement of the articular cartilage fragmentation and any impinging synovitis. Postoperative rehabilitation includes extension block bracing, hamstring strengthening, and closed-chain exercise. With this regimen, there was improvement in the Tegner scores and a reduction in postoperative knee hyperextension. Identification of this uncommon condition requires a complete evaluation of the medial femoral condyle in patients with knee hyperextension.
________
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)
__________________________________________________
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
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