resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Balancing Spring Challenges
As the winter months come to a close and warmer spring weather appears, patients may begin to present with new challenging pattern presentations.
News in Brief
ACA Adopts New Governance Model; ACA 2017 Awards; CCA Helps Calif. DCs "Share the Love"; $1 Million to Help Advance the Profession; D'Youville Raises the Bar on Anatomy Education; ErRatum.
Women's Hormones: A Western & Eastern Perspective
Sometimes it may seem that you require a degree in medicine to understand hormones and how they function.
Creating Good Business Buzz
What do patients really think about working with you? Rarely do you hear the whole truth. Those who improve may be candid in their gratitude.
Why I Quit Doing House Calls
My father was a chiropractor who did house calls, so when I became a DC, I figured doing house calls was part of the job. My March article recalled my experience as a small boy, accompanying my dad while he went to patients' homes to treat them.
New Relationships, Old Trauma: AOM & Other Healing Strategies
Being in love is one the most beautiful and enjoyable experiences. Most of us are willing to pay almost any price to have that experience, and still often find it elusive or fleeting. Navigating the ups and downs of loving relationships are often challenging — even for the most psychologically balanced among us.
Clearing Blocks: A Way to Improve Cosmetic Acupuncture
As a Five Element acupuncturist who teaches facial acupuncture classes nationally, I was surprised to learn that one of the basic principles I was taught in school is unfamiliar to most acupuncturists.
Raditation & Your Smartphone: Is it Worth the Risk?
If radial arteries could talk (and in my experience they can to some extent), they would say, "Step away from the smartphone." At least that is the message I am receiving loud and clear as I feel the pulses of many patients.
Eczema & Acupuncture: A Sound Solution (Part 1)
Eczema affects approximately 3.5 percent of the global population and is one of the most common skin complaints seen by dermatologists.
Universal Design: Principles & Practice
In many respects, universal design serves as the core of ergonomics. It's also a good tool to use when designing a return-to-work program for injured and/or ill patients. Let's take a closer look at universal design and why it should matter to you and your patients.
Give Yourself the Digital Advantage
When you see this article in the print version of this issue and swear you read it already, don't be alarmed: you probably did. That's because by that time, the May issue will have been available online in digital format for three weeks.
A Major Role in Back Pain: The Multifidus
Back pain affects roughly 80 percent of the population at one time or another and is one of the leading causes of doctor visits.
Taking the Chiropractic Message to the Press
"There is no better place on earth to have a news event," the National Press Club boasts, and it's easy to understand why: Every year, the 108-year-old Washington, D.C.-based organization hosts countless press conferences on the hottest topics impacting America and often the world.
A Daily Strategy for Heavy-Metal Detox
In modern society, we are constantly exposed to heavy metals such as cadmium, lead and mercury. These heavy metals have no essential biochemical roles in our body, and conversely, can cause us a great deal of harm if they build up to toxic levels.
The Visual Error Scoring System: A Concussion Tool
Postural stability and oculomotor function are the most easily recognized physical indicators of neurologic motor dysfunction associated with concussions.
Is It Time to Rethink Mental Illness? (Pt. 1)
Invariably, patients will ask their chiropractor about depression or various mental illnesses. Some practitioners will reflexively offer a cervical adjustment, suggest St. John's wort or contemplate a referral to a specialist.
An Integrated Approach to Chronic Pain
Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction.
Is the New Medicare Reporting Exemption Right for You?
What you've heard is not a rumor – there will be exemptions for providers of Medicare patients, with no penalties assessed for offices that do not do Quality Payment Program (EHR, PQRS, MACRA and MIPS) reporting.
Bill With Confidence: Learn What to Collect
Q: I am trying to understand what I may collect from my patient when there is insurance. Do I have to accept the amount allowed by the plan or may I collect up to my billed amount? Please note, I am not a member of any insurance plan.
February, 2009, Vol. 09, Issue 02
By Erik Dalton, PhD
Every year, more and more clients come in complaining of generalized pain around the kneecap (patella) aggravated by activities such as squatting, stair climbing, or hiking over hilly terrain. Symptoms typically worsen during prolonged knee flexion (i.e., long car rides, sitting in class or in a movie theater). Clients often carry with them a diagnosis of chondromalacia or patellar tendinitis. In most cases, neither of these terms accurately describes the cause of this painful condition, which remains elusive and poorly understood.
