Knee pain and the the semitendinosis?

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

The semitendinosus hails from the posterior compartment.

During an ideal gait cycle, the semitendinosus from mid swing through nearly loading response, with a brief firing at toe off.

We remember that the abdominals should initiate thigh flexion with the iliopsoas, rectus femoris, tensor fascia lata and sartorius perpetuating the motion. Sometimes, when the abdominals are insufficient, we will substitute other thigh flexors, often the psoas and/or rectus femoris, but sometimes sartorius, especially in people with excessive midfoot pronation. Think about all of the medial rotation occurring at the knee during excessive midfoot pronation and when overpronation occurs, the extra compensatory external rotation that must occur to try and bring the knee back into the sagittal plane. The sartorius is positioned perfectly for this function, along with the semitendinosus which assists and external rotation and closed chain.

The semitendinosis is the most superficial of the hamstrings and originates between the biceps femoris, with which it shares a common tendinous attchment, which is anterior and slightly lateral and the semimembranosis which is just beneath it and slightly medial. It is fusiform and the muscle body ends about mid thigh, before becoming a long "piano string" and ultimately inserting most inferiorly of the trio, below the gracilis, on the pes anserine.

Call it pes anserinus bursitis or pes anserine tendinitis but they both add up to medial knee pain when the thigh needs help flexing. Look to this troublesome trio the next time you have recalcitrant medial knee pain.

 

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #gaitdysfunction, #thegaitguys, #pesanserine, #semitendinosis

 

Imani F, Rahimzadeh P, Abolhasan Gharehdag F, Faiz SH. Sonoanatomic variation of pes anserine bursa. Korean J Pain. 2013;26(3):249-54. 

Gupta, Aman & Saraf, Abhinesh & Yadav, Chandrajeet. (2013). ISSN 2347-954X (Print) High-Resolution Ultrasonography in PesAnserinus Bursitis: Case Report and Literature Review. 1. 753-757. 

Gray H:  Anatomy of the Human Body  Lea and Febiger, Phildelphia and New York 1918

https://www.anatomy-physiotherapy.com/knee/articles/systems/musculoskeletal/lower-extremity/knee/test-your-knowledge-the-pes-anserinus

 Michaud T: in Foot Orthoses and Other Forms of Conservative Foot Care Williams & Wilkins, 1993 Pp. 50-55

 Michaud T: in Human Locomotion: The Conservative Management of Gait-Related Disorders 2011

Achilles Tendinitis?

You should read this study if you haven't already

We all treat different forms of achilles tendinitis and tendonosis. This landmark study uses loaded eccentrics and showed better tendon organization and decreased tendon thickness at follow up. 

Tendons do seem to respond better to tension and loaded eccentrics certainly seems to do the job. Though, this study is 2004 and much new research has leaned us all more toward looking at pain free isometrics , in other words, taking that tension in a pain free single range load and helping the tendon to reestablish appropriate stiffness. Tension and time under pain free load is the key, then expanding from that into more dynamic load challenges like eccentrics. But, as always, it is finding the load your client can pain free tolerate, get the organism to reload the tissue without threat and then build durability and tissue tolerance to load.

"Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon."

Ohberg L, Lorentzon R, Alfredson H, Maffulli N. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of Sports Medicine. 2004;38(1):8-11. doi:10.1136/bjsm.2001.000284.

link to abstract: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724744/