help with knee prob patient pls

[robbloxsom]

Hello everyone...I'm new

Just wondered if anyone can help me with the following:

I have received a referral from a physio, who is suggesting that this patient requires orthoses:

The patient in question is a 27 y.o. female who has developed bilateral knee pain - medial to patella since she started recreational running.

she reports that she was born with "funny legs". She has not had problems before; she has a sedentary job.

She has a (very) internal knee position, that to me, appears to be due to her femoral/hip position. Her foot posture in relaxed stance appears 'normal'...ie. moderate supination resistance, and Jack's test scores 2. Her tib/fib alignment seems ok too.

She has weak quad strength & under-developed Vast. meds.

Her gait, surprisingly, also didn't look too bad...knees look internal as expected, & there seems to be a little abductory twist at heel lift.

I feel I am likely to cause her to develop some foot problems if I try to supinate her foot to gain some external limb rotation. Should I be looking more proximally & giving her exercises that encourage ext hip rotation? The physios gave her quad strengthening exercises but she hasn't been doing these yet (...thought she should get my opinion first

Help! I'm seeing her again this Tues.

Ta

Rob

[ianl]

Hi Rob

1 "I have received a referral from a physio, who is suggesting that this patient requires orthoses"

Fantastic, great opportunity, make sure you write a brief report to them after discharge.


2 "bilateral knee pain - medial to patella since she started recreational running."

Partly answers your questions really and the physios have said that they consider the situation to not just be a soft tissue one but, by refering, mechanical as well. So far, on a possible winner. BTW the medial knee pain aspect may respond to orthoses but I suspect the orthoses and physio together are the key.


3 "She has not had problems before; she has a sedentary job..... she has a (very) internal knee position, that to me, appears to be due to her femoral/hip position..."

Now running so dynamics very different, introduced forces that the tissues are not used to.


4 "Her foot posture in relaxed stance appears 'normal'...ie. moderate supination resistance, and Jack's test scores "

Static stance tests are unlikely to be overly helpful in a runners situation - different base and angle of gait, very different levels of forces going through the tissues and joints


5 "Her gait, surprisingly, also didn't look too bad...knees look internal as expected, & there seems to be a little abductory twist at heel lift."

She is not running so walking gait at best may give a few clues but you need to see her run.


6 "I feel I am likely to cause her to develop some foot problems if I try to supinate her foot to gain some external limb rotation."

Doubt that you will supinate the foot enough to gain external rotation with general orthosis intervention. You may, however, resist any MTJ or STJ tendency to be pushed further into pronation than it wants to go, or, that the leg and foot musculature has been able to cope with.


7 "Should I be looking more proximally & giving her exercises that encourage ext hip rotation?"

No, stick with the foot in this case and work the rest in conjunction with the physio's


8 "The physios gave her quad strengthening exercises but she hasn't been doing these yet (...thought she should get my opinion first)"

Why not. Why seek an opinion then not do the exercises. Back up the physio's on their suggestion, aftre all you agree she has weak quads so your 2nd opinion agrees with the physios.


You do not mention what the STJ range of movement is like or whether there is any varus heel component.

I understand your desire to get it right but how much of it is also driven by a desire to succeed for the physios view. This can make us make intervention more complicated because we are thinking of the physios more than we realise!

Good luck
Ian

[Admin]

Hi,

Welcome to the forum!
Re-advice.

As Ian says.

I would add that whatever you do, do it gently to begin with. For example, you could try felt posting at the forefoot initially.

Good though this forum is, we can't teach sports biomech in one thread .

Cheers,

[robbloxsom]

Thanks for responses chaps.

Unfortunately, I don't really have the facilities/space to assess her running though I realise her mechanics during running are likely to be different to her mechanics in stance and walking gait, especially degree of STJ & MTJ pronation.

To this end you have inspired me to try 'something gentle', as you suggest David.

Ianl: "You do not mention what the STJ range of movement is like or whether there is any varus heel component."

Non-weight bearing STJ motion is normal bilaterally. I must say I didn't specifically look for a rearfoot/calcaneal varus as I tend to use more static stance tests generally these days. She is not excessively pronated in stance and has a fair bit of STJ pronation to go before her maximally pronated position, so I'm guessing there's not a significant rearfoot varus.

Ianl: "Partly answers your questions really and the physios have said that they consider the situation to not just be a soft tissue one but, by refering, mechanical as well."

I'm not really sure I understand your point here. Is it likely that she might develop a soft tissue injury that was not mechanically induced, especially one that coincided with her commencing running?

Ianl: "Doubt that you will supinate the foot enough to gain external rotation with general orthosis intervention."

I'm guessing that this is exactly what the physios were hoping I might be able to achieve!

Thanks again for your help.

Rob

[robertisaacs]

Good though this forum is, we can't teach sports biomech in one thread

No? And there i thought biomechanics was simple ;D .

Sorry Rob, Local joke. Welcome to the forum.

My thoughts.

Firstly i'd agree with Ian on the exercises. If you are sharing care with the physios you must respect their area of expertise as they respect yours.

You said

I feel I am likely to cause her to develop some foot problems if I try to supinate her foot to gain some external limb rotation.

Ian said

Doubt that you will supinate the foot enough to gain external rotation with general orthosis intervention. You may, however, resist any MTJ or STJ tendency to be pushed further into pronation than it wants to go, or, that the leg and foot musculature has been able to cope with.

The jury is still out on whether orthotics create a kinematic change (ie movement) as well as a kinetic change (ie just forces) in leg rotation. I could point you at research which shows they do... but only by a few degrees.

However as Ian astutely points out the lack of kinematic change does not mean you have not changed internal forces. If i tie a large helium balloon to my waist it won't cause any movement, however it will change ground reaction forces.

There is also some controversy over whether the internal hips / knees push the feet into pronation or whether the pronating feet allow the knees to internally rotate. But thats a whole other thread.

Personally i know less about the kinematics of running than i'd like. Not my specialism. However there are a few basic truisms i find applicable in most cases.

1. When doing sport the background muscle tone is higher, therefore the foot is more rigid. As such i find i can acheive more with less, insole wise.

2. Presuming there is no medial knee osteoarthritis, medially wedged orthotics often work well for medial knee pain caused by tendons / ligaments.

3. Due to the high level of muscle tension involved in sport i am much less reluctant to resort to forefoot varus extensions (not having the worry of creating forefoot supinatus / invertus.)

My usual sports prescription in a 3mm heel raise, a relatively mild valgus pad and a 3mm V9 (dense memory foam) medial wedge heel to sulcus. Obviously i modify this depending on the specifics of the case but thats usually a good starting point.

Hope that helps

Robert

[ianl]

Hi Rob

"I'm guessing that this is exactly what the physios were hoping I might be able to achieve!"


My experience with physios is that this is not necessarily the case, more likely they know something needs to change mechanically, distally, and are looking to you to help achieve it, which ever way seems best to you.

"Ianl:" "Partly answers your questions really and the physios have said that they consider the situation to not just be a soft tissue one but, by refering, mechanical as well."

The key is in the above fact (linked with your first post) is that she has introduced major changes to her muscle and joint function quite quickly. So it is likely that mechanics need aiding and orthoses can be part of this.

There are foot and ankle mob's that might be worth doing but I am not good at describing them on the net I'm afraid.

Cheers
Ian