In attempting to discern the source of the client's pain, an important question is whether it primarily involves the surrounding soft tissues or the patellofemoral articulation itself. Some clinicians (including myself) tend to lump patella-related symptoms into a category of chondromalacia. Since most researchers agree that nerve endings are relatively absent in articular cartilage, chondromalacia shouldn't be labeled as the true anatomic cause of anterior knee pain.1 Chondromalacia is a surgical finding that denotes areas of softening of hyaline cartilage due to trauma or aberrant loading, but is not the cause of pain.
Oddly, this shiny, smooth tissue underlying the patella and covering the surface of the femoral head receives the most accolades as a knee pain generator but is possibly the least innervated of all human tissues. I don't mean to say that cartilage degeneration may not be a precursor to knee pain. Certainly, a roughened and degraded cartilaginous surface could impair mobility and joint function leading to irritation in surrounding tissues. But the anatomical source of pain in this area probably originates from compression and torsion to the richly innervated subchondral bone, infrapatellar fat pad, or medial and lateral retinacula.
I've had surgeons tell me that many of their non-traumatic, non-specific knee pain cases have been traced to pinching of the synovial lining between the patella and femur. They speculate that accumulation of inflammatory waste products leads to increased swelling and even greater synovial "nipping." But when it comes to understanding patellofemoral pain, no one can top this guy. In 2005, a surgeon and renowned researcher Scott F. Dye, MD, enlightened the orthopedic community in a rather unusual way. In a brazen experiment using no anesthesia, Dr. Dye, a long-time sufferer of patellofemoral pain, opened an incision in his affected knee large enough to insert a probe so he could test the sensitivity of various interarticular tissues. As he prodded the damaged hyaline cartilage beneath the patella, to his surprise, he found the tissue to be completely painless. But when the probe contacted the joint's synovial lining, the familiar pain he had been feeling for months screamed back at him. I encourage you to review this man's outstanding work in an article, "The Pathophysiology of Patellofemoral Pain: A Tissue Homeostasis Perspective."2
As the knee flexes and extends, the patella glides through the trochlear groove in the distal femur. (See Figure 1) This patellar mechanism enhances leverage of the quadriceps by improving the angle of pull on the tibia. Resembling a shim (the thicker the better), the patella helps push the quadriceps tendon further away from the tibia to allow for more powerful knee extension - and powerful it is. The forces executed during knee extension exceed all other body movements. Surprisingly, much of the literature implies that the patella moves only in an up-and-down direction when, in fact, it also tilts and rotates. Imagine the massive forces the patella must withstand during hill climbing or squatting. Pressures per square inch under the patella rise to more than three times the body weight when climbing a ladder and greater than eight times the body weight during various stages of deep squatting...whew!
Many believe that repetitive contact caused by maltracking of the patella is a likely mechanism of non-traumatic patellofemoral pain. Some of the factors believed to be the main culprits are: overuse or repetitive weight-bearing activities, arch variations - flat or high arches, wider hips and knock-knees (known as the Q angle), and lower limb muscle imbalances. Although I've had some success alleviating stubborn cases of patellofemoral pain using myoskeletal alignment and joint mobilization routines, I've found no consensus in the literature indicating that manual therapy procedures are of significant value. Regrettably, no solid (reproducible) research has surfaced to confirm that any type of medical or manual intervention is reliable. Having said that, I'd like to discuss a couple of strategies you might try when dealing with this illusive and pervasive condition.
Theory & Treatment
The therapist's treatment goal is to eliminate excessive compressive and/or torsional forces at the patellofemoral articulation. (Figure 2) Early in my days as a certified Rolfer, I'd place a dot in the middle of the kneecap and ask the client to slowly squat so I could observe the direction of the knee tracking. It was an interesting experiment trying to identify the painful knee strictly from my tracking observations. Surprisingly, I only got it right about 60 percent of the time so I abandoned the test and proceeded on to a more holistic evaluation that garnered better results.
