resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Jingei Diagnosis: An Effective and Powerful Diagnostic
I graduated from the Kotatama Institute under the direction of Drs. Masahilo and Katsuharu Nakazono in 1984. As a student, I was exposed to the practice of most of the various theories and modalites of Oriental Medicine.
Managing Today's Fertility Patient
I recently received an email from one of my fertility patients: "Got my lab results back. FSH is 11, AMH is 0.7. My doctor said these numbers aren't good. I guess I'm infertile. Just as a thought. Just set up an appointment to speak with an adoption agency."
Calcium Helps Prevent Colorectal Cancer
Over the past 25 to 30 years, studies have suggested calcium may confer protection against colorectal cancer.
The Tao of Gender
If you think gender is as simple as having a new client check off the "male" or "female" box on your intake form, we hope this article will expand your understanding and thus the reach of your health care.
Healing With TCM at San Quentin State Prison
For the prisoners at San Quentin State Prison, life-sentences are the reality of every day life. It is not often that prisoners get the opportunity to use alternative medicine to deal with common ailments they encounter behind bars such as, depression, anxiety and pain.
5 Ways to Occupy Occupational Health
Despite the progress that has been made to better protect workers, occupational health and safety remains a priority area for many national governmental organizations due to the widespread problem of occupationally related morbidity and mortality.
Talking to Patients About Healthy Aging
I've noticed that a particular category of patients seems to make up more and more of my practice – they work out, but still experience lots of degenerative joint disease (DJD) issues.
Managing Patient Expectations About Acupuncture
Last year, I attended the Pacific Symposium in San Diego for the first time in six or seven years. It was the 25th anniversary of this event, and on one evening there was a panel discussion with the title; "What is Qi?."
Help Patients Achieve Optimal Vitamin D Levels
Much research has been done on vitamin D levels and their impact on health; optimal levels have been correlated with a reduced risk of developing numerous conditions.
Web Marketing: Content Is King
Google's sweeping updates to its search algorithms over the past few years have brought a paradigm shift in how you can optimize your chiropractic website to gain maximum marketing leverage.
Transparency and Accountability: Q&A With the CCE
Every profession needs an organization dedicated to upholding the quality and integrity of its degree programs and educational institutions.
The Heart Protector
On the physical level, the Pericardium is a double-layered sac of fibrous tissue that envelops the Heart. The space between the layers is filled with serous fluid that protects the Heart from external shock or trauma and lubricates to allow for normal Heart movement.
Simple Ways To Find True Happiness
Patients in our clinics are always seeking happiness. As their health advocate, we need to ensure we inform them that in order to find happiness, they have to make sure to identify what makes them happy in the first place.
Lime Jello on Morphine
Taste is in the eyes... actually the mouth... of the beholder. My food preferences have changed, lightening from the food of my youth. My parents loved heavy eastern European cuisine and I loved it as a child. Now I enjoy leaner, healthier whole foods.
Understanding and Identifying Pediatric Growth-Plate Fractures
In general, fractures in children heal well with little intervention as long as the alignment is good. Fractures involving the growth plate, however, are a different issue. In fact, growth-plate injuries are the primary reason for the subspecialty of pediatric orthopedics.
Saying No to Medicine
An interesting article recently appeared in Men's Journal titled "When to Say No to Your Doctor." The article begins with the summary statement above and effectively arms readers with information that will help them "take more responsibility for your own health care, because you can't be sure anyone else is.
The Wonders of Light Therapy: An Interview with Wes Burwell
I first met Wes Burwell in 2011 when he was teaching a class on light. Since then, every time I hear him speak, his understanding of the benefits, function and capacity of light has evolved.
The X Factor in Clinical Research: The Patient
It was the great baseball legend, former New York Yankees catcher Yogi Berra – he of countless aphorisms, each with a mind-bending twist – who once declared, "You can observe a lot by watching."
Blaming the Gluteus Medius, Overlooking the Deltoid
The gluteus medius (Gmed) is commonly written about, strengthened and blamed for many conditions, and rightfully so. After all, the Gmed plays a role in pelvic stability, hip motor control and lower-quarter dynamic movements.
AOMA Strengthens Leadership Team
AOMA Graduate School of Integrative Medicine, a leading college of acupuncture & herbal medicine, announced the appointment of Donna LaPoint Hurta, MBA as the new VP of Finance & Operations this Fall.
Pulse Diagnosis: What We Know
I am still finding pearls of wisdom from the books and papers that I inherited from my pulse diagnosis mentor Jim Ramholz.
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."
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