One common structural abnormality that seemed to respond better than the rest is depicted in Figure 3. Basically, this drawing represents a person presenting with a pronated foot, internally rotated tibia, externally rotated femur and pelvic obliquity. As the tibia internally rotates, and the kneecap is being pulled laterally (squinting patella), strong torsional forces travel through the knee during gait. Tissue often builds up on the medial side of the knee as the stretch weakened vastus medialis recruits help from the adductor magnus muscle. Theoretically, during running, the person with this dysfunction would land on the lateral portion of the flat foot and roll inward, causing the lower leg to internally rotate. At the same time, vastus lateralis and iliotibial band (ITB) resist this motion by externally tugging on the lateral side of the kneecap causing increased friction between the patella and femur. Figure 4 shows an effective spindle-stimulating technique for tonifying the weakened arch muscles, mobilizing the ankle and foot, and correcting the internal fibular rotation.
When working properly, the patella acts as an efficient pulley system between the medial and lateral quads in leg extension and during deceleration of leg flexion. (Figure 5) Unfortunately, when massive lateral thigh muscles shorten and their fascial bags glue together, the medial knee musculature loses the patella-tracking battle. As the patella begins migrating too far laterally, the eloquently designed pulley system is compromised predisposing surrounding tissues to injury. Reciprocal weakness and loss of anti-gravity function in the foot and ankle's "stirrup spring system" (tibialis anterior and peroneus longus) produces painful compensations at the knee and hip. (See "Don't Get Married, Part 2" MT August 2008.) Foot pronation also interferes with precisely coordinated neurological movements during gait.
Neurologic coordination demands balanced and rhythmic lower extremity movement. An infant's "cross crawl" pattern organizes many innate musculoskeletal functions at the spinal cord level permitting a smooth cross-patterned gate without thinking about posture and conscious planning of each movement. But when a foot maintains prolonged pronation, many global and core muscles forget how to "turn on" and "shut off" in proper sequence. This leads to altered posture, excessive efforting during normal movements and "kinetic chain kinks" that often manifest in the knee. In Figure 6, a fibular mobilization technique is applied to help lift the lateral arch and restore functional balance between the tibia and fibula.
Myofascial manipulation and joint stretching routines designed to restore alignment, function and firing order are helpful, particularly when combined with home retraining exercises using elastic bands, loops and ball squeezes. Together, they can help correct aberrant tracking patterns decreasing the risk of injury. I find the vastus medialis a difficult muscle for clients to isolate so I recommend general quadriceps strengthening which includes a properly designed deep squat training program.
It's reasonable to blame much of the escalation of patellofemoral knee pain syndromes on our society's transition from a population of movers to a nation of sitters. The advent of chairs has been one of the major predisposing factors leading to the prevalence of knee, hip and back pain in modern man. The deep squat position used for working and resting was, and is, an extremely beneficial exercise. Millions of people in Africa, Asia and Latin American countries still practice this very therapeutic squatting position. Contrary to popular opinion, I believe deep squatting exercises performed correctly are a very therapeutic adjunct for preventing and rehabbing certain types of knee pain.
The deep squat is, perhaps, the single best exercise for leg strength and development. Squatting significantly balances the muscles responsible for knee and hip extension: quadriceps, hamstrings, and glutes, as well as the smaller stabilizing core musculature. It has benefits not just for strengthening, but for balance, cardiovascular capacity, and active flexibility. Knee injury usually results from varus or valgus force (twisting of the joint in either direction), inappropriate loading or forcible shear across the joint. It does not occur simply by taking the knee joint through a full range of motion using correct squatting exercises. As my grandaddy used to say, "Squats are the only thing standing between me and getting stuck on the toilet."
Click here for previous articles by Erik Dalton, PhD.
Join the conversation
Comments are encouraged, but you must follow our User Agreementcomments powered by Disqus
Keep it civil and stay on topic. No profanity, vulgar, racist or hateful comments or personal attacks. Anyone who chooses to exercise poor judgement will be blocked. By posting your comment, you agree to allow MPA Media the right to republish your name and comment in additional MPA Media publications without any notification or payment.